Progress towards the Millennium Development Goals,1990-2003
GOAL 4 – Reduce child mortality
Goal 4 aims to cut child mortality by two thirds by 2015. Substantial progress towards this goal has been made since 1990 in northern Africa, Latin America/Caribbean and south-eastern Asia, much less in eastern, south-central and western Asia and Oceania.The under-five mortality rate actually increased in 14 countries, nine of which were in sub-Saharan Africa.[1]
There were an estimated 10.8 million under-five deaths in 2001and the world’s poorest countries continue to bear the brunt of these deaths. Four and one half million deaths were in sub-Saharan Africa alone, where 17 per cent of children will not live to see their fifth birthday.[2] And within poor countries, it is the poorest families that fare worst. Vaccination coverage of children of the poorest 20 per cent of population in developing countries has been found to be half that of the richest fifth of the population.[3] In Bolivia, the under-five mortality rate for the poorest fifth of the population is 140 per 1,000 live births compared to 30 in the richest fifth of the population.[4] In Brazil, an infant from the northeastern region has a risk of death that is over five times higher than that of an infant from the more prosperous South.[5]
These are shaming statistics. Most of these millions of deaths could have easily been prevented with modest resources and tested policy interventions. There are safe, inexpensive and effective few treatments for childhood illnesses that are proven lifesavers. Comprehensive immunization against measles could have saved 2.3 million children from death in Africa this decade according to World Health Organization and United Nations Children’s Fund estimates.[6] Indeed, countries that have adopted well-known effective strategies in Africa, including Botswana, Malawi, South Africa and Namibia, have reduced measles deaths to near 0 since 2000.[7]Diarrheal disease kills over 2 million children in developing countries each year[8] but it is well understood that protected drinking water, basic hygiene in the home and cheap oral rehydration solutions could reduce these numbers to a fraction of their present rates. Acute respiratory infections are another big killer, yet they too can be effectively treated with antibiotics. Breastfeeding all babies would save an additional 1.5 million lives each year, according to UNICEF.[9]
Poverty, conflict, lack of education and inadequate health and water and sanitation infrastructures all contribute to these unacceptably high levels of under-five mortality. Children stand a greater chance of dying when mothers do not know how to recognize and treat basic illnesses, cannot afford medicines or the trip to the nearest health centre.
How the indicatorsare calculated / Country data /Child mortality indicators
Progress in achieving this goal is assessed by tracking levels of under-five mortality rates—the number of under-five deaths per 1,000 live births—and coverage of children immunized against measles, the leading cause of deaths among the vaccine-preventable diseases. Immunization coverage is measured by the percentage of children 12-23 months who have received at least one dose of vaccine.
Target 5 - Reduce by two thirds, between 1990 and 2015, the under-five mortality
Under-five mortality
More than ten million children under the age of five die each year and 99 per cent of them are in developing countries. Levels of under-five mortality vary widely across countries—from 4 to over 300 deaths per 1,000 live births, with the latter being equivalent to over 30 per cent of children dying before reaching the age of 5. Under-five mortality accounts for the major part of mortality of children under the age of 18 (over 90 per cent, worldwide).
Table 14. Under-five mortality rate, 1990-2001Deaths per 1,000 live births
Region / 1990 / 2001 / Change (%)
Developed regions
/ 13 / 9 / -31Developing regions
/ 102 / 90 / -12Northern Africa / 88 / 43 / -51
Sub-Saharan Africa / 176 / 172 / - 2
Latin America/Caribbean / 54 / 36 / -33
Eastern Asia / 44 / 36 / -18
South-central Asia / 125 / 95 / -24
South-eastern Asia / 77 / 51 / -34
Western Asia / 70 / 62 / -11
Oceania / 85 / 76 / -11
Source: United Nations Statistics Division,“World and regionaltrends”,Millennium Indicators Database, available from (accessed December 2003);based on data provided by United Nations Children’s Fund and World Health Organization.
