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How can we end the lottery of birth?

Bianca, six hours old, at a health clinic in Kenya
Bianca, six hours old, at a health clinic in Kenya (photo: Colin Crowley/Save the Children)


The past few years have seen the issue of inequality placed firmly at the centre of international development debate. Many aspects remain hotly contested, especially when it comes to economic inequality.

But when we look at the issues through the eyes of children, the stark injustice of inequalities comes into sharp focus. I’ve yet to find anyone who argues that a child’s chances in life should be determined before they are born. But this is the case for too many children across the world. Children whose health and academic prospects are affected by their mothers not being able to access nutritious food during their pregnancy, or by the absence of a skilled health worker at their delivery. Children whose parents can’t afford to invest as much in their wellbeing as more affluent families, and who don’t have access to the same valuable social networks and political influence that give many of their peers a helping hand along the pathway from childhood to adulthood.

The side of the inequality divide that children find themselves on can affect the course their lives take, and can even be a matter of life or death. Research we conducted for our recent report, The Lottery of Birth, found that gaps in children’s chances of surviving to celebrate their fifth birthday are growing between advantaged and disadvantaged children in nearly 80% of the countries included in the study – whether between rich and poor, urban and rural areas, subnational regions or ethnic groups. While many countries have achieved reductions in national average child mortality rates, particular groups of children are being left behind.

But, as our report also shows, this situation isn’t inevitable. So what can be done to close unfair gaps in mortality rates between different groups of children, while maintaining good overall rates of mortality reduction?

Our review of literature in this area, coupled with analysis of country case studies, reveals that countries that have seen inequalities in child mortality fall have taken proactive steps to ensure that poor and disadvantaged groups can access the health services they need without facing financial hardship. In other words, they’re taking an equitable approach to pursuing universal health coverage. Tackling the injustice of unequal life chances for children depends not only on ensuring that adequate resources are invested in good-quality health systems, but also that these resources are invested equitably, reaching groups that need them the most and tackling the social, geographic and economic barriers that undermine access.

But research also suggests that, for long-term and sustainable change, we need to look beyond the health sector to tackle underlying drivers of poverty and inequality. This includes pursuing equality in other sectors such as education, water and sanitation. Tackling the intersection between gender and other forms of inequality is particularly important for reducing inequalities in child survival. The statistics speak for themselves on the importance of tackling harmful social norms that keep women out of schools and away from health centres, and that push them into early and unequal marriage. If all women completed primary school, child mortality rates could fall by an estimated 49%, saving 2.8 million children’s lives. And stillbirths and newborn deaths are 60% higher among mothers who give birth before they are 18 than those over 19.

Women’s and girls’ participation in public and political life has been shown to be particularly important for shifting countries onto faster trajectories of child mortality reduction. Enhancing voice and influence is also important for groups that suffer from disproportionately high child mortality rates and other indicators of poor health as a result of their ethnicity, geography or income level – groups that are excluded from corridors of political power that would give them access, directly or via representatives, to decision making about policies and practices that affect their lives.

This point was firmly established back in 2008 by the authoritative Commission on the Social Determinants of Health. But it remains relatively neglected within the wider body of health research, much of which focuses rather narrowly on technocratic approaches to improving the coverage of health interventions to treat specific diseases. While there’s some great work out there, much more needs to be done to understand and address the underlying, systematic reasons why certain groups of children have suffered decades of neglect and marginalisation in comparison with others within the same country, translating in many cases into shocking disparities in child mortality rates.

This is no easy task. It will not only require researchers, practitioners and advocates to grapple much more squarely with imbalances of power and influence in society, but also to step out of sector-specific silos to look at how relative disadvantage in education, health, politics, social life and other areas feed into and off each other. Only then will we be able to dismantle the unfair lottery of birth that condemns millions of the world’s most disadvantaged children to unnecessary death every year.


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