Tackling the Main Causes of Child Mortality in Developing Countries

Evidence from Non-clinical Interventions

30 October 2013

Miguel Niño-Zarazúa

Children have been at the centre of recent global efforts to improve well-being conditions in developing countries. Since 1990—the year when Millennium Development Goal 4 (MDG4) began to be monitored, and which called for a two-thirds reduction in the under-five mortality rates by 2015—developing countries have made important strides towards reducing child mortality. Over the last 20 years, child mortality rates have fallen considerably, from 87 deaths per 1,000 live births to 51. In absolute terms, this means a reduction from 12 to 6.9 million in the number of children dying every year (Unicef 2012).

© UN Photo/David OhanaDespite this remarkable achievement, more than 19,000 children still die every day, most of them of preventable and treatable infectious diseases. Recent estimates suggest that nearly 80 per cent of under-five deaths occur in sub-Saharan Africa and South Asia, and about half of the deaths, in one of five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China (Black et al. 2010). India and Nigeria alone account for more than one-third of  child deaths worldwide. The fact that a large proportion of child deaths are caused by preventable and treatable infectious diseases is symptomatic of dysfunctional health systems in the developing world.

Assessing ‘what works’ in tackling the main cause of child morbidity and mortality is thus fundamental for effective policy actions.

Acute respiratory infections, notably pneumonia, and diarrhoeal diseases are the first and second leading causes of death among young children, respectively. Pneumonia and diarrhoea alone lead to 1.6 and 1.3 million child deaths per year respectively, amounting to almost 3 million deaths in total. Young children are particularly vulnerable to the negative health implications of diarrhoeal infections, including poor nutritional absorption, dehydration, and susceptibility to infections. Prolonged periods of diarrhoea can cause malnutrition and micronutrient deficiencies that increase the risk of contracting pneumonia while impairing children’s growth and development (World Health Organization 2003). Early malnutrition is also linked to poor cognitive functioning and learning capacity, which in the longer term leads to lower labour productivity, and poverty (Grosse and Roy 2008; Hoddinott et al. 2008).

The good news is that there is evidence of a decline in incidence and mortality rates—due to diarrhoea and pneumonia—among young children in developing countries.

In Africa, where the highest numbers of deaths per 1,000 live births are registered among children aged 5 and younger, there has been remarkable reductions in mortality rates due to diarrhoreal diseases and acute lower respiratory infections (see Figures 1 and 2). Much of the reduction in child mortality rates have been attributed to, and analysed in the context of, clinical interventions, particularty those devoted to increase the distribution of rotavirus vaccines, zinc supplements and oral rehydration salts solutions to prevent and treat diahorrea, and antibiotics and immunization against haemophilus influenza type B, pneumococcus, measles and whooping cough (pertussis) to treat and prevent pneumonia. However, much less is known about the effectiveness of non-clinical interventions such as education and training programmes, and/or improved sanitation, water supply, water quality, and hospital equipment. 

Figure 1: Deaths per 1 000 live births among children aged < 5 years due to diarrhoeal diseases
Figure 1: Deaths per 1 000 live births among children aged < 5 years due to diarrhoeal diseases Source: Global Health Observatory of the World Health Organization
Source: Global Health Observatory of the World Health Organization

Figure 2: Deaths per 1 000 live births among children aged < 5 years due to acute lower respiratory infections
Figure 2: Deaths per 1 000 live births among children aged < 5 years due to acute lower respiratory infections Source: Global Health Observatory of the World Health Organization
Source: Global Health Observatory of the World Health Organization.

I recently conducted with Maureen Seguin what  is, to our knowledge, the first systematic review on non-clinical non-clinical interventions for preventable and treatable childhood diseases in developing countries. We focused on small children, notably neonatal, and the health interventions that target that population, as the share of under-5 mortality rates occurring at a very early age is increasing worldwide. We focus on non-clinical interventions that both complement and serve as channels through which preventive clinical devices such as vaccine immunizations, and treatment innovations such as zinc supplements, oral rehydration salts, and antibiotic treatment of pneumonia, are enhanced.

Overall, we have identified two general policy strategies with regard to non-clinical interventions against diarrhoeal and respiratory diseases: first, policies that aim at enhancing supply-side capabilities in the area of material resources and/or infrastructure. Second, policies that aim at promoting behavioural change, primarily through information and education.

Enhancing supply-side capabilities

A number of interventions aim at improving the allocation of resources and/or infrastructure. These include include sanitation and hospital upgrades, and improving water supply, its distribution, and/or quality. These types of non-clinical interventions are depicted in the first column on the left-hand side of Figure 3, and are often enhanced by being combined with other policies.

