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Association between community management of pneumonia and diarrhoea in high-burden countries and the decline in under-five mortality rates: an ecological analysis
  1. Cynthia Boschi-Pinto1,2,
  2. Thandassery Ramachandran Dilip1,
  3. Anthony Costello1
  1. 1Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
  2. 2Instituto de Saúde Coletiva, Universidade Federal Fluminense, Niteroi, Brazil
  1. Correspondence to Dr Cynthia Boschi-Pinto; pintoc{at}


Objective The objective of the paper is to explore if the adoption of national policies to use community-based health providers for the management of pneumonia and diarrhoea is associated with the decline in under-five mortality, including achievement of the Millennium Development Goal (MDG)4 target, in high-burden countries.

Setting This country level analysis covers 75 high-burden low-income and middle-income countries which accounted for 98% of the 5.9 million global under-five deaths in 2015. One-fourth of these deaths were due to pneumonia and diarrhoea.

Methods χ2 tests and multiple regression analysis were used to examine the association between reduction in under-five mortality rates and community case management of pneumonia and diarrhoea by adjusting for the influence of other possible determinants.

Participants No patient or population interviewed/examined for this analysis. Countries were the unit of analysis.

Interventions Community case management (CCM) of pneumonia and diarrhoea policies.

Outcome measures Changes in under-five mortality rates over time.

Results Countries that had adopted both CCM policies were three times more likely to achieve the MDG4 target than countries that did not have both policies in place. This association was further confirmed by the multivariate analysis (β-coefficient=10.4; 95% CI 2.4 to 18.5; p value=0.012).

Discussion There is a statistically significant association between adoption of CCM policies for treatment of pneumonia and diarrhoea and the rate of decline in child mortality levels. It is important to promote CCM in countries lagging behind to achieve the new target of 25 or fewer deaths per 1000 live births by 2030.

  • Under-five mortality
  • Community case management
  • Pneumonia
  • Diarrhoea

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors The authors bring a combination of expertise in epidemiology, demography, interventions, policies, public health and advocacy. CBP conceptualised the paper. TRD performed the statistical analysis. Both CBP and TRD wrote the first draft of the manuscript and AC contributed intellectual content and critical revisions to the manuscript. All authors approved the final manuscript. CB-P is the guarantor.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The authors are staff members of the WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the WHO.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data are available in public domain. Sources can be found in Web Appendix 1.

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