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In East Asia, where several countries are among the top emitters of carbon dioxide globally, the need to address the dual challenges of reducing carbon footprints and ensuring health security is paramount. Against this backdrop, this study used a descriptive analysis to provide a comparative assessment of the carbon footprints and the level of health security in East Asia using secondary data, sourced from the World Development Indicators. The findings from the study show that it is only North Korea that its average carbon footprint of every person is less than 2.3 tons. However, China, Japan, Mongolia and South Korea are currently lagging behind in meeting the SDG 13 target. Meanwhile, North Korea recorded the highest incidence of tuberculosis in the region. Despite the fact that South Korea and Japan were the highest emitter of CO2, the duo had the lowest under five mortality, infant mortality, incidence of TB alongside the highest life expectancies which surpassed the regional performance. In view of the above, the policymakers in Asia and the rest of the countries with health insecurity should emulate the policymakers in Japan and South Korea by making adequate investment in health, education, and standard of living of their citizens.

En Asie de l'Est, où plusieurs pays comptent parmi les plus grands émetteurs de dioxyde de carbone au monde, la nécessité de relever le double défi de réduire l'empreinte carbone et d'assurer la sécurité sanitaire est primordiale. Dans ce contexte, cette étude a utilisé une analyse descriptive pour fournir une évaluation comparative des empreintes carbone et du niveau de sécurité sanitaire en Asie de l'Est à l'aide de données secondaires provenant des indicateurs de développement mondial. Les résultats de l'étude montrent que seule la Corée du Nord a une empreinte carbone moyenne par personne inférieure à 2,3 tonnes. Cependant, la Chine, le Japon, la Mongolie et la Corée du Sud sont actuellement à la traîne dans la réalisation de l'ODD 13. Pendant ce temps, la Corée du Nord a enregistré la plus forte incidence de tuberculose dans la région. Bien que la Corée du Sud et le Japon soient les plus grands émetteurs de CO2, ces deux pays ont les taux de mortalité des moins de cinq ans, de mortalité infantile et d'incidence de tuberculose les plus faibles, ainsi que les espérances de vie les plus élevées, dépassant les performances régionales. Compte tenu de ce qui précède, les décideurs politiques d'Asie et du reste des pays souffrant d'insécurité sanitaire devraient imiter les décideurs politiques du Japon et de la Corée du Sud en investissant de manière adéquate dans la santé, l'éducation et le niveau de vie de leurs citoyens.

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BACKGROUND: Child mortality is one of the key indicators of the Sustainable development goals. The Ethiopian healthcare system in general and Tigray's healthcare system in particular has shown a remarkable progress in terms of reducing maternal, neonatal, and under-five mortality in the last couple of decades. However, the war erupted in November 2020 caused the healthcare system to collapse and little is known about the status of child mortality in Tigray. Thus, this study aimed to examine the magnitude and causes of under-five child mortality in the embattled Tigray region was conducted from October 2020 - May 2022. METHODS: A cross-sectional community-based survey was employed. The study included all zones except the western zone and some areas of eastern and north western Tigray bordering Eritrea. These areas were skipped for security reasons. Based on multistage cluster sampling, 121 tabiyas in districts were selected. Census was conducted to survey 189,087 households in the 121 Tabiyas. A locally developed household screening tool and the latest world health organization verbal autopsy instrument were used. The Verbal Autopsy data was processed using the Inter-VA-5.1 (probabilistic modeling) to assign the cause of death. Under-five mortality rate (U5MR) was calculated per 1000 live births with a 95% confidence interval (CI). RESULTS: In the present study, out of 29,761 live births, 1761 under-five children died giving an under-five mortality rate of 59(95% CI, 57-62) per 1000 live births. Deaths in the neonatal period and post-neonatal period accounted for 60% and 19.9% of the deaths respectively. Overall, the top 3 causes of under-five child mortality in the present study were: Perinatal asphyxia (n = 277,18%,) prematurity (n = 235,16%) and diarrheal diseases (n = 162, 12.5%). In those who died after first month of life, diarrheal diseases, lower respiratory tract infection, sever acute malnutrition and HIV were the main causes of death. Concerning the place of death, 61.6% of the children died at home. CONCLUSION: The present study revealed the doubling of under-five mortality in Tigray from where the figure stood in the pre-war period. The leading causes of death in under-five mortality are potentially preventable in situation where the healthcare system is functioning. Restoring the healthcare system and its apparatus, improving access to skilled institutional delivery, smooth perinatal transition, improving nutrition status of children, access to full course of vaccines could ameliorate the staggering under-five mortality rate in the war in Tigray.

