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The DHS Working Papers series is an unreviewed and unedited prepublication series of papers 

reporting on research in progress based on Demographic and Health Surveys (DHS) data. Funding for 

this research was provided by the United States Agency for International Development (USAID) 

through the MEASURE DHS project (#GPO-C-00-03-00002-00). The views expressed are those of 

the authors and do not necessarily reflect the views of the United States Agency for International 

Development, the United States Government, or the organizations with which the authors are 

affiliated. 

MEASURE DHS assists countries worldwide in the collection and use of data 

to monitor and evaluate population, health, and nutrition programs. Additional 

information about the MEASURE DHS project can be obtained by contacting 

ORC Macro, Demographic and Health Research Division, 11785 Beltsville 

Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-

572-0999; e-mail: reports@orcmacro.com; internet: www.measuredhs.com). 
Under-five Mortality Trends in Africa: 

Reconstruction from Demographic Sample Surveys 

Michel Garenne, Research Director 

French Institute for Research and Development (IRD) 

Enéas Gakusi, Research Associate 

Centre d’Études et de Recherches sur le Développement International (CERDI) 

Clermont-Ferrand 

September 2005 

Corresponding author: Michel Garenne, IRD/ISD, 15 Rue de L'école de Médecine, 75270 

Paris Cedex 06, France. Email: mgarenne@bhdc.jussieu.fr
ACKNOWLEDGMENTS

The authors would like to thank the Wellcome Trust for sponsoring in part this 

research and the Centre d’Études et de Recherches sur le Développement International 

(CERDI) in Clermont-Ferrand for administrative support. 

ABSTRACT 

 The study presents a reconstruction of under-five mortality trends derived from data 

provided by the Demographic and Health Surveys (DHS) and World Fertility Surveys (WFS) 

in sub-Saharan Africa from 1950 to 2000. Death rates were first calculated by single years for 

each of the 64 surveys available. When several surveys were available for the same country, 

they were combined for each of the overlapping years. Then the series was analyzed to 

identify periods of monotonic trends, whether they were declining, steady, or increasing. 

Changes in trends were tested using a linear logistic model. All calculations were done at the 

national level and by urban-rural residence. Among the 33 countries studied, which account 

for some 80 percent of the sub-Saharan population, only eight had monotonic or quasimonotonic mortality trends, which indicate a smooth health transition. Another eight countries 

had periods when mortality rose significantly for a variety of reasons. In at least eight other 

countries mortality increased through 1985-90—the most recent period covered in the study—

as a result of increasing levels of AIDS mortality. Reconstructed levels and trends are 

compared with other estimates made by international organizations. These estimates are 

usually based on indirect methods. 

Results indicate that in sub-Saharan Africa, progress was made in the health transition 

during the second half of the twentieth century. However, improvement was slower than 

expected, with an average decline in mortality of -1.7 percent per year. The transition was not 

smooth in more than half of the countries, and cases of reversals in mortality trends occur that 

appear to be linked to political, economic, and epidemiological crises, particularly the 

HIV/AIDS pandemic. 

Key words: under-five mortality, mortality trends, health transition, HIV/AIDS mortality, 

political crises, economic crises, emerging diseases, demographic impact, sub-Saharan Africa. 
1

INTRODUCTION

 The steady decline in mortality called the “health transition” has been one of the most 

salient features of demographic change in the twentieth century, and has had numerous 

economic and social consequences. The transition started in the second part of the nineteenth 

century in Western Europe and in North America, South America, and the Pacific countries 

where Europeans settled. This major change spread rapidly to most of the world, and by 1950 

data showed that a steady decline in mortality and an increase in life expectancy had occurred 

worldwide since 1900 (Stolnitz, 1955; Stolnitz, 1965). Data from the second half of the 

twentieth century confirmed these trends, and until the sudden emergence of HIV/AIDS, these 

trends were expected to continue in the pattern of the most advanced countries, such as Japan. 

 The steady decline in mortality occurred with the emergence of modern states, and 

with the development of modern public health policies based on biomedical knowledge and 

the theory that disease is caused by germs. The decline also took place during a time of steady 

economic growth and major improvements in nutrition, housing, and living conditions. 

Modern public health practices, which developed in the second half of the nineteenth century 

in Western Europe and the United States, were applied within a few decades around the world 

by independent states and colonial powers. Among the first benefits were improvements in 

water and sanitation, hygiene, and child feeding practices, and the development of 

vaccinations. Further developments included the production of efficient medicines 

(particularly antibiotics and antimalarial drugs) and a variety of preventive and curative 

practices. The result was a dramatic decline in mortality, especially among infants, young 

children, and young adults (including mothers), primarily because of the decline in deaths due 

to infectious and parasitic diseases (Preston, 1976; Preston, 1980; McKeown, 1976). 

 Sub-Saharan countries began the health transition later than other countries. Although 

much change has occurred there since 1930, most countries still have relatively low levels of 

life expectancy and high levels of infant and child mortality. To fairly judge the health 

transition in Africa, it is appropriate to consider trends rather than simply current mortality 

indicators. In countries where the health transition started later, a relatively high level of 

under-five mortality during a period of steady mortality decline could still indicate a favorable 

health transition despite the apparent lack of change. However, where mortality trends are 

increasing, a relatively low level of under-five mortality could hide a negative change. It 

therefore is more useful to document mortality trends to understand the status of the health 

transition in Africa, and to identify gaps where further action is needed. This approach is 

particularly important for under-five mortality, the main target of public health policies and 

the most common indicator of levels of mortality. 

Comprehensive registration data, the best source for assessing mortality trends, are 

currently not available in sub-Saharan Africa. To assess trends in mortality among young 

children, researchers rely on demographic sample surveys or other sources such as mortality 

data collected in censuses (United Nations, 1982; Brass et al., 1968; Feachem and Jamison, 

1991; Mandjale, 1985; van de Walle, et al., 1988). A synthesis of indirect mortality estimates 

in Africa was conducted by the World Bank for the period before 1985. It revealed a steady 

decline in mortality (Hill, 1991; Hill and Hill, 1988). However, this synthesis suffers from the 

lack of precision of indirect methods to estimate trends. A more recent analysis was conducted 

by the World Health Organization (WHO) using direct and indirect estimates, and 

reconstructing trends by five-year periods from 1955-59 to 1995-99 (Ahmad, Lopez, and
2

Inoue, 2000). This compendium made better use of all available data, in particular direct 

estimates provided by DHS surveys. However, it covers five-year periods, which provide 

reasonable estimates of mortality levels and major trends, but often obscure the specific 

periods when changes in mortality trends occur. Precise knowledge of the date of reversals in 

mortality trends is important to understand the causation of the changes. 

 The aim of this study is to provide new estimates of under-five mortality trends in 

African countries with data from demographic sample surveys. The main rationale of this 

analysis is to identify periods of monotonic change and the precise times that trend changes 

occurred. This study was a prerequisite for a larger study of the determinants of reversals in 

mortality trends in sub-Saharan Africa currently being conducted by the authors. As will be 

described later in this report, periods of increasing mortality can be attributed to a variety of 

situations: political crises, economic crises, and epidemiological crises or emerging diseases. 

Special attention is devoted in this report to the possible impact of pediatric AIDS since 1985. 

The methods used to reconstruct under-five mortality trends, to test changing slopes in 

mortality trends, and to examine the main results by country are described below. There are 

separate estimates by urban and rural residence. The appendix presents figures for each 

country, with brief descriptions of the determinants that are likely to explain changes in 

mortality trends. The full analysis will be published in a separate book. 
3

DATA AND METHODS

 To reconstruct mortality trends, data from the Demographic and Health Surveys and 

the World Fertility Survey were used. Data from both projects came from the collection of 

maternity histories from a representative sample of women of reproductive age (15-49 years). 

Maternity histories allowed the reconstruction of deaths among children born to women 

interviewed in the survey. On average, the mean number of women interviewed per survey 

was about 6,500, the mean number of births was 21,000, and the mean number of deaths was 

4,000. Full maternity histories at the time of interviews included the date of birth and the age 

at death (when applicable) for each live birth. Date of birth was given by month and year, with 

no missing values in the standard recoded files. Age at death was provided in days for 

neonates, in months for young children, and in years for older children. Age at death included 

a few missing cases. These data allowed the computation of period death rates by month. 

Only under-five mortality was considered in this study. 

 A total of 56 DHS surveys and 10 WFS surveys were used, covering 32 sub-Saharan 

countries. These countries constitute about 70 percent of all African countries and 80 percent 

of the total population of sub-Saharan Africa and Madagascar, not including the small African 

islands (including Cape Verde, São Tomé and Principe, Mauritius, the Seychelles, Mayotte, 

Reunion, and Saint Helen). A Multiple Indicator Cluster Survey (MICS) was included to 

cover Angola, which had no DHS or WFS surveys. The MICS survey is based on a somewhat 

different methodology: only the birth histories of the last three pregnancies were included. 

The list of countries and surveys included in this study is presented in the appendix. 

 Maternity history data represent a biased sample of births and deaths in the years 

before the survey. Only births to women age 15-19 are considered, thus leaving out births that 

occurred previously among women now over age 50, which accounts for roughly half of the 

births in the 35 years before the survey. In the few years before the survey the biases are 

minimal, because older women have few births. However, when considering births more than 

20 years before the survey, the biases become more prominent because the sample is more 

skewed, and the proportion of births to very young women increases. This phenomenon tends 

to result in overestimation of the level of mortality in earlier periods. Second, births to women 

who died before the survey are not counted. This omission tends to underestimate the 

mortality of young children because of the correlation between deaths of mothers and their 

children, that is, higher mortality among orphans. Third, there may be recall errors when 

recording births that occurred many years ago among women with high parity. In practice, 

these biases (positive and negative) tended to counterbalance each other. After many trials, it 

was decided to keep all the information available; that is, to not discount births that occurred 

more than 20 years before the survey. Of course, the sample size determines the confidence 

intervals of the point estimates and the slopes. In particular, for periods long before the 

survey, estimates are based on a small number of deaths and have wide confidence intervals. 

Justification of this strategy was primarily empirical. In countries where several surveys were 

available, estimates for an earlier period of a later survey were not significantly different from 

estimates for the same period in earlier surveys. 

Computation of yearly death rates 

In the first step, age- and period-specific death rates were calculated. The period used 

in this step is the year according to the Gregorian calendar. In the case of Ethiopia, the 

Amharic calendar was converted into a Gregorian calendar. Only two age groups were 
4

considered: 0-11 months and 12-59 months, to better specify the under-five death rate. Using 

each year of age between 0 and 4 years would have led to erratic estimates because of the 

small number of deaths after age two. For practical purposes of using the date function day, 

month, and year in computer programs, date of birth was considered to have occurred on the 

first day of the month. In cases of child death, the date of death was calculated by adding the 

age at death to the date of birth. When age at death was given in days, the calculation was 

direct. When the age at death was given in months, the date of death was calculated as the 

corresponding number of days (number of months = 365/12) plus 15 days (mid-month). When 

age at death was given in years, the date of death was calculated similarly, by adding the 

corresponding number of days (number of years/365 plus 183 days (mid-year). In rare cases 

when age at death was not known, it was imputed as the mean value for the other children, 

that is, 24 months. This procedure allowed the direct calculation of the person-months spent 

between birth and the date of the survey, by age and period. When the sample was stratified 

and weighted, the weights of the mother were applied to each birth. All the calculations were 

done in a program written for Dbase/FoxPro databases. The first step provided estimates of 

infant mortality rates (age 0-11 months) and child mortality rates (age 12-59 months) by 

calendar year. These were converted into under-five mortality rates (q(5)) by applying the 

standard formula: q(5) = (1-1q0)*(1-4q1), with a mean duration until death of 0.33 for the 

infants and 1.35 for the children. These values were derived from the United Nations Model 

Life Tables, General Model for Developing Countries. 

Figure 1 illustrates the results of these calculations for Kenya, a country with four 

surveys. Results show the general agreement among the four surveys (both in terms of level of 

mortality and trends) that allowed the four data sets to be combined. Values pertaining to the 

earliest years are strongly affected by random fluctuations, with the number of deaths for each 

year often less than 50. These fluctuations have no value for analysis; none of the differences 

in the various estimates for the same year are statistically significant. They all seemed to be 

due to random fluctuations. Furthermore, the data show a steady decline in mortality through 

1984, followed by a sustained increase. This indicates a reversal in mortality trends, which is 

the focus of this study. 

Aggregating the various surveys

In the second step, data from various surveys in the same country were aggregated. 

