Why is it difficult to solve?
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.
Currently, rapid progress on reducing under-five mortality is hampered by a lack of timely and accurate mortality data. In some low-resource settings, children’s deaths may not be reported to health authorities. If they are reported, an accurate cause of death may not be known or recorded. This information may not be communicated to national authorities in a timely manner. To support evidence-based policymaking, we need to increase and improve the under-five mortality data collected at the local, national, regional, and global levels.
In addition to data challenges, another challenge is connecting poor and vulnerable communities to higher functioning health systems, with a heavy focus on both prevention of disease and provision of quality, people-centered treatment.
Beyond having access to quality care, families must want to receive care and must develop health-seeking behavior when their child is sick. Governments must also improve equity, ensuring that quality care is accessible to all, including rural and other vulnerable, poorly-served communities. Beyond building and staffing health facilities, governments can leverage community health programs to expand the reach of health services, while also ensuring that the care provided is adapted to the culture of the local community.
Indeed, some countries have successfully utilized community health workers to help bridge the gap between vulnerable communities and the formal health system. Examples include Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal. One specific example is Peru’s conditional cash transfer program, Juntos, which helped to establish health-seeking behavior among vulnerable communities.
Lastly, while many of the key interventions for addressing health-related causes of under-five mortality are well-known, it is also imperative to find the most effective and appropriate implementation strategies to deliver these interventions. This involves coordinating donors and partners, using data effectively for decision-making, integrating into existing systems, building local research capacity, and focusing on equity, among other strategies.
The challenge of neonatal mortality:
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).
The number of children who do not live past their first 28 days of life, the most vulnerable time for a child’s survival, accounted for 47 percent of global under-five deaths in 2017 .1 As countries have reduced their under-five mortality, the share of under-five mortality comprised by neonatal mortality is growing.2 For example, Global Burden of Disease analysis indicates that across Central, Eastern, Southern, and Western sub-Saharan Africa, neonatal mortality as a fraction of under-five mortality increased from between 24 to 31 percent in 2000, to between 32 to 41 percent in 2017.3
Percentage of under-5 deaths that are neonatal deaths, 2000–2017
Causes of neonatal deaths can be much more challenging to address. Some causes of neonatal mortality, such as birth defects, currently have no definitive means of prevention. Other causes of neonatal mortality, such as pre-term birth, require higher-level health personnel and equipment that are not readily accessible in low-resource settings.
Neonatal mortality. UNICEF website. https://data.unicef.org/topic/child-survival/neonatal-mortality/. Accessed January 21, 2020.
United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO). Countdown to 2030: Tracking Progress towards Universal Coverage for Reproductive, Newborn and Child Health: The 2017 Report. Washington, DC: UNICEF and WHO; 2017. http://countdown2030.org/pdf/Countdown-2030-complete-with-profiles.pdf.
Institute for Health Metrics and Evaluation (IHME). Probability of death. Seattle, WA: IHME; 2018.