Reducing child mortality rates by two-thirds from 1990 to 2015 is one of the main objectives of the Millennium Development Goals (MDG 4).Footnote 1 Progress has fallen short, however, despite the substantial support from various international development forums, donor agencies, and political leaders influential in both international and domestic politics [1–6]. According to the 2014 MDG progress report (p. 25), the goal of reducing child mortality by two-thirds from 1990 levels will take an additional 15 years, that is, until 2028 [2]. The report suggests that Sub-Saharan African countries in particular, many of which have gone through cycles of armed conflict, are the laggards (p. 26). In fact, the United Nations International Children’s Fund (UNICEF) suggests that eight out of the ten countries with the highest child mortality rates are either in armed conflict or considered to be in politically unstable situations [3]. These recent UNICEF and MDG reports highlight the importance of political stability, noting that reducing child mortality depends on states’ abilities to end the cycle of armed conflict and transition out of political fragility.
A reduction in infant mortality is one of the indicators of the overall performance of the health sector, a sector highly influenced by the policy choices the political regime makes. Studies show that democracies consistently have higher levels of public service provisions (i.e. health education) than autocracies [7]. One of the reasons could be that the ruling party’s chance to win elections in democracies depends on the successful provision of public goods and services [8–10]. Regardless of the level of per capita gross domestic product (GDP), the child mortality rate is significantly lower in democracies than in autocracies for the reasons mentioned above [8, 11, 12].
In the past decade, studies have established that armed conflicts cause breakdowns in countries’ healthcare systems [13–17]. Such breakdowns lead to limited or no access to healthcare facilities. In many instances, postnatal care is nonexistent because trained healthcare professionals are forced to leave the communities they serve. While overall child mortality rates have declined in countries undergoing armed conflict due to shrinking costs of war, low cost health interventions during peacetime, humanitarian interventions, immunization and localized nature of armed conflict [18], child mortality is consistently shown to be significantly higher among countries undergoing armed conflict [19]. Nicaragua and Eastern Myanmar demonstrate two realities of child mortality and armed conflict. The outbreak of armed conflict in Nicaragua stalled a trend of declining infant mortality rates [13], and Eastern Myanmar, an area affected by ongoing ethnic conflicts, has a high level of infant mortality [16, 20]. Such negative effects on the public health sector do not disappear immediately after conflict termination. Public health and social science studies have reported that conflict-related deaths and injuries are likely to be observed even after the conflicts are terminated for reasons related to a reduced economic capacity to support public health sector in a post-war context [15, 21–23]. Other reasons for a higher conflict related deaths and injuries in a post-war period are related to interruptions in access to basic services, availability of healthcare professionals, and conflict caused environmental damages that could give rise to disease and ill health. While studies suggest the significant impact of deaths and disabilities related to armed conflict [24], most of these studies do not address the conditions under which societies emerging from the cessation of conflict are performing better in reducing child mortality rates. This study addresses this gap in scholarship by examining the rates of neonatal, infant, and under-5 mortality in relation to the negotiation and implementation of comprehensive peace agreements in 73 post-armed conflict countries between 1989 and 2012. In this study, a post-armed conflict country is a country where at least one conflict or one conflict dyad is coded “terminated” in the Uppsala Conflict Data Program (UCDP) conflict termination data [25].Footnote 2
Pattern in neonatal, infant, and under-5 mortality rates
The 2014 MDG annual progress report and other earlier studies suggest a consistent pattern of decline in the infant mortality rate [3, 5, 26]. According to the World Bank data [27], over the last two decades (between 1989 and 2012), global neonatal deaths declined by 11.7 %, infant mortality by 26.4 %, and under-5 mortality by 39.7 %. Post-armed conflict countries follow the global pattern despite having relatively high mortality rates, but show a slower decline in the neonatal and infant mortality rates. For post-armed conflict countries in the same time period, the neonatal death rate declined by 9.47 %, infant mortality by 24.93 %, and under-5 mortality by 42.17 %. However, two things remain unaddressed. First, post-armed conflict countries are consistently behind the global average in terms of child mortality rates. Second, significant variation exists among post-armed conflict countries, with some countries retaining high rates of child mortality and others seeing a decline in child mortality following conflict.