This was done by adding for the same year the person-months and the deaths, to recalculate 

the rates described above. Before this step, the surveys were examined graphically for 

compatibility. The surveys were found to be compatible in all the countries investigated, with 

the exception of Nigeria. This compatibility shows the high quality and high degree of 

consistency of WFS and DHS surveys. The aggregation of the data from several surveys was 

based on the principle of keeping and adding the number of deaths and the number of personmonths observed in a given age group in a given year. This method allowed the calculation of 

the appropriate confidence intervals and the appropriate statistical tests for slopes. These 

procedures depend only on the number of deaths observed and the level of mortality. 
5

Figure 1: Annual under-five mortality rates by survey, Kenya 

0

50

100

150

200

250

300

350

400

450

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

WFS-1978

DHS-1988

DHS-1993

DHS-1999

Search for monotonic periods and inflexion points 

In the third step, the authors searched for monotonic periods of mortality change and 

inflexion points where a change in slope occurred. In a regular health transition, the rate at 

which death rates decline tends to be constant over long periods of time. For example, in 

France under-five mortality declined at a rate of about 5 percent per year between 1950 and 

1999. The search for inflexion points was conducted graphically first, and then tested 

statistically. Graphically, a high-degree polynomial (degree 4 to 6) was fitted to the 

aggregated data to identify changing slopes. Once monotonic periods were identified, the 

slope was estimated, and a test was performed to verify whether the changing slope was 

significant (see section 2.5). Changing slopes resulting from erratic values in the earliest 

periods were discarded. In the example shown in Figure 2, two monotonic periods appear: a 

steady decline before 1984 and a steady increase thereafter. When compared with trends, 

differences with point estimates were not statistically significant, with the exception of two 

points: 1954 and 1964. Differences between observed data and trends were therefore 

interpreted as random fluctuations. 
6

Figure 2: Aggregation of the four surveys and polynomial adjustment, Kenya 

0

50

100

150

200

250

300

350

400

450

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Combined

Poly. (Combined)

Inflexion point

Estimations of under-five mortality by two-year periods 

Annual data were used to maximize the precision of trends and inflexion points, which 

is important for understanding the determinants of trends. However, as seen above, annual 

data are affected by random fluctuations. To improve the presentation of the raw estimates, 

data were grouped by two-year periods for most of the estimates, and by five-year periods for 

the earliest dates. This was done by adding deaths and person-months. Estimates by two-year 

periods are more stable in countries with a large number of deaths, as in the case of Kenya 

(Figure 3). 

Calculation of trends by monotonic period and testing changing trends 

After monotonic periods were identified, trends could be formally calculated. This was 

done by considering the equivalence of period and cohort estimates and applying a Logit 

model. A period estimated of q(5) based on D(5) deaths was considered to apply to N(5) = 

D(5)/q(5) births in a theoretical cohort. Each period estimate in year (t) of under-five mortality 

q(t) could therefore be used to generate a sample of N(t) births, among which D(t) died. These 

samples were used to compute the slope of mortality decline, given the exact number of 

deaths observed each year in the combined sample. We used the linear logistic model (Logit 

model) in SPSS to calculate the slopes and the corresponding confidence intervals. Thereafter, 

we call “logistic slope” the slope of the Logit adjustment made on these data. The logistic 

slope provides a measure of the speed of the mortality decline, or the speed of the mortality 

increase, depending on the sign of the slope. This method also allowed the testing of changes 

in slopes between periods of monotonic change. This was done by using a T-test between the 

two slopes. Comparing the observed values to the predicted value by the Logit model also 

permitted the identification of periods of abnormally high or low mortality compared with 

trends. When the difference is statistically significant, the corresponding point appears as 
7

Figure 3: Under-five mortality by two-year periods and Logit adjustment, Kenya 

0

100

200

300

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Prolonged

transparent on the figures. The Logit model also allowed the authors to prolong previous 

trends, and in case of reversal in mortality trends to compare the observed values with the 

expected value from earlier trends, that is, to compare the mortality crisis with the normal 

course of the health transition. Figure 3 shows two points of high value (1954) and low value 

(1974) in Kenya, which do not affect the interpretation of the trends. It also shows that 

according to previous trends (1950-84), mortality in 1998 was expected to be 52 per 1,000, 

whereas a much higher level was found (115 per 1,000) after the mortality increase. This 

provides a measure of the magnitude of mortality increase, which could be compared with the 

net effect of pediatric AIDS. 

HIV seroprevalence and expected impact of pediatric AIDS 

Pediatric AIDS has become a leading cause of mortality in many African countries. 

Pediatric AIDS causes as many deaths as all the other major causes of infant and child 

mortality combined. By itself it could cause a reversal in mortality trends in countries with 

high HIV seroprevalence among adult women, when other causes are held constant or in 

regular decline. It is therefore important to assess what the mortality trends would have been 

without pediatric AIDS in order to evaluate the course of the health transition in the absence 

of HIV. Pediatric AIDS comes almost entirely from the vertical transmission of the HIV virus 

from mother to child, during pregnancy, at the time of delivery, or through breastfeeding. HIV 

seroprevalence among pregnant women, the most commonly available source of information 

on HIV in Africa, is therefore an adequate indicator of pediatric AIDS mortality, assuming 

constant probabilities of vertical transmission and constant probabilities of death among HIVinfected children. 

 To estimate the net effect of pediatric AIDS on under-five mortality, we have 

reconstructed the dynamics of HIV seroprevalence among pregnant women in African 

countries. This was done using data provided by the AIDS database of the U.S. Bureau of 

Census, International Programs. For many countries, HIV seroprevalence estimates are 
8

available for several years between 1980 and 2000. In only one case, South Africa, is the 

series complete for all years between 1990 and 2000. In other countries, only a few data 

points are available. The authors developed a model of the increase in seroprevalence based 

on the South African data. The model is simply a hyperbolic function of the Logit of the 

proportions of seropositive women. This model fit well with the South African case and with 

many other countries for which more than five points were available, and where 

seroprevalence increased steadily until the last point available before 2000. In two cases 

where the increase in seroprevalence was halted and even reversed (Uganda and Zaire), two 

curves were fit, one ascending (Logit-hyperbolic) and one descending (Logit-linear). These 

models were applied to all countries with HIV seroprevalence data for the period 1980-2000. 

Figure 4: Estimation of pediatric AIDS mortality as a function of seroprevalence, Kenya 

HIV seroprevalence and under-five mortality impact, 

Kenya 1980-2000

0%

2%

4%

6%

8%

10%

12%

14%

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

HIV seroprevalence

0.000

0.005

0.010

0.015

0.020

0.025

0.030

AIDS mortality among childre

Seroprevalence

Aids mortality

After the dynamics of the HIV epidemic among pregnant women is reconstructed, year 

by year, one can estimate the expected pediatric AIDS mortality. A constant vertical 

transmission of 25 percent was assumed, without modulating for the duration of 

breastfeeding. It was assumed that 30 percent of infected children were dying of HIV/AIDS 

each year between ages 0 and 5, in a life table framework, without taking into account the 

level of mortality in the country. These estimates could be refined when more data on AIDS 

mortality become available. The parameters taken correspond to the mean of various studies 

conducted in sub-Saharan Africa. Results show a close correlation between the dynamics of 

seroprevalence of AIDS among pregnant women and the net effect on under-five mortality. In 

the case of Kenya, where seroprevalence has increased steadily, the two curves are almost 

parallel (Figure 4). In the case of increasing-then-decreasing seroprevalence, as in Uganda, the 

effect on under-five mortality is diluted over a longer period, and somewhat smoothed by the 

cohort effects. 
9

Trends without AIDS 

To calculate mortality trends without AIDS, it was assumed that causes of death were 

additive and that mortality without AIDS was equal to total mortality minus the mortality 

attributable to pediatric AIDS. Figure 5 displays the net effect of HIV/AIDS for Kenya. In 

1998, under-five mortality was estimated from trends at 120 per 1,000 and at 98 per 1,000 

without AIDS. AIDS accounted for only part of the mortality increase after 1984, and even 

without AIDS a change occurred in mortality decline after 1984. 

Figure 5: Estimation of under-five mortality trends without AIDS, Kenya 

0

100

200

300

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Without AIDS

In some countries, data on HIV seroprevalence among pregnant women are of poor 

quality, and any assessment should be considered with caution. In other countries, HIV 

seroprevalence among pregnant women remained at a low level until 2000, and the net effect 

of pediatric AIDS is therefore small compared with all causes of mortality. When AIDS 

accounts for less than 10 percent of under-five mortality, the net effect of AIDS was not 

presented in the figures. Calculation of trends without pediatric AIDS was done in all 

countries with high HIV seroprevalence; that is, all countries in Eastern and Southern Africa, 

plus three countries in West Africa: Côte d’Ivoire, Mali, and Burkina Faso. 

Comparison with other data sources 

Our estimations of mortality trends, before correcting for pediatric AIDS, were 

compared with other data sources: the estimates based on indirect methods published by the 

World Bank (Hill, 1991); the estimates published by WHO (Ahmad, Lopez, and Inoue, 2000); 

the direct estimates provided by DHS data; and, in some cases, the Institut National de la 

Statistique et des Études Économiques (INSEE) surveys conducted in francophone countries 

in the 1960s and 1970s. These comparisons allowed the authors to validate the reconstruction 

and to measure the inaccuracy of other estimates, in particular indirect estimates. 
10 

Figure 6: Comparison with indirect estimates and other data, Kenya 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)

In the case of Kenya (Figure 6), indirect estimates come from censuses conducted in 

1948, 1960, 1970, and 1980. Indirect estimates appear to be close to the reconstructed values, 

and the values before 1950 are consistent with the reconstructed trends. Average values of 

points located between 1948 and 1978 are virtually identical to reconstructed estimates (210 

and 208 per 1,000, respectively). Indirect estimates fall within a +/- 20 percent range of 

reconstructed trends (+19 percent for the 1970 census and -19 percent for the 1948 census), 

which indicates the inaccuracy associated with indirect methods. Trends also would be 

approximately the same between 1948 and 1978. Logistic slopes were -4.3 percent and -3.8 

percent respectively. Direct estimates published by DHS surveys are almost identical to the 

authors’ reconstructions, a finding expected since the data are the same. However, the 

reconstructed series goes back to earlier periods, and the yearly estimates as well as the twoyear estimates allow better documentation of the inflexion point. The World Health 

Organization (WHO) series, based on a mixture of direct and indirect estimates, is less 

precise. They erased the inflexion point, neglected the mortality increase after 1985, and 

underestimated the slope between 1955 and 1985 (-2.6 percent compared with -4.3 percent 

observed). All of these elements are important in documenting the mortality transition in 

Kenya. The reconstructed series without AIDS indicates that under-five mortality increased in 

Kenya after 1985 for causes of death other than those associated with HIV, a result that 

requires explanation. The 1950-1985 trend predicted a low value of 51 per 1,000 in 1998. 

Observed values show a marked increase in mortality of an estimated 69 per 1,000 compared 

with the expected course of the health transition, of which 22 per 1,000 was attributed to 

HIV/AIDS and 47 per 1,000 to other causes. The reconstruction and the evaluation of the net 

effect of pediatric AIDS seem therefore to be critical to understanding mortality changes in 

Kenya, and to analyzing their underlying determinants. 
11 

Urban and rural estimates 

Similar computations were done by urban and rural residence. Presented here are twoyear series and reconstructed trends for urban and rural residence. In Kenya, the trends appear 

to be similar for urban and rural populations, with almost parallel slopes between 1950 and 

1984 (-4.7 percent and -4.3 percent, respectively) and a similar mortality increase after 1985. 

It can be seen that mortality may have increased a few years earlier in urban areas, though 

precise estimates of inflexion points and ways of testing the differences are lacking or would 

require other types of modeling. 

Figure 7: Reconstructed under-five mortality trends in urban and rural areas, Kenya 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)
12 

RESULTS 

 Results by country are presented in the appendix, which includes (as much as possible) 

the same details as those provided for Kenya, plus urban and rural data. Estimated values of 

under-five mortality by year are provided in the tables in the appendix. These reconstructions 

were done for 33 countries. Data quality and quantity vary markedly. Reconstruction usually 

starts in 1950, except in countries for which the data were not available. It should be 

remembered that data for the period 1950-59 are based on the earliest years of the earliest 

surveys, and therefore tend to be overestimated because of the bias associated with selecting 

younger women. They were kept as such, to provide data consistent with later estimates for 

persons interested in using them for regression analysis over the whole period, in particular 

for correlations with GDP (gross domestic product) per capita, for which series are available 

since 1950 for most countries. Estimates of mortality declines in the 1950s will often seem 

faster than estimates in later periods. This may be partly due to the forecasting method. 

