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A world where children everywhere live beyond the age of five

It is likely that 90 countries, 53 of them developing nations, could reduce child mortality rates by two-thirds by 2015 if they maintain their current rate of progress. Worryingly, however, 98 developing countries lag behind, finds a new Unicef report

In a world where the quality of one's life depends largely on where one is born, a child's chances of survival are no different. In industrialised countries, only seven children out of 1,000 die before their fifth birthday. This number rises to 97/1,000 in South Asia and 174/1,000 in sub-Saharan Africa . As the globe's two most populous regions, the latter two are where most of the world's children live, and die

'Progress for Children: A Child Survival Report Card', brought out by Unicef in October 2004, measures global and region-wise progress towards achieving the fourth Millennium Development Goal (MDG) that aims to reduce under-five child deaths by two-thirds between 1990 and 2015.

While children born today are less than half as likely to die before the age of five, than those born in the 1960s, stark regional differences in the under-five child mortality rate persist. Also, while much progress has been made towards decreasing under-five child deaths in the last 40 years, from one in five globally in 1960 to one in 12 in 2002, the continuing seriousness of the problem is evident from the fact that this still represents 11 million preventable child deaths annually.

It was to address this concern that one of the Millennium Development Goals -- adopted by the United Nations in 2000, to be reached by the world in 2015 -- was to achieve a two-thirds reduction in the number of child deaths in 1990. That is, from the 1990 figure of 93/ 1,000, world governments would work to cutting under-five child deaths to 31/1,000.

The setting of MDG 4 meant an annual average reduction rate (AARR) of 4.4% in the under-five mortality rate (U5MR) each year between 1990 and 2015. When the target was set late in 2000, it was already evident that countries that had faltered in the 1990s would need to intensify their efforts at reducing child deaths between 2000 and 2015 -- in some cases doubling the AARR if they were to have a chance of meeting the goal.

2002 marks the mid-way point of the MDG target period (1990-2015). It is also the year for which the latest U5MR serves well as a reference for assessing progress made in achieving MDG 4.

Overall findings

It is likely that 90 countries, 53 of them developing nations, could reduce child mortality by two-thirds by 2015 if they maintain their current annual reduction rate. But 98 developing countries lag behind.

There are wide regional variations in reducing U5MR worldwide . While the rate of children dying before the age of five fell by over a third in Latin America and the Caribbean , between 1990 and 2002, in sub-Saharan Africa , where almost half of under-five deaths occur, there has been only slight progress in reducing the rate. The disturbing truth is that one out of every six children born in sub-Saharan Africa dies before the age of five, compared to one out of every 29 children in Latin America and the Caribbean, and one out of every 143 children in industrialised countries.

Countries currently on schedule to reduce under-five mortality by two- thirds between 1990 and 2015
  Armenia Austria
Bahamas Bangladesh
Bhutan Bolivia
Brunei Darussalam


Czech Republic


Dominican Republic







Islamic Republic of Iran


Libyan Arab






New Zealand







Republic of Korea





Although steady progress has been made in Central and Eastern Europe and the CEE/CIS, South Asia, East Asia and the Pacific since the early 1990s, it has been at an average annual reduction rate that will fall short of ensuring that MDG 4 is met. Unicef estimates that, at present rates, under-five mortality will be reduced by approximately 23% globally over the 1990-2015 period -- well below the goal of a two-thirds reduction.

With developed countries accounting for 37 of the 90 countries that are on target, efforts to reduce under-five mortality in developing countries will need to intensify if the 2015 global target is to be met. The global AARR will have to reach 7.5% (up from the original AARR of 4.4% implied by the 25-year target), and stay at that pace in the 2002-2015 period.

Countries where the und  er-five mortality rate has increased since 1990



Côte d'Ivoire  






South Africa  






Poor neonatal and perinatal care is the single most prominent cause of young deaths, at 23%, followed by infectious and parasitic diseases, particularly in developing countries. Acute respiratory infections (18%) and diarrhoea (15%) together are at the root of approximately one-third of child deaths. Significant progress has been made in reducing measles deaths, and the goal of decreasing them by half by 2005 is likely to be met. However, measles still accounts for around 5% of child deaths.

With HIV/AIDS on the rise, as evidenced by the increasing number of children orphaned by the epidemic -- most visibly in sub-Saharan Africa -- and only modest inroads achieved in countering malaria, which accounts for more child deaths than HIV/AIDS, at 10%, the threats facing young children's chances of survival are as serious as ever. Malnutrition is a major health issue concerning under-five children -- it contributes to 54% of all child deaths worldwide.


Countries where the under-five mortality rate has remained the same
since 1990





Central African Republic

Democratic People's Republic of Korea

Democratic Republic of Congo







Russian Federation

Sao Tome and Principe



United Republic of Tanzania



Region-wise progress towards achieving MDG 4

Sub-Saharan Africa : Efforts must double

Sub-Saharan Africa is home to 42% of the world's children who die before they are five. A ccording to the Unicef report, the AARR in this region has slowed sharply, falling from 1.3 in 1960-1990 to just 0.3% in the 1990-2002 period. In 18 countries in the region, the under-five mortality rate has either stayed the same or worsened since 1990.

