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IMPACT OF COMMUNITY HEALTH WORKERS ON REDUCING UNDER-5 MORTALITY: KEBBI STATE
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Under-five mortality is one of the most significant indicators of the performance of the health system and socioeconomic development in a country. In 2024, 4.9 million children were dying under the age of five worldwide, almost half of whom were living in fragile and conflict-prone environments (UNICEF, 2024). The worst hit area is Sub-Saharan Africa which has most of the preventable child death cases. With a low under-five mortality rate of about 86 per 1,000 live births (UNICEF, 2023), Nigeria is estimated to contribute 17% of deaths under 5 years old in the world about 835,030 deaths in 2022 alone this is not the highest contributor to under-five mortality in the world (Adedini et al
In Nigeria, the magnitude of subnational disparities is immense. North West has the highest under-five mortality rate at 140 deaths per 1, 000 live births compared to the South West at 42 deaths per 1,000 live births (NDHS Key Indicators, 2023-24). Kebbi state is one of the high-risk states of child mortality in Nigeria and it is always placed in the North West geopolitical zone (Ogunyemi et al., 2022). The predominant causes of fewer than five years of age deaths in this region are pneumonia, diarrhoea, malaria, malnutrition, and neonatal complications all of which can be prevented by preventive measures at the community level.
The community health worker (CHWs) has become a very important strategy especially in the resource-constrained environments throughout the world as a way of bridging healthcare access gap. According to the WHO, CHWs are front-line community-focused public health workers who have an in-depth knowledge of the community in which they work and act as the vital conduit between formal health services and underserved communities (Peprah et al., 2020). Sub-Saharan Africa shows that properly implemented CHW programs can decrease the percentage of under-five deaths in program regions by 32 to 44 percent (Perry et al., 2015). CHW interventions usually involve promotion of sole breastfeeding, assistance in immunization, oral rehydration treatment of diarrhoea, provision of insecticide-treated nets and referral of ill children.
The National Primary Health Care Development Agency (NPHCDA) in Nigeria has Been implementing CHWs such as Community Health Extension Workers (CHEWs) and Village Health Workers (VHWs) in states such as Kebbi. Nevertheless, the coverage of programs, quality of training, and supervision are still substandard, especially in rural Kebbi State. There is a dearth of empirical evidence that would precisely measure the effect of CHW interventions on infant deaths in the Kebbi State to enable policy makers to prove that their decision to scale up or improve the programs is justifiable.
1.2 Statement of the Problem
The State of Kebbi has consistently had among the poorest child health outcomes in Nigeria, and high prevalence and mortality rates of under-five morbidity and mortality due to preventable causes. Although CHWs are implemented throughout the state as the primary healthcare system in Nigeria, their real effect on the outcome of child survival is not well-documented. The major challenges are; CHW training is of inadequate quality, high attrition of CHWs, inconsistent supervision and lack of community trust all of which reduce the effectiveness of CHW.
Moreover, the current national-level research on the determinants of child mortality in Nigeria fails to reflect the finer, state-specific relationships of the CHW performance in Kebbi. In the absence of solid, locally based evidence, there is no way of knowing whether CHW programs are having their intended effect, which CHW activities tend to be most effective, and what systemic changes are required. Such evidence gap has practical implications: in the absence of such evidence, interventions cannot be effectively targeted to the most in need. This paper seeks to address this gap by studying the effects of CHW activities on the under-five mortality outcomes in Kebbi State.
1.3 Aim of the Study
To assess the impact of community health workers on reducing under-five mortality in Kebbi State, Nigeria.
Specific Objectives
- To assess the coverage and reach of community health worker programs in selected LGAs in Kebbi State.
- To determine the CHW activities associated with reduced under-five mortality in the study area.
- To evaluate caregivers’ knowledge and utilization of CHW-provided child health services.
- To identify barriers to effective CHW service delivery in Kebbi State.
- To examine the association between CHW contact frequency and child health outcomes in the study communities.
1.4 Research Questions
- What is the coverage and reach of CHW programs in the study LGAs of Kebbi State?
- Which specific CHW activities are most associated with improved child health outcomes?
- What is the level of caregivers’ utilization of CHW-provided services in Kebbi State?
- What barriers limit the effectiveness of CHW service delivery in the state?
