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Acknowledgements

This report was commissioned from the Overseas Development Institute It should be noted that Save the Children and UNICEF made a number (ODI) by Save the Children and UNICEF. It was written by Rachel Marcus, of factual edits to the report before publication. They also edited the Paola Pereznieto, Erin Cullen and Patrick Carter at the ODI. The ODI executive summary. authors would like to thank Andrea Locatelli, Hanna Alder, Evie Browne and Chloe Brett for their research assistance during the development of Disclaimer: The views presented in this paper are those of the author(s) this report and Nicola Jones for very helpful peer review comments. and do not necessarily represent the views of ODI, Save the Children or UNICEF.

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First published 2012

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List of tables, figures, boxes and case studies iv List of abbreviations vi Executive summary viii

1 Introduction 1 1.1 The context 1 1.2 Why invest in children? 1 1.3 Methodology and focus of report 2

2 Global overview 3

3 Progress on key child-sensitive sectors 5 3.1 Child survival 5 3.2 Nutrition 16 3.3 Preventing mother-to-child transmission of HIV/AIDS 25 3.4 Water, sanitation and hygiene 33 3.5 Early childhood development 40 3.6 Education 48 3.7 Child protection 60 3.8 Multidimensional poverty reduction and progress across different dimensions of child well-being 68

4 Drivers of progress 73 4.1 A supportive political and policy environment 73 4.2 Well-planned and implemented programmes 74 4.3 Resourcing 74 4.4 Role of growth 77 4.5 Social change 78 4.6 Increased availability of key technology and dissemination of ideas 78

5 Conclusions and recommendations 79

References 82 Appendix 1: Critical drivers of change for child-focused development, additional figures and tables 89 Appendix 2: Primary data analysis 95

iii List of tables, figures, boxes and case studies

Tables Table 1: Trends in primary school enrolment by region, 1998–2008 48 Table 2: Changes in secondary school gross enrolment rates and reductions in numbers of out-of-school adolescents by region, 1999–2008 49

Figures Figure 1: Proportion of people living on less than $1.25 a day, 1990 and 2005 (%) 3 Figure 2: Under-five mortality rate, by MDG region, 1990 and 2010 (deaths per 1,000 live births) 5 Figure 3: Official development assistance to child health and to maternal and newborn health, Countdown countries, 2007 (2005 $ billion) 8 Figure 4: Global trends in nutrition-related aid, 1999–2009 (constant 2009 $ million) 19 Figure 5: Aid for basic nutrition by region. 19 Figure 6: Regional trends in aid for HIV/AIDS, 2000–2010 (constant 2009 $ million) 26 Figure 7: Commitments to HIV/AIDS as a share of social sector aid, 2000–2010 (%) 27 Figure 8: Relationship between aid and rates of HIV among children in sub-Saharan , 1995–2010 (population-weighted means per 1,000 population) 28 Figure 9: Population using an improved, shared or unimproved sanitation facility, by MDG region, 1990 and 2008 (%) 34 Figure 10: Population using piped drinking water on premises, other improved water source or an unimproved source, by MDG region, 1990 and 2008 (%) 34 Figure 11: Trends in school water and sanitation coverage, 2008–2010 (%) 35 Figure 12: Sanitation and drinking water aid commitments in relation to all other ODA commitments, 2008 ($ billion) 36 Figure 13: Aid to ECD as a proportion of education aid, 2000–2010 (%) 42 Figure 14: Aid to ECD by region (constant 2009 $ million) 43 Figure 15: Total bilateral and multilateral aid disbursements to education, 2002–2009 (constant 2009 $ billion) 51 Figure 16: Women aged 20–24 married or in union before age 18 by region (1987–2006) (%) 60 Figure 17: ODA to social sectors by sector, 2005–2008 (%) 75

iv Boxes Box 1: Progress in immunisation 7 Box 2: What is the relationship between aid and infant mortality? 9 Box 3: What is the relationship between aid and child ? 20 Box 4: Aid to HIV/AIDS – countries that have been effective in reducing HIV rates among children are high aid recipients 28 Box 5: Some trends in water and sanitation 33 Box 6: Reducing primary school drop-out in Tanzania 52 Box 7: Education and conflict in Afghanistan 54 Box 8: Universal birth registration 61 Box 9: Key insights from primary data analysis: have countries that received the most aid also made the most progress in improving children’s lives? 76

Case studies Case Study 1: Improvements in mother and child health in Bangladesh 12 Case Study 2: Brazil – a multifaceted approach to improving children’s nutrition 21 Case Study 3: Preventing mother–to–child transmission of HIV/AIDS in Botswana 29 Case Study 4: Fit for School in the Philippines – a model for a simple, scalable and sustainable school health programme to promote child well-being 37 Case Study 5: Reducing inequalities – ECD programmes in Chile 44 Case Study 6: Rapid and equitable expansion in primary and secondary education in Ethiopia 55 Case Study 7: Post-conflict child protection in Sierra Leone 62 Case Study 8: Child labour in 65 Case Study 9: Exceptional poverty reduction and multi-sectoral development with positive impacts on children in Vietnam 69

v List of abbreviations

3iE International Initiative for Impact Evaluation AfDB African Development Bank AIDS Acquired Immune Deficiency Syndrome ALC Accelerated Learning Class ARV Antiretroviral AusAID Australian Agency for International Development BRAC Building Resources Across Communities CASH Know Your Child Programme CCT Conditional Cash Transfer CDC Centres for Disease Control CEmOC Comprehensive Emergency Obstetric Care CPN Child Protection Network CPRC Chronic Poverty Research Centre CRS Creditor Reporting System CSUCS Coalition to Stop the Use of Child Soldiers DAC Development Assistance Committee DDR Disarmament, Demobilisation and Reintegration DFID UK Department for International Development DHS Demographic Health Survey EC European Commission ECLAC Economic and Social Commission for and the ECD Early Childhood Development EHCP Essential Healthcare Programme EPI Expanded Programme on Immunisation EU European Union FDI Foreign Direct Investment FGM/C Female Genital Mutilation/Cutting FIT Fit for School GAVI Global Alliance for Vaccines and Immunization GDP Gross Domestic Product GIZ German Agency for International Cooperation GoB Government of Bangladesh HAART Highly Active Antiretroviral Therapy HCFP Healthcare Fund for the Poor HIV Human Immunodeficiency Virus HRRAC Human Rights Research and Advocacy Consortium IDA International Development Association IFSN International Food Security Network

vi List of abbreviations vii International Labour Organization Labour Organization International Illness of Childhood Management Integrated MonetaryInternational Fund Child Labour Project Indo-US Labour Elimination of Child the for Programme International Rescue Committee International National Nursery Schools Council Programme Goal Millennium Development Cluster Survey Multiple Indicator Report Weekly Morbidity and Mortality and Child Health Newborn Maternal, Ministry of Finance and Economic Development Ministry of Health Affairs and Social Invalids Ministry of Labour, National Child Labour Project of Child Rights the Protection National Commission for Organisation Non-governmental Official Assistance Development Institute Development Overseas Economic Co-operation and Development Organisation for Oral Therapy Rehydration Basic ServicesProtecting and Child Health Newborn Partnership Maternal, for Transmission of Mother-to-child Prevention Parity Power Purchasing and Reconciliation Commission Truth Leone Sierra Vietnam Socialist Republic of Approach Sector-wide Understanding Child Work United Kingdom United Nations on HIV/AIDS UN Programme Joint on the Rights of the Child UN Convention Programme UN Development Scientific and Cultural Organization UN Educational, Fund UN Population Refugees UN High Commissioner for on Estimation Group UN Inter-Agency Fund UN Children’s UN Standing Committee on Nutrition United States International Development Agency for US US Department of Labor of Social Sciences Academy Vietnamese Programme Food World Health Organization World ILO IMCI IMF INDUS IPEC IRC JUNJI MDG MICS MMWR MNCH MoFED MoH MOLISA NCLP NCPCR NGO ODA ODI OECD ORT PBS PMNCH PMTCT PPP SLTRC SRV SWAp UCW UK UN UNAIDS UNCRC UNDP UNESCO UNFPA UNHCR UNIAGCME UNICEF UNSCN US USAID USDoL VASS WFP WHO Executive summary

Remarkable progress Building on this evidence, this report makes a compelling case for greater investment in ‘child- The world has made remarkable progress in sensitive’ development. It sets out the drivers of improving the lives of millions of children over the change and the key steps to achieving progress. past two decades. • 12,000 fewer children under five died every day in 2010 than in 1990. The case for • Stunting – damage to children’s physical and investing in children cognitive development caused by malnutrition – declined in developing countries from 45% to 28% The moral case for investing in children is compelling. between 1990 and 2008, while the prevalence of In a world so rich in resources, know-how and underweight children also fell. technology, it is unacceptable that we allow today’s • Fewer children are becoming infected with HIV levels of child deprivation to continue. or dying of AIDS. World leaders have made commitments to children • The number of children enrolled in pre-primary through the UN Convention on the Rights of the education worldwide increased from 112 to Child (UNCR), which 192 states have ratified, and 157 million between 1999 and 2009. the Millennium Declaration. Investing in child- • From 1999 to 2009 an additional 56 million sensitive development is a key mechanism for children enrolled in primary school and the realising children’s rights and meeting the Millennium number of out-of-school primary-age children Development Goals (MDGs). decreased by 38 million. • Globally, girls now make up 53% of out-of-school Investing in children’s well-being also has significant primary-age children, compared with 58% in 1990. potential pay-offs for economic growth: greater More children are being registered at birth, and productivity, reduced population growth and lower rates of child marriage and child labour have gone child and infant mortality. It is crucial in breaking the down in many countries. cycle of intergenerational poverty. • The proportion of adolescents of lower • Good infant and child nutrition leads to an secondary age who were out of school worldwide estimated 2-3% growth in the economic wealth fell by 21 per cent from 1999 to 2009. of developing countries (UNSCN, 2010). • More children are being registered at birth, and • Tackling malnutrition in early life can increase rates of child marriage and child labour have gone lifetime earnings by 20% (Grantham-Macregor down in many countries. et al., 2007, in Save the Children, 2011b). Tackling malnutrition in early life can increase lifetime Development works earnings by 20% (Grantham-Macregor et al., 2007, in This report analyses the improvements to children’s Save the Children, 2011b). lives during the past two decades in five sectors: health, nutrition, water and sanitation, education Investing in adolescents means countries are better and child protection. The extraordinary progress placed to reap demographic dividends as a skilled achieved on many fronts should be celebrated. It’s a youth cohort reaches adulthood and contributes to clear demonstration that, when the right steps and the economy and society, and helps build social and approaches are taken, ‘development works’. political cohesion.

viii Executive summary ix child health and education. They are also key to protecting to protecting also key are They health and education. Social investment and economic growth and economic growth Social investment neither are growth of economic High levels necessary to bring about improvements nor sufficient stagnation and However, well-being. in children’s associated with a decline in economic decline are their well-being. Ethiopia and Brazil, Our case studies (on Bangladesh, where indicate that, Vietnam) and sectoral analysis resources has led to greater economic growth this sectors and to social investment, key for However, has helped bring about improvements. resourced with adequately ambitious sector policies, have to implement them, and capacity programmes been particularly important economic in converting well-being. in children’s into improvements growth that economic policies redistributive In addition, households’ disposable incomes are increase in nutrition, investment for increased beneficial of infants, and collaborative working between parties between working and collaborative of infants, governance Where Afghanistan. Leone and in Sierra of services donors by non-state provision is weak, (NGOs) has a organisations and non-governmental to play. crucial role has seen a dramatic rise in the number the number a dramatic rise in has seen Ethiopia having at primary enrolled school, of children donor with spending on education, increased in more invested The government assistance. introduced school fees, abolished facilities, and children, disadvantaged to reach programmes gender inequalities and took action to reduce education quality. improve one of the sharpest Vietnam has achieved due decades, in recent poverty declines in absolute development in part child-focused to an explicitly spending on children’s with increased strategy, and access to clean education nutrition, health, water and sanitation. on Other case studies in the report focus ECD programmes inequalities through reducing situations in post-conflict child protection (Chile), health and child labour (India), Leone), (Sierra in schools (Philippines). delivered initiatives saw a steep decline in the proportion proportion a steep decline in the saw Botswana a with HIV after it introduced infected of children transmission mother-to-child reduce to programme pregnant HIV testing for including free of HIV, to those found for antiretrovirals and free women be HIV-positive. has dramatically reduced the prevalence the prevalence reduced Brazil has dramatically through in children of stunting and underweight children’s a package of interventions to improve and food (including better access to nutrition activities among income-generating promoting with a large-scale cash poor families) in conjunction scheme.transfer has achieved remarkable reductions reductions remarkable Bangladesh has achieved in sustained investment following in child mortality, child health. stories Success that of countries includes case studies The report children’s in improving progress made strong have example: For well-being. Developing a supportive policy environment is a supportive policy environment Developing particularly difficult in fragile states and conflict- The report identifies some positive countries. affected immunisation to allow such as ceasefires examples, It’s vital that government addresses underlying issues, issues, underlying addresses vital that government It’s alongside its action and inequality, such as poverty and child protection, nutrition, education, on health, child improving example, For water and sanitation. survival on tackling the underlying rates depends and such as poverty social determinants of ill health, at the same time as strengthening gender inequality, accessible to them more health systems to make the quality of healthcare poor families and to improve and mothers. children to provide they Government commitment Government the political leadership – often from Strong Brazil’s by as demonstrated – is critical, president and poverty nutrition in health, improvements This on education. progress Ethiopia’s and by reduction into adequately commitment needs to be translated that can sustain their programmes resourced (see of government changes through momentum even case studies on Bangladesh and Brazil). ? drives progress What x progress in child well-being 1 more thantheeffect inindividual ofinterventions sanitation. The combinedeffect canbesignificantly education, health, poverty reduction, andwater where there hasbeensimultaneous investment in Child well-being indicatorshave oftenimproved most avoided competing donordemands. these strategieshasprovided vitalresources and In aid-recipient countries, donor alignmentbehind (see casestudiesonBrazil, Chile, Ethiopiaand Vietnam). and have invested inthecapacity toimplementthem detailed programmes thatmake linksbetween sectors, have translatedambitiouspolicycommitmentsinto Progress for children hasoccurred where governments implemented programmes Multidimensional, well-planned and and services. the implementationofeffective programmes development assistancecanstrengthen andfacilitate child well-being already exist. Inthesecircumstances, effective for children where nationalcommitmentsto In bothcontexts, development assistanceismost promote knowledge-sharing ongood practices. income countries, aidisessentially catalytic, helpingto the educationbudget. Bycontrast, inmany middle- African countries, aidprovides asmuch as25%of progress across different sectors. Insomelow-income to allocateenoughresources tomake significant Many low- andlower-income countriescannotafford children’s lives eachyear. from becomingmalnourishedandsave 63,000young Saharan Africa would prevent 2.7million children per 1,000. Replicatingthisprogress across allofsub- over tenyears, by four andinfantmortality deaths malnutrition by anadditional two percentage points large amountsofaidtypically reduced childhood progress inchildwell-being. Countriesthatreceived most aidover thelastdecadealsomademost countries insub-Saharan Africa thatreceived the countries. Ouranalysis demonstratesthatthose children’s well-being, inlow-income particularly Development assistanceplays akey role inimproving Development assistance stunted andunderweight children). of malnutrition (evident inthelower numbers of protection were crucialfor achieving reduced rates Brazil, higherminimum wagesandenhancedsocial the mostvulnerableattimesofeconomiccrisis. In Nevertheless, there isclearly anassociation between aid andimproved childwell-being. These findingsare basedonacorrelation and are notproof thataidcausedthese improvements. 1

health andeducationservices. well-being dependsontheexistenceofadequate a magicbullet. Their effectiveness inimproving child protection programmes shouldnotbeconsidered improved healthandnutrition. However, social rates andcontributingtoreduced childlabourand of incomepoverty, improving schoolattendance on several fronts simultaneously –reducing rates contribute toimprovements inchildren’s well-being transfers) are thatcan asingletypeofintervention Social protection programmes cash (particularly India respectively). and casestudies78onSierra Leoneand government structures (seebox 7on Afghanistan government provision, working collaboratively with that NGOsanddonorscanplay infillinggaps in It iscrucialthatgovernments acknowledge therole are instructive. quintiles andpoorestofthecountry parts amongthepoorestmalnutrition andchildmortality mortality, andBrazil’s experienceinreducing experience inreducing sexdifferentials in child disadvantaged minorityethnicgroups, Bangladesh’s Vietnam’s totargetprogrammes efforts at increased likelihood ofmeetingtheMDGs. development impact, returns oninvestment, and can behighly cost-effective intermsofoverall groups, investing inthemasamatterofpriority being are oftenmuch lower amongdisadvantaged resource-intensive. However, given thatlevels ofwell- remote ruralareas orunder-served slumscanbe todisadvantagedgroups in Extending services inaddressing important particularly socialexclusion. both middle-income andpoorcountries–is A sharpfocus ondisadvantagedgroups –within nutrition (Mehrotra, 2004; seecasestudyonBrazil). education underpinslatergainsinhealthand can beimportant; typically, early investment in sectors (Mehrotra, 2004). Sequencingofinvestment by focusing onthoseindividuals whoare closerto saved, protected andenhancedinpoorcountries Conventional wisdom hasbeenthatmore lives are the poorest andmostmarginalisedgroups. directing resources toandimproving thesituationof where there hasbeenanexplicitemphasison Progress inchildwell-being hasoftenbeengreatest Reducing inequities, includinggenderinequality Executive summary xi Government commitment, with the state commitment, Government as both a provider possible acting where and services of programmes and regulator political leadership is crucial to improve Strong This needs to be supported well-being. children’s which sector strategies, accepted widely clear, by where donors and NGOs align behind and, provision. government in fill gaps necessary, successful Examples of success include Chile’s and programme, childhood development early pioneering cash transfer Brazil and Mexico’s programmes.