However, in most countries for which reliable data are available, mortality decline in the 

1950s is always dramatic, probably because of the arrival of antibiotics and antimalarial 

drugs. Estimates stop in the year of the last survey, with ranges from 1987 to 2000. In Lesotho 

only the WFS survey was conducted in 1977. All the DHS data sets available in early 2003 

were included. With the new rounds of DHS surveys, more data is coming that will allow 

researchers to complete estimates for the entire 1950-2000 period for many countries. The 

reconstructed trends allow a basic typology of health transitions in sub-Saharan Africa. 

Regular mortality decline 

Among the 33 countries studied, only nine had a regular health transition; that is, a 

steady decline in under-five mortality over the period covered by the surveys. They were 

Benin, Burkina Faso, Comoro Islands, Ethiopia, Guinea, Liberia (up to 1986), Mali, Chad, 

and Togo. All these countries had high levels of mortality in 1950, and exhibited no reversals 

in mortality trends throughout the period covered by the surveys. The case of Liberia is 

unusual because no data were available after 1986. This situation is probably due to the civil 

war there during the 1990s. The analysis indicates that only a few African countries have had 

a smooth health transition. 

Short-term increases in mortality 

Despite a steady decline in mortality, some countries experienced a few years of 

excess mortality that did not substantially affect overall trends. For instance, in Burkina Faso 

mortality increased in 1994-95 in rural areas but not in urban areas. In Lesotho mortality 

increased significantly between 1962 and 1965. In Namibia, mortality increased during the 

struggle for independence (1977-82), then decreased until the arrival of HIV/AIDS in the 

1990s. Similarly, mortality increased in Zimbabwe during the struggle for independence 

(1978-82) in that country. In Nigeria, mortality increased during the Biafra war (1964-68). In 

Chad, mortality increased in 1980-81, and in Togo, mortality increased in rural areas in 1993-

94. However, all these changes appear to have been transitory because they did not have any 

substantial long-term effects on mortality trends. 

Changing trends in under-five mortality: Political and economic crises 

Several countries went through prolonged periods of mortality increase as a result of 

political crises, economic downturns, or civil war. In Angola, the limited data available 
13 

showed that under-five mortality declined during the late colonial period and the years 

following independence (1975-79), then increased during the civil war years (1980-89). A 

similar pattern prevailed in Mozambique, a country that went through similar political change 

and was also strongly affected by civil war. In Ghana, under-five mortality increased between 

1979 and 1983, during a severe political crisis. In Madagascar, mortality increased during the 

Malagasy revolution period (1975-86), when GDP per capita underwent a rapid decline. In 

Nigeria, mortality increased between 1978 and 1988 in rural areas, and stagnated in urban 

areas during the same period. In Uganda, mortality increased markedly during the Idi Amin 

Dada years (1971-79) and the few years of political uncertainty following his departure (1980-

84), until a stable situation returned with the arrival of Yoweri Museveni (1986). In Rwanda, 

as in Burundi, mortality increased in the period after independence (1965-76). In Rwanda, 

mortality increased during the attacks of the Tutsi refugees after 1991, peaked during the 

genocide (1994), and rose again in 1998. In Tanzania, mortality increased during the 1979-85 

period, particularly in urban areas. In Zambia, mortality increased between 1975 and 1992, 

especially in urban areas, after the major decline in copper prices on the international market 

(the main export and the main source of income of the country) and during the political and 

economic crisis that followed. This major downturn occurred even after discounting for the 

effect of HIV/AIDS. 

Stagnation 1980-1990 

 Several countries underwent periods of stagnation in under-five mortality in the 1980s 

and 1990s. For instance, in Benin, mortality stopped declining between 1979 and 1989 in both 

urban and rural areas despite favorable economic indicators. In the Central African Republic, 

mortality stagnated between 1977 and 1989, a difficult period following the installation and 

fall of Jean-Bédel Bokassa. In Gabon, mortality stagnated after 1985, even after discounting 

for the impact of AIDS. In Niger, mortality stagnated in rural areas between 1972 and 1992. 

In Sudan, mortality stagnated in 197484 and even increased slightly in rural areas. 

Epidemiological crises (malaria) 

 In only one case was evidence found of a specific mortality crisis, probably caused by 

malaria. In Senegal, under-five mortality increased during the period 1960-70, and this 

increase was associated with an increase in malaria morbidity that followed the failed attempt 

to eradicate malaria from 1955 to 1959. Malaria mortality increased again in the 1990s, 

according to local studies, although there was no discernible effect on mortality (all causes). 

Mortality increases caused by HIV/AIDS 

 Pediatric AIDS has had a strong effect in several countries, provoking or exacerbating 

mortality increases. This is particularly evident in southern African countries (South Africa, 

Botswana, Zimbabwe, Malawi, and Zambia), in some eastern African countries (Kenya, 

Uganda, Tanzania), and in one western African country (Côte d’Ivoire). In Zimbabwe and in 

Botswana, all of the increase in under-five mortality was attributable to HIV/AIDS, whereas 

in other countries pediatric AIDS contributed to only part of the increase. 

Mortality increases after discounting for HIV/AIDS 

 In several countries, under-five mortality has increased in recent years not only as a 

result of HIV/AIDS, but also after discounting for HIV/AIDS, according to our model. For 
14 

instance, in South Africa, even after subtracting the effects of pediatric AIDS, under-five 

mortality stopped declining after 1993. In Cameroon, under-five mortality after discounting 

for HIV/AIDS was 145 per 1,000 in 1998, although a lower level (101 per 1,000) was 

expected from previous trends. In Côte d’Ivoire, the recent change in under-five mortality 

remained favorable after discounting for HIV/AIDS, but the slope is much lower than it was 

before 1983. In Kenya, under-five mortality increased after 1985, even after discounting for 

HIV/AIDS. 

Differentials in mortality change by urban-rural residence 

 Overall, mortality change in a country is similar in urban and rural areas. However, 

several cases of differentials in mortality change by urban-rural residence were documented. 

In Burundi, rural mortality declined between 1976 and 1986, whereas it increased in urban 

areas. In the Central African Republic, mortality increased in rural areas between 1976 and 

1990, but decreased in urban areas during the same period. In Malawi, urban mortality 

increased substantially after 1984, but mortality remained unchanged in rural areas. In 

Mozambique, differences in mortality between urban and rural areas occurred during the civil 

war, and rural areas were most affected. In Niger, mortality remained unchanged between 

1972 and 1992 in rural areas, but continued to decline in urban areas. 
15 

DISCUSSION 

 Available data on under-five mortality in sub-Saharan Africa cover only a limited 

number of countries and a limited number of years between 1950 and 2000. Further, sampling 

errors as well as several minor biases affect the data. However, the data were sufficient to 

reconstruct the main trends in under-five mortality, some of the erratic changes, and major 

mortality increases caused by HIV/AIDS and other causes (such as political and economic 

crises). The data show that the health transition has been sustained over the period 1950-2000, 

with a rate of decline in under-five mortality of about -1.7 percent. This decline, however, has 

been affected by numerous situational factors, some minor increases in mortality, and some 

major increases in mortality such as occurred as a result of pediatric AIDS. 

 Explaining these changes, both positive and negative, calls for a renewed look at 

mortality determinants. On one hand, major changes have occurred in the field of public 

health, including the increased number of physicians per capita, increased vaccination 

coverage, and the extensive use of modern medicines, as well as urbanization and modern 

education, all of which have contributed to mortality decline. On the other hand, political 

crises, civil wars, poor state management, and, to a lesser extent, economic crises have 

contributed to increases in mortality. HIV/AIDS arrived in the mid-1980s to complicate the 

health situation, and now accounts for a large part of recent increases in mortality. 

Fluctuations in the prevalence of malaria may also have played a role. Recent mortality 

increases after discounting for the effects of HIV/AIDS require additional explanation. 

Increases in poverty, particularly in large cities, may explain increases in mortality in places 

such as Kenya, Cameroon, and Côte d’Ivoire. 

 This attempt to reconstruct under-five mortality trends has several advantages over 

earlier estimates. Compared with indirect estimations, which often are out of date, the direct 

estimates provide more robust levels and trends and more inflexion points. Compared with 

WHO estimates, which are based on a mixture of direct and indirect estimates, reconstructed 

trends often show patterns that have been smoothed. Furthermore, discounting the effects of 

HIV/AIDS allows for better documentation of what portion of mortality is due to emerging 

diseases and what portion is due to other causes. 

 This reconstruction was a prerequisite to a detailed analysis of the determinants of 

mortality change in sub-Saharan countries, whose complexity is readily apparent when 

examining the country figures. Health transition in sub-Saharan Africa is complex because of 

several factors, the most important of which seem to be political instability, poor state 

management, and emerging diseases. The diversity of situations among the countries should 

be taken into account to better understand the various patterns of under-five mortality seen 

during the second half of the twentieth century. 
16 

REFERENCES 

Ahmad, O.B., A.D. Lopez, and M. Inoue. 2000. The decline in child mortality: A reappraisal. 

Bulletin of the World Health Organization 78(10): 1175-1191. 

Brass, W. et al. 1968. The demography of tropical Africa. Princeton, NJ: Princeton University 

Press. 

da Costa Carvalho, C. 1978. Bilan de la démographie angolaise. Thèse de maîtrise en 

démographie, Université Catholique de Louvain. [A synthesis on the Demography of Angola. 

Master’s dissertation in Demography, Catholic University of Louvain, Belgium]. 

Feachem, R., and D. Jamison, ed. 1991. Disease and mortality in sub-Saharan Africa. New 

York: World Bank/Oxford University Press. 

Heisel, D.F. 1968. The demography of the Portuguese territories: Angola, Mozambique and 

Portuguese Guinea. In The demography of tropical Africa. ed. W. Brass et al., 440-465. 

Princeton, New Jersey: Princeton University Press. 

Hill, A. 1991. Infant and child mortality: Levels, trends and data deficiencies. In Disease and 

mortality in sub-Saharan Africa, ed. R. Feachem and D. Jamison, 37-76. New York: World 

Bank/Oxford University Press. 

Hill, A. and K. Hill. 1988. Mortality in Africa: Levels, trends, differentials and prospects. In The 

state of African demography, ed. E. van de Walle, P.O. Ohadike, and M.D. Sala-Diakanda, 67-

101. Liège, Belgium: IUSSP-Derouaux. 

Mandjale, A.E. 1985. Mortalité infantile et juvénile en Afrique: Niveaux et caractéristiques, 

causes et déterminants. Louvain la Neuve, Belgium: CIACO. 

McKeown, T. 1976. The modern rise of population. New York: Academic Press. 

Preston, S.H. 1980. Causes and consequences of mortality declines in less developed 

countries during the twentieth century. In Population and economic change in developing 

countries, ed. R.A. Easterlin, 289-353. Chicago: University of Chicago. 

Preston, S. H. 1976. Mortality patterns in national populations. New York: Academic Press. 

Schoffield, R., and D. Reher. 1991. The decline of mortality in Europe. In The decline of 

mortality in Europe, ed. R. Schoffield, D. Reher, and Alain Bideau, 1-17. Oxford: Clarendon 

Press. 

Stolnitz, G. 1955. A century of international mortality trends. Pt. 1. Population Studies 9 (1): 

24-55. 

Stolnitz, G.J. 1965. Recent mortality trends in Latin America, Asia and Africa: Review and reinterpretation. Population Studies 19(2): 117-138. 

United Nations, Population Division. 1982. Levels and trends of mortality since 1950. UN 

Population Study No. 74. New York: United Nations. 

van de Walle, E., P.O. Ohadike, and M.D. Sala-Diakanda, ed. 1988. The state of African 

demography. Liège, Belgium: IUSSP-Derouaux. 
Appendix 

17

Appendix 

Under-five Mortality Trends in Africa: 

Country Estimates 
Angola 

18

1. Angola 

 Angola is the only country in this study for which no Demographic and Health Survey 

(DHS) was conducted. However, given the economic importance of this country and its 

difficult internal political situation, we reconstructed mortality trends using the limited 

information available from the Portuguese census of 1940 and the Multiple Indicator Cluster 

Survey (MICS) conducted in 1996. Compared with a formal DHS survey, the MICS survey 

has two serious shortcomings: It is based on only the last three births instead of a full 

maternity history, and it does not cover the areas controlled at that time by UNITA, the rebel 

movement. However, the results from the recent period are so dramatic that we decided to 

include them. Brass-type data from the 1940 census were taken from Dr. da Costa Carvalho’s 

dissertation (da Costa Carvalho, 1978), from which indirect estimates were derived using the 

United Nations General Model for developing countries. Results indicate an average value of 

q(5) of 363 per 1,000 in 1927 and 392 per 1,000 in 1937, a level roughly equivalent to A. 