While poor perinatal conditions remain the main cause of infants dying in sub-Saharan countries, infections and disease are the main killers of young children. HIV/AIDS is responsible for 8% of under-five deaths in the region, more than double the global average.

Interestingly, the under-five mortality rates in most sub-Saharan countries appear to be less affected by household wealth than in other developing regions. This is in part explained by high levels of absolute poverty still prevailing in these countries, which translate into lack of adequate and essential services at the household level, and lack of health infrastructure and basic resources. However, children born into the poorest 20% of the population are 1.7 times more likely to die before the age of five than the wealthiest 20%, with an under-five mortality rate of 80 deaths per 1,000 live births (181 vs 100 respectively).

Sub-Saharan Africa faces the greatest challenge of any region in meeting MDG 4. The region will need to raise its AARR to 8.2% -- almost double the rate originally required -- if it is to make the 2015 target.

Sub-Saharan Africa: Countries where child mortality has stayed the same or risen, 1990-2002






Côte d'Ivoire

Democratic Republic of the Congo



Central African Republic



Sao Tome and Principe

South Africa


United Republic of Tanzania



South Asia : Falling behind

Every one of the nine countries in South Asia has made progress in reducing child mortality rates since 1990. But some still struggle to attain the required pace of reduction. In many cases, progress made in the 1990s has not been sustained into the next decade, in this region, says the Unicef report.

India's 1 billion-plus population, together with young and large populations in Bangladesh and Pakistan, means that the region has the world's second largest child population. However, of the three countries, only Bangladesh , with a lower rate of child mortality than either India or Pakistan , is on track to meet MDG 4. It reduced under-five deaths to almost half of its 1990 level by 2002, at an average annual rate of reduction of 5.2%.

In contrast, India and Pakistan lag behind with a slowdown in child mortality reduction in the 1990s. India must accelerate its annual rate of reduction to over 6% to meet MDG 4. For Pakistan the required rate is 7%.

Of the remaining countries in the region only Bhutan is on schedule to meet MDG 4, while Nepal is not far behind. The Maldives and Sri Lanka will have to intensify their efforts. Child mortality in Afghanistan remained virtually unchanged in 2002 compared with 1990, and although the situation is likely to have improved in the past year, the country is still facing the daunting challenge of reducing child deaths by 8% a year to achieve MDG 4.

Poor perinatal care is the leading cause of children under five dying in South Asia -- at 30% it accounts for almost one-third of all deaths. Acute respiratory infections (20%) and diarrhoea (18%) are the other main killers. In proportionate terms, diarrhoea as a single cause of child deaths is at its worst in the South Asian region. According to the latest available statistics, HIV/AIDS is not yet a major cause of child mortality in the region; only 1% of deaths are linked to the disease.

The Middle East and North Africa : A mixed picture

While most countries in this region will meet MDG 4, eight are falling behind, according to the Unicef report. Almost two-thirds of the 21 countries in the Middle East and North Africa were on schedule to meet MDG 4 as of 2002. Five North African countries ( Algeria , Egypt , Libyan Arab Jamahiriya, Morocco and Tunisia ) have demonstrated significant reductions in under-five mortality in the 1990s, averaging an impressive annual reduction rate of 6.6%.

Each has made substantial progress in providing services to the population to:

  • Reduce levels of malnutrition to below 10%.
  • Increase coverage of water and sanitation to above 80%.
  • Increase immunisation coverage to 90% of children, with three doses of diptheria, polio and typhoid vaccine and more than 80% of children vaccinated against measles.
  • Provide antenatal care during pregnancy and skilled attendants at delivery.

Of the eight countries falling behind, three -- Bahrain, Jordan and Lebanon -- have an under-five mortality rate of less than one child in 30, compared with the regional average of one child in 17. By contrast, reductions in Sudan and Yemen are less than 2.5%.

In three countries of the region -- Djibouti , Iraq and Yemen -- one in every 10 children dies before the age of five. All three, especially Iraq, will need to increase their efforts markedly to meet MDG 4.

East Asia and the Pacific region: Worrying slowdown

The East Asia and Pacific region has cut child mortality rates by over 75% since 1960. But the momentum has slowed.

At present, only 43 children out of every 1,000 live births do not reach their fifth birthday, tantalisingly close to the MDG of a 31/1,000 under-five mortality rate. Unlike Latin America and the Caribbean, however, the momentum of reduction has slowed sharply over the past two decades. Between 1980 and 2000, the annual reduction rate averaged just 2.8%, compared with almost 5% in the 1960s and 1970s.

The slowdown mostly reflects trends in China. At 39/1,000 live births, China's child mortality rate is half the global average and below any regional average apart from Latin America and the Caribbean . However, in the past two decades, progress on reducing child mortality has slowed sharply and was less than 2% during the 1990s. In contrast, under-five mortality has fallen rapidly in Indonesia , the second most populous country in the region. Indonesia managed to halve its infant mortality from 91/ 1,000 live births in 1990 to just 45/1,000 in 2002, a level approaching China's rate for the same year. Indonesia remains on schedule to meet MDG 4.