Recommendations to approaches key identifies five Our analysis well-being: in children’s progress achieving 1.

education remain extremely low; in 2009 they were were they in 2009 low; extremely remain education 2009). (UNICEF, respectively and 22% 18% countries within and between Inequality on indicators the worst of Many is growing. high child mortality such as or well-being, children’s in low-income concentrated are rates, malnutrition and/or in the most disadvantaged and countries, within countries. marginalised communities death, at most risk of early are children The poorest and violations school non-attendance malnutrition, in access to inequalities remain, Gender of rights. in some countries, child survival and, education, to be missing likely more girls are Globally, nutrition. risk of at greater are although boys out on school, and adolescent boys labour, in hazardous involvement risk of violent at the greatest men are and young urban and between Disparities in progress death. in slums within urban areas, and problems rural areas, of needs of the poorest and the daunting, also remain and pervasively the poor – and those disadvantaged age, sex, discriminated against because of their be addressed. ethnicity or disability – must in conflict- has been particularly slow Progress home to These countries are countries. affected but primary school-age children, 18% of the world’s out-of-school primary school- 42% of the world’s of the Almost 70% 2011). (UNESCO, age children of child mortalitycountries with the highest burden decades experienced conflict in the past two have 2010a). the Children, (Save be done? to out of school in 2015 (UNESCO, out of school in 2015 (UNESCO, 2 Out-of-school children refers to children of primary school age not enrolled in either primary or secondary school. of primary in either primary to children school age not enrolled or secondary refers school. Out-of-school children The ages of children concerned vary countryThe ages of children entry from for to country ages and lengths of on different depending the primary cycle. 2 The challenges are on a large scale. on a large Global are The challenges only In 2010, high. child mortality extremely remains life-saving 42% of babies with HIV/AIDS received A total of 2011). drugs (UNAIDS, antiretroviral 67 million primary worldwide children school-age trends and if current not in school in 2008; were could be there with population growth, continue, 72 million children remains What has lagged well-being in children’s Progress nutrition, – in particular, behind in some areas from children and protecting water and sanitation, abuse and exploitation. Technology and innovation offer the opportunity offer for and innovation Technology efficiencies and greater and for impact, multiplied development accountability along the spectrum of in of telecommunications, growth The rapid work. dissemination of key the has promoted particular, and in children, such as the value of investing ideas, It has also helped health. example, for of self-help on, particularly – in the most remote livelihoods improve capacity The growing and underserved communities. solutions and local development local innovation for of change. scalable driver is a true, to global problems New technologyNew and innovation Progress on gender equality has played a key role in role a key has played on gender equality Progress girls’ in Improvements well-being. children’s improving example, for Brazil and Bangladesh, education rates in in child health, been critical to improvements have of year Each additional and child protection. nutrition child mortality 9%. by girls’ education can reduce the poverty line, or closer to meeting a particular to meeting or closer line, the poverty is evidence there However, target. development Important gains can case. the is not always that this most vulnerable on the focusing by be achieved the example, for is because, This and marginalised. populations within in excluded of children proportion fertility to higher owing larger, countries is generally die in these groups children more or because rates, Examples in this diseases. or treatable of preventable where strategies development report of equitable among the been concentrated have improvements Vietnam. Brazil and include poorest 2011). In sub-Saharan Africa and the and Africa and the Middle In sub-Saharan 2011). pre-primary for rates enrolment gross Africa, North xii progress in child well-being 4. 3. 2.

had strong pay-offs. For example, Brazil’s progress being, eitherinsequenceorsimultaneously, has Investment inseveral aspectsofchildren’s well- are introduced. multi-year socialprotection programmes different sectors, andthedevelopment of thatareInterventions integratedacross Bangladesh andEthiopia). with government-led sectordevelopment (eg, in in Botswana). Effective aidhasoftenbeenaligned issues (eg, inhelpingtoaddress highHIVrates some upper-middle-income countriesfor specific and lower-middle-income countries, andalsoin period). inlower-incomeAid hasbeenimportant an increasing share ofthebudgetover akey expenditure (eg, educationinEthiopiareceived protecting areas particular withingovernment at timesofausterity, by prioritisingand/or growth (eg, inBangladeshandBrazil), oreven commitments have beenfacilitatedby economic governments, andmore aid. Increased government combination ofincreased investment by national financial investment, usually through a Progress inchildwell-being requires significant fairly shared social andeconomicpolicies. Economic growth alongsideambitious, approach tofinancingthesector.. hasallowedhealth strategy for amore coherent withthegovernment’salignment ofdonorsupport progress andstrengthen outcomes. InBangladesh, In thiscontext, externalassistancecancatalyse thatcanbescaledup.programmes andservices child development andthere are functional there are nationallevel commitmentstopursue Development assistanceworks bestwhere government strategies. key prioritiesandalignedsupportive of Development assistancethatisfocused on

5.

schools fees were abolished. drop-out wassubstantially reduced afterprimary Tanzania, Ethiopia, GhanaandMozambiqueschool making itfree topregnant women andchildren. In quality andaccessibilityofhealthcare, typically by swift progress by improving inchildsurvival the cycles. For example, GhanaandNiger have made and canhelpbreak intergenerationalpoverty inequality alsofosters greater socialcohesion been concentratedamongthepoorest. Reducing Brazil and Vietnam, where improvements have report citesequitabledevelopment strategiesin often dieofpreventable ortreatable diseases. The higher proportion ofchildren inthesegroups children, owingrates. tohigherfertility And a countries generally have ahigherproportion of in childwell-being. Excludedpopulationswithin approach’ hasoftenledtothegreatest progress marginalised communities through an ‘equity that focuses resources onthepoorest andmost Well-designed investment inchildwell-being countries. more impoverished communities within protection tothepoorest children and andonextending in accesstoservices A greater focus onaddressing inequalities rights simultaneously. child well-being andfor theachievement ofmany optimal for progress inthemultiple dimensionsof sanitation. These cross-cutting investments are investment ineducation, healthcare, andwater Vietnam shows thepay-offs from simultaneous advice, andcontributedtopoverty reduction. mothers abletoactonnutritional andchildhealth in education, of whichledtoaneducatedcohort in nutrition wasfacilitatedby itspriorinvestment 1 Introduction

1.1 The context economic development and productivity (as in East Asia’s rapid growth in the 1970s and 1980s, for There has been significant progress on child rights example). Educated, qualified and healthy workers can and well-being in developing countries in the past few better contribute to economic growth, since they decades, with major gains in some areas of well-being. are better equipped to assimilate the new knowledge For example: and skills required by a rapidly changing economic • One-third fewer children under five died in 2010 environment. In turn, economic growth – when as compared with 1990. distributed equitably – widens the resource base of • Between 1999 and 2009, an additional 58 million a society; this enables a virtuous cycle of sustained children enrolled in primary school and the investments in people and increases in productivity, number of out-of-school primary-age children which feed back into economic growth (Mehrotra decreased by 39 million. and Jolly, 1997; see also Case Study 9 on Vietnam • The number of children enrolled in pre-primary for a discussion). Mutually supportive economic and education worldwide increased from 113 million social policy can reduce inequality, facilitate economic in 1999 to 157 million in 2009. growth, and lead to greater poverty reduction. • The proportion of adolescents of lower Investment in children – via social services, and secondary age who were out of school worldwide by ensuring that households have adequate fell by 21% between 1999 and 2009. livelihoods – can play a particular role in breaking In 2010, at the Millennium Development Goals intergenerational poverty cycles (Harper et al., (MDGs) Summit world leaders reaffirmed their 2003). For example, ensuring adequate nutrition commitment to the MDGs and called for intensified for children under two can have major economic collective action, a reaffirmed global partnership, and spin-offs in terms of health gains, better education the continuation of proven successful approaches completion rates and higher earnings in later after 2010 (United Nations, 2010). This report life. Experimental evidence suggests that tackling synthesises approaches that could be adopted or malnutrition in early life can increase adult earnings expanded to achieve greater progress on child by an average of 20% (Grantham-Macgregor et al., well-being. Given how much can be achieved 2007, in Save the Children, 2011b). The health burden through child-sensitive policies and programmes, and poor productivity associated with malnutrition the report aims to encourage governments and are estimated to cost poor countries 2–3% of gross donors to strengthen their support to child-sensitive domestic product (GDP) every year (UNSCN, 2010). development. World Bank analysis indicates that if Ugandan girls who currently complete only primary school were to complete secondary school, they would contribute 1.2 Why invest in children? an additional 34% of GDP over their working lives (Hempel and Cunningham, 2010). Economic arguments Expenditure on policies and programmes that Ethical arguments foster universal and good-quality education and It is simply morally unacceptable that, in a world with health services, boost nutrition and increase access the money, know-how and technology we have at our to improved water and sanitation represents an disposal, 7.6 million children under five die annually of investment in human capital. It increases individuals’ largely preventable diseases, 67 million children miss productive capacities and therefore their potential out on their right to basic education and millions income (Becker, 1993) and their contribution to more endure schooling of such poor quality that it overall development. Social investment underpins fails to equip them with basic literacy and numeracy.

1 2 progress in child well-being successes andidentifythefactorsthatcontributedto child well-being inthepasttwo decades, document It wasmotivatedby adesire toidentifytrends in 30 person-days between August andOctober2011. datacarried outthrough andsecondary of primary This reportisbasedonadeskreview andanalysis 1.3 near future. to more stableandprosperous countries inthe the rightsofchildren today andtocontribute should beupheldasanessentialpriority, toachieve documented inSections2and4, investing inchildren To acceleratetheprogress already achieved, as social integration. social mobilityandgeneratingstableprocesses of sectors ofthepopulation, openingupchannelsfor on theotherhand, for broad widenopportunities Social investment andsustainedhumandevelopment, popular protests inseveral Arab countriesin2011/12. can underminesocialcohesion, ashasbeenseenin and severe poverty togetherhinderdevelopment and Inadequate socialinvestment, highlevels ofinequality Political arguments expenditure plans. legal andpolicyframeworks andprogramme and provisions related totheserightsintonational achievement ofchildren’s rights, by incorporating the internationalcommunity tocontributethe 1989). This statementobligesbothgovernments and to ensure thefulfilmentofchildren’s rights(UN, within theframework ofinternationalcooperation” of theiravailable resources and, where needed, measuresof undertaking tothemaximum extent establishes that have“States Parties theobligation the Child(UNCRC). 4oftheConventionArticle have ratifiedtheUNConvention ontheRightsof of socialandeconomicrights. Moreover, 192states since itisakey instrumentintheimplementation imperative forthatupholdshumanrights, any country Investment inkey socialsectorsshouldbeanethical OFreport Methodology and focus

primary quantitative analysis.primary usedfor the Appendix 2outlinesthemethodology number ofgraphs ontrends inchildwell-being and policy andprogramming. Appendix 1presents a outlines conclusionsandrecommendations for improvements in childwell-being andSection5 consolidates theanalysis ofthekey drivers of different aspectsofchilddevelopment. Section4 framework thatpromotes synergiesbetween benefits ofemploying acomprehensive policy child development policyapproach to show the additional casestudyillustratesamultidimensional states, anddifferent regions oftheworld). An contexts (low-income, middle-income andfragile area. These were selectedtoreflect adiversity of in childwell-being are discussedinrelation toeach remain. Oneormore casestudiesofachievements progress andoutlinesomeofthechallengesthat highlight thefactorsthathave contributedto an overview ofprogress inthedeveloping world, protection (Section3). For eacharea, we present (including early childhooddevelopment); andchild HIV/AIDS); nutrition; waterandsanitation; education and prevention ofmother-to-child transmissionof to childwell-being: health(focusing onchildsurvival progress achieved infive areas thatare linked closely income poverty globally (Section2). Itthenexplores The reportprovides anoverview oftrends in tochildwell-being.their importance large literature, cannotbediscussedindepth, despite Some areas, suchasgovernance, where there isa picture ofresearch findingsonalltheabove areas. report isintendedtopainta ‘broad brushstroke’ Given timeavailable theshort for thisproject, the child well-being. and ontherelationship between aidandaspectsof on trendssectorsandcountries inaidtoparticular data This wascomplementedby analysis ofprimary successes, sources. onthebasisofsecondary well-being andanalysing thefactorsunderpinning case studiesofsignificantimprovements inchild evidence ontrends inchildwell-being, identifying role ofaid. The research involved collatingexisting this, emphasisonresourcing withaparticular andthe 2 Global overview

Significant strides have been made toward achieving Using more recent data, Chandy and Gertz (2011) the first target of MDG1 – halving the number of estimate that, between 2005 and 2010, the total people living under the monetary poverty line of number of poor people around the world fell by $1 a day by 2015. Between 1990 and 2005, the nearly half a billion to under 900 million in 2010. number of people in developing countries living This means that, while it took 25 years to reduce on less than $1.253 a day dropped by 400 million poverty by half a billion people up to 2005, the – down to 1.4 billion – and the global poverty rate same accomplishment took 6 years from 2005. declined from 46% to 27% (UN, 2011) (Figure 1). Their analysis links progress to high and sustained The UN estimates that the world as a whole is on economic growth achieved throughout most of the track towards meeting the goal despite deceleration developing world over the past six years (ibid.). in progress during the 2008/09 economic crisis. This trend of monetary poverty reduction is Nevertheless, progress is uneven. Sub-Saharan Africa, occurring in most regions of the world, albeit west Asia and parts of central Asia and eastern at different paces. Some of the fastest economic Europe are not expected to meet the MDG growth and the most dramatic reductions in poverty target (ibid.).

figure 1: Proportion of people living on less than $1.25 a day, 1990 and 2005 (%)

27 Developing regions 45

3 Northern Africa 5

6 Western Asia 2

7 Latin America 11

16 Eastern Asia 60

19 South-Eastern Asia 39

19 Caucasus and Central Asia 6

26 Caribbean 29

Southern Asia (excluding India) 31 45

Southern Asia (including India) 39 49

51 Sub-Saharan Africa 58

0 10 20 30 40 50 60 70

2005 1990

Source: UN (2011).

3 The $1.25 poverty line is measured at 2005 prices in purchasing power parity (PPP) $, http://mdgs.un.org/unsd/mdg/ Metadata.aspx?IndicatorId=0&SeriesId=584) (accessed 9 February 2012).

3 4 progress in child well-being 5 4 amid areduction inoverall poverty levels. Meanwhile, would explainworsening levels ofchronic poverty easier andlessexpensive toreach (CPRC, 2009). This closest tothepoverty line, whoare comparatively be achieved largely by addressing theneedsofthose poverty. There isadangerthatpoverty reduction may increase inthenumber ofpeoplelivinginchronic regarding poverty (ODI, monetary 2010a)andan countries there have beenlimitedimprovements Progress hasnotbeenuniform. Inone-third of school (Sumner, 2010). childrenchildren outof and56%ofprimary-age countries; thesameistrueof71%malnourished the world’s poorare now livinginmiddle-income income asaresult ofgrowth inrecent years, 72%of with largepoorpopulationsare considered middle- poverty rates. However, becausemostcountries have alsoexperiencedsignificant reductions intheir and Vietnam, andEthiopia(alow-income country) countries –Bangladesh, Brazil, Indonesia, Pakistan many ofthemnow classedaslower-middle-income Other countrieshometolargepoorpopulations, expected totake placeover theperiod2005–2015. reduction by three-quartersintheworld’s poor andIndiaaloneare responsible for the by 2015(UN, 2011). extreme poverty rateisexpectedtofallbelow 36% on record (ChandyandGertz, 2011). The global number ofpoorhasbeenfallingfor thefirsttime a wholemoved below the50%poverty rate, andits significant progress (UN, 2011). In2008, the region as Many sub-Saharan African countrieshave also made both highandlow initialincomepoverty rates. 1990 to39%in2005), includingincountrieswith in 1990to16%2005)andSouth Asia (49%in the populationlivinginpoverty went from 60% have beeninEast Asia (where theproportion of %28E%29%20MDG%20Report%202011_Progress%20Chart%20LR.pdf (accessed 11 February 2012).%28E%29%20MDG%20Report%202011_Progress%20Chart%20LR.pdf (accessed11February MDG Progress Charts, suchashttp://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2011/11-31330%20 mortality, educationandlivingstandards (http://hdr.undp.org/en/statistics/mpi/ 2012])or (accessed11February Multidimensional Poverty Index, which, thoughnotchild-specific, incorporatesdimensions suchas nutrition, child those focused onhumandevelopment more broadly, suchastheUNDevelopment Programme’s (UNDP’s) which involves analysis ofnutrition, andeducation(Hague, childmortality 2008). Otherrelevant measures include sanitation, shelter, information andincome/consumption; andSave theChildren UK’s Child Development Index, UNICEF’s GlobalChildPoverty Studyandtakes intoaccountdeprivationsineducation, health, nutrition, water, Fund (UNICEF)/BristolUniversity measure ofchildpoverty developed by Gordon etal. (2003), whichhasinformed in thedifferent componentsofchildwell-being, eitherseparately orinaggregate. These includetheUNChildren’s middle-income countries. Sumner (2010)estimatesthat23%oftheworld’s poorlive infragilestates, evenly splitbetween fragilelow- and estimate that40%oftheworld’s poorlive infragilestates, andthattheproportion willexceed50%by 2015. A number ofothermeasures and analyses have beendeveloped inrecent years todocumentandanalyse trends Estimatesofthepopulationlivinginfragileandconflict-affected statesare contested. (2011) ChandyandGertz concentrated infragileandconflict-afflictedstates. and childdeprivationare becomingincreasingly while stablecountriesare showing progress, poverty considerably skewed (Kenny, 2011). Furthermore, rich ones, whichhasleftglobalincomedistribution economies have beengrowing more slowly than income inequalityisgrowing. Poor countries’ trends, are thefocus of thenextsection. of childwell-being, andthefactorsunderlying those income andwealth. Trends inthesedifferent aspects etc), whichare affected by arangeoffactorsbeyond malnutrition, lackofaccessto safe waterorsanitation, years ago (ibid.). better qualityoflife compared with50ormore Nevertheless, agrowing number ofpeoplelive a extremely low inmany developing countries. is widespread andeducationqualityhasremained are someconcerns: for example, globalviolence rapid advancesare possible. Despitethis, there (Kenny, 2011). This indicatesthat, withcommitment, of thecountriespreviously behind thefurthest on qualityofliferapid hasbeenparticularly insome gender equalityandcivilpoliticalrights. Progress of economicperformance, have seenprogress on (see Section3). Similarly, mostcountries, regardless of healthandeducationover thepasthalfcentury economies, hasseenimprovements inaverage levels with stagnanteconomiesandthosevibrant every region oftheworld, includingboththose In additionpoverty, toreductions inmonetary deprivations children may face poverty measuresmonetary donotcapture the actual in overall poverty ratesnotedabove. However, are likely tohave benefitedfrom the reduction children thannon-poorhouseholds)andtherefore poverty (sincepoorhouseholdstendtohave more Children are disproportionately likely tobelivingin 5 (suchaspoorhealth, 4 3 Progress on key child-sensitive sectors