Hill’s estimates (Hill, 1991) with the South Model (362 per 1,000 in 1935). It should be noted 

that mortality rose between 1927 and 1937, although documentation is not available. We 

considered only the last point as a starting point for the trends. The MICS survey gives a first 

value of 197 per 1,000 in 1977. We applied a straight linear-logistic trend between these two 

points, with a slope of -2.7 percent per year, which is realistic. Of course, any anomaly or 

change in trends over that period would have been smoothed out by this procedure. From 

1977 on, the MICS data indicate a rapid decline in mortality between 1977 and 1986 (99 per 

1,000), then a rise of equal magnitude between 1986 and 1993 (185 per 1,000), and then 

another decline (142 per 1,000) in 1996. Both trend changes are highly significant (P = 

6,58 10-9 and 9,82 10-8, respectively). They are also evident in both urban and rural areas. Our 

estimates, especially those relating to trends, are quite different from the estimates of the 

World Health Organization (WHO). Our reconstruction indicates that mortality decreased at a 

moderate rate in the last 25 years of the colonial period (1950-75), then declined dramatically 

in the first few years after independence. Mortality rose during the difficult years of the civil 

war, before stabilizing after the first peace agreement was reached; it then started a moderate 

decline. This situation is much like that of Mozambique, a country with a similar political 

evolution. 
Angola 

19

Figure 1a. Trends in under-five mortality, Angola, total 

0

50

100

150

200

250

300

350

400

450

1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Figure 1b. Trends in under-five mortality, Angola, urban and rural 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Benin 

20

2. Benin 

Benin conducted a World Fertility Survey (WFS) in 1982 and DHS surveys in 1996 

and 2001. Together, these surveys provide substantial information on under-five mortality for 

the period 1950-2000. The three surveys are markedly consistent during the overlapping 

periods (1970-81 and 1970-95) in levels of mortality. Combined data indicate a change in 

trends in 1979-89, a period during which mortality remained almost stable. The changes in 

slopes before 1979 and after 1989 are both highly significant (P = 0.0003 and P = 0.001, 

respectively). We considered therefore three monotonic periods: 1950-79, during which 

under-five mortality declined from 426 to 222 per 1,000; 1979-89, when it remained around 

211 per 1,000 (the slope is not different from 0); and 1989-2001, when mortality declined 

from 199 per 1,000 to 139 per 1,000. No point was significantly different from the 

reconstructed trend. During the period 1950-79, mortality decline was similar in urban areas 

(330 to 175 per 1,000) and in rural areas (447 to 244 per 1,000), with similar slopes 

(-2.9 percent and -3.2 percent, respectively). The stagnation of the 197989 period was more 

pronounced in rural areas (slope of -0.7 percent) than in urban areas (slope of -1.3 percent), 

with none of the difference being significant. The recovery occurred somewhat earlier in rural 

areas during the 1989-2001 period. Over the whole period, the absolute gap between urban 

and rural areas was markedly reduced, from an estimated 117 per 1,000 to 37 per 1,000. 

Indirect estimates are consistent with the reconstruction. The WHO estimates neglect the 

stagnation period of 1979-89. The impact of AIDS remains small in Benin, and was estimated 

at 11 per 1,000 in 2000. 
Benin 

21

Figure 2a. Trends in under-five mortality, Benin, total 

0

50

100

150

200

250

300

350

400

450

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 2b. Trends in under-five mortality, Benin, urban and rural 

0

50

100

150

200

250

300

350

400

450

500

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Botswana 

22

3. Botswana 

 The only DHS survey in Botswana was carried out in 1988. The survey shows a steady 

decline in mortality from 1958 (176 per 1,000) to 1986 (47 per 1,000), one of the lowest 

levels in Africa at that time. The reconstructed mortality decline is similar to that of the WHO 

study and close to indirect estimates, but presents a lower level. The last two years indicate a 

sharp increase in mortality to 67 per 1,000 in 1998; the rise is significant (P = 0.02). The 

AIDS impact model predicts an increase above baseline levels of 51 per 1,000 by 1995 and of 

84 per 1,000 in 2000. This increase is consistent with the rise observed between 1986 and 

1988. During the 1958-86 period, levels and trends were similar in urban and rural areas (174 

to 49 per 1,000 and 171 to 51 per 1,000, respectively); similarly, mortality increased in both 

areas of residence in the past few years. The lack of difference between urban and rural areas 

in Botswana is atypical for African countries, and suggests efficient health services and good 

living conditions in the countryside. 
Botswana 

23

Figure 3a. Trends in under-five mortality, Botswana, total 

0

50

100

150

200

250

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 3b. Trends in under-five mortality, Botswana, urban and rural 

0

50

100

150

200

250

300

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Burkina Faso 

24

4. Burkina Faso 

 DHS surveys were conducted in Burkina Faso in 1993 and 1999. Mortality data from 

the two surveys are consistent in terms of trends, although the most recent survey provides 

somewhat higher estimates—significantly higher for the 1970-79 period, but not significantly 

different for the 1980-89 period. Overall, Burkina Faso has undergone a steady decline in 

under-five mortality. According to the reconstructed trend, mortality declined from 382 per 

1,000 in 1960 to 168 per 1,000 in 1998. Two anomalies departing from the trend can be seen: 

In 1973-74, mortality was above the trend (q(5) = 295 per 1,000, P = 8.82 10-9), which 

corresponds to the drought period in the Sahel and was apparent in both surveys. The second 

anomaly, seen only in the second survey, occurred in 1993-95 (q(5) = 189 per 1,000, P = 

1.37 10-11). Furthermore, some uncertainty remains regarding trends for the 1950-72 period: 

The 1992 data indicate higher levels, although reconstructed trends parallel the indirect 

estimates. Reconstructed trends also parallel the WHO estimates, although at a somewhat 

higher level. Trends in urban and rural areas were parallel during the 1960-98 periods (from 

300 to 109 per 1,000 and from 432 to 189 per 1,000 respectively). However, mortality, which 

stagnated in urban areas between 1989 and 1999, continued to decline in rural areas. Excess 

mortality in 1973-74 was evident in both urban and rural areas, whereas excess mortality in 

1993-95 was apparent only in rural areas. Pediatric AIDS, estimated at 14 per 1,000 in 1995 

and 17 per 1,000 in 2000, has played a minor role in under-five mortality. 
Burkina Faso 

25

Figure 4a. Trends in under-five mortality, Burkina Faso, total 

0

50

100

150

200

250

300

350

400

450

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 4b. Trends in under-five mortality, Burkina Faso, urban and rural 

0

100

200

300

400

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)

1961, Rural

1961, Capital city
Burundi 

26

5. Burundi 

 Burundi conducted one DHS survey in 1987. This survey is important because it 

shows a reversal in under-five mortality trends quite similar to that of neighboring Rwanda, 

which has a similar history and similar ethnic groups. Under-five mortality declined between 

1950 (321 per 1,000) and 1965 (216 per 1,000), then increased through 1975 (233 per 1,000), 

and then declined in 1987 (130 per 1,000). In Burundi, changes in mortality differ by urbanrural residence. Rural mortality declined between 1977 and 1987 (268 to 142 per 1,000), 

whereas urban mortality tended to increase during the same period (159 to 171 per 1,000). As 

a result, urban mortality was higher than rural mortality in 1985-87 (174 and 132 per 1,000, 

respectively,); however, the difference was not significant, P = 0.074. Reconstructed trends 

were consistent with direct and indirect estimates, although somewhat different from the 

WHO estimates. Pediatric AIDS did not play a significant role in 1987 (estimated at 8 per 

1,000), and did not have a substantial impact at the national level until 2000 (estimated at 13 

per 1,000). AIDS did, however, have a large impact in urban areas—estimated at 28 per 1,000 

in 1987—and could explain the urban-rural differential in under-five mortality in 1985-87. 

The impact of AIDS in rural areas was much less (estimated at 7 per 1,000) at the same time. 
Burundi 

27

Figure 5a. Trends in under-five mortality, Burundi, total 

0

50

100

150

200

250

300

350

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 5b. Trends in under-five mortality, Burundi, urban and rural 

0

50

100

150

200

250

300

350

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (R)

Reconstructed (U)
Cameroon 

28

6. Cameroon 

 Cameroon conducted a WFS survey in 1978 and DHS surveys in 1991 and 1998. This 

permits a mortality reconstruction for the entire period 1950-98. The three surveys are 

consistent, and provide approximately the same levels and trends during the overlapping 

periods. Under-five mortality declined steadily from 1950 (336 per 1,000) to 1988 (133 per 

1,000), then increased somewhat to 157 per 1,000 in 1998. The reconstructed trend was 

consistent with other direct and estimates, and with WHO estimates, although the mortality 

increase from 1988 to 1998 was more pronounced. The changing trend noted in 1988 was 

evident in urban and rural areas, although it was more pronounced in urban areas. The net 

increase from 1988 to 1998 could be attributed to pediatric AIDS, which is estimated to have 

increased from 1 to 14 per 1,000 over the period, with similar effects in both urban and rural 

areas. This implies, however, that there were other reasons why the mortality decline stopped 

during this period, which calls for additional explanation. 
Cameroon 

29

Figure 6a. Trends in under-five mortality, Cameroon, total 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

WHO

Indirect

Reconstructed

Direct (DHS)

Without AIDS

 Figure 6b: Trends in under-five mortality, Cameroon, urban and rural 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Central African Republic 

30

7. Central African Republic 

 The Central African Republic (CAR) conducted a DHS survey in 1994. Under-five 

mortality declined between 1950 and 1975, stagnated between 1976 and 1990, then declined 

again in 1991-94, the most recent data available from this survey. Baseline values from the 

1950s are consistent with the indirect estimates drawn from the 1959-60 Demographic 

Survey. Reconstructed trends are, however, lower than indirect estimates derived from the 

1975 census. These later figures appear to be overestimates, and probably affected the WHO 

reconstruction. The stagnation period corresponds to the controversial political period of 

Bokassa and the troubled years that followed. The recent decline was highly significant (P = 

0.0005). Differentials by residence can be seen in changes in under-five mortality. The 

increase between 1976 and 1990 and the recent decline applied only to rural areas; urban 

areas continued to experience a slow steady decline in mortality. Pediatric AIDS has played a 

role in CAR since 1985 and accounted for about 15 percent of under-five deaths in 1994. 
Central African Republic 

31

Figure 7a. Trends in under-five mortality, Central African Republic, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 7b. Trends in under-five mortality, Central African Republic, urban and rural 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Chad

32

8. Chad 

 Chad conducted a DHS survey in 1997. This survey showed a steady decline in underfive mortality from 333 per 1,000 in 1962 to 179 per 1,000 in 1997. The decline was 

approximately the same in urban (290 to 179 per 1,000) and rural areas (341 to 180 per 

1,000). There has been almost no difference in mortality by residence since 1993, which 

contrasts sharply with neighboring Niger. One anomaly could be noted: excess mortality in 

rural areas in 1980-81 that is statistically significant (P = 0.044). Annual data indicate that 

mortality increased from 213 to 319 per 1,000 between 1978 and 1980. This anomaly remains 

to be explained. Other differences in trends are not significant. Indirect estimates drawn from 

the 1964 Demographic Survey are consistent with the reconstruction. They show a similar 

slope, although the estimate is somewhat low (-13 percent). Backward reconstruction, i.e., 

prolonging the 1962-97 trend back in time, furnishes an estimate of 398 per 1,000 in 1950. 

This estimate is rough and should be considered with caution. The impact of pediatric AIDS 

is small in Chad, and was estimated at 7 per 1,000 in 1997. 
Chad

33

Figure 8a. Trends in under-five mortality, Chad, total 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 8b. Trends in under-five mortality, Chad, urban and rural 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstruicted (R)
Comoro Islands 

34

9. Comoros 

 Comoros conducted a DHS survey in 1996 using a sample of 3,050 women. Despite 

the small sample size, the survey allows reconstruction of mortality trends, although at a 

lower level of accuracy than in other countries. At the national level, under-five mortality has 

declined steadily since the early 1970s. It is possible, however, that mortality increased in 

rural areas between 1962 and 1972, although the number of deaths is too small to be 

conclusive and none of the difference is significant. No other data were found that could 

confirm the increase noted in rural areas. Trends were similar in urban and rural areas, with 

convergence in the 1980s and 1990s. AIDS was virtually nonexistent in Comoros during this 

period.
Comoro Islands 

35

Figure 9a. Trends in under-five mortality, Comoros, total 

0

50

100

150

200

250

300

350

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Direct (DHS)

Figure 9b. Trends in under-five mortality, Comoros, urban and rural 

0

50

100

150

200

250

300

350

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Côte d’Ivoire 

36

10. Côte d’Ivoire 

 Côte d’Ivoire conducted a WFS survey in 1980 and DHS surveys in 1994 and 1999. 

