There is global consensus that child health is a fundamental component of sustainable development. For this reason, “reducing infant mortality and under five mortality” was set as a target for achieving the Sustainable Development Goal (SDG) number 3 on healthy lives and wellbeing for all. Target 3.2 aims to reduce neonatal and under-five mortalities to 12 and 25 deaths per 1000 live births, respectively . As one of the measures of child health and the health status of the population, under-five mortality is defined as the number of deaths between birth and the fifth birthday per 1000 live deaths.
Globally, the rate of under-five mortality had fallen from 93 deaths in 1990 to 39 per 1,000 live births in 2018 . Even with this notable drop, under-five mortality remains a global public health challenge faced by many developing countries, particularly in Africa. According to  5.3 million children under the age of five died in 2018 compared to 4.4 million in 2017. The highest under-five mortality for the years 2017 and 2018 and occurred in Sub-Saharan African (SSA) countries with 78 deaths per 1000 live births translating to 1 death in every 13 under-five children. Majority of these deaths (47%) were among neonates (newborns). In the same way, projected estimates by  suggests that about 52 million children below the age 5 will die between 2019 and 2030
The decline in under-5 mortality in sub-Saharan Africa (SSA), has been uneven across countries and age groups . As a whole, the SSA countries will not achieve the SDG target 3.2 at the current rate unless they accelerate their efforts. According the World Population Prospects of 2019, SSA will only reach 40 deaths per 1000 live births by 2030 , Population Division, 2019). Zambia has made strides in reducing the under-five mortality in recent years. Figure 1.1 compares infant mortality rate for Zambia with the SSA country’s average. It shows that Zambia has a lower rate in comparison with the SSA average. In addition Figure 1.2 highlights the fact that mortality is not equally distributed in Zambia with about four provinces having lower than the average national under-five mortality rate while six other provinces have higher than the national average figure. Luapula province for example has the highest rate of 110 deaths per 1000 live births while North-Western province has the lowest at 22/1000 live births. In addition, figure 1.3, shows that between 2002 and 2018, under-five mortality reduced from 168 to 61 deaths per 1000 live births. Between 2013-14 and 2018, under-five mortality reduced by an average constant rate of about 4.13% per annum. In order to meet the SDG target 3.2, Zambia needs to accelerate the average annual reduction rate to about 7.43% so as to move the under-five mortality rate from the current 61 to the targeted 25.
Programmes and policies on under-five mortality in Zambia
Like many other developing countries, Zambia is also adhering to the 2030 Agenda for sustainable development, adopted by all United Nations Member States in 2015. Sustainable Development Goal number 3.2 aims to end preventable deaths of newborns and children under 5 years of age. Specifically relating to under five mortality is the goal to reduce under-5 mortality to a low rate of 25 per 1,000 live births by 2030. At national level, Zambia has taken steps to address the challenge around under 5 mortality; Vision 2030 and the current Seventh National Development Plan (SNDP) as well as other pieces of policies such as The National Health Strategic Plan of 2017-2021 all to reduce the under-five mortality rate from 61 to 56 per 1000 by 2021. In order to achieve this, various practical interventions based on the pieces of legislation highlighted already have been put in place and they include immunization programmes such as the e the Expanded Programme on Immunization (EPI), the Integrated Management of Childhood Illnesses (IMCI), vitamin A supplementation and integrated community case management (ICCM) to mention a few.
While noting positive strides made to improve child health, under-five mortality remains significantly high in Zambia posting a significant challenge to attain the SDG target as set by the UN Member States. In view of this therefore, this study aimed to provide some input into the policy debate on how Zambia can accelerate progress towards achieving the SDG target of between 12-25 deaths per 1000 live births by endeavouring to establish risk factors associated with the survival of children under the age of five.
Under-five mortality has been widely studied around the world. Despite this extent studies, focusing on the length of time it takes from birth to death among children under the age of five are not so common in countries such as Zambia. Under-five mortality reviews suggest that there are various factors that can be associated with under-five mortality among which socioeconomic, biological and environmental factors play a pivotal role . However, so far, there seems to be no consensus in literature on the actual risk factors associated with under-five mortality
 Suggest that factors such as family size, shorter birth intervals, duration of breastfeeding, water sources and mother’s income are associated with under-five mortality in Ethiopia. A similar study in Ethiopia however found some more extensions to the argument and suggested that modern contraceptive use, tetanus vaccinations, mother's age, child's sex, parity, postnatal check-up, marital status, and source of drinking water were instead more associated with under-five mortality . Within this complex web of factors relating to risks associated with under-five mortality, a study by  found that maternal age, place of residence, household wealth index, level of education, employment, marital status, religious background, birth type, birth order and interval, sex and size of child, place and mode of delivery contributed to under-5 mortality rate in much of SSA. Cementing this idea, a study by  in Ghana also found that shorter birth intervals increased the risk of under-five mortality; however, they also pointed out that sleeping under a mosquito net and increased labour force participation of mothers reduces the risk.
In Zimbabwe,  found that children whose mothers who had used contraceptives before and whose children had postnatal check-ups had lower likelihood of dying before the age of five comparatively. The study further observed that small birth size and higher birth order increased the risk of dying. In another study by , it was found that low wealth status, source of drinking water, having an HIV positive mother were positively related to under-five and infant mortality in South Africa.
In Zambia, a study by  found that malaria, diarrhoea and respiratory infections caused mortality among under five children. The study further noted that increased frequency of visits to health centre significantly reduced mortalities in children by 3 out of a 1000 live births each year. Another study by , established that children with marasmus were more likely to die before the age of five with HIV infected children having higher risks of dying compared to HIV negative children.
With all these studies in perspective, none was dedicated, at least in Zambia, to investigate the timing of the deaths at under five although some of the risk factors have been highlighted. In view of this visible lacuna, this study therefore was positioned to determine under-five child survival and associated risks in Zambia.