The relationship between healthcare professionals and under-five mortality: the mediating role of environmental hygiene and the moderating effect of maternal education

Prior researchers have established the association between Health Human Resources (HHR) and children’s healthcare outcomes. However, there has been limited focus on the distribution of both professional and non-professional healthcare workers, as well as their impact on under-five mortality, in the context of environmental hygiene, along with the influence of maternal education as a moderator. Our research applied the data from the Pakistan Demographic and Health Survey (PDHS) 2018, having observations (N = 8022). The outcome comprises the risk of a child’s death before 0–59 months. A multivariate examination was conducted using Cox proportional hazards and regression models. The approximation of under-five deaths was achieved using generalized structural equation modeling (GSEM) and the 5000-bootstrap technique. A total of 4.09% of children died. The normal distribution of the healthcare workforce was professionals (83.34%), non-professionals (1.41%), and those who received no care (15.24%). The average maternal age and education are 29.55 and 4.52 years, respectively. The combined score for environmental hygiene was −0.00 (SD = 1.23). Multivariate regression results show that a one-unit increase in healthcare professional healthcare providers was associated with a 73% lower likelihood of under-five mortality (p < 0.01). Moreover, a one-unit increase in the number of professional healthcare providers was associated with a 30% increase in the likelihood of having a high environmental hygiene score (p < 0.001). The interaction of maternal education in the relationship between environmental hygiene and under-five mortality significantly contributes to the model’s predictive power, with 0.77 at (p < 0.001). Furthermore, professional healthcare providers were positively and significantly associated with under-five mortality (exp(β) = −0.178, 95% BCCI = −0.3585, −0.0017; P < 0.01). Additionally, a reduction in maternal education is associated with an increase in under-five deaths (exp(β) = 0.178, 95% BCCI: 0.0876, 0.2687; P < 0.001). Our findings suggest that environmental hygiene and maternal education play a critical role in reducing overall under-five deaths. Enhancing maternal and household head education, as well as improving environmental hygiene (access to clean water, toilets, and cooking fuel), will aid in addressing the issue of under-five mortality.