This wealth of data allows a full reconstruction of under-five mortality since 1950. The three 

surveys are markedly compatible for the overlapping periods, and indirect estimates are 

compatible. They show a steady decline in mortality from 466 per 1,000 in 1950 to 146 per 

1,000 in 1983. Then, mortality increased slightly to 158 per 1,000 in 1999. This rise in underfive mortality is attributed to HIV/AIDS, which accounted for 28 deaths per 1,000 in 1999. 

Without HIV/AIDS, mortality trends since 1984 would have been lower than in the earlier 

period, and the slope almost nil. In Côte d’Ivoire, HIV/AIDS added to other difficulties, 

particularly the economic recession of the early 1990s and the difficult political period 

following President Houphouët Boigny’s succession. Mortality changes by residence were 

roughly parallel in urban and rural areas, with levels in rural areas being about 50 per 1,000 

higher than levels in urban areas. 
Côte d’Ivoire 

37

Figure 10a. Trends in under-five mortality, Côte d’Ivoire, total 

0

50

100

150

200

250

300

350

400

450

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 10b. Trends in under-five mortality, Côte d’Ivoire, urban and rural 

0

50

100

150

200

250

300

350

400

450

500

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Ethiopia 

38

11. Ethiopia 

 Ethiopia was closed to Western influence for a long time, but a DHS survey was 

conducted in 2000. This survey was based on a sample of 15,367 women, thereby allowing 

detailed analysis of the data, although for a limited period of time. Extrapolations to the 1950s 

and 1960s are dangerous. Mortality declined slowly during the period 1967-93, a troubled 

time marked by the end of the Negus Empire, the installation of a Marxist government, and 

civil and international wars. From 1993 to 1998, mortality declined rapidly, with the change 

in the slope being highly significant (P = 108

). The last two years for which data are available 

indicate a change in the slope, with mortality levels above the expected trend (P = 0.021). 

HIV/AIDS plays a substantial role in mortality in Ethiopia, accounting for 22 percent of 

under-five mortality in 2000. Without HIV/AIDS, mortality decline would have been 

smoother and faster after 1993. The trends were similar in urban and rural areas, with a 

somewhat faster decline in urban areas. Declines in rural areas were slower in the earlier 

period, but increased in recent years. The low mortality level in 1997-98 is attributable 

primarily to low mortality in rural areas. The period of rapid mortality decline coincides with 

the end of the Marxist government, and the opening of the country to the Western world. 

.
Ethiopia 

39

Figure 11a. Trends in under-five mortality, Ethiopia, total 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

WHO

Indirect

Reconstructed

Direct (DHS)

Without AIDS

Figure 11b. Trends in under-five mortality, Ethiopia, urban and rural 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Gabon 

40

12. Gabon 

 Gabon conducted a DHS survey in 2001. The reconstructed mortality data indicate a 

steady decline in under-five mortality from 1968 (199 per 1,000) to 1984 (100 per 1,000), at 

an average rate of -5.0 percent. After 1984, mortality remained stable with a slightly declining 

slope (not significant from 0), reaching 87 per 1,000 in 2000. Under-five mortality trends 

were similar in urban and rural areas, before and after 1984, although declines were somewhat 

faster in rural areas in the first period. By 1984, both urban and rural areas had the same level 

of mortality, which is unusual. Urban and rural mortality remained at a constant level after 

1984. Mortality trends between 1968 and 1984 were consistent with earlier estimates of the 

1940s and 1950s. We estimated mortality in 1950 to be around 380 per 1,000. WHO estimates 

are above the reconstructed trends, and miss the reversal in mortality after 1984. HIV/AIDS, 

estimated at 14 per 1,000 in 2000, has had a moderate impact on mortality in Gabon. Without 

AIDS, under-five mortality would have continued to decline in Gabon after 1984, although at 

a slower rate. Causes of this halt in the health transition in Gabon remain to be explored. 
Gabon 

41

Figure 12a. Trends in under-five mortality, Gabon, total 

0

50

100

150

200

250

300

350

400

450

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 12b. Trends in under-five mortality, Gabon, urban and rural 

0

100

200

300

400

500

600

700

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Ghana 

42

13. Ghana 

 Ghana has a wealth of high-quality demographic data, including a WFS survey (1980) 

and three DHS surveys (1988, 1993, and 1999). It is also one of the few countries in Africa to 

have reliable data from before 1950: indirect estimates derived from census data conducted in 

1948. Under-five mortality has been declining in Ghana since 1950 (even since 1933, the 

earliest date for which data are available). Our estimates are consistent with many of the 

indirect estimates, which are themselves sometimes inconsistent. The decline in under-five 

mortality has not been regular in Ghana. Decline was rapid between 1950 and 1960 (slope = 

6.5 percent), slowed between 1960 and 1978 (slope = –1.5 percent), reversed for a few years 

between 1979 and 1983 (slope = +3.8 percent), and then resumed a steady decline between 

1983 and 1999 (slope = –3.7 percent). All the changes in the slope are highly significant (P = 

0,0074; P < 105

; P < 108, respectively). Mortality changes in urban and rural areas are 

similar, with similar changes in slopes. Excess mortality in urban areas occurred in 195556 

(P = 0.002). Differences between urban and rural areas were negligible before 1960, then 

increased to an average absolute gap of 43 per 1,000 after 1970. HIV prevalence remains low 

in Ghana, with no noticeable effects on under-five mortality. 
Ghana 

43

Figure 13a. Trends in under-five mortality, Ghana, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 13b. Trends in under-five mortality, Ghana, urban and rural 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)
Guinea 

44

14. Guinea (Conakry) 

 After a sudden break from colonial powers in 1958, and the installation of a dictatorial 

and bloody regime, Guinea remained isolated from the Western world until the death of the 

regime leader in 1984. The country conducted DHS surveys in 1992 and 1999, although these 

were preceded by a demographic survey in 1954-55, the first ever conducted in francophone 

West Africa. The data indicate a slow decline in under-five mortality between 1950 and 1977, 

followed by a more rapid decline until 1999. The reconstructed time series is markedly 

compatible with the 1954-55 survey. HIV prevalence remained low in Guinea until 1999, and 

had no noticeable effect on under-five mortality. Trends in urban and rural areas were similar 

during the 1972-99 period, with an average gap of 82 per 1,000. The slow decline in mortality 

may be explained by the toughness of the political system imposed by President Sekou Touré 

or by Guinea’s political isolation. 
Guinea 

45

Figure 14a. Trends in under-five mortality, Guinea, total 

0

50

100

150

200

250

300

350

400

450

500

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

WHO

Indirect

Reconstructed

Direct (DHS)

Figure 14b. Trends in under-five mortality, Guinea, urban and rural 

0

50

100

150

200

250

300

350

400

450

500

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Kenya 

46

15. Kenya 

 As was the case for Ghana, Kenya also has a wealth of high-quality demographic data: 

a WFS (1978) and three DHS surveys (1988, 1993, and 1999). It also has indirect estimates of 

mortality before 1950 derived from census data. Data show a steady decline in under-five 

mortality until 1985. Under-five mortality was estimated at 296 per 1,000 in 1950 and 87 per 

1,000 in 1985, a fast slope of –4.3 percent. The reconstructed trends are consistent with 

indirect estimates before 1950, but are less consistent with the WHO estimates. Since 1985, 

however, mortality has been increasing, and reached an estimated 123 per 1,000 in 1999. The 

rise in mortality can only partly be attributed to HIV/AIDS, which accounted for about 24 

deaths per 1,000 in 1999. Even without AIDS, under-five mortality was on the rise. A 

possible explanation is the increasing poverty in urban areas such as the Nairobi slums, where 

mortality has increased to a level exceeding that of rural areas. Until 1985, mortality trends in 

urban and rural areas were similar, with an average gap of 33 per 1,000. After 1985, mortality 

increased faster in urban areas than in rural areas, thus reducing the gap between urban and 

rural mortality trends. This change is partly due to HIV/AIDS, which has had twice the impact 

in urban areas as in rural areas. However, even after discounting for the impact of HIV/AIDS, 

under-five mortality has increased in both urban and rural areas, a finding that indicates the 

presence of other problems. 
Kenya 

47

Figure 15a. Trends in under-five mortality, Kenya, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 15b. Trends in under-five mortality, Kenya, urban and rural 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)
Lesotho 

48

16. Lesotho 

 Lesotho conducted a WFS survey in 1977. This survey is mentioned here only in 

passing because it covers only half of the 1950-2000 period. Data from this survey indicated a 

relatively high level of under-five mortality for this part of southern Africa, and a mortality 

anomaly in the 1960s. Under-five mortality decline was moderate between 1950 (292 per 

1,000) and 1961 (176 per 1,000), then increased briefly, reaching a peak of 217 per 1,000 in 

1964. Thereafter, mortality decreased steadily to 173 per 1,000 in 1977. These trends pertain 

primarily to the rural areas because urbanization at that time was very limited and the number 

of deaths in urban areas was small (five per year on average). As in South Africa, it is likely 

that pediatric AIDS had a major impact in Lesotho after 1990. AIDS deaths were at 55 per 

1,000 in 2000. However, we lack appropriate data to evaluate the impact of AIDS on underfive mortality in recent years. 
Lesotho 

49

Figure 16a. Trends in under-five mortality, Lesotho, total 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (WFS)

Figure 16b. Trends in under-five mortality, Lesotho, urban and rural 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Liberia 

50

17. Liberia 

 Liberia conducted a DHS survey in 1986. The data are markedly consistent and show 

a steady decline in under-five mortality between 1950 and 1986, from 451 per 1,000 to 208 

per 1,000. Reconstructed trends are different from the indirect estimates that are based on the 

1970-71 Population Growth Survey. Under-five mortality decline was similar in urban and 

rural areas, with a gap of about 30 per 1,000. No data are available after 1986. The difficult 

political situation and the civil war in the 1990s suggest that favorable mortality trends did not 

continue into the recent period. Prevalence of HIV remained low in Liberia up to 2000, and 

probably had little effect on under-five mortality. 
Liberia 

51

Figure 17a. Trends in under-five mortality, Liberia, total 

0

50

100

150

200

250

300

350

400

450

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 17b. Trends in under-five mortality, Liberia, urban and rural 

0

50

100

150

200

250

300

350

400

450

500

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Madagascar 

52

18. Madagascar 

 Madagascar conducted DHS surveys in 1992 and 1997. These surveys are compatible, 

and both indicate a changing trend in under-five mortality between 1975 and 1986. Before 

1975, mortality was declining steadily, from 285 per 1,000 in 1950 to 232 per 1,000 in 1960, 

although estimates before 1960 are less precise. Data from the 1966 Demographic Survey and 

the 1975 census—both based on deaths in the past 12 months—greatly underestimated 

mortality. Data from the 1972 vital registration, which covers primarily urban areas, also 

provide low estimates of under-five mortality. The period of rising mortality corresponds 

closely to that of the Marxist government, the Malagasy revolution (1973-85). It was followed 

by a period of rapid recovery, and by 1997 under-five mortality had fallen to 142 per 1,000, 

though still above what would have been expected from 1960-72 trends (100 per 1,000 by 

1997). The WHO estimates smooth out the crisis period, while the DHS survey direct 

estimates document it properly. 
Madagascar 

53

Figure 18a. Trends in under-five mortality, Madagascar, total 

0

50

100

150

200

250

300

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Other sources

WHO

Direct (DHS)

Figure 18b. Trends in under-five mortality, Madagascar, urban and rural 

0

50

100

150

200

250

300

350

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Malawi

54

19. Malawi 

 Malawi is an exception in eastern and southern Africa because of the high levels of 

under-five mortality. Malawi conducted DHS surveys in 1992 and in 2000. Under-five 

mortality saw a dramatic decline from 1960 to 2000. The decline was rapid from 1960 (456 

per 1,000) to 1982 (253 per 1,000), a slope of -3.8 percent; the decline was less pronounced 

from 1982 to 1991 (239 per 1,000, a slope of -1.5 percent). Then the decline was rapid again 

from 1991 to 2000 (169 per 1,000, a slope of -4.9 percent), with both changes in slope being 

highly significant (P = 0.0007 and P = 0.0001, respectively). The slower slope in the 1980s is 

due to a mortality increase in urban areas (from 171 to 215 per 1,000), while mortality 

continued to decline in rural areas (from 273 to 241 per 1,000). The 1979-80 point estimate is 

significantly lower (P = 0.016) than the reconstructed trend, which may mean that mortality 

declined somewhat faster at the end of the 1970s, and the period of mortality increase might 

have started in 1980; however, these differences remain small and do not affect interpretation. 

Under-five mortality trends were similar in urban and rural areas before 1982 and after 1991. 

