“It doesn’t have to be like this.” That’s how Bill Gates, chair of the Gates Foundation, opens the 2025 Goalkeepers report, “We Can’t Stop at Almost.” The Microsoft co-founder sees a turning point after decades of progress in reducing childhood mortality. “The death of a child is always a tragedy,” he continues, “But there’s something especially devastating about a child dying of a disease we know how to prevent.”
For the first time this century, the report finds, the number of children dying before their fifth birthday is projected to rise. Modeling conducted by the Institute for Health Metrics and Evaluation (IHME) reveals alarming statistics: In 2024, 4.6 million children died before turning five. In 2025, that number is projected to increase by just over 200,000, reaching an estimated 4.8 million children globally. This increase means more than 5,000 classrooms of children, “gone before they ever learn to write their name or tie their shoes.” This alarming forecast comes amid sharp declines in global development assistance for health, which fell 26.9% below 2024 levels this year. In the U.S. the Trump administration has dismantled its aid agency USAID and drastically cut foreign aid.
Gates describes this “significant reversal in child deaths,” as something that should be “sobering” for anyone committed to scientific and human progress. The report warns that if funding cuts persist, the consequences will be catastrophic. If global health funding decreases by 20%—the scale of cuts some major donor countries are considering—an additional 12 million children could die by 2045. Should the cuts be steeper, reaching 30%, the report grimly forecasts 16 million more childdeaths by 2045.
“We could be the generation who had access to the most advanced science and innovation in human history—but couldn’t get the funding together to ensure it saved lives,” Gates writes.
In May, Gates announced that he would commit “virtually all” his remaining wealth—about $100 billion—to the foundation in an all-out effort to eradicate or drastically reduce some of the world’s most lethal diseases so future generations won’t have to worry about them, and to continue reducing mortality rates for children.
But he emphasized that the foundation could not achieve these goals without the support of governments, particularly those of wealthy countries. And with deadly infectious diseases, which can come roaring back from the brink of extinction, zero is really the magic number.
The new report warns of the catastrophic results if the reduction in funding for these efforts continues. “If we take this path, we’re the generation that almost ended preventable child deaths. Almost eradicated polio. Almost wiped malaria off the map. Almost made HIV history. But we can’t stop at almost.”
A roadmap to resilience
Gates emphasizes that though the world is in a time of tight budgets, proven solutions and next-generation innovations exist that can protect the progress made and save millions of young lives. The immediate goal, according to Gates, must be to “do more with less, now.”
The report highlighted opportunities to tackle the preventable health conditions killing children worldwide: malaria, HIV/AIDS, and overall threats to newborns. The tools are within our grasp, the report says, laying out a three-part roadmap and calling for countries to double down on the most effective interventions. These are, according to the report:
1. Prioritizing Primary Health Care: Investing in robust primary health care systems is the “smartest investment now,” the report says. For less than $100 per person per year, these systems can prevent up to 90% of child deaths, catching deadly diseases like pneumonia early and ensuring safe deliveries.
2. Doubling Down on Routine Immunization: Routine immunizations remain the “best buy in global health,” the report says, adding that every dollar spent on immunization yields a return of $54 in economic and social benefits. Innovations such as reduced dosing schedules for pneumococcal conjugate vaccines (PCV) could save around $2 billion by 2050.
3. Investing in Next-Generation Innovations: Modeling suggests that by 2045, new malaria tools could save 5.7 million children, and scaling up new maternal vaccines for threats like Respiratory Syncytial Virus (RSV) and Group B streptococcus (GBS) could save 3.4 million children.
Local leadership in the face of scarcity
On the theme of doing more with less, the report highlights insights from leaders and health workers who are sustaining health progress despite limited resources. In Nigeria, Governor Muhammad Inuwa Yahaya of Gombe State prioritized primary health despite a historic budget deficit. “You don’t need perfect conditions to make progress,” he noted. “You need clarity, and the courage to stick to it.”
The report also featured people stepping in to address funding deficits on a grassroots level. In Kenya, community health worker Josephine Barasa continued her unpaid work as a “mother mentor” after her employment was cut. “They could take away the money, but they couldn’t take me away from my women,” she told the foundation. “The support systems may have disappeared, but the need has not. And neither have I.”