Other than Indonesia , the best performing countries in the region, over the past decade, have been countries that enjoyed the lowest levels of child mortality in 1990 -- Brunei Darussalam, Malaysia , Republic of Korea and Singapore . Their success is all the more impressive given the relatively low starting base and sharp constraints on public finances imposed by the Asian financial crisis of 1997-1999. All four countries have managed to reduce their child mortality rates to levels comparable to those in industrialised nations.

The Philippines also remains on schedule to meet MDG 4 having cut its child mortality rate by 40%. Greater efforts to lower child mortality are required in the Pacific islands, as all of them are falling behind the MDG target. Cambodia , where one in every seven children does not reach the age of five, is sadly the only country in the region that has seen an increase in child mortality since 1990. Progress has also been slow in other countries with high child mortality rates such as Myanmar and Papua New Guinea, and has stagnated in the Democratic People's Republic of Korea .

Central and Eastern Europe and the Baltic states : Most will not
achieve MDG 4

With only eight exceptions, most countries from the region comprising Central and Eastern Europe, the countries of the former Soviet Union and the Baltic states will not meet MDG 4.

Through the 1990s, the average annual rate of reduction slowed to 1.3% -- far below the 3.6% recorded in industrialised countries. Indeed, the region only managed to reduce its child mortality rate by seven points between 1990 and 2002, from 48 to 41. This contrasts sharply with the 20-point reduction in Latin America and the Caribbean .

Child mortality rates are notably higher in the countries of Central Asia than in those of Central and Eastern Europe . The probability of a child dying before the age of five is three times more likely in Central Asian countries than in Central and Eastern Europe .

Only Albania, Armenia, Croatia, Lithuania, Romania, Serbia and Montenegro, the former Yugoslav Republic of Macedonia and Turkey are on target. All other countries in the region are behind schedule on the child mortality MDG.

The Russian Federation , the largest country in the region, with relatively low levels of mortality, has nonetheless barely made any advances in further reducing child mortality over the past decade. In contrast, Turkey has made impressive advances, almost halving its under-five mortality rate.

Latin America and the Caribbean region: Almost home

Progress in reducing child deaths in Latin America and the Caribbean has been substantial in the past 40 years. In 1960, 153 out of every 1,000 children in the region did not make it to their fifth birthday. By 2002 that figure was drastically reduced to 34. Unlike most other regions, Latin America and the Caribbean were able to maintain a steady pace of reduction during the 1990s, posting an annual reduction rate of 4% over the course of the decade. No other region managed to maintain an average annual reduction rate of 3% or above in that period.

Despite these advances, there is still much work to be done to reach levels approaching those of industrialised countries where the probability of a child dying before the age of five is less than 1%.

Brazil , the country with the largest child population in the region, is on schedule to meet MDG 4, having managed to reduce child deaths by just under 4.3% between 1990 and 2002.

Although Mexico's average annual rate of reduction was smaller, at 3.8%, it was from a lower base, leaving the under-five mortality rate at just 29 per 1,000 live births -- the lowest rate among developing countries with populations in excess of 100 million. If this rate is maintained, Mexico will meet MDG 4.

The countries of Central America (with the exception of Costa Rica ) and the impoverished countries of northern South America, Guyana and Suriname are among those with the highest rates of child mortality in the region. Infant mortality is also high in Bolivia, despite the fact that it remains on schedule to meet MDG 4.

Haiti is the only country in the region where child mortality is greater than 1 in 10. Progress on reducing child deaths stalled in Jamaica during the 1990s. The country, which suffered a prolonged recession, is the only one in the hemisphere that failed to register a reduction in under-five mortality rates. Without a near doubling of effort, it will not meet MDG 4.

Industrialised countries: Room for improvement

Industrialised countries have achieved substantial reductions in child mortality since 1990 -- from one in 100 children dying before reaching the age of five then, to one in 143 by 2002.

Among them, Scandinavian countries enjoy the lowest rates of child mortality. The under-five mortality rate of 20 of the 36 industrialised countries is double that of the best-performing country, Sweden, where the rate is just three out of every 1,000 live births. By contrast, in Hungary , Poland and Slovakia , child mortality rates are conspicuously higher than the region's average.

Some industrialised countries still have work ahead of them to further reduce their under-five mortality rates. Yet for those countries with the lowest mortality rates, the specific goal of reducing levels of under-five mortality by two-thirds may not need the same emphasis.

The steady decline in mortality rates in the industrialised countries during the period 1990-2003 has been aided by new and costly medicines, technology, and interventions. This is in sharp contrast to the situation in developing countries that are still struggling to control many preventable causes of mortality, including communicable diseases, maternal and perinatal conditions and nutritional deficiencies, violence and injuries.

InfoChange News and Features, November 2004