Indirect estimates from the 1977 census and the 1996 KAP survey are compatible with the 

reconstruction, but not the indirect estimates for the 1970-71 Population Change Survey, 

which are underestimated. Projecting the 1960-81 trend backward predicts a mortality level of 

550 per 1,000 in 1950, which is higher than previous estimates. Although this level of 

mortality remains plausible, the trend projection may have overestimated the mortality decline 

in the 1950s. WHO estimates tend to smooth out the mortality changes in Malawi and to 

underestimate the recent decline. Under-five mortality declined substantially in the 1990s 

despite the marked impact of pediatric AIDS, which was estimated at 45 per 1,000 in 2000. 

Without HIV/AIDS, the mortality decline in the 1990s would have been even more 

impressive. 
Malawi

55

Figure 19a. Trends in under-five mortality, Malawi, total 

0

100

200

300

400

500

600

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

WHO

Indirect

Reconstructed

Direct (DHS)

Without AIDS

Figure 19b. Trends in under-five mortality, Malawi, urban and rural 

0

100

200

300

400

500

600

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Mali 

56

20. Mali 

 Mali conducted DHS surveys in 1987, 1995, and 2001. The three surveys are 

compatible in levels and trends. Under-five mortality is high in Mali, although declining 

rapidly at a constant slope of -3.0 percent. Under-five mortality was estimated at 466 per 

1,000 in 1960 and 202 per 1,000 in 2001. The only significant anomaly was lower mortality in 

1983-84, a finding that is surprising because these were drought years in the Sahel. As in 

Malawi, projecting trends backward to 1950 might lead to an overestimation of mortality (542 

per 1,000), although the predicted level remains plausible. The trends in under-five mortality 

were basically the same in urban and rural areas, although the speed of the decline was 

somewhat faster in rural areas (slope = -3.1 percent) than in urban areas (slope = -2.4 

percent), and the difference was significant (P = 0.003). A survey conducted in 1960-61 in the 

Niger delta (a wealthier part of the country) reported a lower level of mortality than the 

national average. The prevalence of HIV/AIDS was moderate over the period covered, with 

the net impact of pediatric AIDS estimated at 17 per 1,000 in 2000. Thus, pediatric AIDS had 

only a small effect on under-five mortality. 
Mali 

57

Figure 20a. Trends in under-five mortality, Mali, total 

0

100

200

300

400

500

600

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 20b. Trends in under-five mortality, Mali, urban and rural 

0

100

200

300

400

500

600

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Mozambique 

58

21. Mozambique 

 Mozambique conducted a DHS survey in 1997. This survey allowed us to reconstruct 

mortality trends during the troubled civil war period. Under-five mortality was declining fast 

at the end of the colonial period and the beginning of the independence period, declining from 

280 per 1,000 in 1970 to 181 per 1,000 in 1981. Under-five mortality underwent a rapid 

increase during the main part of the civil war, reaching 262 per 1,000 in 1991. Thereafter, it 

declined to 158 per 1,000 in 1997. Data are lacking for the period before 1970, however, as in 

Angola, the early Portuguese censuses for 1940, 1950, and 1970 provided some estimates of 

under-five mortality, but they are inconsistent (280, 335, and 223 per 1,000, respectively). A 

study conducted by Don Heisel (Heisel, 1968) estimated the level of mortality to be between 

271 and 367 per 1,000 in the years before 1950, and he estimated life expectancy at 32 years, 

which corresponds to under-five mortality of 340 per 1,000 in a model life table system. 

Looking at later trends, these values still are underestimated, unless mortality rose or was 

steady during the 1950-70 period. To reconstruct the trends, we have arbitrarily assumed a 

steady decline of mortality from 400 per 1,000 in 1950 to 280 per 1,000 in 1970, a slope of 

-2.7 percent, which is realistic. This period is, however, not based on empirical data. During 

the reconstructed period (1970-97), urban and rural trends were complex. No obvious 

difference in mortality existed before 1975, then a major increase occurred in rural areas 

while urban areas stagnated until 1991. Mortality in the two areas converged again between 

1991 and 1997, as a result of the rapid decline in mortality in rural areas. Differences in slopes 

between urban and rural areas were all significant. The complex changes in mortality by 

residence can be explained by the dynamics of the civil war. The rebel movement, RENAMO, 

controlled a large part of the countryside, and had a strategy to destroy the state infrastructure, 

in particular schools and health centers. In contrast, the party in power in Maputo, FRELIMO, 

concentrated all its investments and services in urban areas. The small gap in mortality 

between urban and rural areas before and after the war is notable, and is found in only a few 

other countries in Africa. The impact of pediatric AIDS is still low in Mozambique, and was 

estimated to be 10 per 1,000 in 1997. It could increase in the coming years unless proper 

action is taken. Pediatric AIDS explained only one-third of the mortality increase in urban 

areas between 1991 and 1997 (+25 per 1,000 because of HIV/AIDS for a total increase of 

+78 per 1,000). 
Mozambique 

59

Figure 21a. Trends in under-five mortality, Mozambique, total 

0

50

100

150

200

250

300

350

400

450

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 21b. Trends in under-five mortality, Mozambique, urban and rural 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Namibia 

60

22. Namibia 

 Namibia conducted DHS surveys in 1992 and 2000. The second survey produced 

somewhat lower estimates of under-five mortality and smaller slopes for trends. An average 

of the mortality levels from the two surveys was considered the most reliable estimate, with 

somewhat higher values in 1992 and somewhat lower values in 2000 for unknown reasons. 

The combined estimates indicate a mortality decline from levels that were already quite low 

(161 per 1,000 in 1960); however, trends over the period 1960-2000 are complex. Mortality 

declined between 1960 and 1975 in both urban and rural areas. Then, it rose from 100 to111 

per 1,000 during the period 1975-80 when the struggle for independence was occurring (as in 

Zimbabwe). The increase in mortality during this period was significant only in rural areas; in 

urban areas the mortality decline simply stopped. Because of the small sample size, changes 

in slopes are significant only in the rural areas (P = 0.023 in rural areas, and 0.189 in urban 

areas). This short period of increasing mortality was followed by a period of rapid decline that 

reached 52 per 1,000 in 1996. Finally, mortality increased again, reaching 70 per 1,000 in 

2000. This increase was most likely due to HIV/AIDS. AIDS was negligible in Namibia until 

1992, but played a larger role in 2000 (36 per 1,000). 
Namibia 

61

Figure 22a. Trends in under-five mortality, Namibia, total 

0

50

100

150

200

250

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 22b. Trends in under-five mortality, Namibia, urban and rural 

0

50

100

150

200

250

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Niger

62

23. Niger 

 Niger conducted DHS surveys in 1992 and 1998. Both surveys are consistent in levels 

and trends. They show a steady decline in under-five mortality from 449 per 1,000 in 1958 to 

340 per 1,000 in 1972. This period was followed by a period of stagnation until 1992. A 

renewed decline in mortality took place between 1992 and 1998, reaching 187 per 1,000 by 

the end of the period. The stagnation in the years 1972-92 occurred because of a slight 

increase in mortality in rural areas, while mortality continued to decline in urban areas. The 

gap in mortality between urban and rural areas in the 1980s increased, reaching a high of 182 

per 1,000 in 1992 and then decreased significantly in the following years. Levels of underfive mortality remain high in Niger, among the highest in sub-Saharan Africa, and the gap 

between urban and rural areas remains large, although it has diminished somewhat. There is 

little comparative data available for Niger. The 1959 INSEE survey substantially 

underestimated mortality. The impact of AIDS is negligible in Niger, and was estimated at 3 

per 1,000 in 1998. 
Niger

63

Figure 23a. Trends in under-five mortality, Niger, total 

0

100

200

300

400

500

600

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 23b. Trends in under-five mortality, Niger, urban and rural 

0

50

100

150

200

250

300

350

400

450

500

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Nigeria 

64

24. Nigeria 

 Nigeria conducted a WFS survey in 1982 and DHS surveys in 1990 and 1999. The 

three surveys are not always compatible, and gaps between under-five mortality estimates are 

as high as 50 per 1,000. The WFS survey particularly tends to underestimate mortality for the 

1965-75 period, and the 1990 DHS survey gives higher mortality levels for the 1975-89 

period. However, the 1982 and 1999 surveys are compatible for the 1972-80 period. The 

reasons for these discrepancies, unique among the countries in this analysis, remain unclear. 

Errors in data collection or erratic patterns caused by sampling schemes could be the causes, 

however there is no proof for these theories. The combined group of three surveys is, 

however, more stable, and indicates a series of complex changes in under-five mortality. 

Death rates declined rapidly between 1950 (325 per 1,000) and 1964 (207 per 1,000), and 

then rose for four years (239 per 1,000). This period covers the time of the Biafra war. 

Mortality decline resumed after the war, reaching 172 per 1,000, then it stagnated and even 

increased slightly for about 10 years until 1987 (183 per 1,000). From 1987 to 1999, mortality 

declined steadily and reached 113 per 1,000 in 1999. All the changes in slopes are highly 

significant. Mortality trends were generally parallel in urban and rural areas. In 1964-68, the 

increase in mortality was concentrated in urban areas, while in 1977-83 it was concentrated in 

rural areas. Then in 1988-89 the trend in the mortality decline shifted again and was more 

pronounced in rural areas than urban areas, so the gap between the two trend lines was 

reduced by half, from 83 to 40 per 1,000. Pediatric AIDS had a small impact over the period, 

estimated at 10 per 1,000 in 1999. Its impact could increase in the near future. The main issue 

in interpreting the Nigerian data remains the uncertainty about data quality. Some of our 

estimates are compatible with other sources, direct and indirect, but others are not. Some of 

the other sources are also inconsistent. Also, the overall pattern could be interpreted as a 

steady mortality decline over the entire 1950-99 period, with large fluctuations as a result of 

some erratic data. 
Nigeria 

65

Figure 24a. Trends in under-five mortality, Nigeria, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 24b. Trends in under-five mortality, Nigeria, urban and rural 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)
Rwanda 

66

25. Rwanda 

 Rwanda conducted a WFS survey in 1983, and DHS surveys in 1992 and 2000. All 

three surveys are compatible in levels and trends, despite the complex history of changes in 

under-five mortality. Combined data indicate several monotonic periods and a succession of 

major anomalies in recent years. Under-five mortality declined between 1950 (346 per 1,000) 

and 1965 (229 per 1,000). Then it increased for 12 years, reaching 261 per 1,000 in 1977. 

This period was followed by a rapid decline until 1990 (132 per 1,000). The picture thereafter 

is complicated by the war, genocide, and the difficult recovery period that followed. Underfive mortality had already started to increase in 1991-92 and peaked in 1994, the year of the 

genocide (308 per 1,000). It declined again to 187 per 1,000 in 1996, then increased to 232 

per 1,000 in 1998. In 2000, under-five mortality had declined to 142 per 1,000. It should be 

noted that the 1990s in Rwanda were an unusual time, and concepts of the health transition 

and regular mortality trends do not apply. For this reason, we do not present trends for this 

period. It should also be pointed out that the mortality data presented in this report 

underestimate the mortality over the period of the genocide because Tutsi families that were 

decimated could not be interviewed in 2000 and many Hutu refugees who left the country in 

1994 did not return. The figures presented are thus showing only a net effect for the surviving 

population who stayed or immigrated to Rwanda since 1994. The country had not had time to 

fully recover by 2000, and under-five mortality was still far above the level expected from the 

1950-65 trend (71 per 1,000), a measure of what could have been the health transition if the 

political situation had permitted. Trends were similar in urban and rural areas, with similar 

rises and falls and similar erratic patterns in the 1990s. The difference in slopes in the 1950s 

has been attributed to the small numbers of deaths in urban areas, and is not significant. 

However, in the period 1977-90, mortality declined more rapidly in rural areas than in urban 

areas (P = 0.0001), so that urban and rural mortality were at the same level in 1990. Indirect 

estimates were compatible with the reconstruction, except for the data from the 1970 survey, 

which underestimated mortality. The impact of AIDS is moderate in Rwanda, and was 

estimated at 32 per 1,000 in 1990 and 27 per 1,000 in 2000. A decline in seroprevalence 

among pregnant women is thought to account for the decline in pediatric AIDS. 
Rwanda 

67

Figure 25a. Trends in under-five mortality, Rwanda, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 25b. Trends in under-five mortality, Rwanda, urban and rural 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Senegal 

68

26. Senegal 

 Senegal has a wealth of high-quality demographic data: a WFS survey conducted in 

1978 and DHS surveys conducted in 1986, 1993, and 1997. The data from the four surveys 

are markedly consistent in levels and trends of under-five mortality. The 1950-97 years could 

be divided into three monotonic periods: a rapid decline in mortality throughout the 1950s, 

from 394 per 1,000 in 1950 to 285 per 1,000 in 1959; a period of slow increase in mortality in 

the 1960s, reaching 309 per 1,000 in 1969; and then a long period of steady mortality decline. 

