Determinants of under-five mortality in Africa: evidence from a two-decade panel analysis for public health policy

BACKGROUND: Child survival is a critical indicator for a nation's health and its progress is important in attaining the Sustainable Development Goals. Understanding the regional and country-specific dynamic and interplay of various determinants of under-five child mortality is vital for the African continent, which remains one of the most vulnerable regions for child mortality globally. METHODS: This study investigates the association of economic, health-related, social and demographic, environmental, and infrastructure-related factors with under-five child mortality. It integrates generalisable regional associations using a standard fixed-effects panel model and examines illustrative country-specific associations of the selected determinants through multiple linear regression, based on a balanced panel dataset of 45 countries over a 22-year period. RESULTS: Fixed-effect analysis reveals that the diphtheria-tetanus-pertussis (DTP) immunisation and total fertility rate (TFR) are robust regional determinants of under-five mortality across specifications. While health expenditure, sanitation services, and malaria incidence show significant associations in the baseline model, these findings are sensitive to the inclusion of year fixed effects, suggesting they are influenced by broader temporal trends or common regional shocks rather than serving as stable independent factors within the study period. CONCLUSION: Regional analysis, which controls for unobserved country-specific heterogeneity over an extended period and is complemented by country-specific analysis, facilitates the formulation of policy implications at both national and international levels. Recommended policy measures include increasing immunisation coverage, implementing malaria control programmes, strengthening community health infrastructure, enhancing girls' education, promoting widespread access to modern family planning, and improving sanitation services. These strategies are expected to contribute to the progress toward Sustainable Development Goal 3.2 in the African region.