One reason for this variation is seen in the differences of conflict termination – whether the conflict ends through rebel victory, government victory, or negotiation and implementation of comprehensive peace agreements (CPAs). Between 1989 and 2012, for example, neonatal deaths declined by 12.19 % among post-armed conflict countries that negotiated and implemented CPAs, 2.7 % among countries with rebel victories, and 0.09 % in countries with government victories. The infant mortality rate also showed significant variation. Infant mortality declined by 40.64 % in countries with CPAs, 14.63 % in countries with a rebel victory, and increased by 1.46 % in countries with a government victory. The pattern of under-5 mortality rate follows, with a decline of 70.01 % for countries with CPAs, 16.82 % for the countries with rebel victories, and an increase of 4.47 % for countries with a government victory. As these rates suggest, post-armed conflict states that negotiated and implemented comprehensive peace agreements consistently performed better in reducing child mortality rates than those that did not.
This study explains child mortality decline among post-armed conflict countries by examining the negotiation and implementation of CPAs. The Peace Accords Matrix (PAM) project defines a CPA as the final agreement negotiated to end intrastate armed conflict that involves (a) major conflict actors in the negotiation process, and (b) substantive issues included in the negotiation [28, 29]. Using this definition, the project identifies 34 CPAs negotiated in 31 countries between 1989 and 2012. The project identifies 51 different provisions in a CPA, categorized under six different clusters. Most of the provisions are designed to provide more access for excluded groups (rebel groups and their constituencies) to state power and resources. This access is increased by implementing reforms in government institutions and the security sector, guaranteeing rights to minorities, women and children, and ensuring the socio-economic development of impoverished regions (focusing on infrastructure building and improving the delivery of public services).
Implementation of reforms outlined in CPAs can directly impact child mortality rates. Child mortality rates are disproportionately high in armed conflict countries because of the destruction of healthcare infrastructure (including hospitals and healthcare facilities), security threats to health professionals, and the displacement of populations and health service providers. In conflict zones, health delivery is often politicized and difficult to provide effectively due to the fear of reprisals by rebels or state forces. After the CPA is signed, however, armed hostility may cease, thus facilitating the return of internally displaced persons (IDPs) and refugees. Implementing security sector-related reforms in CPAs might mitigate future violence and increase the chance of a lasting ceasefire [29]. As a result of an improved security environment, health professionals and aid workers may also be encouraged to return.
By implementing CPA provisions, post-armed conflict countries can also improve institutional capacities which may increase an excluded group’s access to state power and resources. Implementing socio-economic provisions in CPAs may help to rebuild damaged or destroyed infrastructure, and improve service delivery in marginalized or excluded areas. Marginalized populations tend to support rebel uprisings, so addressing their grievances is critical to avoid future conflict. In Mozambique, for example, the government prioritized the rehabilitation of the health network and return of health services to previously closed and underserved areas under the control of the rebel group, RENAMO (Resistência Nacional Moçambicana) [30].
All governments respond to the needs of the poor and marginalized segments of the population to varying degrees. However, post-armed conflict governments face a particular challenge. These governments have to make sure that the underlying grievances of the marginalized segments of the population are addressed so that there is no incentive for them to join rebel movements or return to violence. The government has to demonstrate its commitment to a sustainable peace, and the best way to demonstrate its commitment to peace is through implementing provisions negotiated in the CPA. Therefore, countries that negotiate and implement CPAs at a higher rate will be more likely to improve health infrastructure, decrease security threats for health workers, increase opportunities for the return of IDPs and refugees, and increase institutional capacities. All of these factors lead to a declining child mortality rate. In countries where parties did not sign CPAs, inequality persists and grievances of those without access to power or resources mostly remain unaddressed. A decisive government or rebel victory may still lead to a decline in child mortality rates if the post-armed conflict government successfully eliminates the threat of violence, prioritizes the rebuilding of hospitals and health posts shattered during the conflict, and incentivizes healthcare professionals to return to work. These one-sided victories (government or rebel), however, may lead the party in power to focus on a security buildup at the expense of delivering services, as seen in post-2009 Sri Lanka. The victorious side (either government or rebel) may also support exclusionary policies as a way to safeguard their constituencies’ interests.