It has been 12 years since world leaders committed to Millennium Development Goal 4 (MDG 4), which sets out to reduce the under-five mortality rate by two-thirds between 1990 and 2015. Only three years remain before the 2015 deadline. The world has made substantial progress, reducing the under-five mortality rate 41 percent, from 87 (85, 89)1 deaths per 1,000 live births in 1990 to 51 (51, 55) in 2011. Correspondingly, the global number of under-five deaths has dropped from nearly 12 million in 1990 to 6.9 million in 2011. This means that about 14,000 fewer children died daily in 2011 than in 1990.
Figure 1. The global burden of under-five deaths has fallen steadily since 1990
Global under-five deaths, millions, 1990-2011
But many more lives can be saved. While the global number of under-five deaths has dropped since 1990, this still translates into nearly 19,000 children dying every day in 2011. Almost two thirds of all under-five deaths are the result of infectious diseases and conditions, such as pneumonia, diarrhoea, malaria, measles and AIDS – deaths which could have been prevented.
Figure 2. Almost two thirds of all under-five deaths are the result of infectious diseases and conditions
Global distribution of deaths among children under age 5, by cause, 2010
Source: CHERG 2012.
At the regional level, all regions have shown progress since 1990. In particular, four regions – Latin America and the Caribbean, East Asia and the Pacific, Central and Eastern Europe and the Commonwealth of Independent States and Middle East and North Africa – have reduced their under-five mortality rates by more than half over the last two decades.
Figure 3. All regions have experienced marked decline in under-five mortality rate since 1990
Under-five mortality rate (per 1,000 live births), 1990 and 2011, by UNICEF region
However, this progress has not been enough, and the target risks being missed at the global level. The global under-five mortality rate needs to be reduced to 29 deaths per 1,000 live births—which implies an annual rate of reduction of 14.2 percent for 2011–2015, much higher than the 2.5 percent achieved over 1990–2011.
Moreover, sub-Saharan Africa and South Asia are lagging behind other regions. These two regions have made the least rapid progress. The highest rates of under-five mortality continue to be in sub-Saharan Africa, where 1 child in 9 dies before age five. As under-five mortality rates and fertility rates have fallen more rapidly elsewhere, the rest of the world’s regions have seen their share of under-five deaths drop from 32 percent in 1990 to just 18 percent in 2011. Combined, the two regions accounted for four-fifths of the global total number of under-five deaths in 2011.
Figure 4. The global burden of under-five deaths is increasingly concentrated in sub-Saharan Africa and South Asia
Percentage share of under-five deaths, 1990-2011, by UNICEF region
* excludes Djibouti and Sudan as they are included in Sub-Saharan Africa
Also, of the 24 countries with an under-five mortality rate of at least 100 deaths per 1,000 live births in 2011, 23 are in sub-Saharan Africa while the remaining one is in South Asia. The significance of sub-Saharan Africa in particular cannot be ignored: By 2050, it is projected that 1 in 3 children will be born in sub-Saharan Africa, and almost 1 in 3 will live there, so the global number of under-five deaths may stagnate or even increase without more progress in the region.
Figure 5. Children in sub-Saharan Africa and South Asia face a higher risk of dying before their fifth birthday
Under-five mortality rate (per 1,000 live births), 2011, by country
At the national level, the burden of under-five deaths is concentrated in a handful of countries, with more than half of all under-five deaths worldwide occurring in just five countries: India (24%), Nigeria (11%), Democratic Republic of the Congo (7%), Pakistan (5%) and China (4%). Some four-fifths of the global under-five deaths in 2011 occurred in only 25 countries.
Figure 6. Half of all under-five deaths occur in just five countries
Share of under-five deaths (percent), 2011, by country
But there are encouraging signs. Globally, the annual rate of reduction in under-five mortality has accelerated from 1.8 percent a year over 1990–2000 to 3.2 percent a year over 2000–2011. In sub-Saharan Africa, the region with the greatest burden of under-five deaths, this rate has doubled from 1.5 percent a year in the 1990s to 3.1 percent over 2000–2011. On the other hand, South Asia has seen its own burden of under-five deaths nearly halving from 4.3 million in 1990 to 2.3 million in 2011 – by far the largest absolute reduction among all regions.
Furthermore, out of the 66 high-mortality countries with at least 40 under-five deaths per 1,000 live births in 2011, 20 have reduced their under-five mortality rates by at least half between 1990 and 2011, with 4 of them achieving at least a two-thirds decline in their under-five mortality rates – Lao People’s Democratic Republic, Timor-Leste, Liberia and Bangladesh. In absolute terms, 10 countries made reductions surpassing 100 deaths per 1,000 live births during the period – Niger, Liberia, Malawi, Timor-Leste, Mozambique, Ethiopia, Zambia, Lao People’s Democratic Republic, Guinea and Rwanda.