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Reducing under-five mortality is a crucial indicator of overall development in a country. However, in Angola, understanding the factors contributing to hospital deaths in this vulnerable demographic remains incomplete despite improvements in healthcare infrastructure and public health policies. With one of the highest under-five mortality rates in sub-Saharan Africa, Angola faces significant challenges such as malaria, malnutrition, pneumonia, neonatal conditions, and intestinal infectious diseases, which are the leading causes of death among children. This study aimed to identify factors associated with hospital deaths among children aged 28 days to five years admitted to DBPH in Luanda between May 2022 and June 2023. Using a hospital-based case-control design, the study included 1020 children, among whom 340 experienced hospital deaths. Distal and intermediate determinants emerged as primary predictors of hospital mortality, showing significant associations with: mother without schooling (OR [95%CI] 4.3 [1.2-15.7], p < 0.027); frequent alcohol consumption during pregnancy (OR [95%CI] 3.8 [2.5-5.9], p < 0.001); hospital stay ≤24 h (OR [95%CI] 13.8 [6.2-30.8], p < 0.001); poor nutritional status (OR [95%CI] 2.1 [1.4-3.2], p < 0.001); short interbirth interval (OR [95%CI] 1.7 [1.1-2.5], p < 0.014); maternal age ≤19 years (OR [95%CI] 5.6 [3.0-10.8], p < 0.001); and maternal age ≥35 years (OR [95%CI] 2.1 [1.2-3.7], p < 0.006). These findings highlight the preventable nature of most under-five hospital deaths and underscore the urgent need to address social inequities and improve the quality of primary healthcare services to effectively reduce child mortality in Angola.

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The physical expansion of the city of Ouagadougou, the capital and largest city of Burkina Faso, subsided in 2015 after the government banned land speculation that contributed to the growth and entrenchment of informal areas. The government subsequently implemented social policies such as free health care for pregnant women and children under 5 years of age. Against this background, we tested the convergence of under-5 mortality trends between formal and informal areas in the city between 2010 and 2019; data covering that period came from the Ouagadougou Health and Demographic Surveillance System (HDSS). The analyses included the calculation of all-cause and cause-specific mortality rates, the implementation of a Poisson regression model, and competing risk models. Over the study period, children in formal areas had lower mortality than those in informal areas. However, the inequality gap decreased over time due to a faster mortality decline in informal areas. This decline was explained by a rapid decline in deaths from malaria and other causes including sepsis, HIV/AIDS, measles, meningitis, and encephalitis. The pursuit of upgrading informal areas and the implementation of social policies targeting the poorest are likely to accelerate the mortality decline in Ouagadougou overall.

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A burgeoning demographic literature documents the exceedingly high rates at which contemporary cohorts of women across the Global South experience the death of their children-even amid historic declines in child mortality. Yet, the patterning of maternal bereavement remains underinvestigated, as does the extent to which it replicates across generations of the same family. To that end, we ask: Are the surviving daughters of bereaved mothers more likely to eventually experience maternal bereavement? How does the intergenerational clustering of maternal bereavement vary across countries and cohorts? To answer these questions, we make use of Demographic and Health Survey Program data from 50 low- and middle-income countries, encompassing data on 1.05 million women and their mothers spanning three decadal birth cohorts. Descriptive results demonstrate that maternal bereavement is increasingly patterned intergenerationally across cohorts, with most women experiencing the same fate as their mothers. Multivariable hazard models further show that, on average, women whose mothers were maternally bereaved have significantly increased odds of losing a child themselves. In most countries, the association is stable across cohorts; however, in select countries, the risk associated with having a bereaved mother is shrinking among more recent birth cohorts.

