Abstract
Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. Most deaths are preventable or avoidable through interventions delivered in the primary healthcare system. However, evidence regarding the impact of health system characteristics on child survival is sparse. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa. We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Between 1995 and 2015 we observed 13,629 deaths in infants and 5149 in children. In fully-adjusted models, the largest effect sizes were related to fees for services. Immunization fees were correlated with poor child survival (HR = 1.20, 95% CI 1.12–1.28) while delivery fees were correlated with poor infant survival (HR = 1.11, 95% CI 1.01–1.21). Accessibility of facilities and greater concentrations of private facilities were associated with improved infant and child survival. The proportion of facilities with a doctor was correlated with increased risk of death in children and infants. We quantify the impact of health service environment on survival up to five years of age. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. In the absence of these fundamental investments, more specialized interventions may not achieve their desired impact.
Highlights
Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday
We focus on subnational measures of health system context motivated by the observation that child mortality varies more within countries than between countries[20]
We assembled a longitudinal cohort of children born in seven countries over 20 years and estimate the impact of their local health services context on the risk of death in infancy and early childhood
Summary
Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. The objective of this study is to better understand the impact of the health system as a delivery platform, independent of specific interventions, on child survival. We assembled a longitudinal cohort of children born in seven countries over 20 years and estimate the impact of their local health services context on the risk of death in infancy and early childhood. We divide the health context into three dimensions—access, quality and cost—and individually investigate their relationship to survival
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