This section presents an overview of progress annual rate of reduction doubled from 1.4% in the in five key sectors for children’s well-being, 1990s to 2.8% in the 2000s (ibid.). It also doubled in illustrated by case studies, which identify sub-Saharan Africa over this period (UNIAGCME, promising practices that have contributed to 2011). Figure 2 shows progress by region (see also positive achievements for children. Figure A.1, Appendix 1). Ten of the countries with the highest child mortality rates have managed to cut child deaths by half. One 3.1 Child survival of these, Bangladesh, achieved a 65% reduction in child mortality between 1990 and 2009. How this Child mortality rates have fallen substantially since was achieved is discussed in Case Study 1 below. 1990, when 12.4 million children under five died (UNIAGCME, 2010). In 2009, nearly 12,000 fewer Although there has been significant progress in children died every day than in 1990. Globally, the reducing child mortality, there is an extremely long

Figure 2: Under-five mortality rate, by MDG region, 1990 and 2010 (deaths per 1,000 live births)

200

180 174

160

140

121 120 117

100 97 88 82 80 75 77 71 66 67 63 60 57 52 54 48 45 40 32 32 27 23 18 20 15 7 0

World Africa Oceania Eastern Asia Sub-Saharan Caucasus and Western Asia Southern Asia Central Asia Northern Africathe Caribbean South-eastern Asia Latin America and Developed regionsDeveloping regions

1990 2010

Source: UNIGME (2011)

5 6 progress in child well-being 31% to97%. mosquito netsandimmunisation coverage leapt from from 22%to58%; 78%ofallhouseholdsbeganusing been introduced, exclusive breastfeeding increased example, inMadagascar, intheareas where IMCIhas treat lessseriousillnesseseffectively athome. For of illnessneedmedicalattentionandhow to of greater community awareness ofwhichtypes on prevention ofchildhoodillness, andpromotion childhood illness, sensitisationorpubliceducation includes improved healthworker skillsintreating at community level isanotherkey factor. This Integrated managementofchildhoodillness(IMCI) 6 at community level. as much vitalhealthcare aspossiblecanbeprovided improving theirtrainingandskills, andinensuringthat in increasing thenumbers ofhealthworkers and communities. Typically, thishasinvolved investment to geographically remote andsocially disadvantaged andpostnatalcaredelivery andfor otherillnesses– role inextendingaccess tocare –bothfor antenatal, (Save theChildren, 2010a), hasplayed animportant pregnant women andchildren, asinGhanaandNiger Brazil (Victoraetal., 2011a), ortokey groups suchas rural areas andmakinghealthcare free toall, asin healthcare iscritical. Investing inprovision inremote improve thequalityandincrease theaccessibilityof Equitable investment inhealthcare systemsto Health system-related progress structural andsocialcausesofill-health. underpinned by actionbothonhealthsystemsand Achievements inreducinghave childmortality been been achieved? How hasprogress inreducing childmortality couldbeachieved.mortality some ways thatprogress towards reducing child subsection onongoing challengesbelow discusses another third inSouth Asia (UNIAGCME, 2011). The 2010, halfofwhomwere insub-Saharan Africa and way togo: 7.6millionchildren underfive diedin 7 (accessed 4 February 2012). (accessed 4February countries now have over 90%immunisation coverage or affordability ofmedicaltechnologies: 131 driven by improvements intheavailability Use ofeffective preventive approaches, often www.who.int/pmnch/topics/part_publications/essential_interventions_18_01_2012_executive_summary.pdf www.unicef.org/health/index_imcd.html 2012). (accessed4February 7

6

MNCH expenditure inCountdown consistently available. Approximately 85%of aggregate dataontheseexpenditures are not investments are vitalfor childhealth. However, child health(MNCH)andbroader healthsector Both expenditures onmaternal, newborn and How have thesereductions beenfinanced? increasing genderequality(for example, • including: , on socialfactorsunderlying childmortality on HIV/AIDS(seeSection3.3), andprogress factorshaveOther important beenaction under five worldwide (Blacketal., 2010). which isresponsible for 15%ofdeathschildren has beenshown tobeeffective inpreventing malaria, affected countries, useofinsecticide-treated bednets causes by about23%(UNSCN, 2010). Inmalaria- immunity, canreduce theirriskofdeathfrom all supplementation, which, by boostingchildren’s There hasalsobeensignificantprogress invitamin A 63 countriesin1990(MMWR, 2011)(seeBox 1). preventable childhooddiseases), ascompared with for diphtheria, (major tetanus andpertussis increasing levels ofgirls’education, • women’s greaterinhousehold participation • broader poverty reduction (Section2). • enhancedaccesstosafe waterandsanitation • governments adoptingfamily-friendly social • children’s nutrition (UNICEF 2007) decision-making, whichisshown toimprove of treatment over traditional(UNICEF2007) illnesses, includingpreferences for moderntypes decisions aboutseekingtreatment for children’s resources towards childwell-being, andtomake which hasincreased women’s capacity todirect healthcare for theirchildren [World Bank, 2011]), mothers’ educationandtheirprovision of recognition oftheproven positive linkbetween improved hygiene practices(section3.4) Health, 2008) (WHO CommissiononSocialDeterminantsof women towork onanequalfooting withmen incomes for bothmenandwomen, orthatallow protection policiesthat provide equitable to improved childcare practices contributed bothtowomen’s empowerment and 15 countries(the whichhave

3 Progress on key child-sensitive sectors 7 14

10 12 The private sector has also played has also played The private sector 11 Further funding and efforts are 13 substantially larger donor funds have been larger donor funds have substantially These funds have immunisation. mobilised for vaccines and of new enabled the introduction vaccination of longer-standing coverage increased programmes. a key role, both in developing vaccines and in both in developing role, a key and as catalyst role GAVI’s extending access. partly prices were reduced for NGOs’ advocacy in major drug companies agreeing for responsible vaccines in developing key 2011 to cut prices for These vaccines included rotavirus countries. against which protect vaccines, and pentavalent B and hepatitis pertussis, tetanus, diphtheria, Haemophilus influenzae type B. Ongoing challenges: 1.7 million children still die still 1.7 million children challenges: Ongoing – mostly a year illnesses vaccine-preventable from or conflict-affected areas in remote poor children limited or those whose mothers have countries, education. needed to achieve 90% vaccination levels for for vaccination levels 90% needed to achieve 23.2 million of 2010, As of the end diseases. key all under 12 months had not received children DTP3 vaccine doses of the recommended three had in the same age group and 23.7 million children measles vaccine. a single dose of the not received from developing country governments over over country governments developing from GAVI in 2000 of the Since the formation time. Vaccines Alliance for Global Alliance (formerly a public–private partnership and Immunization; of immunisation levels dedicated to increasing diseases), against vaccine-preventable

9 8 immunisation in Progress x 1: Donors have played a significant role in progress role in progress a significant played Donors have WHO and UNICEF have on immunisation: been major funders of national immunisation contributions with increasing typically programmes, New immunisations have been introduced in recent in recent introduced been have immunisations New pneumococcal against children protecting years, (the cause of 50% of disease and rotavirus children). killer of young the foremost diarrhoea, in 40 low-income of these vaccines Provision to 7 million deaths. up countries should avert Bo six major vaccine- for coverage Immunisation childhood – pertussis, diseases preventable measles and diphtheria polio, tetanus, tuberculosis, Health World the since significantly – has risen began its Expanded Organization (WHO) At (EPI) in 1974. on Immunisation Programme were children 5% of the world’s only the time, vaccine-preventable against the six key immunised of doses DTP3 (three 1980, By diseases. and polio) tetanus diphtheria, vaccinations against was estimated year of life in the first coverage to an it increased children; at 20% of the world’s is on Polio the end of 2010. estimated 85% by measles, from Deaths of eradication. the verge declined under five, a major killer of children sub-Saharan 92% in and by 78% worldwide by 2009). 2000 and 2008 (CDC, Africa between hundreds has saved against tetanus Immunisation and 20 of thousands of mothers and newborns, eliminated countries have and middle-income low- maternal and neonatal tetanus. www.childinfo.org/immunization.html (accessed 29 September 2011). www.childinfo.org/immunization.html www.childinfo.org/immunization.html (accessed 5 October 2011). www.childinfo.org/immunization.html (accessed 4 February 2012). www.bbc.co.uk/news/business-13665501 (accessed 29 September 2011). www.gavialliance.org/advocacy-statistics/ In the 1990s, there was a severe withdrawal of donor funding for immunisations after UNICEF announced the immunisations of donor funding for withdrawal was a severe there In the 1990s, www.gavialliance.org/advocacy-statistics/ ((accessed 29 September 2011). www.gavialliance.org/advocacy-statistics/ www.childinfo.org/immunization.html (accessed 28 September 2011). www.childinfo.org/immunization.html 14 11 12 13 10 Due to campaign. Childhood Immunisation target of the Universal of the 80% coverage successful achievement of the 2000 global coverage by and donor fatigue, such as HIV/AIDS, diseases new WHO leadership, a change in 50% (Hardon, to below dropped and in some places DTP3 coverage to 75%, six traditional vaccines had dropped For funding. dependent on GAVI heavily are countries and many this, in reversing role a large has played GAVI 2001). did not change significantly, for immunisations funding government existing donor and GAVI, years of the first five a major for responsible is largely that GAVI implying 52%, by increased immunisations but spending on routine in its programme plans a large-scale increase currently GAVI 2007). (Chee et al., in vaccination coverage increase jeopardise may which funding gaps, to create This threatens but faces funding constraints due to the economic crisis. 2010). (Usher, lives children’s 8 9 8 progress in child well-being disproportionately favoured countriesthathave However, ODA toMNCHhasoften have increased dramatically (Pittetal., 2010). multilaterals –theGlobalFundandGAVI Alliance two bilateraldonors(theUKandtheUS)two 2003 and2007. Inparticular, thecontributionsof (Countdown, 2010). Figure 3outlinestrends between This constituted31%ofODA tohealthin2007 on 2006andnearly doublethe$2.1billionin2003. (ODA) toMNCHin2007was$4.1billion, up16% sector overall. Total officialdevelopment assistance of aidcommittedtobothMNCHandthehealth 16 15 economic crisis) The late2000s(before theonsetofglobal for specificprogrammes orinitiatives (ibid.). aid toMNCHprovides resources thatcanbeused salaries), makingreprioritisation difficult. Asa result, with financing recurrent healthsectorcosts (including However, government resources are oftentiedup comes from domesticsources (Pittetal., 2010). 60 countriesthataccountfor 90%ofchildmortality) 17 the health-related MDGs (inthe68countrieswhere 95%ofchildandmaternal deathsoccur)(Countdown, 2010). Lancet asakey partner. progress country datato stimulate towards andsupport Ituses country-specific achieving academics, governments, internationalagencies, healthcare professional associations, donorsandNGOs, withThe Source: Pittetal. (2010)andothersinCountdown (2010). A breakdown ofglobalMNCHaidby region wasnotavailable. Datafor the periodafter2007were notavailable. Countdown to2015: Tracking Progress inMaternal, isaglobalmovement Newborn andChildSurvival of 0 1 2 3 4 5 and newbornhealth,ountdown C countries ,billion) 2007(2005$ Figure 3: Officialdevelopment

2003 2004 1.4 0.8 16 saw anincrease inthevolume 1.5 0.6 assistance 2005 20062007 2.1 0.8 to child health 2010) (seeFigure A.4, Appendix 1). live have births) received much less(Countdown, those withthehighestlevels (ofover 200per1,000 rates(betweenmortality 150and199per1,000), has beenbettertargetedatcountrieswithhighchild in 2008(Countdown, 2010). While aidtoMNCH ratesremaintheir childmortality high: 109per1,000 despitereceivingmortality relatively little aid, but Ethiopia, have madegood progress onreducing child aid (Pittetal., 2010). Somelargecountries, suchas populations have received much lower percapita The result isthatlow-income countrieswithlarge small populationsbutare geo-stratically important immunisation andprovision ofantiretrovirals in ‘vertical interventions’, suchasextending to children. These have beenespecially effective developing countries, many ofdirect relevance programmes onvariousaspectsofhealthcare in in mobilisingfundingandcatalysingof delivery for NeglectedDiseaseshave played acrucialrole Fund, GAVI, RollBackMalariaandthePartnership Global healthpartnerships, suchastheGlobal 2.3 1.2 and 2.8 1.3 to maternal 17

newborn health Maternal and Child health 3 Progress on key child-sensitive sectors 9 to underlying malnutrition (Countdown, 2010) which 2010) (Countdown, malnutrition to underlying their and weakens growth undermines children’s be but which can largely ability to fight infections, extension of a set of nutritional/ eliminated through (see health interventions reduction and poverty Section 3.2). of action include the following: areas Key at most risk of on children Focusing death early in who live with uneducated mothers, children Poor from Appendix 1) or are A.2, (see Figure rural areas at greatest are marginalised social and ethnic groups, in Children 2008). death (UNICEF, risk of early particularly vulnerable: countries are conflict-affected almost 70% of the countries with the highest experienced armed child mortality have burden the decades (Save the past two over conflict 2010a). Children, on progress in 60% of countries making date, To been concentrated have improvements child survival, 2010a). the Children, (Save groups among well-off narrowed have such as Bangladesh, Some countries, rich and poor households and between the gap Brazil has cut 2010a); and girls (ODI, boys between and households regions child deaths in the poorest rate of infant mortalityrate of infant 46 deaths per 1,000 was rate of infant mortality If the by fell (our analysis). that the region, across 4 per 1,000 an additional each year. 63,000 infant lives save would particularly full details, 2 for Appendix See descriptive are These A2.3. and A2.2 Figures an attempt to determine a causal not statistics, around variation is much and there relationship, certainly but the data are these averages, helped to reduce having consistent with aid infant mortality. between relationship the So over the course of a decade the the course of a decade So over More recently, global initiatives have placed have global initiatives recently, More 19 ? mortality and infant 18 is What x 2: Our analysis of data from sub-Saharan Africa Africa sub-Saharan of data from Our analysis an receiving country, that a typical high-aid suggests (roughly of aid per year $20 per capita additional and a low-aid a high-aid between the difference country) by infant mortality year reduced each deaths per 1,000 0.4 an additional approximately births.

