Why equitable progress is critical to end preventable child deaths

A newborn baby at a health clinic in Uganda.
A newborn baby at a health clinic in Uganda. Uganda has demonstrated that equitable progress in tackling child mortality is possible. (photo: Sylvia Nabanoba/Save the Children)

Developing countries as a whole made unprecedented progress in reducing the number of children dying in the past two decades. But big disparities in children’s survival chances persist in most of those countries – as documented by Save the Children’s recent The Lottery of Birth report. What’s more, in far too many countries these inequalities are widening: only a fifth of all countries are experiencing a fall in inequalities between all major social and economic groups.

Persistent or rising inequalities are unacceptable from a moral point of view. But they also make the objective of eliminating preventable child deaths globally a more remote possibility. Pursuing equitable progress is, then, a critical precondition for future progress.

So, what is equitable progress in reducing child mortality?

Put simply, equitable progress implies that all groups experience a similar rate of progress. The most disadvantaged groups – those from the poorest families, in rural areas, from ethnic minorities or living in remote regions – experience at least the same reduction in child mortality as other more advantaged groups, and are even able to catch up with them. In short, equitable progress captures the essence of the ‘Leave No One Behind’ principle, which is part of the discussions about the post-2015 framework of global development goals.

Evidence from our newly developed group inequality dataset (GRID) indicates that so far not many countries have achieved equitable progress. Take Nigeria, which accounts for 13% of all under-five deaths. Between 1999 and 2013 child mortality fell by only 2.9% a year here in rural areas and by 4.5% a year in urban areas. As a result, the absolute gap in child survival odds has widened (figure 1).

What’s more, had the progress been equitable – ie, if child mortality in rural areas had also fallen by 4.5% a year – by 2013 the probability of rural children dying before their fifth birthday would have been 108 per 1,000 live births, instead of 136/1000. That would have meant 127,000 fewer rural children would have died in 2013 alone.

Figure 1. Under-five child mortality trends in urban and rural areas in Nigeria

Nigeria_graphEquitable progress matters because, unless narrowed, this disparity will continue to exert excessive death toll on rural children in Nigeria. A simple linear projection shows that if the current rates of progress for the two groups continue unabated, by 2030 rural children’s risk of early death will still be high – 82/1,000. That’s more than three times the threshold of 25/1000, proposed as a post-2015 target to indicate that countries are on the path to end preventable child death. In real numbers this means 410,000 deaths of rural children in 2030 alone.

But if rural areas experience the same progress as urban areas have, the rural child death rate would decrease to 62/1,000 by 2030, reducing the death toll that year by 100,000.

To be sure, even this rate would be unacceptably high – Nigeria needs to step up several gears in order to eliminate preventable child deaths in rural, as well as urban locations. But as this example shows, reducing inequalities should be at the heart of these efforts.

Is equitable progress in reducing child mortality plausible?

Let’s look at Uganda as an example. Between 2000 and 2011 Uganda made significant progress in reducing child mortality – by 5% a year in urban areas and by 6% in rural locations. As a result, the urban mortality rate fell from 95/1,000 to 54/1,000 and rural mortality halved from 154/1,000 to 77/1,000 (figure 2).

If these trends continue, by 2030 the disparity between urban and rural areas will be minimised and the child mortality rate will be below the post-2015 target of 25/1,000 in both types of location.

Of course, that progress is due to high rates of reduction in both areas. But it’s also due to equitable progress. Had the rural progress rate been even a decimal percentage point lower than the urban one, by 2011 the rate would have been 88/1,000 instead of 77/1,000, meaning that more than 14,000 more children would have died in that year alone. What’s more, preventable child deaths in rural locations would still persist in 2030, at a rate of 34 under-fives’ deaths per 1,000 live births.

Figure 2. Under-five child mortality trends for urban and rural groups in Uganda


Is the example of Uganda a rare exception, and therefore not generalisable to other countries? The answer shown in Lottery of Birth report is a resounding no. Evidence from a diverse range of countries clearly indicates that equitable progress is possible in any setting. Countries where progress has been both fast and equitable include low-income Malawi, upper-middle income Peru, relatively egalitarian Egypt, and highly unequal Zambia.

We should emphasise here something that’s obvious but critical: equitable progress does not occur by accident – it requires effective public policy measures by national governments and the donor community.

Drawing on the experience of successful countries where progress in reducing child mortality has been both fast and equitable, the Lottery of Birth identifies multiple measures that are relevant for all developing countries, ranging from the progressive realisation of universal right to healthcare to supporting women’s and girls’ empowerment. Designing and implementing these measures will no doubt be a challenging and lengthy process, but setting equity in child survival as one of the cross-cutting development objectives would be the right starting point for any developing country.


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