Small World

How Cheap Investments Are Saving the World's Children


Indian schoolboys and girls walking to school at Doeli in Sawai Madhopur, Rajasthan, Northern India, 2011

Photograph by Tim Graham/Getty Images

Indian schoolboys and girls walking to school at Doeli in Sawai Madhopur, Rajasthan, Northern India, 2011

Each year about 15 million parents suffer the loss of a child younger than school-age. On June 14-15, health ministers from more than 80 countries, joined by Secretary of State Hillary Clinton and Unicef Executive Director Anthony Lake, met in Washington and issued a call to action for a global effort to fight child mortality. Their goal is for every country in the world to reduce the number of kids who die before the age of five to less than 2 percent by 2035.

It’s an ambitious goal. The current global average under-five mortality rate is almost 6 percent, and in Sub-Saharan Africa it’s twice that. Achieving the 2 percent goal would involve slashing the number of under-five deaths worldwide by nearly 75 percent each year. And yet there is reason for optimism that such an objective can be realized. That’s because child mortality has reduced progressively during the last two decades, and international development aid had a major part to play in that decline.

According to Unicef the number of under-five deaths has plummeted, from more than 12 million in 1990 to 7.6 million in 2010. Progress has been particularly heartening in Africa. Gabriel Demombynes and Sofia Trommlerova of the World Bank estimate that the proportion of kids across the region who died before their fifth birthday fell more than 4 percent per year from 2000 to 2010. In the five years between 2005 and 2010, under-five mortality in Senegal fell 40 percent.

The reason for all of this progress regarding child health is the increased use of cheap health interventions such as vaccines and insecticide-treated bed nets, which help prevent the spread of malaria by warding off mosquitoes. In Kenya, from 2003 to 2008, the under-five mortality rate dropped from 7.7 percent to 5.2 percent, and Demombynes and Trommlerova suggest that more than half of that decline may be because of bed nets alone.

What lessons can be learned from this success story? One is the undeniable role of development assistance in improving global health—and in particular the effort to use rigorous evaluation to improve the effectiveness of that aid. The number of kids who died as a result of catching measles fell from 477,000 in 2000 to 114,000 in 2010—in large part due to the Global Alliance for Vaccines and Immunizations (GAVI), founded by donors in 2000 to fund vaccination programs in the world’s 70 poorest countries.

Likewise, in the first few years of the new millennium, debate raged in the development community about the efficacy of giving out bed nets. Critics feared that if you handed them out for free, the nets wouldn’t be valued. They pointed to cases where free bed nets were being used in ways that were unlikely to reduce the malaria burden—as a wedding veil, for example. But a series of randomized trials—where bed net distribution was decided by lottery—consistently found that the free nets were used as intended from 60 percent to 90 percent of the time. Those results suggested free bed net distribution would be a powerful and cost-effective weapon in the fight against malaria. Donors responded, and the number of insecticide-treated bed nets in use in Sub-Saharan Africa climbed from 5.6 million in 2004 to 145 million in 2010, according to Unicef.

All of which suggests that meeting the 2 percent child mortality goal by 2035 is not just achievable but affordable. The four most common causes of death among young children are pneumonia, diarrhea, preterm birth complications, and birth asphyxia. Most of these deaths can be easily and cheaply prevented. Cases of pneumonia will decline thanks to a new vaccine, being rolled out with the support of GAVI. Others can be treated with antibiotics. Most diarrhea deaths can be prevented by using an oral rehydration solution—a mixture of salt, sugar, and water. And the mortality rate from both preterm birth complications and birth asphyxia can be reduced with the presence of a skilled birth attendant such as a midwife or a doctor.

Lowering mortality rates, however, is not just a matter of money and technical inputs. It also requires behavior change among parents—vaccinating their kids or increasing skin-to-skin contact with newborns, for example. That kind of change can take time. And yet randomized trials funded by donors have also shown that with the right incentives, such as bags of lentils in return for vaccinations or peer pressure from respected figures in the village regarding behavior around newborn children, behavior can change fast. Countries with the highest child mortality rates have been outperforming long-term trends during the past 20 years already—thanks in part to aid programs.

In an ideal world, child mortality would be as rare in poor countries as it is in rich ones. The good news is, with relatively little aid and a small change in attitude over the next couple decades, that ideal can become reality.

Kenny is a senior fellow at the Center for Global Development and author of The Upside of Down: Why the Rise of the Rest is Great for the West.

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