average high-aid country infant mortality reduced average with compared 4 deaths per 1,000, an additional by were there In 2009, country. low-aid the average Africa 15.7 million births in sub-Saharan roughly and the average 2011b), (UNICEF data in UNICEF, aid Bo Global initiatives have often led the extension of results-based aid into the health sector; they have been less have they sector; aid into the health often led the extension of results-based have Global initiatives either in infant mortality significant at the 1% level, aid and reductions is statistically between The relationship greater emphasis on integrating their support greater and sector health strategies with government-led (SWAps) approaches sector-wide through plans, the However, 2010). in particular (Isenman et al., emphasis of some global health partnerships on with disbursement can be at odds results-based (ibid.). health sector strengthening longer-term a tendency to meet targets It can also reinforce – often better-off easiest to reach the reaching by regions remote quintiles in less geographically 2008b). et al., (Jones 18 19 successful at harmonising aid with government strategies (Isenman et al., 2010). strategies (Isenman et al., successful at harmonising aid with government Ethiopia and Nigeria, most populous countries, two population or when the by not weighted when the data are the analysis. excluded from are Around 7.6 million children under five still die every still die under five 7.6 million children Around diseases, preventable of them from two-thirds year, the most at risk (Save children with the poorest is pace of reduction current The 2010a). Children, to meet MDG4 – halving child mortalitytoo slow by Asia South Africa, 2015 – particularly in sub-Saharan of The major killers 2011). and Oceania (UNIAGCME, for (responsible – pneumonia and diarrhoea children respectively) 18% and 15% of child deaths worldwide, HIV/AIDS and malaria (together and measles, 2010) – another 15%) (Black et al, for responsible be targeted. and can easily preventable largely are related are worldwide of child deaths Another third Ongoing challenges Ongoing (ARVs). 10 progress in child well-being exclusive breastfeeding for thefirstsix monthsoflife Initiation ofbreastfeeding withinonehourofbirth, feeding practices Promoting betterinfantandyoung child Agreater focus ondiseaseswiththegreatest • 20 Agreater focus on reducingamong mortality • • Achieving thiswould require: approach does(UNICEF, 2010c). child deathsper$1millioninvested thanthecurrent approach would prevent tochildsurvival 60%more UNICEF hascalculatedthatanequity-focused over a10-year period(Save theChildren, 2010a). an additional 4millionchilddeathscouldbeaverted as they didfor thefastest-improving incomegroup, progress across allincomegroups atthesamerate that accountfor over 90%ofchilddeathsmade (Victora etal., 2011). Ifthe42developing countries faster thaninbetter-off householdsandregions 21 weightlow-birth infants; andtreatment ofinfection (UNICEF, 2008a). and exclusive breastfeeding; andkeeping drying newborns warm; accesstoresuscitation, ifneeded; specialcare of deaths. This includes: tetanus toxoid immunisation; skilledattendants atbirth; accesstoobstetriccare; immediate Dataontrends inotheraspectsofinfant andyoung child feeding were notavailable. recentlyA packageof16interventions identified by TheLancethasthepotentialtoavert 72%ofnewborn equity focus ofactiononchildsurvival. diseases, actiononthesewould alsoimprove the children are atgreater riskofdyingfrom allthese need them(Bhuttaetal., 2010). Sincepoorer reachand interventions only halfofthosewho malaria killmore than3millionchildren peryear burden.child mortality Pneumonia, diarrhoea and and community outreach (UNICEF, 2008a). improved antenatal, obstetricandpostnatalcare, deaths couldbeprevented through apackageof (UNIAGCME, 2010). Three-quarters ofnewborn in thefirstmonthoflife and70%inthefirst year half ofallchilddeathsinsouth Asia) now occur 40% ofchilddeathsindeveloping countries(and among children agedbetween oneandfive. Nearly in recent years have beeninreducing deaths newborns andinfants. Many oftheimprovements (Bhutta etal., 2010). malaria casesamongchildren are correctly treated (ORT) and27%withantibiotics, and30%of correctly treated withoralrehydration therapy show thatamedianof42%children are upskilling. Datafrom Countdown countries of care provided through healthworker of healthcare andtoimprove thequality increase theaccessibilityandaffordability Continued investment inhealthsystemsto 20

1995 to37%in2008(ibid.). first sixmonthshasbeenmodest, going from 33%in Overall, progress onexclusive breastfeeding for the any otherpreventive (UNICEF, intervention 2009a). under-five deathsindeveloping countries, more than the potentialtoprevent anestimated19%ofall food) untilthechildisatleasttwo years old have and continued breastfeeding (withcomplementary (Bhutta etal., 2010). with declinesofbetween 0.5%and0.8%peryear rates, butonewhere progress slow, hasbeenvery thus anothercriticalfactorinincreasing childsurvival (UNICEF, 2008a). Improving maternalhealthcare is 2011b) are much more likely todiethemselves related complicationsevery year (Save theChildren, women orfrom whodieinchildbirth pregnancy- babies. Furthermore, thebabiesof358,000 weightcomplications andoflow birth amongtheir 2010), increasingand/or theriskofmortality to 40%ofpregnant women are anaemic(UNSCN, attendant(UNICEF,skilled birth 2008a), whileup antenatal care atalland40%givewithouta birth Worldwide, 25%ofpregnant women receive no Improving maternal healthandnutrition discussed inSection3.2. Other measures toimprove children’s nutrition are established culturalpractices. achievable, even thoughitrepresents achallengeto increasing exclusive breastfeeding rates iswholly (UNICEF, 2009a). These successesindicatethat channels andmessagestailored tothelocalcontext strategies topromote breastfeeding, usingmultiple actions have beenaccompaniedby communication groupsmother support in thecommunity. These on infantandyoung childfeeding; andmother-to- building healthworker capacity tooffer counselling facilities (andnoinfantformula isgiven infacilities); ensuring breastfeeding isinitiatedinmaternity marketing; maternityprotection for working women; Key factorshave beencontrol ofinfantformula exclusive breastfeeding rates(Figure A.3, Appendix 1). and Madagascar, have made impressive increases in However, somecountries, suchasCambodia, Ghana 21

3 Progress on key child-sensitive sectors 11

46 47 Improved access to water and sanitation: and sanitation: access to water Improved up to 2 million potential to prevent This has the (Section 3.4). year every children young deaths of See the discussion on on the discussion See reduction: Poverty and multi-sectoral 2) (Case Study transfers cash 3.8). (Section reduction poverty and in only five does families’ own spending on does families’ five and in only less than 15% of total health health represent meaning that 2010), (Bhutta et al., expenditure. and private low relatively are public contributions of spending Although high levels contributions high. very low health outcomes, no guarantee of good are countries health spending in some of per capita levels up from Africa, sub-Saharan of $13 across (an average a critical constraint to are 2011b]) $9 in 2001 [WHO, child health outcomes. improving $60 billion is needed An estimated additional 2009 and 2015 to implement a full package between of MNCH interventions in the 68 countries with the If both highest child and maternal mortality levels. commitments meet financial donors and governments will still be $22 billion the funding gap made, already efforts both by so greater 2010), (Countdown, partners needed. are and development governments Financing countries currently MDG Countdown five Only national budget to health, 15% of their over devote • • This can increase This can increase empowerment: Women’s independent and ability to make autonomy women’s 2010a). (ODI, decisions about child healthcare Increasing rates of girls’ education: Each rates Increasing is estimated of girls’ education year additional child mortality 9% (Caldwell, to reduce rates by analysis A recent 2011). in UNESCO, 1986, in child deaths to attributes half of the reduction 1990 in girls’ education between improvements in UNESCO, 2010, and 2010 (Gakidou et al., secondary Universal education could 2011). in lives an estimated 1.8 million children’s save 2011) through Africa (UNESCO, sub-Saharan about child care mothers’ knowledge increasing capacity and their health and nutrition, practices, to act on this knowledge. A commitment under the Abuja Declaration. the A commitment under Calculated from statistics in ODI (2010b). Calculated from 47 46 on structural causes of progress Greater child mortality through: • • Increasing use of healthcare services use of healthcare for Increasing delivery and care antenatal children, young for packages of care Integrated of treatment and early immunisation, including Demand-side necessary. illnesses are childhood as conditional cash mechanisms such financing to child health monitoring (see Case linked transfers ) and maternal healthcare Study 2 on Bolsa Família utilisation and contribute to can increase vouchers child survival. improved 12 progress in child well-being php?option=com_content&view=article&id=70&Itemid=117. Source: ofHealthandFamily welfare, Ministry Bangladeshstatistics, http://dmis-bd.homelinux.net/dmis/index. have alsobeen reduced (Figure B). Disparities between socio-economicgroups 48 deathsper1,000live(Figure births) A). under five reduced by 62%(from 126to rateofchildren1993 to2010themortality live 66years (ODI, 2010a). Duringtheperiod whereas anewborn in2008canexpectto could expecttolive only untiltheageof44, improved significantly: ababy bornin1970 inBangladeshhas Life expectancyatbirth in Bangladesh Improvements inmotherandchildhealth C 100 150 200 250 300 (per 1,000livebirths) Figure A: Under-fivemortality rate, 1993–2007, B 50 0

ase Study 1 1993 19951999 126 51 88 114 49 81 42 66 91 2004 52 68 35 2007 2008 44 31 57 attendance; socialmobilisationongenderissues on women; stipendstoencouragegirls’school microfinance movement thathas focused largely the positionofgirlsandwomen. These includea a rangeoffactorshave contributedtoachangein Progress ongender equality:Over thepast30years, Structural factors have contributedtoimproving ratesofchildsurvival: Several structuralandhealthsystem-related factors achieved inB How has progress been 54 42 30 angladesh 2009 2010 29 40 51 angladesh? 27 48 38 Child under5 Infant (1–11months) Neonatal 3 Progress on key child-sensitive sectors 13 Poorest Second Third Fourth Wealthiest 49 2007 2007 and 2007 Health-system-related factors Health-system-related adopted and has placed IMCI: IMCI has been widely emphasis on the major causes of child increasing pneumonia, malaria, mortality measles, – especially – and on improving and malnutrition diarrhoea health worker through of children care community showed of the programme An evaluation training. that the IMCI strategy improved had substantially 1999 Between a sick child. for the quality of care in the use increase was a three-fold there and 2007, in children breastfeeding exclusive of these facilities, and prevalence than six months increased, younger The 2010a). the Children, of stunting declined (Save using locally ORT, affordable of simple, introduction an important role has played sugar and salt, available 2007). illness and death (BRAC, diarrhoeal in reducing were 1% of children only In 1985, Immunisation: diphtheria and polio. against measles, immunised Headcount poverty rates have also rates have Headcount poverty Poverty reduction: increasing 2009, 57% in 1992 to 31.5% in from fallen, and healthcare food, for available the resources of housing. in the quality investment , 1994 1994 , quintile wealth the result of the result 48 1994 0 40 80 by rate mortality -five Under B: Figure ) live births (per 1,000 120 160 200 See World Development Indicators, database and HIES 2010. database and HIES 2010. Indicators, Development World See From World Bank databank: http://databank.worldbank.org/ http://databank.worldbank.org/ Bank databank: World From sustained efforts to ensure women’s access to family access to family women’s sustained efforts to ensure improving both reflect This may planning services. by them, contributed to child survival have rates and food for of household resources the level increasing per child. available and healthcare 49 48 Reduced fertility: Bangladesh has also seen a substantial 4.54 in 1990, in fertility rates ((from reduction and 2.3 in 2009), to 3.12 in 2000, and on social issues more broadly, by government government by broadly, and on social issues more and outspoken of strong the growth and NGOs; of women’s and the growth organisations; women’s The particularly in the garment industry. employment, girls are so that has increased, social value of females equal priority in to be given likely more much now their with education and healthcare access to food, in girls’ education The substantial increase brothers. 33% of girls attending primary(from school in 1970 secondary 13% attending to 82.5% in 2009 and from MICS, 2010a; school in 1990 to 53% in 2009 (ODI, 2009) has led to a cohort more who are of mothers as well generations, than in previous knowledgeable confident in independent decision-making as more health. concerning their children’s Source: ODI (2010a), based on Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data. Indicator Cluster Survey (DHS) and Multiple Health Survey based on Demographic ODI (2010a), Source: 14 progress in child well-being 50 from 71%in1983to43%2007. children underfive whoare severely stunted fell contributed tochildsurvival. The proportion of NutritionalimprovementsNutrition: have also thecourse.those whostart polio injectionsissubstantially lower thanthatof complete allthree dosesofdiphtheria, tetanus and (BRAC, 2007). However, theproportion who 3% ofone-year-olds hadreceived noimmunisations against thesediseases(ODI, 2010a). In2004, only By thelate2000s, 88%ofchildren were immunised 51 Health, Population suggests10.9% ofchildren andNutritionStrategy were severely underweight in2007. 1985 to4.1%in2005, butthat4%ofchildren underfive were stuntedin2005. An evaluation ofthe government’s past 20years. ODI(2010a)reportsafallintheproportion ofchildren whoare severely malnourishedfrom 74%in postnatal care in2004(BRAC, 2007). it isoperational. Only 18%ofwomen received any care anduseofinstitutionaldeliveries inareas where has contributedtoincreased uptake ofantenatal 2008). The pilotMaternalHealth Voucher programme trained personnelincreased from 13%to18%(GoB, 2007, attendedby thenumbermedically ofbirths drugsandequipment.necessary Between 2004and levels, through provision ofskilledstaff andthe atdistrictandsub-district Care (CEmOC)services establishing Comprehensive EmergencyObstetric deliveries (currently only 20%[GoB, 2011]), andon care, toincrease theproportion ofinstitutional access topublicsectorhealthfacilitiesfor maternal attendant. Current policyfocuses onimproving In 2009, were only 29%ofbirths assistedby askilled within thefirst week oflife (BRAC, 2007). 2011). Additionally, 75% ofthesemothers’babiesdie related causesevery year inBangladesh(NIPORT, and meansthat12,000women diefrom pregnancy- 1985 and2010. However, thisisstillahighlevel, from 650per100,000 to194per100,000between Maternal mortality: This hasalsodeclinedsignificantly, MDG targetinthisarea (GoB, 2009). in2009,country Bangladeshisunlikely tomeetthe but, asthiscovered only justover one-fifthofthe Area-based Community Nutritionprogramme attempting toreduce malnutrition through its 10% in2000to17%2007). The government is children underfive hasincreased recently (from (Saymen etal., 2011). However, wastingamong supplementation now covers 88%ofchildren Noinformation couldbefound onthe scaleoffinancialflows to BangladeshiNGOs for MNCH activities. http://data.worldbank.org. We have found atleast three different estimatesof trends inchildmalnutrition over the 50 Vitamin A Vitamin contributed toimprovements inchildsurvival. health sector, financialassistancetoNGOshasalso Given thesignificant role ofNGOsinBangladesh’s and introducing ‘kangaroo care’ for pre-term infants. Saving Newborn Lives, maternalhealthvouchers health strategies, withspecificprojects including to financingtheimplementationof government Development (USAID)andUNICEFhave contributed Development (DFID), theUS Agency for International Foundation, for International theUKDepartment Various donors, includingthe World Bank, theGates problems ofchildmortality. health strategy, makingitmore effective intackling in Bangladeshhasbeenalignedwiththegovernment’s MNCH care andoutcomes. Aid tothehealthsector have synergieswith, andhave contributedto, better wider healthandeducationsectorinvestments 1999–2009 (authors’calculations), althoughofcourse approximately 8%ofaidfor healthover theperiod On average, commitmentstoMNCHconstituted have contributedtodomesticspendingonMNCH. aid, andalsobudgetsupport, whichislikely to of aidtoMNCHincomparisonwithgeneralhealth health expenditure. Figure Cindicatesthevolume thereafter until2009, whenthey rose againto8%of in 1995topeakat8.8%2004. They declined climbed from just3%oftotalhealthexpenditure to 6.58%in2009/10. Externalresources for health 8% respectively, althoughthelatterfigure declined relatively constantsince1995ataround 1%and expenditure devoted tohealthhave stayed The proportions ofGDP andofgovernment and Financing ofinterventions and refocusing onemergingchallenges. ofefforts broader governance challenges, withperiodic review health over successive governments anddespite sustained commitmenttoimproving thepopulation’s Public policycommitment. There hasbeena Drivers ofsuccess the role of aid 51

