Chapter 1:

A chance to survive

The world has made tremendous progress in reducing child mortality. But unless we change course, by 2030, 69 million children will die before reaching their fifth birthdays – most of them from poor countries.

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Kaltum Mallamgrema, 40, at her home in Maiduguri, Nigeria. Three weeks ago, Kaltum lost her eighth child to stillbirth.

When the labour pains came, Kaltum handled the delivery like she had all seven of her previous births: at home, alone.

There was no mad rush to the hospital; no experienced staff standing by, ready to spring into action in the event of a complication; no skilled birth attendant to count the frequency of her contractions or measure the dilation of her cervix. Just an abundance of blood, nausea and the bare concrete walls of her temporary home.

By the time the baby arrived, she was already gone. Kaltum never had a chance to give her daughter a name or cradle her in her arms. She was never able to ask a doctor what went wrong. “It is God’s will”, is all she knows for sure. “We must be patient.” For around 1 million babies born in 2015, their first day of life was also their last.

Many of these babies were born with the odds stacked against them. Children’s deeply unequal chances of surviving their infancy and early childhood depend on a range of factors, including the wealth of their families, whether they’re born in a city or in the countryside, whether they’re born into a majority ethnic or religious group in their society – and whether the country they’re born in is rich or poor.


Despite global progress in reducing deaths of children under 5 since 1990, children born in sub-Saharan Africa, where Kaltum lives, are still 12 times more likely than those in high-income countries to die before their fifth birthday.


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The overwhelming majority of these deaths could be prevented through well known, low-cost and easily deliverable interventions. Regular check-ups make it possible to spot complications early, and address them before they end a child’s – or mother’s – life. Micronutrient supplements help pregnant women stay healthy and give their babies the nutrients they need to develop. Skilled birth attendants and the essential care they provide to mothers and newborns can also dramatically improve prospects for safe delivery and children’s survival in the fragile first month of life when 45 per cent of under-5 deaths occur. But access to these basic services is marked by extreme inequity – and this is one of the main reasons behind the staggering disparities in children’s chances of surviving their early years.

Often, there are simply not enough health providers to reach all mothers and children with these critical services. According to an estimate from the World Health Organization, covering basic health needs takes at least 23 health workers for every 10,000 people. Countries falling below this threshold struggle to provide skilled care at birth as well as the emergency and specialized services that some babies require.


Data visualization


Sub-Saharan Africa has 1.8 million fewer health workers than its population needs – a staggering deficit. One of the consequences is that women in the region face a 1 in 36 chance of dying from pregnancy-related complications over the course of their lives, compared to 1 in 3,300 in high-income countries. Without concerted action to recruit more skilled health workers and connect them with the people who need care the most, the deficit will rise to 4.3 million over the next 20 years as the population grows – a terrifying prospect for millions of women like Kaltum, and for their families and communities.


Vast disparities in child survival


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Remi and Temitoye Falayi dote over their three-month-old daughter, Oluwatomini. Despite a complicated pregnancy, Oluwatomini arrived healthy and on time via a scheduled caesarean section at a well-equipped hospital in Nigeria's capital, Abuja.

Across the world, women from the poorest 20 per cent of households are less than half as likely as those from the richest 20 per cent to have a skilled attendant at birth. Kaltum is among that poorest 20 per cent. Her neighbourhood in north-eastern Nigeria has a primary care clinic, but she didn’t go because she has no money to pay for its services.


Children from Nigeria’s poorest families, like Kaltum’s, are more than twice as likely to die before age 5 as those from the richest.


Behind regional data lie vast disparities within countries. Even in richer countries, the health and survival prospects of the poorest, most disadvantaged citizens can lag significantly behind the average. In the United States of America, for instance, data from 2013 show that infants born to African American parents were more than twice as likely to die as those born to white parents.

In Europe, children and families from the Roma community have a harder time getting the health services they need compared to those from ethnic majority populations. As of 2012, only 4 per cent of Roma children in Bosnia and Herzegovina had all the recommended vaccinations, compared to 68 per cent among non-Roma children. The effects of this neglect can be seen in children’s health and wellbeing: For example, one in five Roma children in Bosnia and Herzegovina and Serbia are moderately or severely stunted.


Child survival begins with women’s health


It’s a celebratory time in the Dervišaj household. Ermina and Durmiš have just welcomed a new daughter to the family. In her honour, their relatives bought the couple a new stove to help keep their room warm through the cold Serbian winters.

But their happiness is tinged with worry. It has been a month since baby Kaja was born, and Ermina still hasn’t brought her home from the hospital. She visits Kaja every other day, and on days when she can’t make it, she calls the hospital from her father’s landline to check in. The hospital is watching Ermina closely. If she shows insufficient interest in her daughter, they may place the baby in foster care.


