Naoko Kozuki
Nov 16, 2017 · 5 min read

Graphics by Holly Dowell, Research Communications Fellow

Data: World Bank

November 20 is Universal Children’s Day.

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Millennium Development Goal #4 set an ambitious target of reducing under-five mortality by two-thirds between 1990 and 2015. Globally, we have made significant strides towards achieving this objective, ultimately cutting under-five deaths by half in that time frame, from 12.7 million in 1990 to 5.9 million in 2015. In fact, 30% of countries met the stated goal, and more than half cut their under-five mortality rates (U5MR) by 50% or more.

Data: World Bank

Unbalanced Progress

We should celebrate the child health community’s tremendous strides over the last few decades; however, progress has not been made evenly.

Despite our collective global advances, six countries still see more than one in ten children die before their fifth birthday, and in 17 countries, their U5MR is more than double the global average.[1]

Somalia has the highest U5MR, with 133 deaths per 1000 live births. That figure is three times higher than the global average (41 deaths per 1000 live births) and 67 times higher than the lowest national rates; Luxembourg, Finland, Iceland, and Slovenia each see only 2 deaths per 1000 live births.[1]

The inequity is not limited to across countries; disparities exist within countries as well. For instance, in Ethiopia’s Affar region, the U5MR is twice the national average (125 vs. 67 deaths per 1000 live births).[3] Similarly in Uganda, the U5MR in the northern region is 1.5 times the national average (122 vs. 90 deaths per 1000 live births),[4] and these data do not capture the possible repercussions of the recent one million-person influx of South Sudanese refugees into that region.

The Gaps: Where, Why, and What To Do

The child mortality burden is disproportionately represented in fragile and conflict-affected situations (FCAS). Thirty-four countries are considered FCAS by the World Bank, representing 18% of the world, yet they account for roughly 50% of the countries with U5MRs above the global average. Seven of the ten countries with the highest U5MRs are classified as FCAS.

There is some concern that key stakeholders may see the global progress in child mortality reduction and disengage from the remaining work to be done. We may already be witnessing consequences of this disengagement; for instance, we have seen decreased funding in key child survival programs like integrated community case management (iCCM) of childhood illness, an equity-focused strategy that delivers treatment for the main killers of under-five children (pneumonia, diarrhea, malaria) in the hardest-to-reach areas. The Global Strategy for Women’s, Children’s, and Adolescents’ Health pushes the global health community to enlarge our vision for child health beyond ending preventable deaths (“survive”) and to incorporate efforts to ensure health and well-being (“thrive”) and expand enabling environments (“transform”). [5] These goals are commendable, but this more holistic vision cannot come at the sacrifice of survival objectives; our work on child survival is not complete. The Global Strategy declares itself to be “universal and applies to all people (including the marginalized and hard-to-reach), in all places (including crisis situations).” For the global health leadership to meet these ambitious objectives, it must assure that child survival is not put on the back burner. It is also crucial for donors like the World Bank that are supporting investments in FCAS to explicitly include child survival on their agenda.

Also, FCAS are a victim of a lack of investment in research to understand what cost-effective, scalable solutions exist to reach the children at highest risk. Fragile contexts are faced with unique health burdens and operational challenges, and only when that evidence gap is acknowledged and filled will we be able to adopt the most impactful strategies. Particularly with the current push for Universal Health Coverage by 2030, health systems research to develop new methods for service delivery in FCAS, which have unique security, geographic, human resource, and other challenges, will be invaluable. Funding and conducting research in these challenging contexts come with inherent risk, but donors, researchers, and implementers need to face the facts — that inequity increases each day and deaths continue to mount by failing to invest in evidence generation in and for these contexts.

The International Rescue Committee is committed to evidence-based programming and evidence generation in FCAS. Our investment in implementation research on community-based child health programming has led us in promising directions like:

We recognize and hope to unlock the potential of community health systems to increase health care access to vulnerable children and strengthen the resilience of communities against onset of crisis.

We urge our partners across the development and humanitarian communities to tackle the growing inequity in child health. By focusing attention and resources on the most vulnerable children, we together can meet the Sustainable Development Goals of ending all preventable under-five deaths and achieving universal health coverage by 2030.


1. UNICEF: State of the World’s Children, 2017. In. New York; 2016.

2. The World Bank, World Development Indicators (2016). Mortality rate, Under-5 (per 1,000 live births). Retrieved from

3. Central Statistical Agency/Ethiopia and ICF International: Ethiopia Demographic and Health Survey 2016. Edited by Central Statistical Agency/Ethiopia and ICF International. Addis Ababa; 2017.

4. Uganda Bureau of Statistics -UBOS- and ICF International: Uganda DHS, 2011. In: UBOS and ICF International. Kampala; 2012.

5. Every Woman Every Child: The Global Strategy for Women’s, Children’s and Adolescents’ Health. 2015.

The International Rescue Committee responds to the world’s worst humanitarian crises, helping to restore health, safety, education, economic wellbeing, and power to people devastated by conflict and disaster. Founded in 1933 at the call of Albert Einstein, the IRC is at work in over 40 countries and 26 U.S. cities helping people to survive, reclaim control of their future and strengthen their communities.

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From the International Rescue Committee’s Policy & Practice team focused on humanitarian reform and effectiveness to achieve better outcomes for people whose lives have been shattered by conflict and disaster. #BetterAid

Naoko Kozuki

Written by

Health Research Advisor @theIRC | working toward a world of healthy mamas, babies, and kids | Assc Faculty @JohnsHopkinsIH | views are my own

Rescue Aid

From the International Rescue Committee’s Policy & Practice team focused on humanitarian reform and effectiveness to achieve better outcomes for people whose lives have been shattered by conflict and disaster. #BetterAid

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