3 Progress on key child-sensitive sectors 15 MNCH Health health Reproductive supportBudget Ongoing challenges place within 71% of all infant mortality takes Around reducing this is a high and so the first month of life, Child survival rates lag behind action. priority for and disadvantaged in some remote national averages Tracts, Hill such as Sylhet and the Chittagong regions, will be needed action in these regions and focused attention to More chances. life to equalise children’s such child mortality, structural factors underlying and to improving and girls’ education, as poverty particularly availability health system, the overall will be critical to areas, in remote of MNCH care progress. future health sector investments (ODI, 2010a), allowing for a for allowing 2010a), (ODI, health sector investments Aid to financing the sector. approach coherent more Female Stipend Programme, has also co-financed the which has helped to raise girls’ secondary school levels. enrolment 2004 2006 2008 ) $ million 2009 (constant by category aid 2000 2002 angladesh 1998 0 C: B C: Figure 100 200 300 400 500 600 In addition to commitments to extending health In addition numbers greater training and deploying facilities, of the supply and improving of health workers, has there 2008), medicines and equipment (GoB, on health promotion been a long-standing focus in key and public education level at community health messages. Aid aligned with the government’s health health Aid aligned with the government’s in supporting an important role strategy has played A strong focus on reaching the most on reaching focus A strong has been crucial. and disadvantaged vulnerable partnerships through Much of this has been achieved been particularly innovative which have with NGOs, the most disadvantaged people (ODI, in reaching in improvement This has made Bangladesh’s 2010a). equitable than in other countries. MNCH more in the past 20 years economic growth Strong (making poverty has contributed both to reducing household living conditions in nutrition, improvements the and to increasing affordable) and education more in investment for to government available resources child health. Source: AidData.org, accessed August 2011. MNCH coded by authors. MNCH coded by August 2011. accessed AidData.org, Source: 16 progress in child well-being 23 22 Children, 2011b). to 0.65percentage points peryear (Save the from 40%to29%between 1990and2008, equivalent Stunting prevalence indeveloping countries declined Stunting and key micronutrient-deficiency-related diseases. underweight (low weight for age), weight low birth trends heightfor age)and instunting(shortened are neededtosustainprogress. This sectionoutlines though, thisisanarea where much greater efforts in 2005to83%2008(UNICEF, 2009a). Overall, vitamin A duringacalendaryear increased from 16% children aged6–59monthsreceiving two dosesof of malnutrition: inMozambique, thepercentage of have mademajorprogress aspects onparticular considerably (Save theChildren, 2011b), andothers and Ghana, have reduced childmalnutrition rates However, somecountries, suchasBangladesh, Brazil well-being, andeducation. suchaschildsurvival have beenslower thaninotherkey areas ofchild malnutrition over thepast20years, butimprovements Globally, there have beensomereductions inchild developing countries(Countdown, 2010). the underlying causeofone-third ofchilddeathsin throughout theirlives. Malnutrition isestimatedtobe their healthandabilitytolearnearn undermines theirphysical andcognitive development, Malnutrition inchildren undertheageoftwo 3.2 Nutrition 24 WHO reference norms(UNICEF, 2009a). Honduras andPeru). Overall, stuntingprevalence in prevalence of30–50% (eg, Bolivia, Guatemala, Haiti, some SouthandCentral American countries, with Stunting continues tobeasignificantproblem in significantly reduced stuntingrates(UNICEF, 2009a). some countries, suchasEritrea andMauritania, have 43 millionin1990to522008. However, old whoare stuntedhasincreased, from anestimated overall number of African children underfive years 2008. Moreover, becauseofpopulationgrowth, the from 38%ofunder-fives stuntedin1990to34% The declineinsub-Saharan Africa hasbeensmaller, (UNICEF, 2009a). declinesinBangladesh,particular Chinaand Vietnam from 44%around 1990to30%around 2008, with in some Asian countries, where prevalence dropped varies slightly becauseofthetiming ofkeyThe periodfor eachcountry surveys. Underweight isdefinedaslower than average weight-for-height asa result ofmalnutrition. Moderateorsevere stunting isdefinedasheight-for-age two standard deviations ormore below 22 Progress hasbeenconcentrated by region. detailontrendsfurther inunderweight prevalence (Roadmap, 2010b). SeeFigure A.6, Appendix 1for target of16.5%children underweight worldwide rate ofreduction isinsufficienttomeettheMDG Despite significantfallsinsomecountries, the overall between 1990and2008(UNICEF, 2008a). of underweight children fallingfrom 67%to43% has madesignificantprogress, withtheproportion children (UNICEF, 2009a). Bangladesh, however, population) accountfor halftheworld’s underweight India andPakistan(with29%oftheworld’s child are thehighestinworld: togetherBangladesh, the absolutenumbers ofunderweight children 37% to31%between 1990and2008. However, In , underweight prevalence fell from 18%) (UNICEF, 2009a). 21%), Ghana(27%to9%)andMozambique Mauritania (57%down to27%), (29.9%to prevalence over theperiod1990–2008 achieved impressive reductions inunderweight 2010). There are exceptions: countriesthathave and improvement rateshave been faster(UNSCN, Africa, where underweight prevalence isrelatively low from is insufficienttomeetMDG1 apart inNorth over thecontinentasawhole. This rateofprogress prevalence declinedby 0.1percentage pointsperyear improvement have beenslower. Underweight underweight in2008(UNICEF, 2009d), ratesof For Africa, where 21%ofchildren underfive were Salse-Ubach, 2010). children are underweight (Sanchez-Montero and of 3.8%every year). Currently, 4%oftheregion’s going from 11%in1990to6%2008(by anaverage were fastestinLatin America andtheCaribbean, underweight prevalence amongchildren underfive severely underweight (UNICEF, 2006). Reductions in that have progress. madeparticular in sub-Saharan Africa, Asia andselectedcountries Figure A.5, Appendix 1shows reductions instunting in high-prevalence countries(UNSCN, 2010). the region isfalling, butthere hasbeenlittlechange one infour) were underweight five years oldinthedeveloping world (nearly In 2006, anestimated129millionchildren under Underweight 23 and10%were 24 include 3 Progress on key child-sensitive sectors 17 , in particular through social in particular through , reduction Poverty transferred that have programmes protection income to poor households and enabled nutritious more food, more households to afford and better access to healthcare. food as in , security and livelihoods Action on food and Mozambique (IFSN, Malawi Brazil, Bangladesh, 2010), and Salse-Ubach, Sanchez-Montero 2011; availability of food problems underlying to address this has Often, access to food. and poor people’s support and to smallholder agriculture involved women farmers. targeting specific programmes and to safe access to healthcare Increased (see Section 3.1 water and sanitation sources and Section 3.4). How has progress in improving nutrition nutrition in improving has progress How been achieved? improvements in child survival, As with improvements of action a combination reflect nutrition in children’s which underpin poor causes of malnutrition, on root action on and focused outcomes, health and nutrition nutrition and health issues. specific on health and nutrition action Focused to provide This includes targeted programmes aimed at programmes A supplements; vitamin six months for breastfeeding exclusive increasing community- and improved (see Section 3.1); as such programmes, health and nutrition level which Weeks, Health Integrated Child Mozambique’s measles de-worming, A supplements, vitamin offer messages nutrition screening, nutrition vaccinations, and distribution of iodised oil on breastfeeding with a particular on disadvantaged focus supplements, 2009a). (UNICEF, areas causes has included: Action on underlying • • • Iron deficiency anaemia deficiency Iron showing are which problems, nutritional other Unlike half the in about time, over improvements slow of 33) data (16 out are which there for countries of women in the numbers been an increase has there anaemia deficiency iron by affected and children under five children About 60% of 2010). (UNSCN, estimated to be anaemic Africa are in sub-Saharan America and 29% in Latin as are 2010), (UNSCN, and Salse-Ubach, the Caribbean (Sanchez-Montero to anaemia is estimated to contribute Maternal 2010). 591,000 perinatal 115,000 maternal deaths and over 2011b). the Children, (Save deaths a year Iodine deficiency which can lead to brain damage Iodine deficiency, and adults, in older children and goitre in newborns Thirty-six iodising salt. by prevented can be easily the target of at least 90% of reached countries have up from iodised salt, households using adequately made a community when the world 21 in 2002, 2005. salt iodisation by commitment to universal about 41 million Despite this significant progress, the from unprotected remain a year newborns enduring consequences of brain damage associated 2009a). with iodine deficiency (UNICEF, Vitamin A deficiency are worldwide An estimated 163 million children Asia Africa and in 30–40% A-deficient (around vitamin America and the Caribbean), and 10–20% in Latin death: their risk of early increasing significantly for 6.5% of child A deficiency accounted vitamin Globally, 2011b). the Children, mortality in 2004 (Save A reducing vitamin despite some significant successes, particularly in slow, relatively deficiency has been Asia Africa and south and central sub-Saharan 2010). (UNSCN, Micronutrient deficiencies Micronutrient estimated to account are deficiencies Micronutrient child deaths and of malnutrition-related one-third for 2011b). the Children, 10% of all child deaths (Save Incidence of low birthweight (under 2.5 kg) has fallen birthweight (under Incidence of low 18% to 12% Asia and from 34% to 27% in South from China) already Asia (mainly East Asia. in South-East birthweight in the 1980s, incidence of low had a low Incidence 6%. fallen to about and the rate has now Despite overall however. Asia, has risen in west the highest percentage Asia still has improvements, and the America In Latin birthweight babies. of low to 10% in birthweight fell incidence of low Caribbean, the greatest with 13% in the 1980s, the 2000s from Africa, In sub-Saharan America. decline in Central static over birthweight has remained incidence of low in east improvement with some the past 20 years, 2010). Africa (UNSCN, Low birthweight renders babies more vulnerable vulnerable more babies renders birthweight Low account which together and asphyxia, to infections An infant born weighing of neonatal deaths. 60% for to likely is eight times more 1.5 kg and 2 kg between of an adequate weight an infant born with die than causes an estimated birthweight Low at least 2.5 kg. 2009a). child deaths (UNICEF, 3.3% of overall Low birthweight Low 18 progress in child well-being 25 (Sanchez-Montero andSalse-Ubach, 2010). has beenhighly effective inreducing malnutrition will resulting inacoherent policyapproach, which a nationallaw onfood security; andstrong political by civilsociety; arights-basedapproach coupled with evaluation; highpoliticalvisibility, enablingmonitoring (See CaseStudy2)hasstrong monitoringand 2009). Bycontrast, Brazil’s Zero Hungerprogramme programmes tobedelivered effectively (Walton, the needfor institutionalrobustness inorder for delivery.as aduty-bearer ofservice This highlights to seekpoliticalsupport, ratherthanseeingthestate (often ethnic-orcaste-based)over othersinorder clientelism, whichinvolves favouring groups certain structures andinstitutions, especially official 2009). Malnutrition inIndiais linked tounequal and evaluation withfew linkstooutcomes(Haddad, performance, weak incentives, andpoormonitoring Development have Services littleeffect onpoor focused programmes suchastheIntegratedChild attributed topoorprogramme governance. Child- despite excellenteconomicgrowth. Muchofthisis structures: ithasmadelittleprogress onnutrition nutritional improvements dependsonstrong political India provides anexampleofhow theachievement of iodised salt(UNICEF, 2009a). produced salt, whichledto97%ofhouseholdsusing a decisionwasmadein2007toiodisefactory- nutrition. OneexampleisofsaltiodisationinNigeria: toimprovegiven momentumtoefforts important been relatively rare, where ithasoccurred ithas Although politicalprioritisationofnutrition has resourced programmes Political willandwell-planned and birthweight (UNSCN, 2010). role inimproving maternalnutrition andreducing low education andagainstearly marriage canplay acrucial communication andsocialmobilisationinfavour of implementation ofminimum marriage agelaws and them to stay in school (as in Bangladesh and Ethiopia), young women are fully grown, through incentives for Bangladesh andBrazil). Preventing childbearinguntil improving childhealth(seeCaseStudies1and2on have beencriticalinreducing childmalnutrition and In particular, increasing levels ofmaternaleducation Increased gender equality 26 Assistance Committee (DAC) data. Ithasnotbeenpossible tofindequivalent regionally aggregated figures for government spending on nutrition. Basedonauthoranalysis of Organisationfor EconomicCo-operationandDevelopment (OECD) Development $8 billionfor health) compared withover $11billionfor educationand in 2006(Roadmap, 2010a); $522millionin2009(as been dedicatedto ‘basic nutrition’ (3%ofhealthaid Overall, asmallproportion ofaidhashistorically How have thesereductions beenfinanced? factors isrequired. mean thatactionfocused simultaneously onseveral complex factorsunderlying nutritional problems shared littleinthisgrowth becausethe andpartly UNESCO, 2011), becausepoorpeoplehave partly reducing malnutrition (Save theChildren, 2011b; growth rateshave hadlimitedprogress intermsof Several middle-income countrieswithhigheconomic is notenough nutritional problems isessential: growth Expanded focused actiontocombat Children, 2011b). stunted by 2025(UNIAGCME, 2011, inSave the action, anestimated450millionchildren willbe were stunted(Roadmap, 2010b). Without focused (90% ofwhomlived insub-Saharan Africa and Asia) In 2006, anestimated195millionchildren underfive large-scale problem Child malnutrition remains a Ongoing challenges region. concentration ofmalnourishedchildren inthis committed have beenmuch lower, despitethe in aidtonutrition insouth Asia andtheamounts in sub-Saharan Africa andthe Americas. The rise has alsobeenasharpriseinthelatter, particularly agriculture fardwarfsthattobasicnutrition, there the wake ofsudden food pricerises. Although aidto possibly reflecting a renewed focus on nutrition in significantly since2007, inagriculture, particularly shows thatglobalnutrition-related aidhasrisen likely toaffect nutrition issignificantly higher. Figure 4 reduction andbroader healthservices, thevolume food security, waterandsanitation, education, poverty with nutrition isconsidered, suchasagriculture and However, whenaidtosectorswithsignificantlinkages in low-income countries. reason for slower progress inthisarea, particularly nutrition (ratherthanindirectly influencingit)isone relatively limitedamountofaidresources focused on donor-financed inlow-income countries. Arguably, the 26 Vitamin A supplementationhaslargely been 25 (seeFigure A.7, Appendix 1.) 3 Progress on key child-sensitive sectors 19

Global Sub-Saharan Africa Latin America and the Caribbean East Asia Asia South and Central East Middle Agriculture security Food Basic nutrition , 1999–2009 1999–2009 , aid correct?] [is this -related nutrition in trends 2000 2005 2010 2010 2000 2005 0 0 100 200 300 400 500

2,000 4,000 6,000 8,000 basicAid for nutrition by region Figure 5: $ million) (2009 constant 4: Global 4: Figure $ million ) (2009 constant 10,000 Source: OECD-DAC data, authors’ calculations. data, OECD-DAC Source: Source: OECD-DAC data, authors’ calculations. data, OECD-DAC Source: 20 progress in child well-being Section 3.4onwaterandsanitation). Case Studies2and9onBrazil and Vietnam, and address underlying causesofchildmalnutrition (see and ensure theaccessibility ofhealthservices, to to safe waterandsanitation, fillhealth worker gaps children’s accesstonutritious food, improve access toreduce poverty,This isnecessary increase poor action Extending complementary prevent substantial illness(Save theChildren, 2011b). malnourished children couldsave 2.5millionlives and 36 countriesthatare hometo90%oftheworld’s children. Implementationof thispackageinthe feeding ofmoderately andseverely malnourished de-worming toprevent nutrient loss; andtherapeutic children, through supplementationandfortification; vitamin A, zincandiron) amongpregnant women and increasing theintake ofmicronutrients (particularly improving hygiene practices, suchashand-washing; of nutritious food afterbabiesreach sixmonths); feeding (introductionand optimalcomplementary 2010a; 2010b). This involves promoting breastfeeding Committee onNutrition(UNSCN)(Roadmap, TheLancetanddisseminatedbyby theUNStanding children indeveloping countrieshasbeenidentified eliminate themostcriticalnutritional problems facing A packageof13evidence-based to interventions 27 Figure from OECD-DAC aiddatabase. aid Bo course ofadecade, atypicalhigh-aidcountry 0.2 percentage pointsperyear. So, over the of childhoodmalnutrition by anadditional reduceda low-aidtheprevalence country) (roughly thedifference between ahigh-aidand receiving anadditional $20annual aidpercapita malnutrition suggeststhattheaverage country The relationship we estimatedbetween aidand recipients inabsoluteterms). in percapita terms(althoughbothare majoraid goodvery progress withoutreceiving much aid countries, EthiopiaandSudan, whichhave made significance appears tobeexplained by two not statistically significant. Thelackofstatistical over thepastdecade, buttherelationship is progress inreducing childhoodmalnutrition receiving more aidpercapita have mademore dataanalysis shows thatcountries Our primary x 3: What is and childmalnutrition? the relationship between A focus onreducing inequalities of stuntedchildren (Roadmap, 2010b). to improve nutrition inthe36countrieswith90% to fully implementakey packageofinterventions An additional $5–6billionofaidperyear isneeded figure Appendix2andfigure A2.1 forfulldetails. considerable variationaround theseaverages. See to estimateacausalrelationship, andthere is These are descriptive statistics, notanattempt children would nolongerbemalnourished. points across theregion, anadditional 2.7million malnutrition ratesfell by anadditional 2percentage children were malnourished(ouranalysis). If from UNICEF, 2011b)andonaverage 24%of under five insub-Saharan Africa(UNICEFdata In 2009, there were roughly 137millionchildren malnutrition by anadditional 2percentage points. will have reduced theprevalence ofchild be factored intotheaid agenda. highrates ofreturnchallenge withvery thatshould annually (Roadmap, 2010b). nutrition from $522millionin2009to$5billion sources, thiswould require ascaling-up of aidto half theremaining costscouldbefundedby domestic financed privately by better-off householdsandthat 2010a). Assuming approximately $1.5billioncouldbe between 4.8:1and15.8:1, respectively (Roadmap, per year, andwould have abenefit-to-costratioof wouldinterventions costanestimated$11.8billion Full implementationof ‘The Lancet package’of Significant additional resources are needed which nutritional disparitiescanbeeliminated. highest quintiles(seeCaseStudy2)illuminatesways in malnutrition inthelowest quintilesfasterthaninthe health andfood security, Brazil’s record onreducing households. Through targetedactiononpoverty, more likely tobestuntedthanthoseintherichest , children inthepoorest householdsare 11times to eliminatemalnutrition isneeded. For example, in some middle-income countries, more targetedaction for universal approaches (Save theChildren, 2011b). In across allsocio-economic groups, indicatingtheneed In many poorcountries, ratesofstuntingare high 27 This isanimportant 3 Progress on key child-sensitive sectors 21 1989 1996 2007 (see 28 Richest 4th achievements nutritional Figure A), and in the north-east, the country’s poorest poorest the country’s and in the north-east, A), Figure 1996 and 2006 22% to 6% between from region, 2011). (IFSN, the poorest for The decline in stunting was far faster and inequalities in the rich, households than for points 25 to 6 percentage from stunting reduced 2009). (Monteiro, factors (2009) suggests that the following Monteiro been particularlydramatic significant in the have in child malnutrition: reductions and, in maternal education Improvements of elementary the universalisation in particular, Key fell five under among children Stunting prevalence 1996 and 2007, 13.5% to 7.1% between from 3rd 2nd

tudy 2 Study ase

Poorest 0 10 20 30 40 50 , 1989–2007 by income quintile, prevalence Stunting A: Figure (% of children under five) Information extracted from World Development Indicators database for this project. Indicators database for Development World extracted from Information 28 Source: Monteiro and others, in Countdown (2010). in Countdown and others, Monteiro Source: Although malnutrition rates in Brazil were rates in Brazil were Although malnutrition 1990s as in some other not as high in the its population America, parts of Latin in 1990) meant that size (157 million affected. were of children large numbers major disparities were there Furthermore, and richest quintiles. the poorest between and rates of stunting however, Since 1990, through fallen dramatically, have underweight security and food a combination of improved reduction driven significant poverty nutrition; and enhanced wages higher minimum by in social and investment social protection; education and healthcare. policies, to improving children’s nutrition children’s to improving Brazil approach a multifaceted – C 22 progress in child well-being 33 32 31 30 29 disadvantaged children (UCW, 2011). and increased theaccessibilityofeducationfor improved thequality(lowering pupil–teacherratios) 1985 onwards (Monteiro, 2009), whichhasboth investment ineducationover theperiodfrom decline inchildstunting. This reflects substantial schooling are estimatedtoaccountfor 26%ofthe in termsofsanitation. substantial regional disparities, well below ofthecountry these averages, andnorth-east withthenorth particularly official Brazilianpoverty line isR$70permonth. For thisindicator, theofficial datais8.5%(IBGE, Census, 2010). the householdpermonth; R$70perpersoninthehouseholdmonth), each withdifferent results. The current targeted, coverage is73%and95%, respectively. disadvantaged regions, where theprogramme is 2010, andnorth-east, butinthenorth themost metropolitan areas. Overall coverage was54%in on ruralareas andsmallcitiesremote from large education andequalaccesstoservices, whichfocuses the Family HealthStrategy, emphasisingprevention, decline instunting. This islinked toexpansionof healthcare isestimatedtoaccountfor 12%ofthe Increased coverage ofchild andmaternal from 54%to67%. population withaccesstoadequatesanitationrose between 1990and2010; the percentage ofthe improved watersources rose from 71%to83% in stunting. Overall, thepopulationwithaccessto accountsfor another4%ofthereductionservices Increased coverage ofwater andsanitation Salse-Ubach, 2010). decreased from 16%to5%(Sanchez-Montero and to 2008, thepopulationlivingonlessthan$1perday the purchasing power ofpoorhouseholds. From 1990 and othersocialtransfers (seebelow) hasincreased poor families, viaprogrammes suchasBolsaFamília of economicgrowth andredistribution ofincometo decline inchildstunting. Specifically, acombination families isestimatedtoaccountfor 22%ofthe Increased purchasing power amongpoor more minorrole (ibid.). schemes suchasBolsaFamília played but animportant linked toeducationsectorinvestment; cashtransfer in 1999to85%2008.30 This increase waslargely schoolenrolmentfemale rose secondary from 68% school increased from 85%to97%(ibid.)andthenet and 2009, theproportion of7–15-year-olds attending InstitutoBrasiliero deGeografiaeEstatisticadata (http://www.ibge.gov.br/english/). Theseaggregate figures mask Datafrom SIAB-Datasus(http://www2.datasus.gov.br/SIAB/index.php). Different poverty lineshave beenusedinBrazilover theyearsofminimum wage per personin (one-quarter Information extractedfrom World Development Indicatorsdatabasefor thisproject. Despitethis, problems ofqualityremain. 33 31

