The Men's World Cup's Other League Table - Part 2
What the last two World Cup finals reveal about infant survival, unequal health systems and shrinking health aid
Last week, I lined up the teams by health spending and life expectancy. As discussed, averages mask significant regional variation within each country. For example, rural communities often report higher mortality, and it is not uncommon for data from places outside the big cities to be missing altogether, excluding them from countries’ overall figures.
This week I want to use the last two World Cup finals as waypoints in an appraisal of infant mortality.
Infant mortality is like a barium meal on a country’s health system. Life expectancy compresses what happens across the life course into one average, but infant mortality (obviously) is set in the first twelve months, most of it in the first twenty-eight days. It is heavily dependent on how well the mother was fed and monitored, whether the birth was attended by a skilled health worker and whether any subsequent infection or deterioration was caught in time.
Children of the Qatar final
Argentina beat France in Lusail on 18 December 2022, the World Cup having to be played in the winter.
A child born that week is three now; its first year is well over, and the risk it carried can now be evaluated. If our figurative World Cup final baby was born in Japan, it had a very good chance of still being with us, with approximately one death in every 550 live births.
Were it born in the United States, the figure was around one in 180; if it had been born in Cameroon, roughly one in 24. Basically, one for every player on the football pitch and both managers.
A Cameroonian infant was more than twenty times more likely to die in its first year than a Japanese one.
The US number is the strange one on that list, as a baby born in the United States that week arrived during the first twelve-month period in two decades in which American infant mortality rose: 5.6 deaths per 1,000, or 20,538 babies, up three per cent on the year before. The rate did not continue rising in the following two years, so this was not a sustained reversal, but it was still a warning from the richest health system among the 32 teams that competed in the Qatar men’s World Cup.
The first month
Most infant deaths occur in the first twenty-eight days, and neonatal deaths now account for 47 per cent of all deaths under five, up from 40 per cent in 1990. Diarrhoea, malaria and pneumonia have been beaten back over decades, while newborn deaths have declined more slowly and therefore make up a growing proportion of the overall figure.
Newborn deaths are caused mainly by prematurity, complications during labour and birth, infection and congenital conditions. The risks are shaped by whether the birth was attended by a skilled health worker and whether the woman and baby had access to effective antenatal, obstetric and postnatal care.
Midwife-led continuity of care improves women’s experiences and reduces some interventions during birth, although the latest systematic review is less certain than earlier evidence about its effects on preterm birth, fetal loss and neonatal death. One of the most effective parts of neonatal care remains a midwife who is present before, during and after birth, backed by functioning referral and specialist services when they are needed.
Between now and the next final
Last week I built a table from 2023 spending on health per capita: the United States at $13,473 a head, the Democratic Republic of Congo at $23 and Morocco at $232. By the time of the next final, in 2030, that table will look different, and probably not for a reason anyone will want to be particularly associated with.
In 2025, development assistance for health was estimated to have fallen by 26.9 per cent against the year before, much of it following the dismantling of USAID in the United States, with Britain, Germany and France cutting alongside it.
Child deaths under five had fallen in most years since 2000. Using a separate modelling framework, the Institute for Health Metrics and Evaluation projected that they would rise from 4.6 million in 2024 to 4.8 million in 2025. If confirmed, this would be the first increase this century.
Modelling in the same report estimates what happens if the money never returns. A permanent 20 per cent cut to foreign aid would mean approximately 12.5 million additional child deaths by 2045. A permanent 30 per cent cut would mean around 16.3 million additional deaths.
Of course, it is the countries clustered just above the DRC’s $23 health spend per person per year that are now seeing sharply reduced aid spending. It is hard to see how they escape worsening outcomes.
I do not know which countries will do better or worse in the next four years, but I do know that a baby born during the week of the 2030 final will spend its first month in a global health system carrying considerably less of that funding than the one that provided the data for this article. The number of deaths among children under five, which had been falling for a quarter of a century, is now flattening and, under some projections, going the other way.
Full time
Spain beat Argentina in New Jersey on 19 July, one goal in extra time. It was a bad game, and worse for the comparison: the worst final of the tournament, coming three and a half years after arguably the best one. We saw a worsening not only of the overall game of football but also of the sportsmanship, notably from Argentina.
Their victory in 2022 showed this great nation can do better than this. Over the same period, progress on child mortality has slowed sharply and, under some projections, may reverse.
Infants born in 2022 entered a world in which progress on child survival was very uneven but still moving in the right direction. For those born last Sunday, that direction is considerably less secure.