Figure 7. Success stories: 20 high-mortality countries have cut their under-five mortality rates by at least half since 1990
Decline in under-five mortality rate (percent), 1990-2011, by country
Many countries have also accelerated their annual rates of reduction over 2000-2011 as compared to 1990-2000. In fact, 51 of the 66 high-mortality countries have experienced an acceleration, with most of the sharpest accelerations taking place in sub-Saharan Africa.
Figure 8. Among high-mortality countries, most of the sharpest accelerations in reducing under-five mortality have taken place in sub-Saharan Africa
Top 10 countries with the highest accelerations in the annual rate of reduction (percent) in under-five mortality rate among high-mortality countries
The fact that some countries have been able to sustain high annual rates of reduction in child mortality over the past two decades with many accelerating their rate of decline in the last decade gives us hope.
The same can be said of the achievements of countries which have reduced their under-five mortality rates to low (10-20 deaths per 1,000 live births) or very low (below 10 deaths per 1,000 live births) levels. In 2011, 98 out of a total of 195 countries attained under-five mortality rates below 20 deaths per 1,000 live births, as opposed to only 53 doing so in 1990. Of these 98, 41 belong to the first category of low-mortality countries and 57 to the second category of very-low-mortality countries.
Some of these countries have proven that is it possible to lower child mortality at a sharp pace, even from high rates, when appropriate interventions are in place. Peru had an under-five mortality rate of more than 100 deaths in 1,000 lives births in 1984, but in just 25 years, it was able to reduce the rate to less than 20 deaths in 1,000 live births. Portugal did the same between 1962 to 1986, within an even shorter period of 24 years. In 2011, it had one of the lowest under-five mortality rates in the world, joining the ranks of Singapore, the Nordic countries, small European countries and Japan.
Figure 9. The world's lowest under-five mortality rates are in Singapore, the Nordic countries, small European countries and Japan
Ten countries with the lowest under-five mortality rates in 2011 (excluding countries with total population of less than 500,000)
While conventional wisdom holds that as under-five mortality rates fall, the pace of decline is likely to slow as it becomes harder to make similar percentage gains on a lower base, the experience of the low- and very-low-mortality countries has countered this truism. The annual rate of reduction of the low-mortality countries during 1990-2011 was 5.6%, while that of the very-low-mortality was 3.7%, outstripping the rate of 2.5% at the global level.
Of the 41 low-mortality countries, twenty-two have succeeded in reducing by more than half their under-five mortality rates from 1990 to 2011. Very-low-mortality countries have generally also achieved substantial progress in this regard. Notable examples include Oman, with a decline of 82% in its under-five mortality rate over this period; Estonia, also with 82%; Saudi Arabia, with 78%, Portugal, with 77%; and Serbia, with 75%.
Indeed, the world as a whole has made great strides since 1990; however, an accelerated rate of progress is still called for as the deadline of 2015 to meet the MDG target approaches. Going beyond 2015, the momentum to improve child survival must be sustained in all regions.
Under-five mortality rate (per 1,000 live births)
|UNICEF Region||1990||1995||2000||2005||2010||2011||Decline 1990-2011 (%)||Annual rate of reduction 1990-2011 (%)||Progress towards the MDG target 2015|
|Sub-Saharan Africa||178||170||154||133||112||109||39||2.3||Insufficient progress|
|Eastern and Southern Africa||162||155||135||112||88||84||48||3.1||Insufficient progress|
|West and Central Africa||197||190||175||155||135||132||33||1.9||Insufficient progress|
|Middle East and North Africa||72||61||52||44||37||36||50||3.3||On track|
|South Asia||119||104||89||75||64||62||48||3.1||Insufficient progress|
|East Asia and Pacific||55||49||39||29||22||20||63||4.7||On track|
|Latin America and Caribbean||53||43||34||26||22||19||64||4.8||On track|
Under-five deaths (thousands)
|UNICEF Region||1990||1995||2000||2005||2010||2011||Decline 1990-2011 (%)||Proportion of under-five deaths worldwide in 2011 (%)|
|Eastern and Southern Africa||1,664||1,702||1,635||1,464||1,221||1,177||29||17|
|West and Central Africa||2,058||2,223||2,245||2,225||2,117||2,096||-2||30|
|Middle East and North Africa||656||529||449||396||360||351||46||5|
|East Asia and Pacific||2,164||1,601||1,274||853||629||590||73||9|
|Latin America and Caribbean||610||502||390||295||238||203||67||3|
Li Liu, Hope L Johnson, Simon Cousens, Jamie Perin, Susana Scott, Joy E Lawn, Igor Rudan, Harry Campbell, Richard Cibulskis, Mengying Li, Colin Mathers, Robert E Black, for the Child Health Epidemiology Reference Group of WHO and UNICEF. “Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.” The Lancet, 9 June 2012 vol. 379, no. 9832, pp. 2151-2161. (CHERG 2012).
The UN Inter-agency Group for Child Mortality Estimation (IGME), Levels and Trends in Child Mortality: Report 2012, UNICEF, New York, 2012.
UNICEF, Committing to Child Survival: A Promise Renewed – Progress Report 2012, New York, 2012.