Impact of Social Protection on Child Health in 46 LMICs: A 20-Year Study Including COVID-19

Abstract Background Under-5 mortality and malnutrition are major public health challenges in low- and middle-income countries (LMICs), worsened by crises like the COVID-19 pandemic. Evidence on social protection (SP) reducing under-5 mortality in LMICs is limited. We examined the impact of SP coverage on under-5 mortality, stunting, and wasting across 46 LMICs from 2000 to 2021. Methods 1,012 country-year observations were analyzed. Outcomes included under-5 mortality (deaths per 1,000 live births), prevalence of wasting (weight-for-height Z-scores < -2 SD), and stunting (height-for-age Z-scores < -2 SD). SP coverage was defined as the proportion of population receiving SP benefits. We used fixed-effects Poisson models with robust standard errors to estimate associations, adjusting for socioeconomic, healthcare, and gender-related variables. Interaction terms captured SP mitigation effects during COVID-19, and counterfactual scenarios estimated averted deaths. Analyses were disaggregated by sex and age groups. Findings SP prevented an estimated 3.05 million under-5 deaths overall, including 583,590 during the pandemic. Higher SP coverage was significantly associated with reductions in under-5 mortality (IRR:0.71,95%CI:0.54,0.96), stunting (IRR:0.75,95%CI:0.60,0.94), and wasting (IRR:0.87,95%CI:0.78,0.98). During the COVID-19 pandemic years, SP coverage led to additional reductions in under-5 mortality (IRR:0.68,95%CI:0.59,0.79) and stunting (IRR:0.74,95%CI:0.57,0.95). Toddler mortality (1-2 years) showed the greatest SP reduction effects (IRR:0.62,95%CI:0.41,0.95). SP coverage had slightly stronger effects on reducing female outcomes. Sensitivity and triangulation analyses validated all results. Interpretation SP coverage strongly reduced child mortality, stunting, and wasting in LMICs, with heightened impact during the pandemic years. Scaling up SP programs can be crucial for reducing inequities, building child resilience, and advancing child health targets in the future. Key messages • Social protection programs reduced under-5 mortality, stunting, and wasting, averting 3 million under-5 deaths in 46 LMICs from 2000-2021, including 583,590 deaths during the COVID-19 pandemic. • Our findings support the critical role of Social Protection in improving child health and the urgent need to strengthen these systems to protect children in future crises.