The world has experienced a 59% decline in the deaths of children younger than five years since 1990. New mortality estimates indicate that the largest drop was in 2019, when global under-five deaths were reduced to 5.2 million from 12.5 million in 1990.
The substantial progress in reducing child deaths occurred four years after the Sustainable Development Goals were launched. These goals include eliminating preventable child mortality; reducing neonatal death to less than 12 per 1,000 live births; and reducing deaths of children younger than five to less than 25 per 1,000 live births. The date for reaching these targets is 2030.
It may be too early to attribute any success to the Sustainable Development Goals. But the progress may be the result of related efforts like improved nutrition, housing, water, sanitation, education and financial security. The availability of health services to prevent or treat common causes of child death may have played a role too.
Despite this progress, sub-Saharan Africa recorded the highest neonatal mortality rate at 27 deaths for every 1,000 children born alive in 2019. A child born in sub-Saharan Africa or Southern Asia is 10 times more likely to die in the first month than a child born in a rich country.
Similarly, sub-Saharan Africa remains the region with the highest under-five mortality rate in the world. In 2019, one in 13 children in the region died before reaching their fifth birthday. This is 15 times higher than the risk for children born in high-income countries. Clearly, there is still a lot of work to be done.
We recently published a study that aims to show where countries should focus public health efforts to meet targets by 2030. Our paper is part of the Global Burden of Disease study. It presents the rates and trends in under-five deaths between 2000 and 2019, and makes projections to 2030. These projections are based on multiple health scenarios. We hope they will help to identify the countries and regions that are on course to achieve the Sustainable Development Goals goals and those that are not – and what to do about it.
Study findings
In this study, we analysed secondary data, spanning two decades from 204 countries and territories. The results show that every country has experienced some decrease in child deaths between 2000 and 2019. Worldwide, child deaths decreased from 71.2 per 1,000 births in 2000 to 37.1 in 2019.
Our research also identified countries with the highest number of deaths in 2019. Among them were the Central African Republic, Mali, and Chad. At a regional level, sub-Saharan Africa and South Asia recorded the highest number of deaths.
By 2015, 128 of the 204 countries in our study already reached the Sustainable Development Goals threshold of under-five deaths lower than 25 per 1,000 births. Egypt and Libya were the only African countries among these 128. By 2019, there were 136 countries under this threshold. Other than Morocco, no country in Africa met the threshold in 2019.
Regarding causes of death, neonatal disorders remained the leading cause of death in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects and malaria. More male children died than female children.
Our projections show that 154 countries are likely to meet the targets for reducing child deaths by 2030. This means that 50 (25%) countries are not on course. Most are located in the low- and middle-income countries, particularly in Africa, where Algeria is the only country on track. Thus, a lot more work is needed to put African countries on the path to the target.
The progress outlined above may be hampered by the widespread effect of COVID-19. Child mortality is not affected directly by COVID-19, but the effect on child health delivery services in general cannot be underestimated. It will take considerable effort to maintain and accelerate progress.
The way forward
Our analysis suggests the need for well-designed strategies to optimise child survival. They should include community-based strategies and efforts to address social determinants of health, such as education, family planning, social support, food security and financial security. Investments should strive for balance in all critical areas and overall system strengthening, focusing particularly on reducing inequality.
Specifically:
Balance early newborn care with continuing prenatal and older child health initiatives.
Invest in stronger health systems to scale up interventions.
Reduce disparities within countries and integrate other determinants of health.
Expand community and facility-based strategies for pregnancy, labour, delivery, and the postnatal period.
Counter shortages and retain skilled healthcare workers, reinforce facility infrastructure, develop and strengthen referral networks, and expand integrated services needed to achieve access and quality of care.
Scale up community-based initiatives such as vaccination campaigns, insecticide treated bed nets for malaria, prevention of mother-to-child transmission of HIV, and nutrition as well as integrated management of childhood illness.
Treatment campaigns for diarrhoea such as oral rehydration solution, zinc, and rotavirus vaccines have been successful. They still need improvements in clean water, sanitation and nutrition.
Improve perinatal and newborn care, and expand interventions such as vaccination and infection prevention.
More focus on equity, poverty reduction and education, and investment in strengthening health systems across the development spectrum, can substantially reduce deaths among children younger than five years.