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Excess under-five mortality due to COVID-19 related economic downturn

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Sick child in a village in Botswana. Photo: Shutterstock Sick child in a village in Botswana. Photo: Shutterstock

The economic downturn resulting from COVID-19-related lockdowns may have contributed to the death of hundreds of thousands of children under the age of five in 129 of the world’s low- and middle-income countries in the first year of the pandemic .

This important finding from a recent study shines a light on a hidden COVID-19 death toll – young children who die, not from the disease, but from the disruptions in food and medicine deliveries, closed health clinics, and delays in childhood immunizations  resulting from the measures implemented by countries to reduce the spread of the virus.

Under-5 mortality tied to national income

Recent estimates by the United Nations Interagency Group for Child Mortality Estimation (UN IGME) examined the disparities in under-5 mortality (U5M) between lower income countries and higher income countries– where most of the U5M can be traced to the lower income countries.

The findings of the new study by researchers from Johns Hopkins Bloomberg School of Public Health and Rockwool Foundation in Demark, which focused on developing countries (LMICs), also confirmed that U5M rates are closely tied to national income. Thus, nearly half of all the potential under-5 lives lost due to the COVID-19 related economic recession in LMICs are estimated to have occurred in Sub-Saharan Africa.

The model created by the study authors, using data from the United Nations and the World Bank, examined additional deaths in 2020 expected in children under 5 years of age under a range of assumed recession rates , i.e., 5%, 10%, and 15% reductions in a country’s per capita gross domestic product (GDP).

Severe economic effects on child heath

In the most conservative case, a GDP per capita reduction of 5%, the researchers estimated that between 279,000 and 286,000 additional lives of children under 5 were lost due to the indirect effects of COVID-19-related recessions in 2020 in LMICs . That translates to an additional 43,000 deaths in India and an additional 22,000 deaths in Nigeria compared to a year without the reduction in GDP per capita, as shown in Figure 1.

A 10% and 15% GDP contraction, would lead to higher losses of lives in children under 5, increasing to 585,802 and 911,026 additional deaths in LMICs, respectively. These economic effects on child health are independent of whether the children acquire COVID-19 disease.

The International Monetary Fund estimates that the global economy shrank by 4.4% in 2020, compared to a contraction of just 0.1% in 2009 in the financial crisis known as the Great Recession.

The economic downturns of 2020 have also been projected to reverse a sustained trend of declines in global poverty, with an expected 42 to 66 million additional children falling into extreme poverty as a consequence. 

Most of the increased child mortality in LMICs is a consequence of the adverse effects on diet, environment, and health care seeking of the prolonged COVID-19 related economic downturn.

Continued investments in nutrition and primary health care are pivotal

A key recommendation of the study, therefore, is for policymakers and other public health stakeholders to not only focus their programs and policies on the direct effects of COVID-19, but to also ensure continued investments in food supplementation, growth monitoring, and comprehensive primary health care to mitigate further impacts on children in the face of continued economic contractions.

The lack of access, or inequitable access, to COVID-19 vaccines in LMICs might prolong economic downturns in many countries. Nearly 68% of Americans are fully vaccinated, but most of Africa missed a World Health Organization target of ensuring 40% of people in every country be fully vaccinated by the end of 2021. Less than 10% of people on the African continent were fully vaccinated against COVID-19 in early 2022.

In collaboration with countries and partners, the World Bank Group (WBG) has committed over $157 billion between April 2020 and June 2021 to mitigate the negative impact of the pandemic. This includes over $50 billion of IDA resources provided as grants or on highly concessional terms.

Consistent with the main recommendation of the study, the World Bank has also maintained and strengthened partnerships with organizations such as the Bill and Melinda Gates Foundation and the Government of Japan to support interventions aimed at reducing stunting and malnutrition.

Figure 1: Changes in under-five mortality from a 15% downturn, by country and income group
Figure 1: Changes in under-five mortality from a 15% downturn, by country and income group



Joseph Millward

Senior Researcher, The Johns Hopkins Bloomberg School

David Makram Bishai

Adjunct Professor, Department of Population and Family Health Sciences

Alison Gemmill

Assistant Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health

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