The United Nations’ Millennium Development Goal 4 is to reduce the global under-five mortality rate by two-thirds by 2015. Achieving this goal requires substantial strengthening of health systems in low-income countries. Emergency and critical care services are often one of the weakest parts of the health system and improving such care has the potential to significantly reduce mortality. Introducing effective triage and emergency treatments, establishing hospital systems that prioritize the critically ill and ensuring a reliable oxygen delivery system need not be resource intensive. Improving intensive care units, training health staff in the fundamentals of critical care concentrating on ABC – airway, breathing, and circulation – and developing guidelines for the management of common medical emergencies could all improve the quality of inpatient pediatric care. Integration with obstetrics, adult medicine and surgery in a combined emergency and critical care service would concentrate resources and expertise.