The year 2015 is crucial for policy discussions about child survival, not only because it is the target year for final reporting on the Millennium Development Goals (MDGs), but also because it is the year in which stakeholders are coming together to agree on the post-2015 agenda. In 2000, world leaders agreed on the MDGs and called for a two-thirds reduction in the under-5 mortality rate (U5MR) between 1990 and 2015—known as the MDG 4 target.1 In recent years, global momentum and investment to accelerate gains in child survival have increased. During the UN MDG Summit in September, 2010, UN Secretary-General Ban Ki-moon launched Every Woman Every Child,2 an unprecedented global movement to mobilise and intensify international and national action by governments, international agencies, non-governmental organisations, the private sector, and civil society to address the major health challenges facing women and children around the world. In June, 2012, world leaders renewed their commitment during the global launch of Committing to Child Survival: A Promise Renewed (APR),3 aiming for a continued post-2015 focus to end preventable child deaths, and with a target U5MR of 25 or fewer deaths per 1000 livebirths by 2030 or 20 or fewer deaths per 1000 livebirths by 2035 for all countries. The international community is in the process of agreeing on a new framework, known as the Sustainable Development Goals (SDGs), that will guide and motivate future global and national action. They seek to build upon the foundation laid by the MDGs, not only completing unfinished business but also working towards setting ambitious new goals that will constitute an integrated and indivisible set of global priorities for sustainable development.4 Ending preventable deaths of newborn babies and children younger than 5 years by 2030, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 livebirths and under-5 mortality to at least as low as 25 deaths per 1000 livebirths, has been proposed as an SDG target under goal 3, which seeks to ensure healthy lives and promote wellbeing at all ages.5
Research in context
Evidence before this study
Nationally representative high-quality data for mortality of children younger than 5 years are available at regular time intervals from vital registration for only about 60 countries. For the rest of the world, knowledge depends on data from population censuses, household surveys, and sample registration systems. All publicly available data for under-5, infant, and neonatal mortality are compiled annually by the UN Inter-agency Group for Child Mortality Estimation (UN IGME) to improve monitoring of progress towards child survival goals and to enhance the capacity of countries to produce timely estimates of child mortality. The UN IGME global database before this study contained about 16 000 observations with meta-information from 1950 (or earlier) to 2013 available as of July, 2014. The UN IGME uses this information to produce annual updates, typically released in September, of neonatal, infant, and under-5 mortality rates and trends for 195 countries or areas.
Added value of this study
This study provides estimates of under-5 mortality up to the Millennium Development Goal (MDG) target year (2015) and constructs scenario-based projections from 2016 to 2030 to provide insights into the burden of under-5 deaths in the next 15 years. This study extended the existing UN IGME global database by including 5700 new or updated observations and also incorporated updated HIV/AIDS estimates from UNAIDS and revised population numbers from the UN Population Division. On the basis of this empirical database and updated demographic inputs, we constructed country-specific under-5 mortality rate estimates for 195 countries from 1990 (or earlier) to 2015 to assess levels and trends in child mortality and to monitor progress in child survival. These estimates were constructed with the Bayesian B-spline bias-reduction model to produce estimates of mortality rates and associated indicators, such as rates of change and aggregate outcomes, with 90% uncertainty intervals.
Implications of all the available evidence
Although great progress in reducing child mortality has been made since 1990 (more than two-thirds of 195 countries have at least halved their under-5 mortality rate from 1990 to 2015) progress has been insufficient worldwide to achieve MDG 4, which requires a two-thirds reduction in the under-5 mortality rate. Without any acceleration in the pace of reduction in child mortality as compared with country-specific rates of decline in 2000–15, 68·8 million children will die before they reach their fifth birthday in 2016–30. The more ambitious aim of an under-5 mortality rate of 25 or fewer deaths per 1000 livebirths for all countries by 2030 would correspond to substantially fewer deaths in the next 15 years, but requires concerted efforts to enable continued improvements in child survival in countries that have had recent accelerations and moreover, immediate action to accelerate child survival improvements for countries with little progress in the last decades.
Data-driven estimates for child mortality are necessary to track progress towards child survival goals and to plan national and global health strategies, policies, and interventions for child health.6, 7 As opposed to adult or old-age mortality, child mortality is the one indicator that is based on a comparably large amount of empirical data in low-income and middle-income countries,8 which makes it unique from a monitoring perspective. However, the estimation of child mortality is still challenging for the great majority of developing countries without well functioning civil registration systems due to data quality issues. Modelling exercises are usually required to generate reliable and comparable child mortality estimates. With increasing implementation of evidence-based interventions to reduce child mortality, demand is increasing for frequent, accurate, and transparent monitoring.
Many studies have shown that remarkable progress has been made since 1990 to improve child survival but that progress has been insufficient to achieve MDG 4.9, 10, 11, 12, 13, 14, 15 In the concluding year of the MDGs, it is time to take stock of what has been achieved in improving child survival, and to share success stories and learn lessons from failures. It is also essential to look beyond the MDGs to the post-2015 SDGs to identify potential challenges in ending preventable deaths of children younger than 5 years.
In this Article, we estimate levels and trends for child mortality and provide an overview of global, regional, and country-specific progress towards MDG 4. We also present projections of U5MR and the associated numbers of deaths up to 2030 under five scenarios to provide insight into the post-2015 burden of under-5 deaths.