Impact of multisectoral health determinants on child mortality 1980–2010: An analysis by country baseline mortality

IntroductionSome health determinants require relatively stronger health system capacity and socioeconomic development than others to impact child mortality. Few quantitative analyses have analyzed how the impact of health determinants varies by mortality level.Methods149 low- and middle-income countries were stratified into high, moderate, low, and very low baseline levels of child mortality in 1990. Data for 52 health determinants were collected for these countries for 1980–2010. To quantify how changes in health determinants were associated with mortality decline, univariable and multivariable regression models were constructed. An advanced statistical technique that is new for child mortality analyses—MM-estimation with first differences and country clustering—controlled for outliers, fixed effects, and variation across decades.FindingsSome health determinants (immunizations, education) were consistently associated with child mortality reduction across all mortality levels. Others (staff availability, skilled birth attendance, fertility, water and sanitation) were associated with child mortality reduction mainly in low or very low mortality settings. The findings indicate that the impact of some health determinants on child mortality was only apparent with stronger health systems, public infrastructure and levels of socioeconomic development, whereas the impact of other determinants was apparent at all stages of development. Multisectoral progress was essential to mortality reduction at all baseline mortality levels.ConclusionPolicy-makers can use such analyses to direct investments in health and non-health sectors and to set five-year child mortality targets appropriate for their baseline mortality levels and local context.

引言某些健康决定因素相较于其他因素，需要更强大的卫生系统能力和社会经济水平才能对儿童死亡率产生显著影响。目前，关于健康决定因素对死亡率影响差异的定量分析尚显不足。方法对1990年的149个低收入和中等收入国家，根据儿童死亡率水平将其分为高、中、低和极低四个基线等级。收集了这些国家1980年至2010年间52个健康决定因素的数据。为了量化健康决定因素的变化与死亡率下降之间的关系，构建了单变量和多变量回归模型。在儿童死亡率分析中引入了一种先进的统计技术——MM估计，结合一阶差分和跨国聚类，以控制异常值、固定效应以及跨世纪的变动。发现某些健康决定因素（如疫苗接种、教育）与儿童死亡率降低在所有死亡率水平上均呈一致性相关。其他因素（如医务人员配备、助产士服务、生育率、水资源和卫生设施）主要在低死亡率或极低死亡率的环境中与儿童死亡率降低相关。研究结果指出，某些健康决定因素对儿童死亡率的影响仅在卫生系统、公共基础设施和社会经济发展水平较强时才显现，而其他决定因素的影响则在发展的各个阶段均有所体现。在所有基线死亡率水平上，多部门进步对于死亡率降低至关重要。结论政策制定者可以利用此类分析指导卫生和非卫生部门的投资，并根据其基线死亡率水平和当地环境设定适宜的五年年儿童死亡率目标。