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Ermina Dervišaj with her husband, Durmiš, and their six-year-old son, David, at their home in Kotež, a suburb of Belgrade, Serbia. One month ago, Ermina gave birth to a premature baby. 

Social services consider babies like Kaja to be at risk of abandonment. She was born two months premature, and her parents have limited means to support even a healthy child, let alone one with special needs. Kaja’s situation might have been different had Ermina had access to the health care she needed when she was pregnant. Since her previous pregnancy ended in stillbirth, Ermina was prescribed medicine for maintaining pregnancy. But she could not afford to take it regularly. “When I had the money, I bought the medicine. But when we didn’t have any, I had to wait.”

Ermina requested support from the Centre for Social Welfare, but she was turned down. “I wanted to be enrolled on a list for the soup kitchen, but we were told that we are fit for work and are ineligible.” Like many of Serbia’s Roma people, Ermina’s husband Durmiš works in the informal economy, finding irregular work as a garbage collector. Ermina looks after her son, who is not yet in school. Even if she wanted to work outside the home, her employment prospects are dim. The official unemployment rate in Serbia is 18.5 per cent, and Ermina doesn’t have a primary education.

Ermina and her husband work hard to provide for their children. The two-story home they share with Durmiš’s family in a quaint suburb of Belgrade is the fruit of nine years of steadfast saving. The entire family have pooled their resources, building piece by piece as the money comes in. So far they have managed to complete just two rooms, but they can’t afford the 1,000 euros it costs to connect to the electrical grid.

The young couple could not survive without their extended family’s support. Still, without greater help from the community, Ermina and her husband will continue to struggle to provide a better future for David and Kaja. Because they are Roma, their children’s chances of something as basic as survival lag behind the national average.

Thanks to concerted efforts by the government, international agencies and NGOs, this outlook has been gradually improving, but there is still a long way to go. Ermina can attest to that. She herself grew up during a period of civil war. Today, Serbia is at peace – but, she says, “I wouldn't say [my children] have better opportunities now.”


Community health workers make a difference


In a trailer park on the outskirts of Belgrade, Sonja Selimović is feeling more optimistic. Her settlement has running water, toilets and electricity. She has been living there for six years, ever since the government dismantled her former neighbourhood in town – a “cardboard city”, as she describes it, with no electricity or water.

Sonja says her life has been transformed thanks to the help of Vesna Jovanović, a Roma health mediator who visits the settlement every other day. “Vesna helped us enormously. Not only me, she helped all of us.”


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Sonja Selimović with her children, Andela and Alen, outside their home in Palilula, Serbia. Sonja has received medical support from a Roma health mediator.

Vesna works to connect Roma families with health and social services. Scattered throughout Serbia, the 75 mediators are Roma themselves, so they speak Romanës and understand the community’s concerns – including their misgivings about the state and those who work for it. Vesna explains that, as an employee of the state, she had trouble gaining the community’s trust when she first started the job five years ago. “They were very sceptical at the beginning. They kicked me out. They didn't even want to talk to me.”

Gradually, she managed to prove her worth. By coordinating with the primacy health care centre, Vesna brought nurses, paediatricians and gynaecologists along on her visits. Today, many of the settlement’s residents rely on Vesna to help them navigate the complex web of health and social services that they often encounter as hostile and discriminatory.

“Vesna is like a mother or a sister to us. We can call her in the middle of the night and she comes without any problems”, says Sonja. Vesna helps the community file the paperwork they need to access services, makes phone calls on their behalf and sometimes even accompanies them to health facilities. When Sonja is unsure of the doctor’s instructions, she turns to Vesna. “She always explains to me what the doctor didn't have time to explain.”

Before she met Vesna, Sonja, now a mother of two, spent 13 years trying to get pregnant. Sonja believes that Vesna’s help connecting her with a qualified doctor is what made the difference. “If it hadn’t been for Vesna, I’m not sure I would have had this baby.”

Community health workers like Vesna make a real difference. In communities that have a hard time getting the services they need – like Europe’s Roma communities – as well as in many low- and middle-income countries that struggle to build strong health systems that can cover remote, poor and disadvantaged populations, community-based health interventions have been a key driver of progress in child survival.

Community health workers expand the reach of care, linking vulnerable people to high-impact, low-cost interventions for maternal, newborn and child health. But increasing the number of these critical health workers so they can reach the communities in greatest need will take deliberate choices to direct policies, public spending and health programming to meet the needs of the most disadvantaged children.



Continue to chapter 2:

A chance to learn