For the first time this century, the number of children dying before their fifth birthday is projected to rise, according to the Gates Foundation’s 2025 Goalkeepers Report, titled “We Can’t Stop at Almost.”  

The report lands ten years after 193 governments signed up to the United Nations’ Sustainable Development Goals (SDGs), 17 targets meant to end poverty, protect health and build a fairer world by 2030. With only five years left, it delivers a sobering verdict on how close the world has come, and how much could now be lost. 

According to the report, 4.6 million children died before turning five in 2024. That figure is expected to climb by about 200,000 in 2025, to an estimated 4.8 million, the equivalent of more than 5,000 classrooms of children. 

Working with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, the foundation modelled what happens if development assistance for health, the aid wealthy nations and donors channel into health systems in lower-income countries, falls by 20 or 30 per cent. These are roughly the scale of cuts several major donor governments are now considering or implementing. 

A 20 per cent cut could mean 12 million additional child deaths by 2045. A 30 per cent cut could mean 16 million. Conversely, holding funding at 2024 levels while scaling up newer, cheaper innovations could save an estimated 13 million lives over the same period. 

Cuts to donor aid could contribute to millions of additional deaths across low- and middle-income countries  

The warning is not confined to one report. UNICEF and the World Health Organization (WHO), through the UN Inter-agency Group for Child Mortality Estimation, note in their Child Mortality Report 2025 that progress has already slowed and that cuts threaten to undermine gains at a vulnerable moment. Research in The Lancet Global Health goes further, estimating that cuts to official development assistance could contribute to millions of additional deaths across dozens of low- and middle-income countries by 2030, with young children bearing a disproportionate share. 

UNICEF’s Executive Director, Catherine Russell, has warned that decades of hard-won progress on child survival risk reversing unless funding and policy choices change course. WHO’s Director-General, Dr Tedros Adhanom Ghebreyesus, has echoed that warning. The OECD projects health aid will fall by 29 to 46 per cent between 2024 and 2026, while UNICEF reports official development assistance dropped by 23.1 per cent in 2025, the largest annual decline on record. 

The global figures become more meaningful viewed from where health workers are feeling the pressure directly. Take Josephine Barasa, a community health worker and gender-based violence champion in Kenya. 

Barasa worked as a “mother mentor,” supporting girls and women through pregnancy and early motherhood, many of whom had experienced violence or had been pushed into motherhood before they were ready. Her work included teaching them when to vaccinate their children, what to eat, how to breastfeed, how to maintain hygiene and when to visit a health facility. 

Then, one afternoon in January, she received an email telling her that her services were no longer needed. For four days, she says, she did not speak or leave her bed. But while the support systems had disappeared, the need had not. In February, she returned to work unofficially, unpaid and on her own. “I still show up every day,” she says. Barasa continues to screen women for gender-based violence, offer health education and provide basic care to children. 

Her experience captures what funding cuts look like beyond the language of budgets and projections: fewer health workers, fewer outreach services and fewer chances for women and children to get help before a crisis becomes life-threatening. 

Community health systems cannot be sustained indefinitely by unpaid workers, small donations 

The report notes that the Kenyan government has stepped in where it can, communicating more clearly and responding to some immediate gaps in maternal health services. But Barasa’s story also shows the limits of relying on individual sacrifice, since community health systems cannot be sustained indefinitely by unpaid workers and small donations from churches, mosques and community centres. 

Her account is a reminder that primary healthcare is not an abstract policy idea. It is a person who explains how to care for a newborn, identifies violence, encourages a mother to attend a clinic or notices when a child needs urgent treatment. When these workers lose funding, the first consequence appears not in national statistics but in the missed appointment, the untreated infection, the unrecognised danger sign or the woman who has nowhere safe to turn. 

East Africa’s lessons: When poverty didn’t automatically mean malaria was a death sentence 

Kenya’s experience sits alongside wider lessons from East Africa, where the report highlights community knowledge, domestic leadership and African scientific expertise. 

In Uganda, Krystal Mwesiga Birungi describes growing up in a family that could not afford mosquito nets or malaria treatment. Her younger brother suffered repeated bouts of fever, while her mother had to choose between staying home to care for a sick child and going to work to keep the family fed. When the Global Fund arrived, mosquito nets and medicines became available free of charge, while community health workers could diagnose and treat malaria closer to home. For the first time, Birungi writes, poverty did not automatically mean malaria was a death sentence. 

Today, she is an entomologist working with Target Malaria at the Uganda Virus Research Institute, researching gene-drive technology that could reduce the number of mosquitoes transmitting malaria or stop them passing the parasite to humans. Birungi stresses that scientific progress must be accompanied by trust, with researchers listening to communities and ensuring local people help shape the research. 

The malaria challenge remains immense. Sub-Saharan Africa accounts for 94 per cent of malaria cases, and the disease still kills more than 400,000 children under five every year. Yet the report argues a combination of tools could change the trajectory. Dual-insecticide bed nets, designed to overcome mosquito resistance, have already helped prevent more than 13 million cases across 17 African countries. Targeted campaigns guided by digital mapping can cut costs by directing interventions towards areas of greatest risk, while a single-dose cure, next-generation vaccines, new drugs and genetic technologies could help interrupt transmission. 

