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 hall It happens at a front door.
A community health worker arrives A parent listens. A child waits nearby, perhaps too young to understand why an unfamiliar visitor has come. The caregiver has questions: What is this medicine? Why is it free? Is it safe? Do I need my husband’s permission? Then, in a few short minutes, a child-survival policy becomes intensely personal.
That doorstep moment is worth remembering as public-health leaders gather in Cape Town from September 6 to 9 for the 18th World Congress on Public Health The meeting’s theme—“Health Without Borders: Equity, Inclusion, and Sustainability”—echoes across several countries like Nigeria, where the hardest work of public health is often making sure that a child’s chance of survival does not depend on postcode, income, gender norms or the distance to a clinic.
Nigeria has made progress The 2023–24 Nigeria Demographic and Health Survey estimates that under-five mortality stands at 110 deaths per 1,000 live births. That still means roughly one in every nine Nigerian children dies before reaching age five. The figure is far above the Sustainable Development Goal target of fewer than 25 deaths per 1,000 live births by 2030, but it also reflects a long-term decline from 201 deaths per 1,000 in 2003.
The statistics can feel distant but at the doorstep, they are not They are the reason mothers ask questions before accepting a health intervention. They are the reason a health worker needs enough time, information and credibility to answer. 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 of Mass Administration of Azithromycin in Nigeria project SARMAAN provides carefully approved doses of azithromycin to children aged one to 59 months in high-mortality communities through periodic, supervised mass drug-administration campaigns. It works through health workers, state systems and trusted community structures, while monitoring safety and antimicrobial resistance.
Between 2024 and 2026, the project reached 1576 million unique children across 10 northern states and delivered more than 26 million doses. In the first quarter of 2026, more than 7.2 million children were reached across Kano, Bauchi, Jigawa and Kaduna alone.
Those numbers are substantial But they are not the whole story. The more revealing 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 households, and the parents deciding to open their doors. This is public health in clear partnership with many institutions and people moving in step, often without public recognition.
SARMAAN’s experience also complicates the familiar idea that public-health success is simply about awareness Research connected to the programme found that caregivers’ willingness to participate could be high while their confidence remained fragile. Questions about safety, rumours, household authority and the purpose of free medicine all shape what happens at the point of delivery. In many homes, mothers may be convinced but not have the final word. Trust must therefore travel through health workers, community women leaders, fathers, religious leaders and traditional authorities.
That is what inclusion looks like in practice as it is not only 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 larger global conversation Equity means putting children in high-burden communities at the centre of delivery. Inclusion means treating caregivers as partners with valid questions, not passive recipients. Sustainability means ensuring that programmes with proven reach do not disappear when a funding cycle ends.
SARMAAN is not the whole answer to child mortality Vaccines remain fundamental. So do nutrition, clean water, sanitation, malaria prevention, primary health care and timely treatment for sick children. Child survival is less like a single shield than a woven mat: each strand matters because it strengthens the others.
But SARMAAN offers a clear reminder of what becomes possible when those strands are deliberately connected It shows that Nigeria can deliver a targeted intervention at scale, while learning how to build trust, gather evidence and work through existing systems.
The question now is whether that learning will stay in project reports or travel into policy, financing and routine primary health care A child’s future should not hang on one knock at one door. Yet when the system arrives prepared, trusted and ready to listen, that door can become the beginning of a longer story; one in which more children live long enough to learn, play and thrive.