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Globally, 4.9 million under-five deaths occurred before celebrating their fifth birthday. Four in five under-five deaths were recorded in sub-Saharan Africa and Southern Asia. Childhood diarrhea is one of the leading causes of death and is accountable for killing around 443,832 children every year. Despite healthcare utilization for childhood diarrhea has a significant effect on the reduction of childhood mortality and morbidity, most children die due to delays in seeking healthcare. Therefore, this study aimed to assess healthcare utilization for childhood diarrhea in the top high under-five mortality countries. This study used secondary data from 2013/14 to 2019 demographic and health surveys of 4 top high under-five mortality countries. A total weighted sample of 7254 mothers of under-five children was included. A multilevel binary logistic regression was employed to identify the associated factors of healthcare utilization for childhood diarrhea. The statistical significance was declared at a p-value less than 0.05 with a 95% confidence interval. The overall magnitude of healthcare utilization for childhood diarrhea in the top high under-five mortality countries was 58.40% (95% CI 57.26%, 59.53%). Partner/husband educational status, household wealth index, media exposure, information about oral rehydration, and place of delivery were the positive while the number of living children were the negative predictors of healthcare utilization for childhood diarrhea in top high under-five mortality countries. Besides, living in different countries compared to Guinea was also an associated factor for healthcare utilization for childhood diarrhea. More than four in ten children didn't receive health care for childhood diarrhea in top high under-five mortality countries. Thus, to increase healthcare utilization for childhood diarrhea, health managers and policymakers should develop strategies to improve the household wealth status for those with poor household wealth index. The decision-makers and program planners should also work on media exposure and increase access to education. Further research including the perceived severity of illness and ORS knowledge-related factors of healthcare utilization for childhood diarrhea should also be considered by other researchers.

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Africa bears the greatest brunt of under-five mortality in the world. Among the major approaches used in tackling under-five deaths is childhood immunisation. While income is regarded as a major determinant of demand for child health inputs including immunisation, the existing studies are microlevel analyses, which do not provide a bigger picture of how an enhancement in economic growth (aggregate income) contributes to the utilisation of childhood immunisation in an economy as a whole. Since Africa has experienced economic growth in the recent decades, this study aims to fill this gap in the literature by examining the contribution of economic growth to the utilisation of childhood immunisation in selected African countries. The study uses a panel design involving data on 50 African countries over the period, 2002 to 2019. Utilisation of DPT (diphtheria, pertussis (or whooping cough) and tetanus) and measles immunisation are used as proxies for childhood immunisation while the system Generalised Method of Moments (GMM) regression is used as the estimation technique. We find economic growth to have a positive significant effect on the utilisation of childhood immunisation. Thus, it is imperative to intensify the enablers of economic growth in Africa in order to increase the utilisation of childhood immunisation.

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The long-term trends in maternal and child health (MCH) in China and the national-level factors that may be associated with these changes have been poorly explored. This study aimed to assess trends in MCH indicators nationally and separately in urban and rural areas and the impact of public policies over a 30‒year period. An ecological study was conducted using data on neonatal mortality rate (NMR), infant mortality rate (IMR), under-five mortality rate (U5MR), and maternal mortality ratio (MMR) nationally and separately in urban and rural areas in China from 1991 to 2020. Joinpoint regression models were used to estimate the annual percentage changes (APC), average annual percentage changes (AAPC) with 95% confidence intervals (CIs), and mortality differences between urban and rural areas. From 1991 to 2020, maternal and child mortalities in China gradually declined (national AAPC [95% CI]: NMRs - 7.7% [- 8.6%, - 6.8%], IMRs - 7.5% [- 8.4%, - 6.6%], U5MRs - 7.5% [- 8.5%, - 6.5%], MMRs - 5.0% [- 5.7%, - 4.4%]). However, the rate of decline nationally in child mortality slowed after 2005, and in maternal mortality after 2013. For all indicators, the decline in mortality was greater in rural areas than in urban areas. The AAPCs in rate differences between rural and urban areas were - 8.5% for NMRs, - 8.6% for IMRs, - 7.7% for U5MRs, and - 9.6% for MMRs. The AAPCs in rate ratios (rural vs. urban) were - 1.2 for NMRs, - 2.1 for IMRs, - 1.7 for U5MRs, and - 1.9 for MMRs. After 2010, urban‒rural disparity in MMR did not diminish and in NMR, IMR, and U5MR, it gradually narrowed but persisted. MCH indicators have declined at the national level as well as separately in urban and rural areas but may have reached a plateau. Urban‒rural disparities in MCH indicators have narrowed but still exist. Regular analyses of temporal trends in MCH are necessary to assess the effectiveness of measures for timely adjustments.

