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Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries

Katherine A Muldoon12, Lindsay P Galway3, Maya Nakajima3, Steve Kanters3, Robert S Hogg23, Eran Bendavid4 and Edward J Mills25*

Author Affiliations

1 School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia, Canada

2 British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia, Canada

3 Faculty of Health Sciences, Simon Fraser University, 888 University Drive, Burnaby, British Columbia, Canada

4 Division of General Internal Medicine, Stanford University, Palo Alto, California, USA

5 Faculty of Health Sciences, University of Ottawa, Roger Guindon Hall 451, Smyth Road, Ottawa, Ontario, Canada

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Globalization and Health 2011, 7:42  doi:10.1186/1744-8603-7-42

Published: 24 October 2011



Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.


We used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.


Significant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR.


Several key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.