SDG SERIES: The Slippery Target for Child Survival in the 2030 Agenda for Sustainable Development

SDG Goal 3: Good Health
SDG Goal 3: Good Health

Elizabeth D. Gibbons


After much public consultation and global negotiation, the 2030 Agenda for Sustainable Development has been agreed, along with 17 Sustainable Development Goals (SDGs) and their 169 targets.1 The Agenda seeks to build on the Millennium Development Goals (MDGs) and “complete what these did not achieve”.2 MDG4: Reduce Child Mortality is one the goals which failed to achieve its single target to “Reduce by two-thirds, between 1990 and 2015 the under-five mortality rate (U5MR).”

MDG4 mobilized global efforts to promote child survival and health, (and indeed between 1990 and 2013, the annual number of under-five deaths declined by half to 6.3 million) but was also critiqued from many diverse perspectives. Elisa Diaz-Martinez and I published a critique in the Power of Numbers Project, which undertook 11 case studies of the effects of MDG goals/targets, and concluded that all led to unintended consequences.3 The MDGs did not address realization of human rights, instead, “frame[d] the concept of development as a set of basic needs outcomes rather than a process of transformative change in economic, social and political structures”.4

Despite global progress towards MDG4, the poorest children and indeed the poorest countries, have been left behind. In 2012, UNICEF found that, globally, children born in the poorest 20% of households had only half the chance of surviving to their fifth birthday as children born in the richest 20% of households.5 Furthermore, the 2/3 U5MR reduction target was “a one-size-fits-all goal with no national adaptation and taking no account of the countries starting point or resources, leading to a distortion in measuring ‘success’”.6

For SDGs to build on the lessons of the MDGs, and the demands of the millions who participated in The World We Want post-2015 global consultations, the goals and targets should be framed in the unambiguous terms of reducing inequalities. Indeed the draft Transforming our World: The 2030 Agenda for Sustainable Development (Agenda) commits signatories to combat inequalities within and among countries, protect human rights and, notably “to leave no-one behind”.7 The Agenda also stresses repeatedly that the 17 SDGs are integrated and indivisible and “balance the three dimensions of sustainable development, the economic, social and environmental.” Accordingly, SDG Goal 10: Reduce inequality within and among countries, should be interrelated with all the other goals and targets, including Goal 3: Ensure healthy lives and promote well-being for all at all ages, and MDG4’s successor, Target 3.2, which states:

“By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under five mortality to at least as low as 25 per 1,000 live births.”8

The framing of target 3.2 for reducing neonatal and U5MR is, in some ways, even more problematic than the 2/3 U5MR target for MDG4. Firstly, the target is internally inconsistent; for “ending preventable deaths” to mean what it says, U5MR should reach if not zero, then the lowest levels recorded, which in 2013 was 2 per 1,000 live births in Luxembourg.9  In the very next sentence, however, the U5MR target is ‘at least as low as 25 per 1,000 live births’.

Moreover, States will be meeting the SDG if they merely ‘aim’ to reduce neonatal and under-five mortality. “Aiming” to reach these levels of child mortality can be taken as aspirational (one day, in an ideal world, our country will get there), or as a formulation of the human rights principle of progressive realization (which would demand a plan that demonstrates progress is being pursued ‘to the maximum extent of available resources’).10 The bottom line is that any country can claim it is aiming to reach those levels of child mortality, regardless of what is actually occurring. It is impossible for citizens to hold their government to account for reducing neonatal and child mortality with such a slippery formulation of the target.

A third weakness with SDG target 3.2 is that it is not framed to induce action that ‘leaves no-one behind’ and eliminate the survival disparities between children in poor and rich households. Addressing inequality should be built into all targets. An alternative framing, consistent with global demand to reduce inequalities and with a human rights-based approach, could have required countries to reduce the mortality of the poorest children faster than reduction in the national average, so that the gap in survival outcomes for poor and rich children is eliminated. With this requirement, the poorest gain disproportionate benefit from the global efforts to achieve target 3.2 by 2030. Reducing disparities in child survival outcomes, disaggregated at the least by gender, wealth and locale, should be a measure of success during implementation.

Although target 3.2 is not numeric and requests only that all countries aim for reductions to 12 deaths per 1,000 live births (neonatal) and 25 per 1,000 live births (U5MR), it is likely that the global community will measure against these levels. As such, the target is another form of one-size-fits-all, with the poorest countries and regions again starting off the 2030 agenda at a significant disadvantage. For example, in 2013 the average neonatal mortality rate in the Northern Africa region was 13 per 1,000 live births and U5MR was 24 per 1,000 live births, while the average rates in the Sub-Saharan African region were 31 and 92 respectively.11

The introduction of absolute values risks demanding reduction rates which take no account of historical trends. Table 1 has data on the total rate of U5MR reduction in the 23 years between 1990 and 2013, for the best and worst performing countries. The best performing countries reduced U5MR by an average of 3% each year, compared to 1-2% in the worst performing countries. Since the SDG period is 2016-2030, or only 15 years, even the best performing countries will struggle to reduce U5MR to 25 per 1,000 live births. However, since reduction in U5MR has greatly accelerated during the MDG period, from 1.2% in 1990-95, to 4% between 2005-2013, if the best performing countries maintain or accelerate their rates, they will likely make the ‘at least’ U5MR target of 25 per 1000.12 Not so the worst performing countries, which would have to triple or quadruple their historic rates of change to reach the minimum target.