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Zimbabwe has implemented universal antenatal care (ANC) policies since 1980 that have significantly contributed to improvements in ANC access and early childhood mortality rates. However, Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), two of Zimbabwe's main sources of health data and evidence, often provide seemingly different estimates of ANC coverage and under-five mortality rates. This creates confusion that can result in disparate policies and practices, with potential negative impacts on mother and child health in Zimbabwe. We conducted a comparability analysis of multiple DHS and MICS datasets to enhance the understanding of point estimates, temporal changes, rural-urban differences and reliability of estimates of ANC coverage and neonatal, infant and under-five mortality rates (NMR, IMR and U5MR, separately) from 2009 to 2019 in Zimbabwe. Our two samples z-tests revealed that both DHS and MICS indicated significant increases in ANC coverage and declines in IMR and U5MR but only from 2009 to 2015. NMR neither increased nor declined from 2009 to 2019. Rural-urban differences were significant for ANC coverage (2009-15 only) but not for NMR, IMR and U5MR. We found that there is a need for more precise DHS and MICS estimates of urban ANC coverage and all estimates of NMR, IMR and U5MR, and that shorter recall periods provide more reliable estimates of ANC coverage in Zimbabwe. Our findings represent new interpretations and clearer insights into progress and gaps around ANC coverage and under-five mortality rates that can inform the development, implementation, monitoring and evaluation of policy and practice responses and further research in Zimbabwe.

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BACKGROUND: Many studies have been conducted on under-five mortality in India and most of them focused on the associations between individual-level factors and under-five mortality risks. On the contrary, only a scarce number of literatures talked about contextual level effect on under-five mortality. Hence, it is very important to have thorough study of under-five mortality at various levels. This can be done by applying multilevel analysis, a method that assesses both fixed and random effects in a single model. The multilevel analysis allows extracting the influence of individual and community characteristics on under-five mortality. Hence, this study would contribute substantially in understanding the under-five mortality from a different perspective. METHOD: The study used data from the Demographic and Health Survey (DHS) acquired in India, i.e., the fourth round of National Family and Health Survey (2015-16). It is a nationally representative repeated cross-sectional data. Multilevel Parametric Survival Model (MPSM) was employed to assess the influence of contextual correlates on the outcome. The assumption behind this study is that 'individuals' (i.e., level-1) are nested within 'districts' (i.e., level-2), and districts are enclosed within 'states' (i.e., level-3). This suggests that people have varying health conditions, residing in dissimilar communities with different characteristics. RESULTS: Highest under-five mortality i.e., 3.85% are happening among those women whose birth interval is less than two years. In case of parity, around 4% under-five mortality is among women with Third and above order parity. Further, findings from the full model is that ICC values of 1.17 and 0.65% are the correlation of the likelihood of having under-five mortality risk among people residing in the state and district communities, respectively. Besides, the risk of dying was increased alarmingly in the first year of life and slowly to aged 3 years and then it remains steady. CONCLUSION: This study has revealed that both aspects viz. individual and contextual effect of the community are necessary to address the importance variations in under-five mortality in India. In order to ensure substantial reduction in under-five mortality, findings of the study support some policy initiatives that involves the need to think beyond individual level effects and considering contextual characteristics.

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BACKGROUND: Access to health care remains suboptimal in low- and middle-income countries (LMICs) and continues to hinder survival in early childhood. We systematically assessed the association between problems accessing health care (PAHC) and under-five mortality (U5M). METHODS: Child mortality data on 724 335 livebirths came from the latest Demographic and Health Surveys of 50 LMICs (2013-2021). Reasons for PAHC were classified into three domains: 'money needed for treatment' (economic), 'distance to health facility' (physical), 'getting permission' or 'not wanting to go alone' (socio-cultural). Multivariable logistic regression was used to estimate the association between PAHC (any and by each type) and U5M. RESULTS: In our pooled sample, 47.3 children per 1000 livebirths died before age of 5, and 57.1% reported having experienced PAHC (ranging from 45.3% in Europe & Central Asia to 72.7% in Latin America & Caribbean). Children with any PAHC had higher odds of U5M (OR: 1.05, 95% CI: 1.02, 1.09), and this association was especially significant in sub-Saharan Africa. Of different domains of PAHC, socio-cultural PAHC was found to be most significant. CONCLUSIONS: Access to health care in LMICs needs to be improved by expanding health care coverage, building health facilities, and focusing more on context-specific socio-cultural barriers.

