Impact of social protection on child malnutrition and mortality across 46 LMICs: a longitudinal study over two decades with insights from the COVID-19 pandemic.

Background: Under-5 mortality and malnutrition are major public health challenges in low- and middle-income countries (LMICs), worsened by crises like the COVID-19 pandemic. Evidence on social protection reducing under-5 mortality in LMICs is limited. We examined the impact of social protection coverage, defined as the proportion of the population covered by any form of social protection, on under-5 mortality, stunting, and wasting across 46 LMICs from 2000 to 2021. Methods: Our study analyzed 1012 country-year observations. Outcomes included under-5 mortality (deaths per 1000 live births), prevalence of wasting (weight-for-height Z-scores < -2 SD), and stunting (height-for-age Z-scores < -2 SD). Coverage of social protection was defined as the proportion of the population receiving at least one social protection benefit. We used fixed-effects Poisson models with robust standard errors to estimate associations, adjusting for socioeconomic, healthcare, and gender-related variables. Interaction terms captured social protection mitigation effects during COVID-19, and counterfactual scenarios estimated averted deaths. Analyses were disaggregated by sex and age groups. Findings: Social protection coverage prevented an estimated 3.05 million under-5 deaths overall, including 583,590 during the pandemic. Higher coverage was significantly associated with reductions in under-5 mortality (IRR:0.71,95%CI:0.54-0.96), stunting (IRR:0.75,95%CI:0.60-0.94), and wasting (IRR:0.87,95%CI:0.78-0.98). During the COVID-19 pandemic years, social protection led to additional reductions in under-5 mortality (IRR:0.68,95%CI:0.59-0.79) and stunting (IRR:0.74,95%CI:0.57-0.95). Toddler mortality (1-2 years) showed the greatest reduction effects (IRR:0.62,95%CI:0.41-0.95). Females showed slightly stronger effects. Sensitivity and triangulation analyses validated all results. Interpretation: Social protection coverage strongly reduced child mortality, stunting, and wasting in LMICs, with heightened impact during the pandemic years. Scaling up social protection programs can be crucial for reducing health inequities, building child resilience, and advancing child health targets in the future. Funding: This study was funded by the Rapid Social Response (RSR) Multidonor Trust Fund at the World Bank.