Chart 5. Countries where more than 15 per cent of children die before age five
Under-five mortality rate per 1,000 births, 2000
Sierra Leone / 316
Angola / 295
Niger / 270
Afghanistan / 257
Liberia / 235
Mali / 233
Somalia / 225
Guinea-Bissau / 215
DR Congo / 207
Zambia / 202
Mozambique / 200
Burkina Faso / 198
Chad / 198
Burundi / 190
Malawi / 188
Rwanda / 187
Nigeria / 184
Mauritania / 183
Central African Rep / 180
Guinea / 175
Ethiopia / 174
Côte d'Ivoire / 173
Tanzania / 165
Equatorial Guinea / 156
Benin / 154
Cameroon / 154
Source: United Nations Statistics Division,“World and regionaltrends”,Millennium Indicators Database, available from (accessed December 2003);based on data provided by United Nations Children’s Fund and World Health Organization.
Five diseases—pneumonia, diarrhea, malaria, measles, and HIV infection—account for over 50 per cent of these deaths. Malnutrition is a contributing factor in over 60 per cent of cases. More than one in five deaths among children under five occur during the first week of life, mostly due to malnutrition of the mother and fetus leading to low birth weights, and compounded by poor antenatal care and lack of skilled birth attendants.
Regional estimates of under-five mortality in 2001 vary from a low of 9 per 1,000 live births for developed countries to a high of 172 per 1,000 live births in sub-Saharan Africa.
Progress during the decade has been uneven. The largest reduction in child mortality was achieved in northern Africa, where the rate in 2001 was less than half the rate estimated for 1990. There was also significant progress in south-eastern Asia, Latin America and the Caribbean, and developed regions—where child mortality in 2001 was about 30 per cent less than in 1990.
But the region with the highest level of child mortality, sub-Saharan Africa, experienced the smallest reductions over the 1990s—only 2 per cent. For a small number of countries in sub-Saharan Africa with high levels of HIV infection this can be attributed, to some extent, to AIDS deaths due to mother-to-child transmission of HIV. For most countries, however, progress in reducing child deaths has also slowed because of inadequate efforts to reduce malnutrition and inadequate interventions to address child mortality from diarrhea, pneumonia, vaccine-preventable diseases and malaria.
Nearly half of all under-five deaths occur in sub-Saharan Africa. Thus a major improvement in reducing under-five mortality must occur in sub-Saharan Africa in the next several years if the target is to be achieved.
Measles immunization
Measles is the leading cause of death among vaccine-preventable diseases. It affects nearly 30 million children[10] and killed over half a million in 2000.
Immunization is essential to any hope of reducing these deaths. Over the period 1999-2001, overall estimated measles immunizationcoverage remained unchanged at about 71 per cent. However, estimates indicate that levels of coverage changed considerably across regions. Immunization coverage decreased in eastern and in south-eastern Asiawhile it remained stable at above 90 per cent in Latin America and the Caribbean. Coverage remains very low in sub-Saharan Africa and south-central Asia—58 and 61 per cent respectively—with very little progress over the decade. Coverage will require substantial improvement if measles mortality is to be reduced in a sustainable manner in these regions.
Table 15. Percentage of children immunized against measles, 1990-2001Region / 1990 / 1999 / 2001
Developed regions
/ 83 / 91 / 91Developing regions / 72 / 69 / 70
Northern Africa / 85 / 94 / 93
Sub-Saharan Africa / 57 / 52 / 58
Latin America/Caribbean / 77 / 92 / 91
Eastern Asia / 98 / 84 / 79
South-central Asia / 59 / 57 / 61
South-eastern Asia / 72 / 80 / 73
Western Asia / 80 / 86 / 90
Oceania / 69 / 60 / 64
Source: United Nations Statistics Division,“World and regionaltrends”,Millennium Indicators Database, available from (accessed December 2003);based on data provided by United Nations Children’s Fund and World Health Organization.
In May 2001, during the United Nations Special Session for Children, all member States endorsed a measles mortality reduction goal of 50 per cent compared to deaths in 1999.[11] Since the Special Session, special efforts are being made to reduce measles mortality, particularly in 45 priority countries that account for 94 per cent of all measles deaths. Most of these countries are in south-central Asia and sub-Saharan Africa. In particular, comprehensive immunization, with two opportunities for immunization, is important and a proven life-saver. It is estimated that implementing such a strategy would require an additional investment of $200 million. The scheme launched by the United Nations Special Session for Children has meant that, to date, in 21 of the 45 priority countries, nationwide campaigns to ensure a second opportunity for measles immunization have been either fully or partially completed.
