Primary Health Care Coverage and Child Mortality in Sub-Saharan Africa

Importance Primary health care (PHC) is recognized as pivotal for achieving universal health coverage and reducing mortality rates among children younger than 5 years. Objectives To estimate the association of effective PHC coverage with child mortality in 3 diverse sub-Saharan countries over the past 2 decades and to estimate the number of child deaths that could occur by 2035 if PHC services are dismantled due to the current decrease in development assistance for health funding. Design, Setting, and Participants This cohort study assessed children younger than 5 years from January 1, 2007, to December 31, 2022, in Mozambique, Gabon, and Ethiopia. The study drew on 5 national and subregional representative US Agency for International Development Demographic and Health surveys with longitudinal information from the 3 countries. Statistical analysis was performed from October 2024 to May 2026. Exposure An effective PHC coverage index (PHC index) was developed for this study, integrating core dimensions of child PHC service provision and access and structured into progressively ordered coverage categories. Main Outcomes and Measures The outcome was child mortality, assessed with 2-way fixed-effects multivariable Poisson regression models with child-clustered standard errors, adjusted for relevant confounding factors at the individual, regional, and national levels. This evaluation was also integrated into validated microsimulation forecasting analysis. Results Of the 118 911 child-year observations of 37 583 children (mean [SD] age, 1.4 [1.3] years; 60 252 boys [50.7%]), Gabon had the greatest coverage of service provision, followed by Mozambique and Ethiopia, though Mozambique showed a marginally higher proportion in the highest category (Gabon, 796 of 33 269 [2.4%]); Mozambique, 554 of 20 728 [2.7%]; and Ethiopia, 317 of 64 914 [0.5%]); the inverse pattern was observed for the lowest coverage categories (Gabon, 2143 of 33 269 [6.4%]; Mozambique, 1976 of 20 728 [9.5%]; and Ethiopia, 32 189 of 64 914 [49.6%]). Across all child-year observations, there were 2166 deaths (1.8%). Ethiopia accounted for 2.1% of deaths (1338 of 64 914 child-years), Mozambique for 1.8% (364 of 20 728), and Gabon for 1.4% (464 of 33 269). Increasing PHC coverage was associated with decreases in child mortality in a dose-response manner, reaching a 58% reduction (rate ratio, 0.42 [95% CI, 0.19-0.91]) for consolidated high coverage. The dismantling of PHC coverage, triggered by the defunding of development assistance for health , may lead to an increase in preventable child deaths, amounting to an estimated 373 108 deaths (95% uncertainty interval, 313 152-444 244 deaths) across the 2025 to 2035 period. Conclusions and Relevance This cohort study found evidence indicating that PHC was associated with substantially reduced mortality rates among children younger than 5 years in sub-Saharan Africa over the past 2 decades. These findings suggest that PHC should be expanded rather than dismantled, particularly amid the ongoing defunding of development assistance for health.