As in many other Sub-Saharan countries, Burundi’s fertility rate of over six births per woman on average is likely unsustainable. The high fertility rate has likely presented barriers to lowering the poverty rate. In Burundi, 57.5% of children under the age of five suffer from malnutrition severe enough to stunt growth. In comparison, just 2.1% of American children suffer from this level of malnourishment. Children in Burundi also receive an average of just 2.7 years of education. Also, education is not compulsory in the nation, which likely contributes to the risk of children’s’ involvement in child labor. Many of the nation’s children are forced to work to support subsistence farming, or, tragically, in the sex trade.

4. Chad
> Population: 13.2 million
> GNI per capita: $2,085
> Life expectancy at birth: 51.6 years
> Pct. of pop. with at least some high school: 5.5%

People in Chad receive very little education. The average amount of schooling among the country’s citizens is only 1.9 years, less than in every country reviewed with the exception of Niger and Burkina Faso. Low educational attainment has led to predictably poor outcomes in Chad. Only about 37% of adults in the country are literate.

Residents of Chad also suffer from a range of negative health outcomes. Life expectancy at birth is only 51.6 years, one of the lowest in the world. A high maternal mortality rate, a high child mortality rate, and fatalities attributable to preventable diseases contribute to low life expectancy in the country. There are 980 maternal deaths for every 100,000 live births, the second highest maternal mortality rate of countries reviewed. Additionally, nearly 150 children under five years old die for every 1,000 live births, the third highest child mortality rate in the world. Even though malaria is treatable and preventable, roughly 153 people die every year from the disease for every 100,000 Chadians.

3. Eritrea
> Population:

6.5 million
> GNI per capita: $1,130
> Life expectancy at birth: 63.7 years
> Pct. of pop. with at least some high school: N/A

Eritrea is a highly secretive country, and the United Nations knows little about its internal operations. However, enough is known to rank it among the worst countries by international standards of wealth, health, and education. Eritrean adults spend just 3.9 years in school on average. If current enrollment trends continue, the children of Eritrea will receive just 4.1 years of schooling in their lifetimes, the least of any of the countries reviewed.

Since 2010, the Eritrean population has increased at a 3.2% annual pace, one of the fastest population growth rates in the world. The growth may be unsustainable as more than half of all Eritrean children under five years old are malnourished. The Eritrean government has done little to fix the problem. Despite having one of the lowest GNIs — just $1,130 per capita — the Eritrean government continually refuses foreign aid.

2. Central African Republic
> Population: 4.7 million
> GNI per capita: $581
> Life expectancy at birth: 50.7 years
> Pct. of pop. with at least some high school: 18.1%

The Central African Republic (CAR) is the poorest country in the world with a GNI per capita of just $581. However, not all of the country’s residents are poor. Based on the Gini coefficient, income in CAR is 10th most unevenly distributed of all countries reviewed. Low income and income inequality are not the only problems in CAR. Life expectancy at birth in the Sub-Saharan nation is only 50.7 years, the lowest of all 188 countries examined with the exception of Swaziland and Lesotho. The maternal mortality rate is also one of the worst, with 880 maternal deaths for every 100,000 live births.

Children in CAR suffer from some of the worst health conditions and outcomes in the world. Three-quarters of all infants are not immunized against measles, the largest share of any country examined. Inadequate immunizations have lead to an unnecessarily high child mortality rate. More than one in 10 children in CAR die before their fifth birthday. Educational standards are also lacking in CAR. The dropout rate among those in primary school of 53.4% is one of the highest in the world.

1. Niger
> Population: 18.5 million
> GNI per capita: $908
> Life expectancy at birth: 61.4 years
> Pct. of pop. with at least some high school: 5.2%

Niger, one of 21 Sub-Saharan African nations on this list, ranked as the least livable country in the world in each of the last four years. The country has the highest adolescent birth rate of all 188 countries examined with roughly 205 births for every 1,000 women aged 15-19. The birth rate among all women is also the highest of countries reviewed. The country’s fertility rate is roughly 7.6 births for every woman in the country. Often, a high birth rate is accompanied by a high child mortality rate, and Niger is one example. Roughly one in 10 children in Nigerien die before age five.

Nigeriens also receive very little education. The average Nigerien is enrolled in school for only 1.5 years, the shortest amount of schooling of any country with the exception of Burkina Faso. One consequence of limited education is a high illiteracy rate. Only about 15.5% of Nigerien adults are literate, the worst literacy rate of any country in the Sub-Saharan region. Gender inequality is also a major issue in Niger. Only about 13% of the country’s parliament is female, and the country ranks as the second worst on the gender equality index after only Yemen.

Click here to see the 25 most livable countries in the world.