An agenda for change
Child mortality rates have been reduced by just a little over 10 per cent during the 1990s. This means that for the goal to be achieved, the pace of progress will need to increase significantly. Yet, many of the therapies and medicines needed to combat childhood diseases exist. What is needed is better access to them, coupled with systemic reform of health facilities and the delivery of care, especially in rural areas.
The severity of many childhood illnesses can be reduced, or eliminated altogether, through prevention. These include immunizations, supplements for micro-nutrient deficiency (Vitamin A, iron, zinc, iodine), and breastfeeding. These interventions are not only successful, they are also among the most cost-effective available.[12] Deficiencies in zinc, iron and Vitamin A, are estimated to claim more than 500,000 lives each per year.[13]
A strategy to reduce child mortality rates needs to consider both the specific diseases that threaten children’s lives as well as the functioning of health systems as a whole.
Acute respiratory infections (ARI), primarily pneumonia, kill nearly 2 million children under the age of five in developing countries every year.[14] In total, they account for about 18 per cent of under-five mortality. Effective treatment from oral antibiotics can help preventing bacterial infections which is the primary cause of pneumonia in countries with high child mortality.[15] A key problem for many poor families in developing countries is getting to health facilities fast enough as young children get dangerously sick very quickly with ARI. However, data from 29 countries show that fewer than half of children with such infections are taken to health care providers. In West Africa, the problem is even more acute as fewer than one third are taken to such providers.[16]
Malaria kills at least 1 million people per year, with about 90 per cent of global malaria deaths occurring in sub-Saharan Africa. Some 90 per cent of all malaria deaths in sub-Saharan Africa are children 0-4 years.[17] Young children are particularly vulnerable as they have not developed some of the immunity that comes with repeated infections. This makes it even more important that children and pregnant women receive preventive treatment as well as access to anti-malarial drugs if they develop the disease. In particular, treatment in combination can help where resistance to anti-malarial drugs is widespread. Insecticide-impregnated bed-nets, especially in high-risk areas, are a key preventive treatment. Trials in several countries have shown these can lead to an overall reduction in childhood death rates from malaria of 35 per cent.[18]
During 2002, an estimated 720,000 babies became infected with the HIV/AIDS virus, transmitted mainly through pregnancy or childbirth and breastfeeding.[19] Providing treatment with anti-retrovirals can be effective in reducing mother-to-child transmission of the virus but these drugs are far from being available to all. The fact that women represent an increasingly large proportion of HIV/AIDS infections makes it imperative that childcare be integrated with the reproductive health of mothers.
Many sick children in poor countries are suffering not just from one disease but several. For instance, inadequate access to food can increase the risk of respiratory and diarrheal infections, which in turn can lead to an increase in malnutrition. And children suffering from measles are particularly susceptible to pneumonia.[20]
Treating the overall health status of children in an integrated manner, rather than focusing solely on separate disease programmes can be more effective. This is why in 1992, UNICEF and WHO developed the Integrated Management of Childhood Illnesses (IMCI).[21]
IMCI seeks to reduce childhood mortality and morbidity by helping to train families to take care of sick children where possible (giving fluids in case of diarrhea, breastfeeding, using bed-nets, improving basic hygiene), and improving the skills of health workers in the wider health system. More than 80 countries have successfully adopted the IMCI into their health systems and more than 40 countries are giving special attention to improving family and community practices as a key way of reaching vulnerable children. There are concerns, however, that IMCI is not realizing its full potential because the health systems that are needed to deliver IMCI are too weak and under-resourced in many poor countries.[22]
Many health systems in poor countries also suffer from lack of investment in facilities in rural areas and weak monitoring of their effectiveness. For instance, in Cambodia, 85 per cent of the population lives in rural areas but only 13 per cent of government health staff lives there. In Angola, 65 per cent of the population is rural but only 15 per cent of health professionals work in rural areas.[23] Clearly, these gaps hurt all sick people but are particularly relevant for small children, who may need treatment faster than adults to prevent death. Providing adequate Incentives to health professionals is another key problem that afflicts health systems in poor countries. Absenteeism and lack of training hamper the efforts to reach poor families. A survey of primary health care facilities in Bangladesh, for instance, found an absenteeism rate of 74 per cent.[24]
The success of a number of very poor countries, however, shows what can be done with effective campaigns to educate families on better health practices. Such campaigns can help to mitigate the problems of poorly functioning health systems. For instance, mass media campaigns in Cuba on the importance of boiling water, immunizations and breastfeeding helped to reduce child mortality rates despite economic crisis and very low incomes. Indeed, Cubahas a gross national product per capita lower than one tenth of that in the United States of America and yet its infant and child mortality rates are the same.[25]
Notes
1
[1]United Nations Children’s Fund, The State of the World’s Children 2003, pp.116-119 (New York, 2002).