29 Between 1992 32

reserves (Sanchez-Montero andSalse-Ubach, 2010). and prisons)orfor thecreation ofnationalfood purchases for publicinstitutions(hospitals, schools and afood acquisitionprogramme ensures state programme facilitates accesstoinvestment capital, Food Purchase Programme. A smallholdercredit Guarantee, Family Agriculture Insuranceandthe the NationalFamily Agriculture Programme, Harvest Strengthening smallholderagriculture, through programme. inmonitoringtheFome Zeropublic participation and mobilisation ofprivateandpublicpartnerships Social mobilisationandcitizenshipeducation, tocooperatives.organisation andsupport production-oriented microcredit, productive training, promotion ofsustainableeconomicactivity, Income-generating activities, whichinclude (Sanchez-Montero andSalse-Ubach, 2010). distribution andtaxincentives for food production food andnutritionalsystem, surveillance vitamin A transfers), low-cost restaurants, schoolfeeding, the Access tofood, viaBolsaFamília (householdcash policy. Fome Zero isstructured around four axes: significantly increased attentiontohungerinpublic (Sanchez-Montero andSalse-Ubach, 2010), whichhas indifferenta packageof53interventions sectors children’s nutrition goes toFome Zero (Zero Hunger), ofthecreditPart for Brazil’s successinimproving Fome Zer monitored andtoreceive vaccinations. Mothersmust be taken tobe tohealthclinicsatregular intervals in recipient householdsuptotheageofseven must is targetedtothepoorandextreme poor. Children 2010, inODI, 2011a). BolsaFamília ismeans-testedand 12.5 millionfamiliesin2009(Veras Soares andSilva, an amalgamationofdisparateprogrammes), itreached impact onchildren’s nutrition. Launchedin2003(from has beenthemostrigorously evaluated intermsofits Família conditionalcashtransfer (CCT)programme Of thedifferent elementsofFome Zero,Bolsa the Bolsa Família o 3 Progress on key child-sensitive sectors 23 This 35 political commitment has also been translated into political commitment has also been and Nutritional Security Organic Law the Food the government’s which makes (September 2006), binding security legally commitments on food has Zero The political impetus behind Fome (ibid.). educational and (social, policy coherence promoted allocation and equitable resource policies), agriculture participation (ibid.). stakeholder to social conducive Social and political changes that provided led to transformations development Democratisation from progress. for the foundation vibrant civil society the mid-1980s led to space for including on engagement on public policy issues, urbanisation and falling Greater gender equality. a supportive environment fertility rates also provided 2011b). (Victora et al., social policy investments for sectors: Synergies different Synergies between to improvements reduction, income poverty between Drivers of success Zero political commitment: Fome High-level former builds on a personal commitment by Luiz Inácio Lula da Silva that he would president mission accomplished if every consider his life’s by meals a day three able to have Brazilian were 2009). Silva, the time he left office (Graziano da and coordination planning, The programme’s the president been led by implementation have 2010). and Salse-Ubach, (Sanchez-Montero aged 6–18 years (Sanchez-Montero and Salse-Ubach, Salse-Ubach, and (Sanchez-Montero 6–18 years aged in but two day, per school one meal normally 2010); intended These are 2011). (Evans, areas the poorest This needs. food daily 15% of children’s to supply status nutritional the to improve has the potential learning and to better to ensure of schoolchildren, are generation of mothers that the next help ensure better nourished. Acquisition The Food is a national Programme farmers’ smallholder from food scheme that buys distributes it to prices and organisations at market 11.947 Law and families in need. schools hospitals, provided 30% of resources stipulates that at least food purchase be used to must school food for the access of This enhances farmers. family from to particularly those in isolated areas, small farmers, has The programme fair prices. at guaranteed markets 2011). (IFSN, production food increased stimulated both of which are both of which are 34 Other studies, such as Veras Soares and Silva (in ODI, 2011) have found no impacts on vaccination rates. no impacts on vaccination rates. found 2011) have and Silva (in ODI, Soares Veras as such Other studies, the change of president following for this case study whether this is still the case It could not be verified 34 35 provides provides The National School Meals Programme school students to public meals a day 47 million free earlier this year. with a likely impact on with a likely Zero Other elements of Fome include the following: child malnutrition : evidence of impacts on nutrition evidence : Bolsa Família stunting among The 2005 Nutritional Call found beneficiary aged 6–11 months was 3.3% children non-beneficiary than among (5.3% children lower on children no significant impact It found 2%). vs. because of weaker possibly aged 12–36 months, Some studies 2011). (IFSN, monitoring of their growth arid north-west and such as the in isolated areas, 26% more children found have Amazon, parts of the and height-for- weight- appropriate to achieve likely families as compared recipient age in Bolsa Família some However, 2009). (ILO, with non-recipients Regional Center for Brazil’s such as that by studies, not found have and Planning, Economic Development as a result on child malnutrition effects positive any in 2010, and Silva, Soares Veras (eg, of Bolsa Família and Silva suggest this may Soares Veras 2011a). ODI, in Mexico and Chile, programmes unlike be because, of food provision does not involve Bolsa Família or because health sector infrastructure supplements, and putting in place growth monitoring children’s for developed. is inadequately measures remedial Evaluations have shown positive effects of Bolsa effects positive shown Evaluations have although some studies nutrition, on children’s Família Bolsa Família contradictory (see below). findings have school drop-out has also contributed to reducing attendance among vulnerable children and increasing and some 2010), and Salse-Ubach, (Sanchez-Montero vaccination rates studies find it has led to increased 2011), in IFSN, Modesto, (eg, attend pre- and postnatal check-ups at health clinics health clinics at check-ups and postnatal pre- attend All children and participate seminars. in nutrition in be enrolled 15 must the ages of 6 and between 16–17-year- 85% of classes; attend at least schools and 75% of classes attend school must in olds enrolled school and by monitored Compliance is 2009). (ILO, database in a central and is registered health centres other CCT Unlike – the single registry system. ‘gradual has a system of Bolsa Família programmes, allowing of non-compliance, in the case repercussion’ an opportunitythe family on track before to get back 2011a). cut off (ODI, eventually benefits are associated with nutritional improvements. associated with nutritional 24 progress in child well-being 37 36 effective. (IFSN, 2011), whichimpliestheprogramme iscost- 2009) andcloseto1%ofgovernment expenses approximately $15.2billion, 0.4%ofGDP(ILO, Resourcing: In2008/09, BolsaFamília cost monitoring ofchildwell-being inrecipient households. (ILO, 2009; ODI, 2011a), andwhichenablescontinued which containsdataonallBolsaFamília recipients such asthrough theUnified RegisterofHouseholds, refined systems for managingpolicyimplementation, Sanchez-Montero and Salse-Ubach, 2010). Ithasalso the designofBolsaFamília (BelikanddelGrossi, 2003; Brazil hasincorporatedbestpracticesonCCTsinto systems for managing theirimplementation: Well-chosen evidence-based policiesand falling malnutrition rates. reduction, whichinturnmay well have contributedto such asFome Zero andcontributedtopoverty increased theresource envelope for programmes from 1.9%to5.1%(ODI, 2011a). This hasboth 1998 and2008, annual economic growth ratesrose A positive economicenvironment: Between health policies(Victoraetal., 2011b). movements hasbeenakey advocate for progressive in combinationwithbroader progressive social 2010). An engagedandpoliticisedhealthworkforce of itsactions(Sanchez-Montero andSalse-Ubach, committees andhasinstitutionalisedsocialmonitoring budgets,participatory haslocalimplementation for Food andNutritionSecurity, whichhaspromoted to account. Onesucharena istheNationalCouncil strengthened mechanismsfor holdingthegovernment provided afocus for civilsocietymobilisationand of government commitmentsonfood security has Engaged civilsociety: Thelegally bindingnature and urbanconsumerssimultaneously (Evans, 2011). has strengthened food securityamongsmallfarmers strengthening food production andimproving access Ubach, 2010). The dualemphasisinFome Zero on nutritional status(Sanchez-Montero andSalse- sanitation have contributedtoimproving children’s healthcare and, toalesserextent, waterand smallholder agriculture andfood security, education, moderate food insecurity, citesthat 14.5%ofhouseholdsare food insecure (IBGE, PNDS, 2006). here ismarkedly different from theofficialdatacurrently available in Brazilwhich, when adding inextreme and FIAN, INCIDIN, NIZA, Peuples solidaires, SOS Sahel, SSTEP, UNNAYAN DHARA. Pleasenotethatthe figure cited countries in5continents. are: Officialpartners Abiodes, ActionAidUK, Actuar, Ayuda en Accion, Barcik, CCRD, operational budgetsofspecificsectors. small proportion ofGDP(around 0.745%), targeted has beenminimal. In2009, ODA represented a toFome Zerosupport anditsassociatedprogrammes The InternationalFood SecurityNetwork (IFSN)isanetwork working onfood securityinmore than30 Equivalentfigures for Fome Zero are not available assomeofthe resources perprogramme areofthe part 36 The contributionofexternalfinancial (IFSN, 2011). and youth employment schemesthrough loans for $572millionandin2010aloanfor $200million) BolsaFamíliasupported (in2003itprovided aloan Fome Zeroto support , andthe World Bankhas International Cooperation(GIZ)have chosen Some donors, suchastheGerman Agency for principally atenvironmental andgovernance issues. from food insecurity(IFSN, 2011). households –more than72millionpeople–suffer widespread. Officialdataindicatethat35%ofall and exporter, hungerandfood insecurityare still malnutrition, anditsstatusasamajorfood producer Despite Brazil’s successinreducing poverty andchild Problems offood insecurityremain significant: Challenges provided through theeducationsystem. of children are missingoutonentitlementsto food of theeligiblepopulation)meansignificant numbers levels ofenrolment inpreschools (around one-third 14% ofchildren overweight inthe1990s(ibid.). Low becoming amajornutritional problem, witharound the indigenouspopulation. Being overweight isalso Oliveira etal., 2010), andhigherthan50%among prevalence isover 40%amongchildren (deNovaes increasing (Victoraetal., 2011b), andanaemia are low (40%in2006[Countdown, 2010]), though exclusive breastfeeding for thefirstsixmonths Some nutritional problems persist: Ratesof programmes” (inIFSN, 2011). seriously limitstheredistributive impactofthe seek tobenefit, asthe regressive systemoftaxation essentially fundedbypersonswhomthey thevery Zero Hungerprogrammes are impressive, “they are Right toFood hasconcludedthatwhilethevarious in indirect taxes. onthe The UN SpecialRapporteur earning over 30timestheminimum wagepay 16% of theirincomeinindirect taxes, whereas families than twicetheminimum wagepay anaverage of46% redistribution: Familieswithanincomeofless Reducing taxinequalitieswhichundermine Montero andSalse-Ubach, 2010). population –live below thepoverty line(Sanchez- population, 51%–whocomprise36%ofthetotal 37 Among therural 3 Progress on key child-sensitive sectors 25 that has pioneered an that has pioneered 39 effective approach to prevention of mother-to-child of mother-to-child to prevention approach effective Case Study 3 below transmission (PMTCT) of HIV. impressive the countrydiscusses how has recorded 20.7% of infants of from in PMTCT, achievements in in 2003 to 4.8% mothers infected HIV-positive 2010). 2008 (Baleta, How has progress in PMTCT been achieved? has progress How will and leadership Political political The fight against HIV/AIDS has mobilised much – until recently, will and leadership globally has led in turn, This, diseases. other than for more and for prevention resources to significant such as , and to technical innovations , treatment drugs that cut effective generation of highly the new transmission mother-to-child mortality and prevent of HIV. from resources Significant and donors governments to $15.9 billion was spent on responding In 2009, of governments half of which came from HIV/AIDS, In low-income countries. and middle-income low- HIV/AIDS programmes 88% of funding for countries, of Despite the growth donors. by is provided funders such as the Global Fund to multilateral and Malaria and UNITAID, Tuberculosis AIDS, Fight HIV/AIDS the vast majority of funding for by directly to be provided continues programmes to their babies (UNAIDS, 2010a), and only 35% of and only 2010a), (UNAIDS, babies to their 2010b). (UNAIDS, ARVs received babies infected HIV living with children of the number Moreover, million in 2009 and, to rise – to 2.5 continues so does Africa, such as South in some countries, and maternal and child transmission mother-to-child In many 2010a). (UNAIDS, HIV/AIDS mortality from HIV/ orphaned by of children the numbers countries, an estimated total of from still increasing, AIDS are to 16.6 million in 2009 (ibid.). 14.4 million in 2005 ARV countries, in many fact that, the This reflects adults are and young universal is far from coverage furthermore, on a large scale; AIDS still dying from vulnerable to a range of are ARVs taking people even other diseases. is an example of a countryBotswana with high and 33% among (24.9% overall HIV prevalence in 2010) women pregnant An untreated baby is likely to die before he to die before is likely baby An untreated 38 -child -to mother Preventing UNICEF (2010). www.unicef.org/media/media_58026.html (accessed 4 September 2011). www.unicef.org/media/media_58026.html However, in 2009 an estimated 370,000 infants in 2009 an estimated However, indicating that with HIV, infected were worldwide concertedmore action is needed to prevent on mothers passing their infection HIV-positive or she is two years old (UNAIDS, 2010b). There has There 2010b). old (UNAIDS, years or she is two HIV among in preventing been significant progress in newly was a 24% decline there globally children: dying infants and a 19% decline in children infected 2004 and 2009 (UNAIDS, AIDS between from pregnant of HIV-positive The numbers 2010a). countries taking and middle-income in low- women transmission of the virus to their to prevent ARVs 15% in 2005 to 53% in 2009 from babies rose 2010b). (UNAIDS, 39 38 In countries with high HIV prevalence, HIV In countries with high HIV prevalence, to child survivalstill constitutes a major threat Africa, in Southern example, For 2010). (Countdown, up to half of child and maternal mortality is related to HIV. More than 5 million people are receiving life-saving life-saving receiving than 5 million people are More basic received millions of orphans have ARVs, tolerant and and more education and healthcare, been established have enabling social environments reduce campaigns to countries through in many This would stigma and discrimination. HIV-related mobilisation been possible without strong not have of levels and unprecedented the global community by governments, donors, by collectively funding provided organisations and philanthropic the private sector, 2010a). HIV (UNAIDS, individuals to address Thirty years of investment in preventing and treating and treating in preventing of investment Thirty years becoming now people are Fewer off. HIV has paid dying of are people with HIV and fewer infected height of the pandemic in the 1990s AIDS than at the and Prevention 2010a). 2000s (UNAIDS, and early meant the pandemic have programmes treatment so HIV countries (ibid.), in many peaked has now and infections leading to fewer is falling, prevalence of the most including some 33 countries, In deaths. Africa, countries in sub-Saharan affected severely 2001 and between 25% over by HIV incidence fell being at risk of though these gains are 2009 (ibid.), economic crisis of effects the ongoing undone by 2010). et al., (Jones 3.3 of HIV/AIDS transmission 26 progress in child well-being Source: OECD-DAC, withauthors’ calculations. programmes rose considerably, more thandoublingin the proportion ofsocialsector aiddevoted toHIV in sub-Saharan Africa. Over theperiod2000–10, significant proportion of social sectoraid, particularly Commitments totacklingHIV/AIDSconstitutea Figure 6shows regional trends inaidfor HIV/AIDS. although commitmentshave fallensince2008. in sub-Saharan Africa for almostallthisperiod, of theepidemic. DonorfundingtoHIV/AIDSrose the geographical concentrationanddistribution is concentratedinsub-Saharan Africa, reflecting $719 millionin1999to$7.8billion2009. Funding programmes rose by afactorof10, from Over theperiod2000–10, globalaidtoHIV HIV programmes domestically (ibid.). On average, middle-income countriesfinance54%of donor toHIV/AIDSprogrammes (UNAIDS, 2010a). 2009). The USisby aconsiderablemarginthebiggest bilateral donors(77%ofallHIV/AIDSfundingin Figure 6: Regional 2,000 4,000 6,000 8,000