- Is there an association between frequency of CHW contact and under-five mortality rates in the communities?
1.5 Research Hypotheses
- H₀: There is no significant association between CHW program coverage and under-five mortality rates in Kebbi State.
- H₁: There is a significant association between CHW program coverage and under-five mortality rates in Kebbi State.
- H₀: Frequency of CHW contact does not significantly predict child health outcomes in the study communities.
- H₁: Frequency of CHW contact significantly predicts child health outcomes in the study communities.
1.6 Significance of the Study
This research will produce evidence that is essential in enhancing the primary healthcare of Nigeria especially in the high burden states such as Kebbi. In the case of the Kebbi State Ministry of Health and NPHCDA, the results will be used to make decisions regarding CHW implementation plans, training materials, supervision schemes, and incentive schemes. Since the goals of the country are to work towards the SDG Target 3.2 under-five mortality rate at most 25 per 1,000 live births by 2030, this research will have a direct impact on national policy discourse. To international organizations such as UNICEF, WHO and USAID operating in northern Nigeria, the study can provide local evidence that can inform investment in CHW programs. On an academic level, it adds to the increasing body of literature on CHW performance in West Africa settings. The study will also be valuable to the community health workers and the health authorities of the local government since they will receive suggestions on how to enhance the quality of service delivery.
1.7 Scope of the Study
It will target children below the age of five years and their caregivers living in some rural and peri-urban communities in three local government areas of Kebbi State. CHWs (as well as CHEWs and VHWs) who will work in these communities will be also respondents. The research will evaluate CHW activities that have been undertaken in the last 24 months and they will include immunization support, nutrition counselling, management of sick children at home and referral services. The 2024-2025 academic year will be the timeframe of collecting data.
1.8 Operational Definition of Terms
- Community health worker (CHW): A frontline health worker selected from and working in the community, trained to deliver basic health services including health promotion, disease prevention, and referral, but not holding a formal professional nursing or medical degree.
- Under-five mortality: The probability of a child dying between birth and exactly five years of age, expressed per 1,000 live births.
- CHW coverage: The proportion of households or children under five in a defined catchment area that received at least one CHW visit or service in the reference period.
- Child health outcome: Measurable changes in a child’s health status, including morbidity from diarrhoea, pneumonia, and malaria, nutritional status, immunization completion, and mortality.
- Caregiver: The primary person responsible for the day-to-day care of the child, typically the mother, grandmother, or female guardian.
References
Adedini, S. A., Anjorin, S. S., Mobolaji, J. W., Okolie, E. A., & Yaya, S. (2025). Decomposing the gap in under-five mortality determinants between the low- and high-risk regions of Nigeria. Scientific Reports, 15, 12048. https://doi.org/10.1038/s41598-025-20365-3
Medhanyie, A. A., Little, A., Yebyo, H., Spigt, M., Tadesse, K., Blanco, R., & Dinant, G. J. (2024). The effectiveness and cost-effectiveness of community health workers in delivering antenatal care and immunization services to pregnant mothers and children under 5 in rural Africa: A study protocol for a systematic review and meta-analysis. medRxiv. https://doi.org/10.1101/2024.08.18.24312186
National Population Commission (NPC) [Nigeria] & ICF International. (2023). Nigeria Demographic and Health Survey 2022-23: Key Indicators. NPC and ICF International.
Ogunyemi, B. M., Nwogu, O. S., & Anoke, C. I. (2022). Under age five children survival times in Nigeria: A Bayesian spatial modelling approach. BMC Public Health, 22, 2207. https://doi.org/10.1186/s12889-022-14660-1
Peprah, P., Agyemang-Duah, W., Oduro, A. E., Budu, E., Gyasi, R. M., Appiah, G. P., & Arthur-Holmes, F. (2020). Community health workers: A systematic review of their roles, responsibilities, and determinants of performance. BMC Public Health, 20, 706.
Perry, H. B., Zulliger, R., & Rogers, M. M. (2015). Care Groups II: A summary of the child survival outcomes achieved using volunteer community health workers in resource-constrained settings. Global Health: Science and Practice, 3(3), 370-381. https://doi.org/10.9745/GHSP-D-15-00052
UNICEF. (2024). Under-five mortality. UNICEF Data. https://data.unicef.org/topic/child-survival/under-five-mortality/