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BACKGROUND: The United Nations (UN) Sustainable Development Goal - 3.2 aims to eliminate all preventable under-five mortality rate (U5MR). In China, government have made efforts to provide maternal health services and reduce U5MR. Hence, we aimed to explore maternal health service utilization in relation to U5MR in China and its provinces in 1990-2017. METHODS: We obtained data from Global Burden of Disease 2017, China Health Statistics Yearbook, China Statistical Yearbook, and Human Development Report China Special Edition. The trend of U5MR in each province of China from 1990 to 2017 was analyzed using Joinpoint Regression model. We measured the inequities in maternal health services using HEAT Plus, a health inequity measurement tool developed by the UN. The generalized estimating equation model was used to explore the association between maternal health service utilization (including prenatal screening, hospital delivery and postpartum visits) and U5MR. RESULTS: First, in China, the U5MR per 1000 live births decreased from 50 in 1990 to 12 in 2017 and the average annual percentage change (AAPC) was - 5.2 (p < 0.05). Secondly, China had a high maternal health service utilization in 2017, with 96.5% for prenatal visits, 99.9% for hospital delivery, and 94% for postnatal visits. Inequity in maternal health services between provinces is declining, with hospital delivery rate showing the greatest decrease (SII, 14.01 to 1.87, 2010 to 2017). Third, an increase in the rate of hospital delivery rate can significantly reduce U5MR (OR 0.991, 95%CI 0.987 to 0.995). Postpartum visits rate with a one-year lag can reduce U5MR (OR 0.993, 95%CI 0.987 to 0.999). However, prenatal screening rate did not have a significant effect on U5MR. CONCLUSION: The decline in U5MR in China was associated with hospital delivery and postpartum visits. The design and implementation of maternal health services may provide references to other low-income and middle-income countries.

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The aim of this study is to examine the relationship between health expenditure, institutional quality, and under-five mortality rates in sub-Saharan African countries. Specifically, the study seeks to explore the mediating role of institutional quality in this relationship, focusing on understanding how variations in healthcare spending and institutional frameworks impact child health outcomes. By examining these dynamics, the study aims to provide valuable insights that can inform evidence-based policy interventions to reduce under-five mortality and improve child health outcomes in the region. Utilizing data spanning the years 2000 to 2021 from 46 sub-Saharan African countries, this study employs a systems GMM model to explore the intricate relationship between health expenditure and under-five mortality rates (U5MRs), with a particular focus on the mediating role of institutional quality. The findings reveal that the quality of institutions significantly influences the impact of health expenditures on the U5MR. Strong institutional quality enhances the effectiveness of health expenditure in improving child health outcomes, particularly concerning the allocation of external health funds. Conversely, poor institutional quality amplifies the positive impact of domestic private and out-of-pocket health expenditures on the U5MR, as these serve as coping mechanisms in the absence of robust public healthcare systems. This research emphasizes the need for strategies that increase health expenditure and prioritize institutional strengthening to ensure efficient resource allocation and healthcare system management, thereby reducing under-five mortality rates. Furthermore, it underscores the importance of policies that minimize reliance on private and out-of-pocket health expenditures, which can lead to financial burdens and worsened health outcomes. Sub-Saharan African countries can make significant strides toward improving child survival and overall public health by addressing these issues.

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The under-five age group is a crucial time for development because children's quick mental, physical, and socio-emotional aspects serve as the "building blocks" for their future development. The issue of child health is multifaceted, with certain regions, especially developing nations, experiencing an alarming rise in under-five children morbidity and mortality rates. Progress in reducing these rates in developing countries lags behind that of developed nations. Disparities in children's survival rates are pronounced worldwide, with developing nations bearing a disproportionate burden. Key contributors to child fatalities include malnutrition, respiratory infections, diarrheal diseases, measles, malaria, and neonatal complications. Extensive research utilizing prominent databases like PubMed and Google Scholar has been undertaken to explore this topic. Vaccination, adequate home care, access to medical services, and improved dietary practices emerge as crucial strategies for preventing many child fatalities. This review aims to delve into the underlying causes of illnesses and deaths among children under the age of five in developing nations.

