Quick facts on under-5 mortality
The under-five mortality (U5M) rate represents the risk of a child dying before his/her fifth birthday, expressed in the number of children, out of 1,000 live births, dying before they turn five.
The U5M rate in low-income countries is approximately 73 deaths per 1,000 live births, almost 14 times higher than the average rate in high-income countries. The highest under-five mortality rates are clustered in sub-Saharan Africa and South Asia.
High U5M is usually the result of a combination of failures including poor nutrition, low immunization rates, poor maternal health and education, etc. For this reason, it is a powerful indicator of inequity and systemic health challenges.
Because a majority of these deaths are preventable, the rate reflects, better than any other measure, a lack of access to critical and fundamental health care including family planning, pre- and post-natal services, and disease prevention and case management.
Under-five mortality is most common in low-resource settings, and is caused by illnesses that are largely preventable, treatable, or both.
When children die of these illnesses, it generally reflects multiple failures in the health system—failures in prevention and timely quality treatment. Other factors affecting under-five mortality (U5M) include poor nutrition, low immunization rates, and poor maternal health and education. For these reasons, U5M is a powerful indicator of inequity and systemic health challenges.
The causes of death among under-five children shift as overall mortality rates decline.
In low-income countries, where nutrition and sanitation systems are weak and individuals lack access to basic prevention and treatment interventions, infectious diseases cause a majority of the burden. In wealthier nations, a higher proportion of deaths result from causes that require more complex interventions to address, such as neonatal disorders.
There is no one initiative that can reduce under-five mortality. Instead, to achieve measurable and sustainable results, under-five mortality must be addressed at a variety of levels, including in the household, community, health system, and within government policy.
There are many interrelated factors that make under-five mortality challenging to solve. One of these is a lack of timely and accurate mortality data, at the local, national, regional, and global level. Other challenges include connecting poor and vulnerable communities with higher functioning health systems that can provide quality, people-centered care. From here, families must want to receive care, be able to access the care, and must develop health-seeking behavior when their child is sick. Governments must also ensure the delivery of quality, affordable, accessible, and culturally acceptable care to all, particularly to rural and other vulnerable, poorly served communities.
Even as governments have successfully reduced their under-five deaths, they have been less successful reducing neonatal mortality (the number of children who die in the first 28 days of life). Neonatal deaths are much more challenging to address. There are, currently, no definitive ways to prevent some of the leading causes of neonatal mortality, such as some birth defects. And other causes of neonatal mortality, such as pre-term birth, require higher-level health personnel and equipment that are not readily accessible in low-income countries.
The following interventions have been proven to reduce U5M:
Vaccines are a powerful tool for reducing under-five mortality.
Community-based prevention and management of common child illnesses
Community health workers and community health posts have helped extend the reach of the public health system to rural and vulnerable communities
Integrated management of childhood illness, at the facility level
Integrated management of childhood illness (IMCI), developed by the WHO and UNICEF, is an integrated approach to child health that focuses on the well-being of the whole child
Nutrition education and management of malnutrition
Nutrition education and promotion, including breastfeeding and proper complementary feeding, is also a key factor
Reducing U5M has long been a priority of the international health community, gaining traction with the adoption of the UN Millennium Development Goals (MDGs) in 2000, and the subsequent update of the Sustainable Development Goals (SDGs) in 2015.
Goal #4 of the MDGs was to reduce the rate of under-five mortality by two-thirds by 2015, compared to the 1990 level. While the world made great progress from 1990 to 2015, we missed this goal, as the global under-five mortality rate declined by just under half, from 82 deaths per 1,000 live births in 1990 to 43 in 2015.1 In terms of absolute numbers, globally, the number of under-five deaths have decreased from 12.7 million in 1990 to 6 million in 2015.2
As a result of not meeting this goal, the UN established a new set of goals in 2015: the Sustainable Development Goals (SDGs). SDG #3 sets an absolute target for all countries, rather than a relative reduction at the global level. Specifically, for all countries, it calls for an under-five mortality rate of no higher than 25 deaths per 1,000 live births and a neonatal mortality rate of no higher than 12 deaths per 1,000 live births.
Cross-cutting strategies from Exemplars
Below are five recommended cross-cutting strategies commonly adopted by Exemplar countries. Regardless of specific national circumstances, Exemplar countries prioritized these five strategies while implementing interventions to reduce U5M. The strategies hold value for other countries looking to implement evidence-based health interventions or to address gaps in implementation of existing interventions.
- Stakeholder engagement and coordination: Seeking input from local and international partners, donors, and stakeholders in order to establish buy-in, facilitate adoption, ensure feasibility, and drive coordinated implementation around a national plan.
- Use of data and evidence for decision-making: Drawing upon international, national, and sub-national data and evidence for planning, implementation, and advocacy.
- Integration of new and existing initiatives into health systems: Building upon and strengthening effective health-care systems, including CHW networks.
- Building and using research capacity: Bolstering in-country research organizations and capacity to inform decision-making and gain local buy-in.
- A focus on equity: Emphasizing the needs of the poorest and most vulnerable populations when developing health strategies.
Read MoreWhat works?
Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study (GBD 2017). Seattle, WA: IHME; 2018. http://www.healthdata.org/gbd.
GBD 2017 SDG Collaborators. Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392: 2091–138. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32281-5/fulltext Accessed January 21, 2020
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Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Further, applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing).
Working together over the last three decades, we have expanded coverage of voluntary family planning, dramatically improved access to new vaccines, integrated nutrition and hygiene into global health, and launched innovative public-private partnerships to extend our reach. Since 2010, the Helping Babies Breathe partnership has trained and equipped 130,000 health workers in 60 countries to provide life-saving resuscitation for newborns with asphyxia, with results in Tanzania showing a 47% reduction in early newborn mortality. From 1990 to 2012, the world achieved a 72% reduction in the risk of a child dying from pneumonia or diarrhea, thanks in part to the introduction of vaccines against rotavirus and pneumococcus and improvements in treatment — both advances supported by diverse public and private organizations, including USAID. Together with its partners, the President’s Malaria Initiative contributed to the significant reduction in malaria mortality rates in children under five in Africa by an estimated 54% between 2000 and 2012.
For USAID, Acting on the Call (AOTC) is a continuous improvement process in the Agency’s drive to end preventable child and maternal deaths (EPCMD). Starting in 2012 with the Call to Action, USAID embraced strategic programming shifts and a bold endgame to help USAID priority countries reach parity with more developed countries in child mortality. In 2012 we estimated that to reach this goal, EPCMD countries would need to achieve an average annual rate of reduction (ARR) of under-5 deaths of 4.1 percent. Between 2012 and 2015, we have achieved an ARR in our countries of 3.6 percent, indicating a need for further progress. Despite the need for additional work, some countries are on track to meet these expectations. Based on country specific target ARRs, Bangladesh, India, Indonesia, Malawi, Nepal, Rwanda, Senegal, Tanzania, and Uganda are on track to achieve the SDGs under-5 mortality target of 25 child deaths per 1,000 live births by 2030.