Examples of improved water distribution include the installation of hand pumps in communities, or connecting households to municipal water sources. Water quality interventions to remove microbial contaminants—either at source or in the household—are frequently paired with the provision of improved water storage vessels. A large number of interventions involve sanitation enhancements combined with hygiene education or promotion aspects; for instance, policies that combined handwashing, hygiene education, and soap provision.

Promoting behavioural change

The promotion of behavioural changes represents another major strategy to reduce child mortality and morbidity in developing countries. These types of non-clinical interventions are depicted in the second cluster of policies, located on the left-hand side of Figure 3. The targeted population of these policies are disease-related: interventions focussing on diarrhoea are commonly aimed at mothers of young children, while those focussinged on respiratory infections often contained health worker training and education components.

Several studies combined handwashing promotion along with instructions regarding animal and child faeces. Policy strategies varied by target group, but included group discussion, demonstrations, participatory action learning exercises, flash card displays, folk songs, role playing, a comic story session, and games.

Interventions focused on respiratory infections typically include health worker training components in addition to health education for mothers. For example, community health workers are trained to detect pneumonia and the required treatment with the use of antibiotics. Policies often include strategies to educate mothers on how to recognize pneumonia and to provide appropriate supportive measures. They also emphasize the importance of timely immunization and good nutrition.

Non-clinical interventions are fundamental and complementary to recent global and national efforts to scale up preventive and treatment clinical interventions (see the right-hand side of Figure 3). In our paper we mostly focus on non-clinical interventions although both types of policies, clinical and non-clinical should be seen as an integral part of public health strategies to tackle preventable and treatable childhood diseases in developing countries.

Figure 3: Clinical and non-clinical interventions against childhood diseases in developing countries

Figure 3: Clinical and non-clinical interventions against childhood diseases in developing countries Source: Seguin and Niño-Zarazúa (2013)
Source: Seguin and Niño-Zarazúa (2013)

So, what works against preventable and treatable childhood diseases?

Overall, we find that public investment in sanitation and hygiene, water supply and quality, and the provision of medical equipment that detect symptoms of childhood diseases, along with training and education for medical workers, are effective instruments to reduce diarrhoeal diseases and acute respiratory infections. The size of policy effectiveness is heterogenous. For example, policies that target diarrhoeal incidence show a reduction rate that range from 18 to 61 per cent. This wide range of impact reflects the diverse types of interventions, and socio-economic and insituttional environments in which these interventions have been implemented.

© Ray Witlin / World BankRegarding diarrhoeal diseases, the most recent evidence show that multiple interventions (e.g. a sanitation policy coupled with water quality improvements) were not necessarily more effective than interventions with a single focus. Additional age-disaggregated research is needed to clarify whether multi-faceted policies are more effective than single-focus interventions, as applied to samples consisting of young children.

Several policies proved to be more or less effective according to age. Some interventions, including sanitation promotion among households, seem to have greater protective impact for infants since they often come into more frequent contact with surfaces including faeces-contaminated floors in and around dwellings than adults and older children. Infants and very young children also rely on others to wash their hands for them, which certainly influences the efficacy of handwashing promotion interventions.

Although almost half of deaths globally among young children occur in a handful of countries, only a third of the existing research has been conducted in one of these countries.

The results of our study show a relative dearth of research on respiratory infections, compared to those on diarrhoeal diseases: while over 30 studies were conducted on diarrhoea diseases, only seven were carried out for respiratory infections. This seems to reflect the fact that the bulk of studies on respiratory infections are focused on clinical interventions such as vaccines and antibiotics. The absence of studies on non-clinical interventions is surprising considering the burden of disease from respiratory infections in the developing world. More research is needed in this very important policy area.


Black, Robert E., et al. (2010), 'Global, regional, and national causes of child mortality in 2008: a systematic analysis ',
          The Lancet, 375, 1969-87.

Grosse, Scott D. and Roy, Kakoli (2008), 'Long-term economic effect of early childhood nutrition', The Lancet, 371 (9610),

Hoddinott, John, et al. (2008), 'Effect of a nutrition intervention during early childhood on economic productivity in
          Guatemalan adults', The Lancet, 371 (9610), 411-16.

Seguin, Maureen and Niño-Zarazúa, Miguel (2013), 'What do we know about non-clinical interventions for preventable and
           treatable childhood diseases in developing countries?', WIDER Working Paper Series, WP/2013/087 (September).

Unicef (2012), 'Levels and Trends in Child Mortality', (New York: United Nations Children's Fund).

World Health Organization (2003), 'Treatment of diarrhoea: a manual for physicians and other senior health workers',
          (Geneva: World Health Organization).

Miguel Niño-Zarazúa is a Research Fellow at UNU-WIDER

WIDERAngle newsletter
October 2013
ISSN 1238-9544

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