In addition, two minor anomalies could be noted: (1) excess mortality in 1974 (P = 0.037), 

which could be associated with the severe Sahelian drought, and (2) lower-than-expected 

mortality in 1988-89 (P = 0.007), which could be the result of the successful vaccination 

campaigns. The vaccinations markedly reduced transmission of and mortality from caused by 

measles and whooping cough and had an impact on neonatal tetanus, all major causes of death 

among children under five. The mid-90s (1994-97) saw a small increase in mortality 

(+23 percent, P < 10–7), possibly a result of the return of communicable diseases following the 

decline in vaccination coverage, and the increase in mortality from chloroquine-resistant 

malaria. These variations were small compared with the substantial decline in mortality over 

the period. Indirect estimates are quite consistent with the reconstructed values, although 

estimates from the 1960-61 survey are low. A final point is abnormal: the last estimate of the 

WFS survey. Trends were similar in urban and rural areas in the 1940s, and then diverged 

markedly in the 1950s (205 per 1,000). The mortality increase in the 1960s lasted longer in 

rural areas (until 1969) than in urban areas (until 1966-67). Here again, mass vaccination 

campaigns for measles conducted in 1966-69 could explain the trends. The primary health 

care policy, which aimed at reducing the gap in mortality between urban and rural areas, was 

successful; the gap was reduced to 43 per 1,000 in 1997, about five times less than the gap 

was in the 1950s. The impact of HIV/AIDS remained negligible in Senegal and was estimated 

to be less than 2 per 1,000 in 1997. 
Senegal 

69

Figure 26a: Trends in under-five mortality, Senegal, total 

0

100

200

300

400

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 26b: Trends in under-five mortality, Senegal, urban and rural 

0

50

100

150

200

250

300

350

400

450

500

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)
South Africa 

70

27. South Africa 

 A DHS survey was conducted in South Africa in 1998. This survey allows the 

reconstruction of trends since the mid-1960s. From then until 1992, under-five mortality 

declined rapidly, at an average rate of -6.3 percent, from 188 per 1,000 in 1968 to 48 per 

1,000 in 1992. This was one of the most rapid declines in mortality reported for Africa, and 

parallels major public health efforts during that period. However, mortality started to increase 

rapidly after 1993, at an average rate of +9.8 percent, reaching 74 per 1,000 in 1998. This 

level of under-five mortality is low for the continent as a whole. The increase in mortality was 

almost entirely due to HIV/AIDS. However, even after discounting for pediatric AIDS 

mortality, under-five death rates were stationary in South Africa, around 40 per 1,000, a 

finding that suggests that earlier progress in treating other early childhood causes of death 

were not sustained. The quality of HIV seroprevalence data is excellent in South Africa, and 

assuming that the parameters used in the projection model do apply, it can be concluded that 

South Africa faced two problems since 1993: the increase in HIV/AIDS mortality and the 

stagnation of the health transition for other causes of under-five mortality. It could be, 

however, that the impact of pediatric AIDS was underestimated. Under-five mortality trends 

were quite similar in urban and rural areas before 1991, and the difference between the two 

slopes was not statistically significant. Mortality started to increase in urban areas as early as 

1991, and about two years later in rural areas. However, mortality increase with a slope of 

+3.0 percent occurred only in rural areas. It should be noted that the last points on this graph 

are based on a small number of deaths and the values of the slopes have relatively wide 

confidence intervals. 
South Africa 

71

Figure 27.a Trends in under-five mortality, South Africa, total 

0

50

100

150

200

250

300

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

WHO

D&H survey

Direct (DHS)

Without AIDS

Figure 27b. Trends in under-five mortality, South Africa, urban and rural areas 

0

50

100

150

200

250

300

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Sudan 

72

28. Sudan 

 Sudan conducted a WFS survey in 1979 and a DHS survey in 1989. These surveys 

cover only the northern part of the country, and the 1989 survey deals only with ever-married 

women. Levels and trends in under-five mortality are compatible in both surveys. At baseline, 

under-five mortality was lower than elsewhere in Africa: 199 per 1,000 in 1950; thereafter it 

declined steadily until 1974 (143 per 1,000), stagnated for about 10 years at around 148 per 

1,000, and then declined to 98 per 1,000 in 1990. Indirect estimates for northern Sudan from 

the 1973 census and from the household survey included in the WFS are compatible with our 

reconstruction. Mortality changes were parallel in urban and rural areas during the first period 

(1950-74); after that they diverged. There was a slight increase in rural areas between 1974 

and 1986, while urban mortality continued to decline. In the last period, the gap in mortality 

between urban and rural areas decreased sharply, and at the end of the period mortality 

estimates in the two residence areas were virtually identical (110 and 112 per 1,000, 

respectively). The impact of HIV/AIDS was negligible in northern Sudan. HIV 

seroprevalence among pregnant women was below 1 percent until 1999. 
Sudan 

73

Figure 28a: Trends in under-five mortality, Sudan (North), total 

0

50

100

150

200

250

300

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 28b: Trends in under-five mortality, Sudan (North), urban and rural 

0

50

100

150

200

250

300

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Tanzania 

74

29. Tanzania 

 Tanzania conducted DHS surveys in 1991 and 1996. These surveys are compatible 

and show similar levels and trends. Trends in under-five mortality are presented for four 

monotonic periods: a rapid decline from 1957 to 1972 (from 301 to 210 per 1,000), an even 

faster decline from 1972 to 1979 (151 per 1,000), then an increase through 1985 (180 per 

1.000), which was followed by a steady decline through 1996 (125 per 1,000). All changes in 

slopes are highly significant, including the change in slope between the first and second 

period (P = 0.015). These changes were present in both urban and rural areas, except that the 

increase in mortality occurred earlier and lasted longer in urban areas (1978-87) than in rural 

areas (1982-85). As a result, differences in mortality between urban and rural areas, which 

were stable before 1978 (+38 per 1,000), vanished by 1986 and remained small until 1992 

(+13 per 1,000). The gap increased again in the most recent years (+25 per 1,000). Pediatric 

AIDS is a major problem in Tanzania; without it, under-five mortality would have been 97 

per 1,000 in 1996 instead of 125 per 1,000. The decline in under-five mortality from 1985 to 

1996 would have been even more pronounced except for pediatric AIDS. 
Tanzania 

75

Figure 29a. Trends in under-five mortality, Tanzania, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Without AIDS

Figure 29b. Trends in under-five mortality, Tanzania, urban and rural 

0

50

100

150

200

250

300

350

400

1940 1950 1960 1970 1980 1990 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Togo 

76

30. Togo 

 Togo conducted DHS surveys in 1988 and 1998. The two surveys are consistent in 

levels and trends of under-five mortality. They show a steady decline in under-five mortality 

from 299 per 1,000 in 1956 to 124 per 1,000 in 1998, with a relatively high slope 

(-2.6 percent). The decline in mortality is similar in urban and rural areas, although somewhat 

more rapid in rural areas (slope of -2.7 percent) than in urban areas (slope -2.1 percent), with 

the difference not being significant. As a result, the gap in mortality between urban and rural 

areas narrowed, from 113 per 1,000 in 1960 to 39 per 1,000 in 1998, and this difference is 

significant. Despite the steady decline in under-five mortality, a small anomaly was noted: 

excess mortality in 1993-94 that was highly significant (P = 0.012) occurred only in rural 

areas (P = 0.003). Indirect estimates derived from 1961 and 1971 surveys are consistent with 

the reconstruction in levels and trends. The impact of AIDS has been small in Togo, and was 

estimated at 10 per 1,000 in 1998. 
Togo 

77

Figure 30a. Trends in under-five mortality, Togo, total 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

Indirect

WHO

Direct (DHS)

Figure 30b. Trends in under-five mortality, Togo, urban and rural 

0

50

100

150

200

250

300

350

400

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Zambia 

78

31. Uganda 

 Uganda conducted DHS surveys in 1988 and 1995; a third DHS survey was conducted 

in 2000, but the results were not yet available at the time of this analysis. Data from the two 

sources are fully compatible, and show the same levels and trends. Under-five mortality 

declined rapidly before 1971, from an estimated 330 per 1,000 in 1950 to 156 per 1,000 in 

1970. Then mortality increased steadily for more than 10 years, reaching 206 per 1,000 in 

1982-84. After 1985, mortality declined sharply. This crisis period corresponds to the period 

when Idi Amin Dada was in power (1971-79) and the ensuing troubled years. When Museveni 

took over in 1986, the situation was more favorable and permitted a catch-up from the crisis 

years. Recently published estimates from the 2000 DHS survey indicate that the favorable 

trend in under-five mortality continued through 1996-2000. The increase in mortality from 

1971 to 1984 occurred in both urban and rural areas. The gap in mortality between urban and 

rural areas (77 per 1,000 before 1971 and 58 per 1,000 between 1971 and 1984) decreased 

substantially after 1985 (24 per 1,000). The reconstructed trends are compatible with the 

indirect estimates from the 1969 census. The impact of pediatric AIDS was noteworthy in 

Uganda, but the effect was limited compared with the level of under-five mortality. Pediatric 

AIDS deaths were estimated at 24 per 1,000, with a declining trend echoing the decline in 

HIV seroprevalence among pregnant women that began in the early 1990s. Without pediatric 

AIDS, the decline in under-five mortality in Uganda would have been even faster during the 

period 1986-92. 
Zambia 

79

Figure 31a. Trends in under-five mortality, Uganda, total 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

WHO

Indirect

Direct (DHS)

Reconstructed

Without AIDS

Figure 31b. Trends in under-five mortality, Uganda, urban and rural 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
Zambia 

80

32. Zambia 

 Zambia conducted DHS surveys in 1992, 1996, and 2001. All the surveys are 

compatible for levels and trends of under-five mortality. Together, the data indicate three 

main periods of monotonic change. First, there was a rapid decline in mortality from 1958 

(335 per 1,000) to 1975 (150 per 1,000), averaging -6.1 percent per year. Then, mortality 

increased through 1992 (194 per 1,000) at an average rate of +1.8 percent. In the last period, 

mortality declined to 158 per 1,000 in 2001, at an average rate of -2.9 percent. Both changes 

in the slopes are highly significant (P < 10-10 and P = 5.6 10-8, respectively). Mortality in 

urban and rural areas shows the same pattern of change, with similar increases and declines. 

The decline in mortality was somewhat faster in urban areas from 1958 to 1975 (P = 0.043) 

and from 1975 to 1992 (P < 0.0001). The decline was significant in rural areas only from 

1992 to 2001 (the slope was not different from 0 in urban areas). Some of the erratic patterns 

in the late 1950s and early 1960s were due to the small sample size for urban areas. Indirect 

estimates of mortality for the 1970s and 1980s are consistent with the reconstructed trends. 

They are, however, much lower than estimates for the 1950s and 1960s. This could be due to 

underestimation using indirect methods or overestimation using direct methods in the early 

years. Pediatric AIDS is a major problem in Zambia; it was estimated at 71 per 1,000 in 2000, 

or almost half (44 percent) of the total mortality. This finding emphasizes the heavy burden of 

pediatric AIDS in under-five mortality. Without AIDS, mortality decline would have been 

much greater since 1992 and would have been significant in urban as well as rural areas. The 

1975-92 increase in under-five mortality is closely associated with the decline in copper 

prices on the international market in 1975—copper is Zamiba’s main export commodity—and 

the severe economic crisis in the country thereafter. The recovery phase (discounting 

HIV/AIDS) is associated with the change in the political regime in 1992 and the reforms that 

followed.
Zambia 

81

Figure 32a. Trends in under-five mortality, Zambia, total 

0

50

100

150

200

250

300

350

400

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Observed

WHO

Indirect

Reconstructed

Direct (DHS)

Without AIDS

Figure 32b. Trends in under-five mortality, Zambia, urban and rural 

0

50

100

150

200

250

300

350

400

450

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

q(5) / 1000

Urban

Rural

Reconstructed (U)

Reconstructed (R)
Zimbabwe 

82

33. Zimbabwe 

 Zimbabwe conducted DHS surveys in 1988, 1993, and 1999. The three surveys are 

compatible for levels and trends of under-five mortality. However, the 1999 data tend to push 

the 1978-82 peak in mortality two years forward. With this limitation, mortality trends in 

Zimbabwe can be examined for three periods: between 1956 (173 per 1,000) and 1975 (99 per 

1,000) there was a steady decline in mortality with a slope of -3.4 percent; a short increase in 

mortality occurred in 1977-80 and was followed by a seven-year period of recovery; and then 

mortality increased sharply in 1987. Trends in under-five mortality were similar in urban and 

rural areas and differences between the slopes were not statistically significant. The peak in 

mortality in 1977-82 was more pronounced in rural areas, although it was also evident in 

urban areas. The increase in mortality in 1987-99 was stronger in urban areas (slope of +7.0 

percent) than in rural areas (slope of +4.7 percent). So, by 1998-99, mortality was almost the 

same in both urban and rural areas (106 and 109 per 1,000, respectively). The first peak in 

mortality (1978-82) was associated with the struggle for independence and the difficult period 

that followed; it shares some similarities with events in Namibia. The substantial increase in 

mortality since 1987 is almost entirely due to AIDS. Zimbabwe was one of the hardest-hit 

countries in Africa, and the impact of pediatric AIDS was estimated at 76 per 1,000 in 1999. 