[2] Ibid., pp.84-87.
[3]D.R.Gwatkin, “The need for equity oriented health sector reforms”, International Journal of Epidemiology, 2001.30, pp.720-723.
[4]S. Devarajan and R. Reinikka “Making Services Work for the Poor”, Finance and Development, p.48 (September 2003).
[5]C. Victoria, “Potential interventions to improve the health of mothers and children in Brazil”, World Bank and Brazil Ministry of Health (2000).
[6] Global Alliance for Vaccines and Immunization, “Comprehensive immunization strategy can greatly reduce child deaths from measles”, press release (January 7, 2003), available from
[7] Ibid.
[8] WHO Fact sheet N.180, “Reducing mortality from major childhood killer diseases” (September 1997), available from
[9] UNICEF, “Facts for life: breastfeeding”, available from
[10] Global Alliance for Vaccines…, op cit.
[11]
[12]World Health Organization, World Health Report 2002 (Geneva, 2002).
[13] Ibid.
[14] UNICEF, The Progress of Nations 2000, available from
[15] WHO, “WHO’s contribution to the report for the follow-up to the World Summit for Children. In preparation for the United Nations General Assembly Special Session for Children”, September 2001, p.7.
[16] UNICEF, “The Progress of Nations…, op cit.
[17] WHO/UNICEF, The Africa Malaria Report 2003, p.17 (WHO/CDS/MAL/2003.1093, Geneva, 2003).
[18] WHO Fact sheet N.180 (Geneva).
[19] UNICEF, “Prevention of parent-to-child transmission of HIV/AIDS”, available from
[20] WHO Fact sheet N.180 (Geneva).
[21]
[22] WHO, “The multi-country evaluation of IMCI effectiveness, cost and impact: Progress report, May 2001-April 2002”, available from
[23]S. Mehrotra, and E. Delamonica, Public spending for the poor: basic services to enhance capabilities and promote growth (Oxford University Press, Oxford, forthcoming), cited in United Nations Development Programme, Human Development Report 2003, p.99 (Oxford University Press, Oxford, 2003).
[24] Devarajan et. al.
[25]R. Garfield, Responding to sanctions: Comparison between Iraq and Cuba, p.8 (New York, ColumbiaUniversity,March 15, 2003).
How the indicators are calculated
Under-five mortality rate
The under-five mortality rate is the probability (expressed as a rate per 1,000 live births) of a child born in a specified year dying before reaching the age of five if subject to current age-specific mortality rates. The best source of data for calculating child mortality rates is a complete vital registration system – one covering at least 90 per cent of vital events in the population. However, in developing countries vital registration is often unreliable and incomplete. Estimates must be obtained from sample surveys or derived by applying indirect estimation techniques to registration, census or survey data. Different household surveys, including the Multiple Indicator Cluster Survey 2 and the Demographic and Health Survey, are used. The United Nations Population Division, UNICEF and WHO regularly produce estimates of under-five mortality based on available national data. These estimates, however, may differ as a result of different methodologies used as well as differences in timing for the production and reporting periods of the estimates. Estimates presented in the current report were provided by UNICEF.