Neonatal deaths account for 40% of global under-five mortality and are ever more important if we are to achieve the Millennium Development Goal 4 (MDG 4) on child survival. We applied a results framework to evaluate global and national changes for neonatal mortality rates (NMR), healthy behaviours, intervention coverage, health system change, and inputs including funding, while considering contextual changes. The average annual rate of reduction of NMR globally accelerated between 2000 and 2010

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... (2.1% per year) compared with the 1990s, but was slower than the reduction in mortality of children aged 1-59 months (2.9% per year) and maternal mortality (4.2% per year). Regional variation of NMR change ranged from 3.0% per year in developed countries to 1.5% per year in sub-Saharan Africa. Some countries have made remarkable progress despite major challenges. Our statistical analysis identifies inter-country predictors of NMR reduction including high baseline NMR, and changes in income or fertility. Changes in intervention or package coverage did not appear to be important predictors in any region, but coverage data are lacking for several neonatal-specific interventions. Mortality due to neonatal infection deaths, notably tetanus, decreased, and deaths from complications of preterm birth are increasingly important. Official development assistance for maternal, newborn and child health doubled from 2003 to 2008, yet by 2008 only 6% of this aid mentioned newborns, and a mere 0.1% (US$4.56m) exclusively targeted newborn care. The amount of newborn survival data and the evidence based increased, as did recognition in donor funding. Over this decade, NMR reduction seems more related to change in context, such as socio-economic factors, than to increasing intervention coverage. High impact cost-effective interventions hold great potential to save newborn lives especially in the highest burden countries. Accelerating progress requires data-driven investments and addressing context-specific implementation realities. In 2010, 3.1 million newborns died in the first month of life, 17% fewer than in 2000. The annual rate of reduction of the neonatal mortality rate (NMR) globally (2.1%) has accelerated since 2000, but remains slower than the rate of reduction for maternal mortality (4.2%) and mortality amongst children aged 1-59 months (2.9%). Variation between regions and countries is considerable and not previously analysed. There has been progress in reducing most causes of death since 2000, especially tetanus as well as neonatal infections addressable through child health programmes -pneumonia and diarrhoea. Deaths due to preterm birth complications are decreasing more slowly, and these are now the second leading cause of child deaths, requiring innovation for prevention solutions and urgent scale up of care solutions. Our statistical analysis of inter-country NMR reduction suggests that in the last decade contextual factors, such as changes in income and fertility, are associated with more rapid NMR reduction, with measureable coverage change of newborn-related interventions contributing little. Lack of coverage data for some key interventions is a critical gap. In Africa, NMR change has been so limited that statistical modelling was not helpful in identifying predictors. Official development assistance (ODA) for maternal, newborn and child health nearly doubled from 2003 to 2008, yet even by 2008 only 6.1% of this funding mentioned newborn-related activities. Per live birth in 2009, this equates to US$3.51 in ODA mentioning newborns or US$0.13 in ODA exclusively targeting newborns. Currently, government funding is not systematically tracked for reproductive, maternal, newborn and child health. Over the last decade, and especially since 2005, there have been major advances in the evidence base for newborn survival-particularly more data and greater frequency of burden of disease estimation-and in consensus for implementation, as well as some increases in funding. In order to accelerate progress, greater emphasis is required on scaling up care, especially in the highest burden countries, and addressing context-specific implementation challenges regarding personnel, supplies and monitoring. iii8 HEALTH POLICY AND PLANNING