If the impact of AIDS is removed, the trend in under-five mortality after 1987 generally 

follows the earlier trend in 1982-87, with a highly negative slope (-5.7 percent) similar to that 

of the years before 1978. Indirect estimates of the 1950s and 1960s are consistent with the 

reconstruction; however, indirect estimates from the 1982 census appear to be overestimated, 

whether one uses a North or a South model life table. 
Zimbabwe 

83

Figure 33a. Trends in under-five mortality, Zimbabwe, total 

0

50

100

150

200

250

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Observed

Reconstructed

WHO

Indirect

Direct (DHS)

Without AIDS

Figure 33b. Trends in under-five mortality, Zimbabwe, urban and rural 

0

50

100

150

200

250

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

Year

q(5) / 1000

Rural

Urban

Reconstructed (U)

Reconstructed (R)
84
Appendix 

85

Appendix Table A-1: Estimations of 

Under-five Mortality 

from Trends Reconstruction, 

Sub-Saharan Africa 

Appendix 

87

Under-five mortality q(5) per 1,000 live births 

Year Angola Benin Botswana 

Burkina 

Faso Burundi Cameroon

CentralAfrican

Republic Chad 

1950 320 426 242 451 321 336 348 398 

1951 315 418 232 444 312 329 339 392 

1952 310 410 224 437 303 322 330 387 

1953 305 402 215 430 294 316 322 381 

1954 300 394 207 423 285 309 313 376 

1955 295 386 198 416 276 302 305 370 

1956 290 378 191 409 268 296 297 365 

1957 286 371 183 402 260 289 289 359 

1958 281 363 176 395 251 283 281 354 

1959 276 356 168 388 244 276 273 348 

1960 271 348 161 382 236 270 266 343 

1961 267 341 155 375 228 264 258 338 

1962 262 333 148 368 221 258 251 333 

1963 258 326 142 361 214 252 244 327 

1964 253 319 136 355 214 246 237 322 

1965 249 312 130 348 216 240 230 317 

1966 244 305 125 342 218 235 223 312 

1967 240 298 119 335 219 229 216 307 

1968 236 291 114 329 221 224 210 302 

1969 231 284 109 323 223 218 203 297 

1970 227 278 104 317 225 213 197 292 

1971 223 271 100 310 226 208 191 287 

1972 219 265 95 304 228 203 185 283 

1973 215 258 91 298 230 198 179 278 

1974 211 252 87 292 232 193 174 273 

1975 207 246 83 286 233 188 174 268 

1976 203 240 79 281 235 183 173 264 

1977 199 234 76 275 237 179 172 259 

1978 196 228 72 269 237 174 171 255 

1979 181 222 69 264 223 170 170 250 

1980 166 217 66 258 209 165 169 246 

1981 152 215 63 253 196 161 169 242 

1982 139 214 60 247 184 157 168 237 

1983 127 212 57 242 172 153 167 233 

1984 116 211 54 237 160 149 166 229 

1985 106 209 52 232 150 145 165 225 

1986 99 208 50 227 140 141 164 221 

1987 108 206 47 222 130 137 164 217 

1988 119 205 45 217 133 163 213 

1989 130 199 212 130 162 209 

1990 142 193 207 128 161 205 

1991 156 188 202 131 160 201 

1992 170 182 198 135 152 197 

1993 185 177 193 138 144 194 

1994 184 172 189 142 136 190 

1995 162 167 185 145 186 

1996 142 162 180 149 183 

1997 124 157 176 153 179 

1998 152 172 157 

1999 148 168 

2000 143 Continued ...
Appendix 

88

Under-five mortality q(5) per 1,000 live births (continued) 

Year

Comoro 

Islands 

Côte 

d'Ivoire Ethiopia Gabon Ghana Guinea Kenya Lesotho 

1950 466 346 380 295 368 296 292 

1951 454 342 368 282 366 287 279 

1952 442 339 357 269 364 279 267 

1953 430 335 345 256 362 270 255 

1954 418 331 334 244 360 262 244 

1955 406 328 323 232 358 254 233 

1956 394 324 312 221 356 246 222 

1957 383 321 301 210 354 238 212 

1958 371 317 291 199 352 230 201 

1959 360 314 281 189 351 222 192 

1960 282 348 310 271 184 349 215 183 

1961 275 337 307 261 182 347 208 176 

1962 268 326 304 251 180 345 201 189 

1963 261 316 300 242 178 343 194 202 

1964 254 305 297 233 175 341 187 217 

1965 248 295 293 224 173 339 181 212 

1966 241 285 290 215 171 337 175 209 

1967 235 275 287 207 169 335 169 206 

1968 228 265 284 199 167 334 163 203 

1969 222 256 280 191 165 332 157 200 

1970 216 247 277 183 163 330 151 197 

1971 210 238 274 176 161 328 146 193 

1972 204 229 271 169 159 326 141 190 

1973 199 220 268 162 157 324 135 187 

1974 193 212 264 155 155 322 130 184 

1975 188 204 261 149 153 321 126 182 

1976 182 196 258 142 151 319 121 179 

1977 177 188 255 136 149 317 117 176 

1978 172 181 252 131 144 311 112 

1979 167 174 249 125 148 302 108 

1980 162 167 246 120 153 294 104 

1981 157 160 243 114 158 287 100 

1982 153 154 240 109 163 279 96 

1983 148 149 237 105 168 271 92 

1984 144 150 234 100 158 264 89 

1985 140 151 231 91 153 256 87 

1986 135 151 229 91 148 249 89 

1987 131 152 226 91 144 242 91 

1988 127 152 223 91 139 235 94 

1989 123 153 220 91 135 228 96 

1990 120 153 218 91 130 222 98 

1991 116 154 215 90 126 215 101 

1992 112 154 212 90 122 209 104 

1993 109 155 211 90 118 202 106 

1994 105 155 199 90 114 196 109 

1995 102 156 188 90 111 190 112 

1996 99 157 177 90 107 185 115 

1997 157 167 90 103 179 117 

1998 158 157 90 100 173 120 

1999 158 148 90 97 168 123 

2000 139 90 Continued ...
Appendix 

89

Under-five mortality q(5) per 1,000 live births (continued) 

Year Liberia Madagascar Malawi Mali 

Mozambique Namibia Niger Nigeria 

 

1950 451 285 550 542 400 234 527 325 

1951 443 279 541 534 394 225 517 316 

1952 435 274 531 527 387 217 508 306 

1953 427 268 522 519 381 210 498 297 

1954 420 263 512 512 374 202 488 288 

1955 412 258 503 504 368 195 478 280 

1956 404 252 494 497 362 188 468 271 

1957 397 247 484 489 356 181 459 263 

1958 389 242 475 482 350 174 449 254 

1959 382 237 465 474 343 167 439 246 

1960 374 232 456 466 337 161 430 238 

1961 367 227 446 459 331 155 420 231 

1962 360 222 437 451 325 149 410 223 

1963 352 218 428 444 320 143 401 216 

1964 345 213 419 436 314 137 391 207 

1965 338 208 410 429 308 132 382 214 

1966 331 204 400 422 302 127 373 222 

1967 324 199 391 414 297 122 364 230 

1968 317 195 382 407 291 117 355 239 

1969 311 191 374 400 286 112 346 230 

1970 304 186 365 392 280 108 337 222 

1971 297 182 356 385 275 103 340 213 

1972 291 178 347 378 269 99 340 205 

1973 284 174 339 371 264 95 339 197 

1974 278 170 330 364 259 99 339 190 

1975 272 173 322 357 246 100 339 182 

1976 265 175 314 350 233 101 338 175 

1977 259 178 306 343 220 103 338 172 

1978 253 181 298 336 208 104 337 173 

1979 247 184 290 330 196 106 337 174 

1980 241 187 282 323 185 111 337 175 

1981 236 190 275 316 176 106 336 176 

1982 230 193 263 310 185 102 336 177 

1983 225 197 260 304 194 98 335 178 

1984 219 200 258 297 203 94 335 179 

1985 214 203 255 291 213 90 335 180 

1986 208 206 252 285 223 86 334 181 

1987 193 249 279 233 83 334 182 

1988 187 247 273 243 79 333 183 

1989 182 244 267 254 76 333 170 

1990 176 241 261 266 72 333 163 

1991 171 239 255 260 69 332 157 

1992 166 231 249 239 66 332 150 

1993 161 223 244 219 64 319 144 

1994 156 215 238 201 61 289 139 

1995 151 206 233 183 58 261 133 

1996 146 199 227 167 52 234 128 

1997 142 191 222 152 56 210 123 

1998 184 217 61 187 118 

1999 176 212 65 113 

2000 169 207 70 Continued ...
Appendix 

90

Under-five mortality q(5) per 1,000 live births (continued) 

Year Rwanda Senegal 

South 

Africa Sudan Tanzania Togo Uganda Zambia 

1950 346 394 199 350 334 330 451 

1951 338 381 196 343 328 321 436 

1952 329 368 194 335 322 311 421 

1953 320 356 191 328 316 302 406 

1954 312 343 188 321 311 293 391 

1955 304 331 186 314 305 285 377 

1956 296 319 183 307 299 276 363 

1957 288 308 181 301 294 268 349 

1958 280 296 178 294 288 259 335 

1959 272 285 176 287 283 251 321 

1960 264 293 278 173 281 278 243 308 

1961 257 295 265 171 274 272 236 295 

1962 250 296 253 169 268 267 228 282 

1963 242 298 242 166 262 262 221 270 

1964 235 300 230 164 256 257 213 258 

1965 229 302 219 162 250 252 206 247 

1966 227 304 208 159 244 247 199 235 

1967 230 305 198 157 238 242 187 224 

1968 233 307 188 155 232 237 176 214 

1969 236 309 179 153 226 233 166 204 

1970 239 304 170 150 221 228 156 194 

1971 242 295 161 148 215 223 166 185 

1972 245 285 153 146 210 219 170 176 

1973 249 276 145 144 205 214 173 167 

1974 252 267 137 148 200 210 177 158 

1975 255 258 130 148 187 206 180 150 

1976 258 249 123 148 177 201 184 154 

1977 261 240 116 148 167 197 187 156 

1978 243 232 110 148 158 193 191 158 

1979 232 224 104 148 151 189 195 161 

1980 221 216 98 148 156 185 198 163 

1981 210 208 92 148 160 181 202 166 

1982 200 201 87 149 165 177 206 168 

1983 190 193 82 149 170 173 187 170 

1984 181 186 78 149 175 170 183 173 

1985 172 179 73 144 180 166 179 175 

1986 163 173 69 133 165 162 175 178 

1987 155 166 65 124 160 159 171 181 

1988 147 160 61 115 156 155 167 183 

1989 140 154 58 106 152 152 163 186 

1990 132 148 54 98 148 148 160 188 

1991 154 142 51 144 145 156 191 

1992 181 137 48 140 142 153 194 

1993 243 131 47 136 139 149 192 

1994 308 126 51 132 136 146 187 

1995 208 121 56 128 133 142 183 

1996 187 116 62 125 130 139 178 

1997 203 112 68 127 136 174 

1998 232 107 74 124 132 170 

1999 168 103 129 166 

2000 142 Continued ... 162 
Appendix 

91

Under-five mortality q(5) per 1,000 live births (continued) 

Year Zimbabwe 

1950 204 

1951 198 

1952 193 

1953 188 

1954 183 

1955 178 

1956 173 

1957 168 

1958 163 

1959 159 

1960 154 

1961 150 

1962 146 

1963 141 

1964 137 

1965 133 

1966 130 

1967 126 

1968 122 

1969 119 

1970 115 

1971 112 

1972 108 

1973 105 

1974 102 

1975 99 

1976 103 

1977 107 

1978 111 

1979 116 

1980 112 

1981 103 

1982 95 

1983 87 

1984 80 

1985 73 

1986 67 

1987 61 

1988 64 

1989 67 

1990 70 

1991 74 

1992 77 

1993 81 

1994 85 

1995 89 

1996 93 

1997 97 

1998 102 

1999 107 

2000