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Under-five (U5M) is one of the most significant and sensitive measures of the community's health. Children who live in rural areas are more likely than those who live in urban areas to die before the age of five. Therefore, the study aimed to assess the Survival status of under-five mortality and its determinants in rural Ethiopia. The 2019 Ethiopia Mini Demographic and Health Survey was used in this study as a secondary source (EMDHS). A total of 4426 weighted under-five children were included in the study. To determine survival time and identify predictors of death among children under the age of five, the Cox's gamma shared frailty model and the Kaplan Meier model, respectively, were used. An adjusted Hazard Ratio (AHR) along with a 95% Confidence Interval (CI) were used to measure the size and direction of the association. The Study showed that in rural Ethiopia, 6.03% of children died before celebrating their first birthday. The median age of under-five mortality in rural Ethiopia was estimated to be 29 Months. The hazard of death among under-five children and those who had given birth to two children in the last five years was 4.99 times less likely to be at risk of dying than those who had given birth to one Child in the previous five years (AHR 4.99, 95% CI 2.97, 8.83). The Study Concluded that under-five mortality remained high in rural Ethiopia. In the final model, the Age of Mothers, Sex of Household, Breastfeeding, Types of Birth, Sex of Child, Educational Level of Mothers, Wealth Index, Child ever born, Marital Status, and Water Source were significant predictors of under-five mortality. Twins and children who are not breastfed should receive additional attention, along with improving water resources for households and mothers income.

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BACKGROUND: Under-five mortality remains a significant public health issue in developing countries. This study aimed to assess the effectiveness of various machine learning algorithms in predicting under-five mortality in Nigeria and identify the most relevant predictors. METHODS: The study used nationally representative data from the 2018 Nigeria Demographic and Health Survey. The study evaluated the performance of the machine learning models such as the artificial neural network, k-nearest neighbourhood, Support Vector Machine, Naïve Bayes, Random Forest, and Logistic Regression using the true positive rate, false positive rate, accuracy, precision, F-measure, Matthew's correlation coefficient, and the Area Under the Receiver Operating Characteristics. RESULTS: The study found that machine learning models can accurately predict under-five mortality, with the Random Forest and Artificial Neural Network algorithms emerging as the best models, both achieving an accuracy of 89.47% and an AUROC of 96%. The results show that under-five mortality rates vary significantly across different characteristics, with wealth index, maternal education, antenatal visits, place of delivery, employment status of the woman, number of children ever born, and region found to be the top determinants of under-five mortality in Nigeria. CONCLUSIONS: The findings suggest that machine learning models can be useful in predicting U5M in Nigeria with high accuracy. The study emphasizes the importance of addressing social, economic, and demographic disparities among the population in Nigeria. The study's findings can inform policymakers and health workers about developing targeted interventions to reduce under-five mortality in Nigeria.

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Background: Rate and pattern of under-five mortality is a reflection of a society's healthcare system and quality of life. This study is aimed at reviewing the causes of infants and under-five morbidity and mortality in Calabar, Southern Nigeria. Methods: This study used retrospective descriptive cross-sectional design. We did a retrospective collation of data on under-five morbidity and mortality from 2012 to 2017 of under-five patients admitted or died while in admission in University of Calabar Teaching Hospital. The causes of morbidity and mortality were reported based on International Classification of Diseases 10 (ICD-10). The morbidity, mortality and fatality rates were computed. Results: A total of 11,416 under-five admissions and 391 deaths were recorded within the study period giving a fatality rate of 3.4%. Age 1-4 years category represented 50.5% of the admissions while infants (<1 year) constitute majority of the deaths (64.7%). There were 5652 infant admissions and 253 infant deaths giving fatality rate of 4.5% within the study period. Males constituted majority (55.8%) of under-five morbidity whereas females constituted majority (51.2%) of the deaths. Conditions originating from perinatal period; and infectious and parasitic diseases were the leading broad cause of under-five mortality. Specific disease analysis showed sepsis/septicemia; congenital infectious and parasitic diseases; slow fetal growth, malnutrition and short gestation as the chief causes of both infant and under-five mortality. Conclusion: The leading causes of under-five deaths in the studied population are amenable. Improved healthcare and antenatal will be of immense benefit.