Table 1: Trends in Under Five Mortality Rates and Likelihood of Reaching Target 3.2 by 2030

Top Performing MDG4 Countries13 Total U5MR % reduction between 1990-2013 Level U5MR in 2013*14 


Total % reduction U5MR   needed 2014-2030 to reach ‘at least 25 per 1000 live births’ 2030 U5MR with MDG average rate maintained over 16 years15


2030 U5MR with MDG highest rate maintained over 16 years  (≈4%/year)**
Bangladesh 71% 41 39% 21 15
Malawi 72% 68 63% 35 24
Liberia 71% 71 65% 37 26
Tanzania 69% 52 52% 27 19
Ethiopia 69% 64 61% 33 23
Niger 68% 104 76% 54 37


Worst Performing MDG Countries16 Total U5MR % reduction


Level U5MR in 2013*17 


Total % reduction U5MR   needed 2014-2030 to reach ‘at least 25 per 1000 live births’ 2030 U5MR with MDG average rate, maintained over 16 years (1.5%/year)** 2030 U5MR with MDG highest rate, maintained over 16 years  (4%/year)**
Angola 26% 167 85% 127 60
Sierra Leone 40% 161 84% 122 58
Chad 31% 148 83% 112 53
Somalia 19% 146 83% 111 53
CAR 21% 139 82% 106 50

* Per 1000 live births

** For simplicity’s sake these rates have not been compounded; if they had been total U5MR reduction after 16 years would be less than what is shown in the table above.

With its internally inconsistent and slippery formulation, it is difficult to predict how target 3.2 will be measured, and how countries will be held globally accountable, but all countries should at least report on the gap in child survival between the richest and the poorest, and their progress towards equality of outcomes. To make sure this happens, civil society and human rights mechanisms need to be mobilized around the child’s right to survival and to health, without discrimination.

Although the SDGs are not couched in either the discourse or framework of human rights, the Agenda claims it is grounded in the UDHR, which offers some encouragement to those who consider the realization of human rights the means and the end of sustainable development. And yet, despite the global demand for accountability, made in the consultations leading up to the 2030 agenda, the means of SDG implementation and accountability are weak. There is no mention of tracking SDG progress through human rights treaty body reporting, nor the role of public participation in holding governments accountable. The Agenda suggests tracking SDG progress and “taking into account different national realities, capacities and levels of development and respecting national policies and priorities”.18 For the 2030 agenda to be more than just aspirational, global mechanisms to ensure that every country takes some measures toward realizing the goals and targets should have been elaborated in the Agenda. A good mechanism could be the UN Human Rights Council’s Universal Periodic Review (UPR) and the Committee on the Rights of the Child should embed reporting on target 3.2, and indeed on all SDGs relevant to children, in the periodic reports submitted by States parties.


Elizabeth D. Gibbons is a Senior Fellow at the FXB Center for Health and Human Rights, Harvard T.H. Chan School of Public Health




1 Transforming Our World: the 2030 Agenda for Sustainable Development – Finalised Text for Adoption (1August), available at:

2 Ibid, p. 2

3 S. Fukuda-Parr, A. Yamin, J. Greenstein, “The Power of Numbers: A Critical review of Millennium Development Goals Targets for Human Development and Human Rights,” Journal of Human Development and Capabilities, 15, No 2-3 (2014) pp. 105-117

4 Ibid, p. 111.

5 E. Diaz-Martinez & E. Gibbons, “The Questionable Power of the Millennium Development Goal to Reduce Child Mortality,” Journal of Human Development and Capabilities, Vol. 15, No. 2-3, (2014), pp. 203-217.

6 Ibid, p. 213

7 see note 1, para 3-4

8 see note 1, p, 13

9 UNICEF, State of the World’s Children Report 2015, Table 1: Basic Indicators, available at:

10 States parties to UN human rights treaties which include Economic, Social and Cultural Rights are obliged to realize these rights ‘to the maximum extent of available resources”; e.g. International Covenant on Economic, Social and Cultural Rights, Art. 2,,Convention on the Rights of the Child, Art. 4

11 UN Interagency Group for Child Mortality Estimation, Levels and Trends in Child Mortality, Report 2014, Table 1, p. 11 and Table 3, page 13, available at

12 Ibid, page 10

13 Data on best performers taken from UN Interagency Group for Child Mortality Estimation, Levels and Trends in Child Mortality, Report 2014 page 10, available at

14 All U5MR data from UNICEF, State of the World’s Children 2015, Table 1: Basic Indicators; available at

15 For the purposes of this table, since the latest data available is from 2013, I have calculated the reductions over 16 years (2014-2030). However the SDG period will be for 15 years starting in January 2016.

16 All data on worst performing countries taken from U5MR Ranking, and calculated from the difference in 1990 and 2013 U5MR in UNICEF, State of the World’s Children 2015, Table 1: Basic Indicators, available at

17 ibid

18 see note 1, para 21


Previous publication in HHRJ by this author: Climate Change, Children’s Rights, and the Pursuit of Intergenerational Climate Justice