In a sub-region of this region’€”West and Central Africa’€”this was even higher, at one in six children, according to figures published in The Lancet.

Figures released by UNICEF, based on the work of the Inter-agency Group for Child Mortality Estimation (IGME), show that the overall average annual rate of reduction is much higher from 2000-2008 than it was 1990-2000. However, the rate of decline is still grossly insufficient for the world overall to achieve Millennium Development Goal (MDG) 4.

The latest data, relating to 2008, has heightened concerns that many regions (and countries within them), are not on-track to meet MDG 4, which aims to reduce under-5 mortality by two thirds between 1990 and 2015.

The highest under-5 mortality rates continue to be in Africa, with 132 deaths per 1000 live births across the whole continent. In sub-Saharan Africa, the rate is 144 deaths per 1000 live births. This is 24 times the rate in industrialised countries.

Africa has reduced its under-5 mortality rate by 21% 1990-2008; this is not enough to reach MDG4. Asia has done better, reducing its own rate by 38%; but this is still insufficient to reach MDG4.

The highest numbers of deaths also occurred in sub-Saharan Africa, with 4.4 million children under-5 dying during 2008’€”half of the total world deaths. Due to high fertility in this region, combined with high mortality, numbers of deaths have actually increased from 4.0 million in 1990 to 4.4 million in 2008.

However, the authors highlight that the effect of interventions such as various vaccination programmes and insecticide-treated bednets, may have happened too recently to appear in the estimates.

Some other key findings are:

·                 The estimated global mortality for children under-5 in 2008 is 65 per 1,000 live births, versus 90 in 1990;

·                 Around 8.8 million children under 5 died during 2008, compared with 12.5 million in 1990;

·                 In 2008, around 10,000 fewer children die every day, as compared to 1990 the baseline year for the MDGs;

·                 Together, Africa (51%) and Asia (42%) represented 93% of all deaths globally;

·                 In terms of progress towards MDG4, the best performing region is Latin America and the Caribbean, which has reduced under-5 mortality by 56% between 1990 and 2008, and is on-track to meet MDG4. The region comprising central and eastern Europe (CEE) and the Commonwealth of Independent States (CIS’€”formerly USSR) is also on track, with a 55% reduction 1990-2008;

·                 The only other two regions on track to meet MDG4 are industrialised (high-income) countries (40% reduction 1990-2008) and East Asia and Pacific (48% reduction 1990-2008);

·                 99% deaths occurred in developing countries, with 1% in high-income countries;

·                 Mortality in developing countries (71 deaths per 1000) was 12 times that in industrialised countries (6 per 1000);

·                 Under-5 mortality is increasingly concentrated: 75% of the world’€™s under-5 deaths in 2008 occurred in only 18 countries. Half of the deaths occurred in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan, and China. And India and Nigeria together account for nearly one-third of the total number of under-5 deaths worldwide (21% and 12%, respectively);

·                 At country level, the best performers (based on the average annual rate of reduction among countries with under-5 mortality of 40 or higher) include Nepal, Bangladesh, Eritrea, Lao, Mongolia, Bolivia, and Malawi which have all consistently achieved annual rates of reduction of under-5 mortality of 4 ·5% or higher. Additionally, Niger, Malawi, Mozambique, and Ethiopia have achieved absolute reductions of more than a 100 per 1000 livebirths since 1990.These countries are providing proof of concept that MDG4 is achievable, even in the poorest environments;

·                 Most of the recent survey data incorporated in these estimates generally reflect mortality over the preceding 3’€“5 years. Thus the major improvements in coverage in recent years for insecticide-treated bednets for malaria, prevention of mother-to-child transmission and paediatric HIV, HiB vaccine, and further progress on measles, tetanus, and vitamin A supplementation, for instance, might not yet be fully reflected in these mortality data;

·                 The rate of decline in under five mortality is still grossly insufficient to obtain the goal by 2015, particularly in sub-Saharan Africa and South Asia, and it is alarming to note that among the 67 countries with high mortality rates (40 per 1000 or more), only ten countries are on track to meet MDG 4;

·                 In addition to the countries with highest mortality rates, a renewed focus on high-burden countries with the greatest numbers of deaths is required, such as India, Nigeria, Democratic Republic of the Congo, Pakistan, and China (which make up nearly 50% of all under-5 deaths);

·                 An analysis of countries with the highest mortality levels, or slowest progress, shows that those in conflict or transition are over-represented. Best practices must be adopted in these countries, and donors must prioritise these nations in support programmes.

Dr Danzhen You of UNICEF in New York commented in The Lancet article: ‘€œAccelerated progress can be achieved, even in the poorest environments, through: integrated, evidence-driven, and community-based programmes that focus on addressing the major causes of death, including pneumonia, diarrhoea, newborn disorders, malaria, HIV, and undernutrition; reaching the unreached with a basic package of interventions at large scale and achieving coverage with equity; and using data for action and advocacy.’€