The report estimates next-generation malaria tools could save 5.7 million children by 2045 if delivered effectively at scale, but only if countries have the financing, health workers, laboratories, supply chains and community trust needed to deliver them. 

Africa’s uneven progress: Over14 million infants unvaccinated in 2024, measles jabs below 95 per cent  

The Goalkeepers dashboard tracks 18 key indicators against the SDGs, drawing on IHME modelling. Sub-Saharan Africa remains the lowest-performing region on several measures, but is also among the fastest-improving, showing that progress is possible when countries receive sustained investment adapted to local realities. 

On vaccination, global coverage of the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3) stood at 81 per cent in 2024. Sub-Saharan Africa recorded about 70 per cent, the lowest of any region, while improving by nearly 11 per cent since 2015. WHO and UNICEF’s WUENIC estimates confirm global coverage has broadly plateaued: more than 14 million infants remained unvaccinated in 2024, and measles vaccination remains below the 95 per cent coverage generally required to prevent outbreaks. 

The report points to ways of stretching scarce resources: updated WHO guidance now allows countries with established pneumococcal programmes to move from three vaccine doses to two. If eligible countries adopt the reduced schedule, it could save around $2 billion (Ksh258.9 billion) by 2050, funds that could be reinvested in reaching unvaccinated children. 

Family planning shows a similar picture. Globally, 78.3 per cent of women who want to avoid pregnancy are using a modern contraceptive method; in Sub-Saharan Africa the figure is 52.2 per cent, though it has improved by 8.8 per cent since 2015. Access to contraception reduces risky pregnancies and supports education, income and women’s ability to shape their futures. 

Sanitation shows the same pattern of progress against a large gap. Safely managed sanitation reaches approximately 60 per cent of the global population, but only 25 per cent of people in Sub-Saharan Africa, a region that has improved by 23.2 per cent since 2015. The definition is demanding: facilities must not be shared between households and must safely treat waste. 

On universal health coverage, Sub-Saharan Africa has again recorded the fastest improvement from a low base, rising by 16.4 per cent since 2015. Yet essential services remain out of reach for millions, particularly in rural and conflict-affected communities. These figures show why progress cannot be judged only by proximity to a global average; the more important question is whether gains are reaching those historically left furthest behind. 

A global stall: Real progress before 2015, disruption during the 2020 pandemic 

The Goalkeepers project’s five selected measures show a common pattern: real progress before 2015, disruption during the pandemic, partial recovery, then a prolonged stall. 

Global DTP3 coverage is projected to reach only 83 per cent by 2030. Family planning coverage is projected to reach 79.4 per cent, leaving roughly one woman in five without the contraception she wants. The universal health coverage effective coverage index stands at 62 out of 100 in 2024 and is projected to reach only 64 by 2030. WHO’s own UHC Service Coverage Index records a higher score of 71 for 2023, using a different method, but both point in the same direction: progress has slowed sharply since 2015. 

Sanitation is one of the stronger performers, rising to 60 per cent globally in 2024, though projected 2030 coverage of 64 per cent would still leave about 2.9 billion people without safely managed sanitation. 

Tobacco control is the clear exception. Adult tobacco use has fallen from 28 per cent in 1990 to 18 per cent in 2024 and is projected to decline further to 17 per cent by 2030, a shift credited to policy measures under the WHO Framework Convention on Tobacco Control. The contrast is instructive: tobacco control advanced through a clear policy framework, while the other indicators depend on continuous service delivery, frontline workers and external financing, none of which can be sustained by innovation alone. 

What is at stake: Every dollar on immunisation saves lives, cuts treatment costs, preserves productivity  

A functioning primary healthcare system can be built for less than $100 per person per year (Ksh12,945) and can prevent up to 90 per cent of child deaths, the report notes. Every dollar spent on immunisation can return around $54 (Ksh6,990) in benefits through lives saved, treatment costs avoided and productivity preserved. 

New technologies could amplify those gains: maternal vaccines against respiratory syncytial virus and Group B streptococcus could protect newborns, long-acting HIV prevention injections could ease the burden of daily medication, and digital tools could target malaria interventions more accurately. But the central challenge is not whether these tools exist. It is whether they will reach the children, women and families who need them. 

For 25 years, global health recorded extraordinary gains, but the world is now approaching the SDG deadline with most indicators well short of target, just as funding falls when countries most need to protect gains. 

“Over the last 25 years, those deaths went down faster than at any other point in history,” Bill Gates says in the report’s foreword. “But in 2025, they went up for the first time this century, an increase driven by less support from rich countries to poor countries.” 

The world has not run out of knowledge, technology or workable solutions. It is running short of political commitment and reliable financing. Governments can protect primary healthcare, maintain routine immunisation, support community workers, fund African-led research and deploy innovations that make every dollar go further. 

The world cannot stop at almost, but it must choose to finish what it started.  

Text by: Yvonne Kawira 

Data visualisation: Stanley Njihia