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A thorough examination of context, and how it influences implementation of evidence-based interventions, is a promising strategy for enhancing child survival initiatives. Spreading approaches that are identified as drivers of successful reduction in under-five mortality from 'exemplar' countries could be pivotal in leading to reductions in other settings facing stagnant mortality rates, in particular for low- and middle-income countries with high disease burden and insufficient programmatic capacity to effectively implement evidence-based interventions at scale. Yet there remains a lack of robust analytic methods to accurately assess mortality and describe the drivers of interventions' implementation success at both national and subnational levels. The field of implementation science and its defining targets and tools is well positioned to address this knowledge gap by integrating qualitative and quantitative research methods into an adaptable evaluation framework that can be tailored to meet the specific needs across varying country contexts. These tools enhance the measurement of population health outcomes and provide crucial evidence on implementation barriers and facilitators that can inform policies that can be adjusted for diverse contexts. This commentary aims to emphasize the role of implementation research in understanding how exemplar countries achieved significant improvements in child survival and in identifying replicable lessons for other settings. Ultimately, all manuscripts underscore the relevance of implementation research in bolstering the reduction of under-five mortality.

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BACKGROUND: Strengthening healthcare systems is a practical approach to enhance healthcare delivery and services. Although there has been a rise in the number of health systems strengthening (HSS) interventions in sub-Saharan Africa (SSA), there is limited evidence on the causal effect of these activities on child survival. Furthermore, the findings reported so far have been varied, and how they relate to each other remains unclear. This systematic review study aims to assess all available evidence to understand the impact of HSS activities on child survival in SSA. METHODS: We developed a search strategy to retrieve all relevant studies from electronic databases such as PubMed/MEDLINE, Web of Science, and African Journals Online. We will use a combination of search terms such as "under-five mortality," "child mortality," "infant mortality," "neonatal mortality," "child survival," and "health systems strengthening." The review will include studies that establish a causal relationship between HSS interventions and child survival. This will include studies with designs such as randomized controlled trials and quasi-experimental and methods like difference-in-difference. Two reviewers will independently screen all citations, abstracts, and full-text data and a third reviewer will act as a tiebreaker in case of disagreements. The primary outcome of interest is the impact of HSS activities on under-five survival. We will evaluate the quality of each study using the Bradford Hill criteria for causation. DISCUSSION: Our systematic review will identify and evaluate all relevant evidence that establishes a causal relationship between HSS activities and the survival of children under five years in SSA. The review's findings regarding the impact of HSS activities on child survival could be of significant interest to the donor community and policy actors in the region. We also anticipate that the review's conclusions could serve as a valuable guide for the development of future health system interventions and strategies in SSA. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022333913.

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While social determinants of health have been perennially linked to child survival in resource-limited countries, the precise and tested pathways to effect are not clearly understood. The objective of this study was therefore to identify the critical pathways as posited a priori in a model through which social factors (at maternal, household, and community levels) determine neonatal, infant, and under-five mortalities in Nigeria. Using a novel analytic approach (hierarchical path modelling for predicting accelerated failure time) to estimate (in)direct and total effects of social determinants of child survival, we analysed 30,960 live births (weighted data for representativeness), obtained from the 2016/2017 Nigeria Multiple Indicator Cluster Survey. There were three outcome variables: time until occurrence of neonatal, infant, and under-five mortalities. The independent variables were layered factors related to child, maternal, household and community. Geographical region, rurality of residence, infrastructural development, maternal education, contraceptive use, marital status, and maternal age at birth were found to operate more indirectly on neonatal, infant, and under-five survival. Child survival is due to direct effects of child's sex (female), gestational type (singleton), birth spacing (children whose mothers delivered at least two years apart), and maternal age at delivery (20-34 years). According to the path coefficients, the indirect effects of geographical regions are the most influential determinants of child survival, accounting for 30% (neonatal), 37.1% (infant) and 39.9% (under-five) of the total effects. This study offers comprehensive set of factors, and linked pathways, at the maternal, household, and community levels that are associated with child survival in Nigeria. To accelerate progress towards Sustainable Development Goal targets for child survival and reduce geographical inequities, stakeholders should implement more impactful policies that promote maternal education, contraceptive use and improve living conditions of women (especially in rural areas of northern Nigeria). Future research should focus on identifying the most effective interventions for addressing these social determinants of child survival in Nigeria.

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