Somewhere in northern Nigeria, the most consequential public health decision of the day may not happen in a hospital ward, a ministry office or a conference room. It happens at the front door.
A community health worker arrives. A father listens. A child waits nearby, perhaps too young to understand why an unknown visitor has arrived. The caregiver has questions: What is this medication? Why is it free? Is it safe? Do I need my husband’s permission? Then, within a few minutes, a politics of child survival becomes intensely personal.
That moment is worth remembering when public health leaders gather in Cape Town from September 6 to 9 for the 18th World Public Health Congress.
The meeting’s theme, “Health without Borders: Equity, Inclusion and Sustainability,” resonates in several countries like Nigeria, where the toughest job in public health is often ensuring that a child’s chances of survival do not depend on zip code, income, gender norms or distance to a clinic.
Nigeria has made progress. The 2023-24 Nigeria Demographic and Health Survey estimates under-five mortality at 110 deaths per 1,000 live births. That still means that about one in nine Nigerian children dies before their fifth birthday. The figure is well above the Sustainable Development Goals target of fewer than 25 deaths per 1,000 live births by 2030, but also reflects a long-term decline from 201 deaths per 1,000 in 2003.
Statistics may seem far away, but they are not. They are the reason why mothers ask questions before accepting a health intervention. They are the reason why a healthcare worker needs enough time, information and credibility to respond. They are the reason public health cannot be reduced to delivering a product and moving on.
That is one of the lessons emerging from SARMAAN, the Safety and Antimicrobial Resistance from Mass Administration of Azithromycin in Nigeria project. SARMAAN provides carefully approved doses of azithromycin to children between one and 59 months of age in high-mortality communities through regular, supervised mass drug administration campaigns. It works through healthcare workers, state systems and trusted community structures, while monitoring safety and antimicrobial resistance.
Between 2024 and 2026, the project reached 15.76 million unique children in 10 northern states and delivered more than 26 million doses. In the first quarter of 2026, more than 7.2 million children were reached in Kano, Bauchi, Jigawa and Kaduna alone.
Those figures are substantial. But they are not the whole story. The most telling achievement is the infrastructure behind them: the routes planned, the supplies moved across difficult terrain, the state teams coordinating schedules, the health workers recording visits, the community leaders preparing the homes and the parents who decide to open their doors. This is public health in clear association with many institutions and people who advance at the same pace, often without public recognition.
SARMAAN’s experience also complicates the familiar idea that public health success depends simply on awareness. Research related to the program found that caregivers’ willingness to participate could be high while their confidence remained fragile. Questions about security, rumors, domestic authority, and the purpose of free medicine shape what happens at the point of delivery. In many homes, mothers may be convinced but not have the final say. Therefore, trust must be conveyed through health workers, women community leaders, parents, religious leaders and traditional authorities.
This is what inclusion looks like in practice, as it is not just about reaching a household but also creating enough clarity, respect and social permission for the household to participate.
The Public Health Congress is an opportunity to connect this lived reality to a broader global conversation. Equity means putting children from high-burden communities at the center of care. Inclusion means treating caregivers as partners with valid questions, not passive recipients. Sustainability means ensuring that programs with proven reach do not disappear when a funding cycle ends.
SARMAAN is not the complete answer to child mortality. Vaccines remain essential. The same goes for nutrition, clean water, sanitation, malaria prevention, primary health care and timely treatment of sick children. Child survival is less like a single shield than a woven mat: each thread matters because it strengthens the others.
But SARMAAN offers a stark reminder of what becomes possible when those threads are deliberately connected. It shows that Nigeria can deliver targeted intervention at scale, while learning to build trust, collect evidence and work through existing systems.
The question now is whether that learning will remain in project reports or carry over into policy, financing and routine primary health care. A child’s future should not depend on a single knock on a door. However, when the system arrives prepared, trusted, and ready to listen, that door can become the beginning of a longer story; one where more children live long enough to learn, play and thrive.
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