UNDERSTANDING THE DETERMINANTS OF DECLINING UNDER-FIVE MORTALITY IN NIGERIA BETWEEN 2008 AND 2013 by Chike William Nwangwu, MBBS, MPH A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Public Health Baltimore, Maryland December, 2017 © 2017 Chike W. Nwangwu All Rights Reserved ABSTRACT Under-five mortality remains high in Nigeria. The country did not meet Millennium Development Goal 4. Knowledge of the determinants of under-five mortality are essential for the design of intervention programs that reduce under-five mortality. In countries with high mortality, universal coverage of key health interventions e.g. newborn care, child nutrition, vaccines; management of childhood illnesses could reduce the number of under-five deaths by more than half. Wide variations exist in the coverage of these interventions across geo-political zones in Nigeria. Determining and prioritizing the interventions driving the decline in child mortality will inform Nigeria as it drives towards the Sustainable Development Goals. This thesis is a retrospective analysis of the different nationally representative household surveys conducted between 2008 and 2013 in Nigeria. Univariate and multivariate logistic regression models were used to explore the effects of selected socio-economic variables on under-five mortality. The Lives Saved Tool was used to determine the additional lives of under-five children saved between 2008 and 2013 based on changes in coverage of health interventions both at the national and subnational levels. The missed opportunity tool was then used to identify interventions with the highest impact for under-five children in each geo-political zone in Nigeria. This study revealed rural-urban and geo-political zone differences in under-five mortality. There were also more deaths among children of mothers with less than secondary education and children from the poor wealth quintiles. A total of 370,000 additional lives of under-five children were saved between 2008 and 2013 with 50 ii percent attributable to household protection from malaria and 25 percent attributable to Vitamin A supplementation. 61 percent of the additional lives saved were from the North-East and North-West zones. ACTs for the treatment of malaria has the potential to avert the most number of deaths across all geo-political zones. This study shows that while progress has been made to some extent, socioeconomic factors continue to play a role in under-five mortality in Nigeria, while significant improvements need to be made to drive the uptake of health interventions in the country in order to achieve the SDGs. Readers: Dr. Bill Brieger (advisor), Dr. Henry Mosley, Dr. Kenrad Nelson, Dr. Neff Walker, Dr. Olakunle Alonge iii ACKNOWLEDGEMENT I am forever grateful to God who made this possible. I wish to also acknowledge Dr. Bill Brieger, my advisor, whose guidance and support enabled me to pull through. I would also like to acknowledge the other members of my thesis committee: Dr. Neff Walker; the LiST plays a vital role in my thesis and this wouldn’t have been possible without your support and guidance, Dr. Kunle Alonge; your encouragement and directions made this possible and you continue to inspire me. I am also indebted to Dr. Ingrid Frieberg who introduced me to the Lives Saved Tool and set the path for me. I would like to extend my immense gratitude to Dr. Kelechi Ohiri and Health Strategy and Delivery Foundation. That I was able to finish this work was through their support. I would also like to acknowledge the Federal Ministry of Health Nigeria where all these began. I would like to specially thank my parents and family. My late father, Barr. Bernard Nwangwu for setting me on the right path to success. He taught me to always stand out because you can. My mother, Mrs. Joe Nwangwu whose intelligence and courage never ceases to amaze me. You taught me to always aim to be best and to chase my dreams. My elder siblings and their families; Kinglsey, Obinna, Uzo and Oge; I am always trying to catch up. Your love and support drives me. Special thanks to my brother-in-law; Mr. Calistus Ubajaka, your support set me on this path. My thanks also go to my parents-in-law, Mr and Mrs. Joe Ani, for their prayers and well wishes. I have reserved my final thanks for the love of my life; my wife, Kene and my son Ifechukwu who are my greatest supporter and motivation. Your love and happiness gave me strength and kept me grounded in reality. We did this together. iv Table of Contents ABSTRACT ................................................................................................................................... ii ACKNOWLEDGEMENT .......................................................................................................... iv List of Tables .............................................................................................................................. vii List of Figures ........................................................................................................................... viii INTRODUCTION ........................................................................................................................ 1 BACKGROUND ........................................................................................................................... 4 CHILD MORTALITY .............................................................................................................. 4 CAUSES OF UNDER-FIVE DEATHS AND GLOBAL TRENDS OF UNDER-FIVE MORTALITY RATE ................................................................................................................ 7 NIGERIA CONTEXT ............................................................................................................ 10 HISTORY AND GEOGRAPHY: ..................................................................................... 10 SUBDIVISIONS: ............................................................................................................... 12 DEMOGRAPHY ................................................................................................................. 12 ECONOMY .............................................................................................................................. 15 HEALTH STATUS, SECTOR AND SERVICES............................................................. 16 UNDER-FIVE MORTALITY RATE IN NIGERIA ......................................................... 17 CAUSES OF UNDER-FIVE MORTALITY IN NIGERIA ............................................ 19 NIGERIA’S EFFORTS AT REDUCING UNDER-FIVE MORTALITY ..................... 19 RESEARCH OBJECTIVES ..................................................................................................... 23 OBJECTIVE 1 ........................................................................................................................ 23 OBJECTIVE 2 ........................................................................................................................ 24 OBJECTIVE 3 ........................................................................................................................ 24 CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW .................................... 26 SOCIOECONOMIC DETERMINANTS OF UNDER-FIVE MORTALITY .............. 26 LIVES SAVED TOOL ESTIMATION ............................................................................... 28 PAPER 1: Effects of socio-economic determinants on under five mortality in Nigeria ....................................................................................................................................................... 33 ABSTRACT: ............................................................................................................................ 33 BACKGROUND ..................................................................................................................... 34 METHODS .............................................................................................................................. 39 RESULTS ................................................................................................................................ 43 v DISCUSSION ......................................................................................................................... 49 CONCLUSION ....................................................................................................................... 52 PAPER 2: Using LiST to understand the significant interventions in reduction of under-five mortality in Nigeria: national and sub-national analysis ............................ 53 ABSTRACT: ............................................................................................................................ 53 INTRODUCTION .................................................................................................................. 55 METHODS .............................................................................................................................. 61 RESULTS ................................................................................................................................ 72 DISCUSSION ......................................................................................................................... 77 CONCLUSION ....................................................................................................................... 82 PAPER 3: Using the