The Lancet Global Health recently published the article Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. In this blog, author Bradley Wagenaar shares insights from the study. Photo Credit: Suzanna Klaucke/Save the Children.
In Mozambique, when a child dies, chances are their death is not recorded in any official capacity. In part, this is because less than half of all children under-5 ever get birth certificates. Officially, they do not exist. If they die, in the eyes of the government, they never died because they never existed in the first place. Even if they were lucky enough to be registered, it is even less likely we will know why they died since less than seven percent of all deaths nationally are reported with their cause-of-death. What little information we do have about the causes and rates of child death come from large, infrequent, and expensive surveys, such as the Mozambican demographic and health survey where researchers physically go door-to-door and ask parents if they know of any children who died, and why.
In a recent article, a group of researchers from the Ministry of Health in Mozambique, the Mozambican National Institutes of Health, and Health Alliance International (HAI is a non-profit organization affiliated with the University of Washington, Seattle and focuses on improving public-sector health systems) used these large-scale population surveys to try to disentangle whether and which health system factors affect rates of child death in Mozambique. Since 90% of the population in Mozambique uses public-sector clinics run by the Ministry of Health that are available to everyone, usually free of charge, we focused on a few factors related to how critical health services are delivered in these facilities.
What we found was that Mozambique has made great strides in decreasing child death over the past decade – a 56% reduction from 2000 to 2010. We also found that three public-health-system factors seem to be most related to gains made in decreasing child death: (1) more women giving birth at public health facilities; (2) more qualified health workers at those facilities; and (3) ensuring there are enough public health facilities as population continues to grow.
What concerned us, however, was that these observed large decreases in the number of child deaths were not distributed equally across Mozambique. While mortality rates aggregated to the country level appear to have made these great reductions, at the provincial level (11 provinces in Mozambique, so ~2 million people per province) or district level (128 districts in Mozambique, so ~200,000 people per district), disparities in child death may actually be increasing.
There is an old adage, which appears to be borne out in some studies, that as the availability or quality of healthcare is improved, disparities in population health may increase in the short-term. This is because the people most likely to take advantage of new health care innovations are those who are more educated and already in better health. When these people access new services, their further separate themselves from the most disadvantaged; often reaching those who most need help is the hardest.
While some provinces in Mozambique showed decreases of up to 80% in neonatal mortality rate over the past decade, some provinces showed decreases as low as 5%. Even more concerning is that current designs of large-scale intermittent community surveys only allow analyses of child deaths to the provincial level in many countries. The differences in rates of death are not trivial. Comparing Provinces in Mozambique, some children are more than three times as likely to die in the first 30 days of life. Disparities in death rates across districts are likely significantly higher.
Alongside proven interventions such as investments in public-sector human resources for health, advocating for safe birth practices in health facilities, and health infrastructure improvements, urgent investments are needed in vital registration systems (births/deaths) and other ways to track district-level (or lower) health disparities. In an age of mobile technology and instant communication, the era of using community surveys to evaluate child deaths at the provincial level or higher should be over. The lack of data on health disparities or real-time statistics on child deaths impedes the development, targeting, and testing of novel innovations to save the lives of children and improve maternal and child health more generally.
We should all advocate for a world where, at the minimum, all children who tragically die before their fifth birthday have their birth, death, and cause-of-death recorded so that we can work to prevent these deaths for other unborn children.