The quiet near-miracle

For almost all of human history, the odds were against children everywhere: in 1800, more than two in five newborns died before the age of five.

The grief of losing a child was still commonplace for our grandparents: in 1950, nearly one child in four died before their fifth birthday.

By 1990, only one child in 11 died. Then progress accelerated. By 2024, the rate had declined to one in 27—the best odds a child has ever had. Ninety-six percent of all children survived past their fifth birthday.

That progress didn’t happen by chance.

It resulted from improvements in science, sanitation, and economic growth. A trained pair of hands assisting at births. Clean water. Antibiotics. Enough food. Vaccines, which on their own have saved an estimated 154 million lives in fifty years.

Reducing child mortality is perhaps the world’s greatest achievement, and it took two centuries of deliberate work.

Then, around 2015, progress slowed sharply.

The latest projections, which factor in deep cuts to health aid, show the decline barely continuing and the goal of ending preventable child deaths by 2030 slipping out of reach.

Uneven odds

Even in the best years, progress has never been even.

Wealthy countries have significantly reduced child deaths. Norway is among the safest places in the world to be born: 2.5 children in 1,000 die before their fifth birthday, compared to a global average of 37.4.

For children living in the poorest countries—particularly those born into the poorest families, rural areas, and places affected by conflict—the risks are much higher.

This is the world Abakar was born into. In Chad, about one child in 10 still dies before turning five, roughly the odds a Norwegian child faced just over a century ago.

Aksel and Abakar arrived at the same moment.

In survival terms, they were born a century apart.

Most of what kills children in the poorest countries can be prevented or treated. That includes infectious diseases like malaria, lower-respiratory infections, diarrhea, and measles. In addition, hunger plays a contributing role in making children weak and susceptible to disease.

None of these causes are inevitable. For each, the odds can be improved to give children everywhere an equal chance to survive and thrive.

Tipping the odds

Some existing solutions can go a long way and cost little.

Vaccines prevent pneumonia, malaria, measles, and rotavirus. Diarrhoea can be countered with rehydration salts and zinc that cost a few cents. For babies born too soon, there is kangaroo care—a parent holding a newborn against their skin—which costs nothing and saves lives.

And new advances could help protect children when they’re most vulnerable: the first month of life. Inexpensive, yet rugged devices are being built for places without big hospitals.

Skin sensors that diagnose newborn jaundice early. Warmers that keep a small baby alive on the way to a clinic. Simple machines that help a struggling newborn breathe. Faster tests for sepsis. Even soft cups that let a baby feed when they cannot breastfeed.

The largest necessary changes are structural. Inadequate public financing for healthcare remains a major problem.

The average person in the poorest countries spends more out of their own pocket on healthcare than their governments or external donors. In contrast, governments in high-income countries spend more than three times what their citizens spend out-of-pocket on healthcare, on average.

In African countries, leaders committed to spend 15% of their budgets on health under the 2001 Abuja Declaration. But health spending has stagnated at around 6% of total budgets.

Fiscal pressures driven by surging debt levels, high costs of capital, and aid cuts add to the challenges governments face in building strong healthcare systems.

Africa takes the wheel

Yet some of the countries with the toughest odds are driving change from within.

Rwanda trained a corps of 58,000 community health workers—four in every village—to treat children where they live. Ethiopia has deployed tens of thousands of salaried health extension workers since 2003.

Since 2000, child mortality in Rwanda has fallen by 80%, from 184 to 38 deaths per 1,000 live births—the largest absolute reduction recorded anywhere in the world. Ethiopia's rate fell from 140 to 45 over the same period, delivered by people trained to keep children alive.

Decisions about Africa’s health are increasingly being made by Africans.

The Africa Centres for Disease Control and Prevention has committed the continent to producing 60% of the vaccine doses it needs on African soil by 2040, up from under 1% today. That ambition is backed by a US$1.2 billion facility that pays African manufacturers on delivery. The necessary infrastructure is being built.

Africa's first mRNA facility—a BioNTech site in Kigali—is due to complete construction this year, with a licence application planned for 2027. Larger facilities are underway in Senegal and South Africa.

Significant progress has been made to reduce child deaths. Yet millions of children still die each year from preventable causes. Finishing the job requires that leaders put child survival at the top of their budgets and plans.

The fifth birthday

Both Aksel and Abakar could grow up: lose their baby teeth, learn to read, and go to school. They could fulfil their ambitions to become a mechanic, a farmer, a doctor, or an entrepreneur.

They might start companies, create jobs, find cures for diseases, make award-winning music that goes global.

All that potential is unlocked at the start of life—with a basic chance to survive and thrive

Humanity has the knowledge and the tools to ensure every child lives beyond their fifth birthday. But we have not yet decided to make those tools available to every child.

Whether we do or not is a choice that leaders can make and their citizens can influence.