The remarkable progress achieved in children’s health over the past several decades is facing a historic setback. According to the 2025 Goalkeepers Report authored by Bill Gates, Chair of the Bill & Melinda Gates Foundation, global child mortality is projected to rise for the first time in the twenty-first century. After years of steady decline, an estimated 4.8 million children will die before the age of five in 2025, an increase of more than 200,000 from the previous year.
Gates describes this moment as a crossroads for humanity. The world has the scientific and public health tools to prevent the majority of these deaths, yet without sufficient funding and delivery, millions of children will continue to die from preventable illnesses. If global development assistance for health declines by 20 to 30 percent, as some countries consider significant reductions, the consequences could be devastating: up to 16 million additional child deaths by 2045.
A Generation of Progress at Risk
Gates emphasizes that the death of a child from a preventable disease represents a failure of systems and priorities. For decades, innovations in vaccines, primary health care, and community-based interventions dramatically improved child survival worldwide. This progress now risks unraveling. The report stresses that current projections are not inevitable. Rather, they reflect choices about funding, delivery, and global commitment.
Through a collaborative analysis with the Institute for Health Metrics and Evaluation at the University of Washington, the foundation outlines the urgent stakes. Cuts in global health financing could halt progress on polio eradication, weaken malaria control programs, and stall efforts to combat HIV/AIDS. Gates argues that with the right investments, the next generation could instead witness the end of several major infectious threats.
Reinvesting in Primary Health Care
The report identifies primary health care as the cornerstone of efficient, life-saving health systems. Robust primary care provides safe childbirth, early detection of illness, routine immunization, and rapid identification of emerging infectious threats. Gates notes that for under USD 100 per person per year, such systems can prevent up to 90 percent of child deaths.
Examples from countries such as Nigeria and Kenya highlight the transformative potential of strategic local leadership and community health workers. Even in settings with budgetary constraints, targeted investments in basic services yield significant improvements in maternal and child survival.
Strengthening Routine Immunization
Routine childhood vaccination remains one of the most cost-effective investments in global health. Since 2000, widespread immunization has cut child mortality nearly in half, yielding an estimated USD 54 return for every dollar spent. The report underscores, however, that these gains remain vulnerable. Declines in vaccine coverage lead to resurgent outbreaks of diseases such as measles, often with far higher long-term costs than maintaining strong immunization programs.
Recent updates from the World Health Organization further demonstrate the role of innovation in extending impact. New pneumococcal conjugate vaccine schedules requiring fewer doses can reduce costs and logistical burdens while maintaining strong protection. These efficiencies free resources for health systems to expand coverage and introduce additional lifesaving vaccines.
Innovations That Maximize Impact
Gates highlights several emerging solutions that enhance the efficiency and reach of health interventions. Subnational tailoring of malaria programs allows countries to direct resources precisely where they are most needed, reducing costs and improving outcomes. Digital technologies, such as smart mapping tools used in Zambia, improve targeting of mosquito-control activities and decrease the cost per malaria case prevented.
Advances in entomology, vector control, and vaccine science also offer hope for the long-term eradication of malaria. Dual-insecticide bed nets, spatial repellents, and next-generation malaria vaccines are creating a multilayered defense against the disease. With sustained investment, these tools could save an estimated 5.7 million lives by 2045.
Ending HIV Transmission for Future Generations
The report also envisions transformative progress against HIV/AIDS. Innovations in long-acting prevention tools, such as twice-yearly injections of lenacapavir and monthly oral PrEP under development, could dramatically reduce HIV transmission. Ensuring access in high-incidence regions may prevent up to one-fifth of new infections. As these technologies evolve and become more affordable, they hold promise for ensuring that future generations grow up in communities where HIV-related deaths are rare.
Protecting Newborns with Next-Generation Maternal Vaccines
Nearly half of all child deaths occur within the first month of life. Gates underscores the urgent need for maternal vaccines that protect newborns during the critical early weeks when they are too young for direct immunization. Respiratory Syncytial Virus (RSV) remains a leading cause of pneumonia and hospitalization in infants worldwide. Scaling maternal immunization and monoclonal antibody strategies could prevent millions of deaths and long-term respiratory complications.
Written by Nare Hovhannisyan, MD