Social protection and the level and inequality of child mortality in 101 low- and middle-income countries: A statistical modelling analysis

Background: Expanding social protection programme is a major target of the Sustainable Development Goals. Previous studies provided evidence for the relationship of social protection programme to greater use of health services and some improved health outcomes for children. Yet, its impact on child mortality has not been clearly revealed. In this study, we examined the association between social protection programmes and child mortality.

Methods: We obtained child mortality data from 379 nationally representative surveys involving 101 low- and middle-income countries (LMICs). We included five child mortality outcomes in the study, which were neonatal mortality rate (NMR), post-neonatal mortality rate (PMR), childhood mortality rate (CMR), infant mortality rate (IMR), and under-5 mortality rate (U5MR). We extracted data on social protection programmes from multiple data sources (eg, Atlas of Social Protection Indicators of Resilience and Equity). Social protection and labour programme (SPL) was the major type of social protection we included. We also included four subtypes of SPL - social assistance, cash transfer, social insurance, and labour market protection. Both unadjusted and adjusted regressions were conducted to measure the associations between characteristics of social protection programmes and child mortality, as well as inequalities in child mortality.

Results: Among the 101 countries, the median coverage rate of SPL was 28.5%, with an interquartile range between 6.5% and 55.2%. Using the adjusted model, we found a one-percentage-point increase in SPL coverage is associated with a reduction of 0.09 (95% confidence interval (CI) = 0.04, 0.14) per 1000 live births in NMR, 0.11 (95% CI = 0.04, 0.18) in PMR, and 0.25 (95% CI = 0.11, 0.38) in CMR. Social assistance programme was the only subtype of SPL to be significantly associated with lower mortality rates. A higher SPL coverage was associated with better equity in child mortality - as the coverage of SPL increased by one percentage point, the concentration index of CMR would increase by 0.08 (95% CI = 0.03, 0.13) in the adjusted model, suggesting an improvement in equity.

Conclusions: The strong association between social protection programme and child mortality suggests that to achieve the SDG targets of universal social protection and to reduce child mortality, LMICs shall consider prioritizing the expansion of social protection programmes.