0 2000 2005 2010 trends in aid forHIV/AIDS, 2000–10(constant 2009$million ) lower-middle-income countries(UNAIDS, 2010a). of internationalfunds, withanother14%going to with HIVglobally. Low-income countriesreceive 78% recipients ofaidaccountfor 71%ofthepeopleliving countries mostaffected by theepidemic. The top20 The majorityofdonorresources are targetedtothe with thegreatest needed Aid hasbeenwell targeted atcountries 30-fold insub-Saharan Africa (Figure 7). Asia andeast Asia, andincreasing approximately Latin America andtheCaribbean, southandcentral the problem, globalinvestment levels are insufficient. (Jones etal., 2010). Given thestillenormousscaleof wiped outby theeffects oftheglobaleconomiccrisis The gainsofthepast30years are atriskofbeing The globaleconomiccrisis Ongoing challenges Middle East South andCentral Asia East Asia the Caribbean and Latin America Sub-Saharan Africa Global

3 Progress on key child-sensitive sectors 27

40 Global Sub-Saharan Africa Latin America and the Caribbean East Asia Asia South and Central East Middle , 2000–10 (%) , aid 2010 those living in remote rural areas, are often less able often less are rural areas, remote living in those by for be paid to have these where ARVs to afford or even facilities healthcare to to travel the patient, ARVs to take food to be able sufficient to have on an empty stomach) not be taken (which must 2009a). (UNAIDS, areas on effective expenditure Focusing drivers the reflect programmes Cost-effective and are particularof the epidemic in contexts, drug combinations, using effective evidence-based: behaviour effective and promoting example, for as emphasising condom use and avoiding such change, abstinence (UNAIDS, rather than partners, multiple be done very of HIV can now PMTCT 2010a). it is estimated that stopping a single cost-effectively: while costs $5, among infants now case of infection of year cost per disability-adjusted life the average 2010a). is $34 (UNAIDS, PMTCT programmes a share of social sector as 2005 HIV/AIDS to 0 5 10 15 20 25 7: Commitments Figure 7: Figure 7 shows aid to HIV as a share of social sector aid, rather than as a share of health aid, for several reasons: reasons: several for of health aid, rather than as a share of social sector aid, aid to HIV as a share 7 shows Figure 2000 40 Source: OECD-DAC, with authors’ calculations. OECD-DAC, Source: Health aid is classified as a separate etc. supports of orphans, – it HIV is not health-focused some aid for care in its as HIV funding is a significant stream Reporting Creditor System (CRS) database, in the OECD’s stream other health funding indicates the scale of spending on HIV and the Separating HIV funding out from right. own in social sector aid. significance of this area Inequalities in access to treatment and in risk of Inequalities in access to treatment disproportionately are women Young remain. infection and particularly people, Poorer to be infected. likely At present, only one-third of countries are investing investing are countries of one-third only At present, income with their commensurate at levels in HIV burden of the epidemic share and their levels HIV budget and crisis-related 2010a), (UNAIDS, and diagnosis, testing affected already cuts have and monitoring resistance programmes, treatment World and UNAIDS 2009; (UNAIDS, prevention a funding UNAIDS (2010a) estimates 2009). Bank, needs investment of $10 billion in 2009 between gap of is evidence and there availability, and resource flat-lining and aid contributions spending government High HIV prevalence falling. to fight HIV/AIDS be Africa may countries in southern middle-income funds on the as donors refocus particularly affected 2010). et al., (Jones countries poorest B ox 4: Aid to HIV/AIDS – countries that have been effective in reducing HIV rates among children are high-aid recipients

It is helpful to divide sub-Saharan Africa into great deal of variation around these averages. See three groups: southern Africa (Botswana, Lesotho, Appendix 2 for full details and Figures A2.4 and A2.5. Mozambique, Namibia, South Africa and Swaziland), Our analysis, excluding the southern African group where HIV infection rates have soared over the of countries, shows that, since 2002, the average past decade and have only recently started to country receiving $10 of additional annual aid per stabilise; high-aid recipients (Kenya, Malawi, Rwanda, capita, roughly the difference between a high-aid Tanzania, Uganda, Zambia and ); and and a low-aid country in the data, has reduced the remainder. Figure 8 tells the story: southern childhood infection rates by 0.2 children per Africa has seen infection rates rocket, the high-

progress in child well-being progress 1,000 of population. So, between 2002 and 2009, aid countries started with initially high levels of high-aid countries reduced HIV infection by an infection but have since made good progress, and additional 1.4 children per 1,000 total population. the remaining, low-aid countries have low infection This is a big number in this context: in 2009 the rates which have also recently started to fall. (unweighted) average rate of infection in the Our case study country, Botswana, is a major aid group of southern African countries was 9 children recipient and the only Southern African country to per 1,000 population; in the rest of sub-Saharan have seen infection rates fall since 2002. Africa, it was 2.5 children per 1,000, and it was 6.5 These are descriptive statistics, not an attempt to in the cluster of high-aid countries. determine a causal relationship, and there is a

Figure 8: Relationship between aid and rates of HIV among children in sub-Saharan Africa, 1995–2010 (population-weighted means per 1,000 population)

8

6

4

2

Southern group High aid group 0 1995 2000 2005 2010 Low aid group

Source UNAIDS and WHO data, authors’ calculations.

28 3 Progress on key child-sensitive sectors 29

45 aid (Figure C). It is not clear what proportion of this It is not clear what proportion C). (Figure that this rising It is likely was allocated to HIV/AIDS. the substantial increase reflects health expenditure from activities in Botswana in aid to HIV-related was a decline in there However, E). 2002 (see Figure HIV on PMTCT activities and on overall expenditure D). 2005 and 2008 (Figure activities between Financing for HIV programmes of and role the over has risen sharply Public health expenditure 2.2% of GDP in 1995 to 8.2% in from past 15 years, expenditure, of total government and as a share 2009, 5–6% in 1995–99 to 16–18% in 2004–09 from over 95% by 2009 (UNAIDS, 2010a). Botswana is Botswana 2010a). (UNAIDS, 2009 95% by over moving Therapy towards Antiretroviral Active Highly women, pregnant all HIV-exposed for (HAART) 2010a). (UNAIDS, 2015 by 90% coverage aiming for This should lead to a further fall in infections testing of infants via In 2005, among infants. Dried Blood Spot technology was introduced, ARVs prophylactic eliminating the need to supply babies. to HIV-negative of HIV-infected of children the proportion As a result, 20.7% in declined from infected mothers who are now 2010) and appears 2003 to 4.8% in 2007 (Baleta, 10,000 An estimated B). off (see Figure to be levelling of (Government been averted have child infections 2010). and UNAIDS, Botswana

42 44 The programme is implemented by a is implemented by The programme 43

41

tudy 3 Study ase

More information on this programme could not be found. But more information on HTC and Community Based on HTC and Community information But more could not be found. on this programme information More XPD.PUBL.ZS/countries/ http://data.worldbank.org/indicator/SH. Indicators, Development World Bank, World www.genderhealth.org/the_issues/women_girls_and_hiv/botswana_stigma/ (accessed 6 September 2011]. www.genderhealth.org/the_issues/women_girls_and_hiv/botswana_stigma/ World Bank World Development Indicators, http://data.worldbank.org/indicator/SP.DYN.LE00.IN/countries/ Indicators, Development World Bank World for of nutrition source is the preferred guidelines which indicate that breastfeeding issued new WHO has recently combination of government and NGO provision; the NGO provision; and combination of government community- of NGOs has led to a more involvement of peer including a programme oriented approach, mothers. support to HIV-positive 44 45 43 http://www.naca.gov.bw/node/26 here: interventions is available Healthcare (accessed 5 September 2011). BW?display=graph 41 42 BW?display=graph (accessed 4 September 2001). BW?display=graph water for either because of limited access to safe option, this is the safest where mothers, infants of HIV-positive (http://www.who. eliminate the risk of transmission. regimens ARV effective or because highly preparation, formula accessed 14 February 2012. int/mediacentre/news/releases/2009/world_aids_20091130/en/index.html), In 2007, 60% of infants born to HIV-exposed mothers 60% of infants born to HIV-exposed In 2007, risen to had This figure ARVs. prophylactic received Between 2002 and 2010, the proportion of pregnant of pregnant the proportion 2002 and 2010, Between 27% to 95% from rose ARVs who received women The programme A). 2010a) (see Figure (UNAIDS, and as women, engaged men as well has successfully in role active a more encouraged fathers to play child health. Starting in 1999, and operating throughout the throughout and operating Starting in 1999, HIV free provides the PMTCT programme country, pregnant medication to HIV-positive ARV testing and Africa the first country making Botswana in women, women among pregnant of testing Uptake to do so. 49% in 2002 to 91% in 2009 (Government from rose who choose Those 2010). and UNAIDS, of Botswana transmission to prevent in order not to breastfeed With one of the highest levels of HIV highest levels With one of the life saw Botswana in the world, prevalence in 1991 to 64 years from expectancy drop and rise again to 55 years in 2002, 49 years in 2009. in Botswana of HIV/AIDS reventing mother-to-child transmission mother-to-child Preventing C are provided with a year’s free supply of infant formula of infant formula supply free with a year’s provided are is because using formula However, 2010). milk (Baleta, mothers who HIV-positive many associated with HIV, about transmission prefer lack adequate information to breastfeed. paragraph split here to shorten standfirst: OK? to shorten split here standfirst: paragraph 30 progress in child well-being Source: World Development Indicators,http://data.worldbank.org/indicator/SH.HIV.0014/countries/BW?display=graph. Source: factsheet, UNAIDSBotswana country www.UNAIDS.org/en/dataanalysis/tools/aidsinfo/countryfactsheets/. has beenby farthemostsignificantsource of UNAIDS, 2010). Bilateralaidfrom theUSgovernment domestic funds(Government ofBotswana and response hasprincipally (66%)beenfinanced by given itsmiddle-income status, Botswana’s HIV/AIDS Unlike many otherhighHIV-prevalence countries, 10,000 12,000 14,000 16,000 18,000 Figure B: Children Figure A: HIV-positive 2,000 4,000 6,000 8,000 HIV positive pregnant women receiving antiretrovirals 10,000 15,000 5,000 0 New childinfections HIV positive pregnant women receiving antiretrovirals 1990 0 1990 1995

1991

1992

1993 aged 0–14living women receiving ARVs 1994

1995

1996

1997 with HIVinBotswana, 1990–2009

1998

1999 2000 and newchildinfections, 1990–2009 HIV programme, includingPMTCT. $15m from thenational theGlobalFundtosupport received $556.8mfrom theUKgovernment andover (see Figure F). Over theperiod2004–11, Botswana international fundingtotackleHIVinBotswana 2000

2001

2002

2003

2004 2005

2005

2006

2007

2008 0 2,000 4,000 6,000

2009 New child infections child New 3 Progress on key child-sensitive sectors 31 Total PMTCT spending Total per Spending on treatment living with HIV woman pregnant

US$ per person 1,000 500 0 means that the bulk of transmission is through the means that the bulk of transmission is through mothers who do not small minority of HIV-infected is women Reaching these ARVs. access to have yet is also there However, challenges. one of the key of the PMTCT that the success some evidence infants and few means that the relatively programme in a way stigmatised with HIV are children young among levels that was not the case when prevalence 2007 2008 2005 2006

0 5

10 PMTCT spending PMTCT 2001 2003 2005 2007 2009 1995 1997 1999

0 1 2 3 4 5 6 7 8 9 , 2005–08 ($ million) , Trends in spending on PMTCT in Botswana Figure D: , 1990–2009 (% of GDP) (% 1990–2009 , otswana in B expenditure health Public C: Figure 10 Preventing infection among women of among women infection Preventing unintended and preventing age reproductive critical are women among HIV-positive pregnancies as is extending antenatal care challenges, ongoing poorest to the (and thus the PMTCT programme) now The success of the PMTCT programme women. Challenges Source: UNAIDS Botswana country fact sheet, www.UNAIDS.org/en/dataanalysis/tools/aidsinfo/countryfactsheets/. country UNAIDS Botswana fact sheet, Source: XPD.PUBL.ZS/countries/BW?display=graph. http://data.worldbank.org/indicator/SH. Indicators, Development World Source: Figure E: Trends in aid to HIV/AIDS in Botswana, 2001–08 (constant $ million)

200

150

100 progress in child well-being progress

50

0 2002 2003 2004 2005 2006 2007 2008

Source: OECD-DAC data, authors’ calculations.

children were higher and children living with HIV were much more common. Widespread knowledge Figure F: International funding of the PMTCT programme has meant that such to HIV/AIDS in Botswana by donor, children are suspected not to have acquired HIV 2000–08 (%) from their mothers but rather through witchcraft or sexual violence.52 Other, perhaps bigger problems are the impact on breastfeeding for both HIV-exposed mothers and the wider population as infant formula has become the norm; and providing support to children growing into adolescence who have grown up HIV-positive, having been infected through MTCT but supported on ARVs. Resourcing: As an upper-middle-income country, Botswana is becoming a lower priority for donors than poorer HIV-affected countries and, for example, has not received further rounds of funding from the Global Fund. One consequence of this shift in United States 85.6% donor priorities is a reduction in funds available for (USD$ 536,842,783) civil society organisations, which could undermine IBRD 8.0% (USD$ 50,000,000) outreach to the most disadvantaged. This projected Global Fund 3.0% (USD$ 18,580,414) decline is occurring at a time when economic growth UNFPA 1.2% (USD$ 7,357,114.19) has not picked up from the effects of the global crisis, UNAIDS 0.8% (USD$ 4,881,470.31)

implying that national and international partners’ Sweden 0.8% (USD$ 4,828,785.54) resources for PMTCT, as for other HIV programmes, Others 0.7% (USD$ 4,668,405.02) could be reduced. Source: OECD-DAC data, authors’ calculations.

52 http://publichealth.brown.edu/ihi/download/proposals/BloodofInnocents_HIV_Botswana.pdf (accessed 6 September 2011).

32 3 Progress on key child-sensitive sectors 33 rising from rising from 54 an additional in trends sanitation population had world’s 87% of the Some x 5: 1.3 billion people worldwide have gained gained have worldwide 1.3 billion people sanitation, access to improved access to improved water, compared with compared water, improved access to billion people. – an extra 1.8 77% in 1990 60% of Only regions. Africa than in other population has access Africa’s sub-Saharan 49% in up from water sources, to improved (a 20 percentage progress greatest The 1990. Asia. been in east has point increase) 54% of the world’s population with access 54% of the world’s in 1990 to 61% in 2009. • in sub-Saharan been slower has Progress • the past 20 years, Over • In 2009, Bo and water Source: compiled from WHO/UNICEF (2010). WHO/UNICEF compiled from Source: Between rural and urban areas: Though the ratio rural and urban areas: Between times was still five there since 1990, has improved using an unimproved people in rural areas more However, in 2010 than in urban areas. water source is outstripping the in urban areas population growth sanitation provision in improved rate of progress people gained access to a billion over Well (ibid.). 1990 and 2010 but between water sources improved in the urban population growth due to the massive 2.3 billion the same time period – rising from over people worldwide, or 37% of the world’s population, population, or 37% of the world’s people worldwide, 72% of sanitation, access to improved do not have if Even 2010b). Asia (ODI, them in south and east 2.4 billion people meets the MDG target, the world or if sanitation in 2015; will be without improved in mostly 2.7 billion people, continue, trends current will lack Africa, Asia and sub-Saharan east Asia, south 2012). sanitation (WHO and UNICEF, improved urban-rural needed to reduce effortsContinued are with poverty; disparities and inequities associated in countries in coverage increase to dramatically global to promote Africa and Oceania; sub-Saharan to bring monitoring of drinking water quality; the MDG and to look beyond ‘on track’; sanitation coverage. universal target towards disparities in provision: Addressing 53 sanitation , ater W Because of greater information availability (related to there being MDGs for water and sanitation), this section water and sanitation), being MDGs for to there (related availability information Because of greater a pit latrine with slab or a composting pit latrine, ventilated improved a This is defined as a flush or pour toilet, 53 54 focuses principally on access to water and sanitation. sanitation. on access to water and principally focuses 2010). toilet (WHO and UNICEF, Large numbers of people remain without of people remain numbers Large water and sanitation access to improved 38% of A total of 780 million people worldwide, lack access to Africa, in sub-Saharan whom are a Of these, of drinking water. sources improved will still be total of 605 million people worldwide A total of 2.5 billion water in. without improved Ongoing challenges Ongoing While some countries have made considerable While some countries have Burkina Faso in in particular (eg, areas progress 2011b)), water (ODI, extending access to improved sanitation water, for slower has been progress overall of development. other areas than for and hygiene prioritisation political profile, lower reflect This may both by commitments to this area, and resource our case studies Unlike and donors. governments childhood education and early HIV, of education, minister or prime the president where malnutrition, of the country has had a particular concerned water, in one of these areas, commitment to progress ‘orphan’ area. of an is more sanitation and hygiene There has been mixed progress in increasing access in increasing progress has been mixed There The latest stocktaking of to water and sanitation. 2012) indicates that the (WHO and UNICEF, progress halving the which calls for MDG drinking water target, drinking to safe population without sustainable access was met in 2010, 1990 and 2015, water between world is the However, years ahead of schedule. five the population to meet the target of halving unlikely 5 Box without access to basic sanitation target. 10 indicate regional 9 and and Figures outlines trends sanitation and water. in access to improved progress in water and sanitation What progress has been achieved? Globally, lack of sanitation, insufficient water insufficient water of sanitation, lack Globally, contribute to an hygiene poor personal and supply 90% of them year, every 2.2 million deaths estimated 2005; Evans, 2010; (Danida, under five among children – which is caused Diarrhoea 2010b). both in ODI, – is still hygiene sanitation and poor water, by mainly child single cause of under-five the second-largest five under children killing more mortality worldwide, malaria and measles combined. AIDS, than hygiene AND 3.4 34 progress in child well-being Source: WHO and UNICEF (2010). Source: WHO andUNICEF(2010). (% ofpopulation)

