The number of children dying before their fifth birthday is expected to rise for the first time this century, reversing decades of global progress, according to new data published Tuesday in the Gates Foundation’s 2025 Goalkeepers Report.
In 2024, 4.6 million children died before age 5. New modeling by the Institute for Health Metrics and Evaluation (IHME), featured in the report, projects that figure will increase by just over 200,000—reaching an estimated 4.8 million deaths this year. The rise comes as global development assistance for health fell sharply in 2025, dropping 26.9% from the previous year.
Beyond the funding cuts, the report warns that many countries are struggling with mounting debt, fragile health systems, and the threat of losing hard-won gains against malaria, HIV, and polio.
Titled We Can’t Stop at Almost, the report cautions that if global health funding reductions continue, as many as 16 million additional children could die by 2045. It outlines a roadmap for sustaining progress through targeted investments in proven tools and next-generation innovations—despite today’s constrained budgets.
“I wish we were in a position to do more with more, because it’s what the world’s children deserve. But even in a time of tight budgets, we can make a big difference,” Bill Gates, chair of the Gates Foundation and author of the report, writes. “With millions of lives on the line, we have to do more with less, now.”
IHME projections show that a permanent 20% cut in global health funding could result in an additional 12 million child deaths by 2045. A 30% cut could push the toll to 16 million. Gates calls this moment a “turning point” for global health, when the right financial and policy decisions can still save millions of lives.
“We could be the generation who had access to the most advanced science and innovation in human history—but couldn’t get the funding together to ensure it saved lives,” Gates writes. “By making the right priorities and commitments, I’m confident we can stop a reversal in child deaths.”
The report highlights the immense value of high-impact health investments. Strong primary health care systems—costing less than $100 per person per year—can prevent up to 90% of child deaths. Vaccines also remain one of the most cost-effective health tools worldwide; every dollar invested in vaccines returns an estimated $54 in economic and social benefits. Since 2000, Gavi, the Vaccine Alliance, has supported vaccinations for more than 1.2 billion children.
Similarly, the Global Fund to Fight AIDS, Tuberculosis and Malaria demonstrates what sustained funding can achieve. Since 2002, it has saved 70 million lives and helped reduce deaths from the three diseases by more than 60%. Last month, global leaders pledged $11.34 billion to the fund’s Eighth Replenishment—evidence of continued commitment, but also a reminder of the risk posed by declining support.
Gates also points to emerging innovations that could dramatically reduce child deaths if funding is sustained. New vaccines for RSV and pneumonia could save an estimated 3.4 million children by 2045. New malaria tools could save an additional 5.7 million children. Long-acting HIV prevention tools, such as lenacapavir, could help drive infections and deaths toward zero in high-burden countries.
The report includes voices of leaders, health workers, and researchers across Africa and Asia who are working daily to protect children’s health. In Nigeria, Gombe State governor Muhammad Inuwa Yahaya describes prioritizing primary health and education despite a budget deficit, saying progress requires “clarity and the courage to stick to it.”
In Kenya, community health worker Josephine Barasa continued caring for mothers and children even after losing her paid position, noting that “the support systems may have disappeared, but the need has not.” In Uganda, entomologist Krystal Mwesiga Birungi is developing next-generation tools to combat malaria and says African researchers are “leading the way.” In India, pediatrician Dr. Naveen Thacker stresses that “affordability of vaccines is key” to healthier children.
Gates urges governments, philanthropies, and citizens to act on the report’s findings by safeguarding or expanding health budgets, increasing philanthropic giving, and reminding leaders that where a child is born should not determine whether they live or die.
“We can’t stop at almost,” Gates writes. “If we do more with less now—and get back to a world with more resources to devote to children’s health—then in 20 years we’ll be able to tell a different kind of story: how we helped more kids survive childbirth, and childhood.”