Figure 10: A (% ofpopulation) Figure 9: Sanitation coverage isimproving in Southern Southern 1990 1990 15 34 27 24 24 67 6 3 Asia Asia Piped onpremises Improved 2010 1990 2010 1990 16 45 26 10 13 41 41 3 Saharan Saharan 34 26 29 11 26 14 24 36 Africa Africa Sub- Sub- ccess 2010 1990 2010 1990 30 15 24 31 30 19 25 26 Shared eastern eastern to piped 20 52 46 24 17 31 South- South- 4 6 Asia Asia 2010 1990 2010 1990 25 65 10 69 15 1 9 6 Other improved Oceania Oceania 16 55 13 32 22 55 7 water suppliedonpremises Unimproved 2010 1990 2010 1990 13 32 55 30 58 9 3 Caribbean Caribbean America America and the and the 18 32 68 56 3 9 5 9 Latin Latin 2010 1990 2010 1990 53 34 80 4 6 9 7 7 Northern Northern Northern Northern Unimproved 35 72 33 25 18 Africa Africa 7 5 5 Open defecation 2010 1990 2010 1990 70 90 21 1 0 6 4 8 almost every developingregion Western Western 29 11 80 58 10 8 2 2 Asia Asia 2010 1990 2010 1990 83 85 9 6 3 5 7 2 varies Surface water Eastern Eastern 72 13 27 59 14 1 7 7 Asia Asia 2010 1990 2010 1990 84 66 19 14 2 1 5 9 widely Caucasus Caucasus Central Central 73 91 12 7 2 8 7 Asia Asia and and 2010 2010 86 96 8 5 3 1 1 among regions Developing Developing 1990 1990 regions regions 32 36 38 22 25 32 7 8 2010 1990 2010 1990 11 56 46 40 19 13 12 3 45 31 18 25 49 20 World World 6 6 2010 2010 15 54 35 63 11 11 8 3 3 Progress on key child-sensitive sectors 35 Data 55 67 43 Progress is Progress 56 64 43 59 38 2008 2009 2010

0 80 60 40 20 % of schools with adequate sanitation facilities, average (data average % of schools with adequate sanitation facilities, countries and 37 priority countries) 100 programme from Mobilising financing for water and sanitation for Mobilising financing the sanitation and sectors, to other Relative decreased aid of development drinking-water share despite its the period 1998–2008, over markedly In almost all of the MDGs. to achieving relevance now aid; 8% of development it accounted for 1997, As 2010). Water, it comprises 5% (WHO and UN is sanitation and hygiene water, 12 illustrates, Figure donors in terms of the for a moderate priority area funds it receives. aid to sanitation and drinking water In 2008, $7.4 billion (as reported to OECD amounted to over of grants was in the form $3.9 billion Of this, CRS). The total aid and $3.5 billion in concessional loans. slow, however, particularly in the poorest and least particularly in the poorest however, slow, than rapid although more countries, developed engagement than in those in those with UNICEF 11). without (see Figure from countries where UNICEF is active show a a show is active UNICEF countries where from past 10 years. the over trend positive with hygiene education, it can help to build hygienic hygienic help to build it can education, hygiene with lack of and generation; the next among practices school impediment to is also a major school toilets girls. adolescent particularly for attendance, 100 , 2008–10 (%) , coverage and sanitation 70 51 water 65 47 63 46 2008 2009 2010 All UNICEF programme countries All UNICEF programme priority countries WASH UNICEF

0 20 40 60 80 11: Trends in school Figure 11: % of schools with adequate water facilities, average (data average % of schools with adequate water facilities, countries and 41 priority countries) 110 programme from 100 Comparable data for countries where UNICEF had no presence were not available. were UNICEF had no presence countries where Comparable data for Overall data on improvements in school sanitation could not be found. data on improvements Overall 56 55 Source: UNICEF (2010b). Source: Improving school sanitation is a strategically is a strategically school sanitation Improving the It reduces investment. important for area at school and being spread of infections likelihood illnesses falling sick with water-borne of children together the Philippines); (see Case Study 4 from Improving school sanitation Improving In many and poor households: In many rich Between sanitation inequalities in access to water, countries, In India, since 1990. sharpened have and hygiene gained access to 166 million people example, for but very 2008, 1995 and sanitation between improved households in the poorest was made little progress Africa as a whole, In sub-Saharan 2010b). (UNICEF, to likely is 16 times more quintile the poorest richest quintile, than the practise open defecation sanitation and to use improved 5 times less likely water source to use an improved half as likely 2010). (WHO and UNICEF, to 3.5 billion people – the number of urban dwellers dwellers of urban the number – billion people to 3.5 109 from increased, actually sources unimproved using the in rural areas, By contrast, 130 million. million to decreased sources of people using unimproved number of more during a time 653 million, 1.1 billion to from 2012). (WHO and UNICEF, growth. modest population 36 progress in child well-being Source: OECD(2010a), inhttp://whqlibdoc.who.int/publications/2010/9789241599351_eng_Part1a.pdf. 0.04% and2.8%ofGDPondrinkingwater Of these37countries, governments spentbetween fundinggap inthesector.important MDG (WHOandUN Water, 2010). This indicatesan of thefundingrequired tomeetthedrinkingwater the MDGonsanitation, andonly 5outof37had75% that they had75%ofthefinancingneededtomeet of 37countries(Kenya andSouth Africa) indicated the waterandsanitationMDGsfound thatonly 2out A UNsurvey ofcountries’ financingneedstomeet increased (WHOandUN Water, 2010). concessional loanstomiddle-income countries to 16%over theperiod2003to2008, whilenon- decreased fromand drinkingwaterservices 27% only 42%ofthetotalaid, andaidtobasicsanitation not well targeted. Low-income countriesreceive Aid todrinkingwaterandsanitationisgenerally available amountedto$5.3billionin2008. DAC membersandmultilaterals for whichdatawere disbursements for sanitationanddrinkingwaterby 57 Noassessmentsof theadequacyofthisspendinginrelation toneedcould befound. to Figure 12: Sanitation Trade policies, regulations, tourism Industry, mining andconstruction Agriculture, forestryandfishing HIV/AIDS, reproductive health all other ODAcommitments, 2008($billion) Banking andfinancialservices Administrative costofdonors Government andcivilsociety Other community assistance Other socialinfrastructure General budget support Actions relating todebt Transport andstorage Water andsanitation Other non-allocable Humanitarian aid Communications Business services NGO support Multisectoral Education Refugees Food aid Energy Health and drinking-water

0 2 4 6 aid commitmentsinrelation water andsanitationcombined. a medianexpenditure of0.48%GDPondrinking between 0.01%and0.46%ofGDPonsanitation, with (WHO andUN Water, 2010). to waterandsanitationover theperiodupto2015 commitment toincreasing fundstoimprove access countries (UNICEF, 2010b). Eleven donorsreporta that thefocus isonmarginalisedpopulationswithin meeting theMDGwaterandsanitationtargets targeted towards countriesthatarefrom farthest water andsanitationare increased, thatthey are encourages memberstoensure thatresources for for –formallyAll partnership launchedin2010– and UN Water, 2010). The Sanitationand Water expenditure onsanitationto0.5%ofGDP(WHO governments, commitssignatoriestoincreasing The Thekwini Declaration, signedby 30 African substantially extendwaterandsanitationcoverage. There isgrowing momentumbehindadrive to sources (WHOandUN Water, 2010). include aidmoniesaswell asfundsfrom domestic 8 10 12 14 161820 57 These figures These 3 Progress on key child-sensitive sectors 37 Approach School The Fit for is an innovative Approach School (FIT) The Fit for in integrated school health concept implemented public elementary schools in the Philippines under Essential Healthcare the Department of Education’s It combines evidence-based (EHCP). Programme interventions some of the most prevalent against infections, worm diseases among schoolchildren: such as diarrhoea, infections hygiene-related tooth decay. respiratory and rampant infections includes hand-washing with soap The programme as and tooth-brushing with fluoride toothpaste organized by children activities for group daily twice-yearly and is complemented by teachers, These activities teachers. also done by de-worming, in water conducted in parallel with improvements are and the community parents where and sanitation, in the construction of washing involved actively are of clean water to schools facilities or the provision determinants of thus tackling key without access, targets more currently The programme health. Material costs than 2 million Filipino children. toothpaste and soap, for of $0.50/child/year very affordable: the programme toothbrushes make budgets of local it can be integrated in the regular sustainability thus ensuring units, government donations or corporate external funding, beyond Fit for the NGO In the Philippines, sponsorship. supported major international by School Inc., Agency Australian the agencies (GIZ, development [AusAID] and International Development for technical development, capacity UNICEF) provides monitoring and evaluation, support to management, with all concerned partners. and advocacy such as the international awards Recognition through Health (2009) from in Global Innovation for Award Programme the UN Development Bank, World the

tudy 4 Study ase

The challenge to school policies related countries have While many the complexities of implementing large-scale health, to a often lead school-based health programmes Difficulties in intention and practice. between gap collaboration to inter-sectoral barriers overcoming sanitation and education, health, between and lack in vertical thinking, administrations trapped an all-too- for among the reasons of leadership are Basic school health. potential for often untapped health education is a topic on most national model and reduce but efforts often stop there curricula, transfer, schools to places of educational knowledge tangible and sustained ignoring the huge potential for approach. a skills-based change through behaviour education facilities not only schools are Furthermore, They life. of community but also centres children, for in changing the leadership role a pivotal can play by communities living conditions of the surrounding some basic health issues. addressing

School health programmes as a platform to as a platform School health programmes high-impact health interventions are deliver decision-makers by underrated currently the from and do not get adequate attention The international public health community. in Approach School Fit for award-winning a large-scale, the Philippines is an example of evidence-based and cost-effective integrated, between the gap that bridges programme and practice. evidence sectors and between is Action Framework School The Fit for that helps approach and tested a realistic places of public health schools to make the wider communities and children for them. surrounding programme child well-being to promote a simple, scalable and sustainable school health school sustainable and scalable a simple, hilippines – a model for for a model – Philippines in the School Fit for C 38 progress in child well-being after one Results of the years tocome. and itisexpectedthatthesetrends willcontinue in results afterarelatively timeofimplementation, short reduced by almost40%. These are promising very incidence inoralinfections duetotoothdecay had mass indexbelow normalhadreduced by 20%and worm infection hadhalved, prevalence ofabody by almost30%, thenumber ofchildren withheavy number ofdays ofabsencefrom schoolhadreduced health andeducationimpactsare significant. The implementation quality. The one-year results ofthe monitoring andevaluation process lookinginto longitudinal healthoutcomestudyandaparticipatory Programme impactsare assessedthrough a Programme impacts Education OrganizationandGIZ. withtheSouth-East partnership Asian Ministersof countries now implementingtheFIT Approach, in Asia, resulting inthree otherSouth-East Asian increased interest from othercountriesthroughout in general. These factorshave allcontributedto ofschoolhealth character ofFITandtheimportance linking research andpractice, highlightthemodel Equity andGrowth Network Award for effectively (UNDP) and WHO, andthePoverty Reduction, Days ofabsencein2009 Indicator Reduction inoralinfection worm infection Prevalence ofchildren withheavy body massindex(thin) Prevalence ofchildren below normal year ofimplementation: the EHCPintervention and control group Intervention Intervention 0.08 ±0.33 3.2 ±3.9 n =544 10.4% 19.7% 28.1% 35.3% 2. 1. school healthprogramme. are key characteristicsofany successfullarge-scale the three Ss: simple, scalableandsustainable. These FIT Approach. At thecore oftheFramework are Framework, whichisthebasisofoperationfor the context for theinnovative Fitfor School Action Friendly Schoolsframework provide theconceptual Promoting SchoolconceptandtheUNICEFChild Cultural Organization(UNESCO), the WHO Health School HealthoftheUNEducational, Scientificand theFocusingparticularly Resources onEffective International policyframeworks for schoolhealth, A The FitforSchool ction Framework teachers, ratherthanhealthprofessionals. on afew implementedby simpleinterventions ofscalability,is anessentialpart suchasrelying templates. Usingexistingstructures andresources a modularstructure andare basedonuniform followimplementation ispossibleifinterventions Scalable: The FIT Approach shows thatlarge-scale implementation aseasypossible. areand theinterventions packagedtomake impact ifonly afew key diseasesare infocus cost-effective andare more likely toachieve high be basedonbestpossibleevidence, shouldbe Simple: inschoolhealthmust Interventions 0.13 ±0.40 4. 4±4.8 Control n =173 Difference – – – – 38.5% 47.2% 20.4% 27.3% 3 Progress on key child-sensitive sectors 39 Using the existing close collaboration between Fit between existing close collaboration Using the is intended to it a basis, and UNICEF as School for approach the scalable and cost-effective combine and sanitation water, UNICEF current of FIT with a uniform to develop in order concepts hygiene schools worldwide. package for basic hygiene agreed infrastructure the essential The package will address as terms of water access as well needs of schools in Furthermore, facilities. washing and sanitation group activities, skills-based daily the package will promote and tooth-brushing, hand-washing such as group by Complemented social norms. healthy to create and appropriate, required where de-worming regular determinants of child key the package will tackle health and well-being. in a community embedded health, school Effective the education sector and by driven context, supported and sanitation sectors, the health by schools makes areas, many benefits across produces health greater healthier places and contributes to Preventing cost. low equity – all at exceptionally life healthy age and promoting diseases at an early Healthy huge long-term returns. skills promises better at perform self-esteem, better have children higher better and stand and develop grow school, Effective their full potential. chances of reaching better child contributor to school health can be a key 2012). in the widest sense (Benzian et al., well-being Outlook Sustainable: Any programme will be successful in in be successful will programme Any Sustainable: is not donor-dependent. if it run only the long of on the principle is based Approach The FIT start- after an initial funding government sustained and communities involves It also actively up phase. a participatory through in the programme parents the or through process monitoring and evaluation washing facilities. group construction of required that addresses A supporting framework policy is issues alike and micro-management macro- and Effective sustainability. crucial in ensuring and monitoring complement research appropriate as management as well programme and inform political decision-makers. 3. 3. principles helps to A set of simple enabling well-intended between bridge the gap pragmatically clear These are: implementation. policy and real-life on the vision and stakeholders between agreements inter-sectoral formalised values of the programme; levels at the different collaboration and advocacy and addressing of the health and education system; regional at local, range of stakeholders the broad helps the approach In this way, and national levels. school health to demonstrate that effective sectors of the overall contributes to different agenda. development 40 progress in child well-being 59 58 basic cognitive skills. emotional development, languagedevelopment and and nutrition) andmotordevelopment, socialand programmes canenhancephysical well-being (health Good-quality early childhooddevelopment (ECD) development 3.5 ratio to155:1, from analready high103:1 (UNESCO, 2008). each oftheseareas. particularly forparticularly nutrition-based inputs. and monitoringthrough thepublichealthsystem, nurseries; homevisitsand/orparenting classes; education andcare, orday suchaskindergartens on theotherhand, typically involve centre-based rather thanbeingdevelopmental. ECDprogrammes, children whileparents are working (Penn, 2004) custodial; thatis, itprovides asafe placefor young countries –isnotofgood qualityandisprincipally provision –inbothdeveloped anddeveloping However, tostress itisimportant thatmuch ECD provided thesechildren canbeguaranteedaccess. educational andlateremployment inequalities, counterparts, they have thepotentialtohelpreduce in key areas of development thantheirwealthier children, whoare typically more likely tobelagging Given thatECDprogrammes helpdisadvantaged development isbeingformed (UNICEF, 2006). and thebasisfor theircognitive, socialandemotional when children’s brainsare developing mostrapidly in schoolingarisestheearliestyears oflife. This is help disadvantagedchildren have amore equalstart later life (World Bank, 2010). to The opportunity were significantly lesslikely tocommitcrimesin attended preschool orreceived home-basedsupport Brazil shows thatlow-income urbanchildren who 2001, inUNESCO, 2007). Evidence from theUSand had nottaken intheproject part (Kagitcibasietal., and hadhigheroccupationalstatusthanchildren who working later, were more likely toattenduniversity (by adifference of19percentage points), began significantly more likely school tocompleteprimary Project inlow-income suburbsofIstanbulwere that childrenby theEarly supported Enrichment example, longitudinalevidence from indicates 2007). These benefitscanbelong-lasting. For reduces schooldrop-out andrepetition (UNESCO, school, schoolcompletion, andprimary andthatit timely enrolment ratesinthefirstgradeofprimary that preschool experienceincreases schoolreadiness, The policyonfree inGhanaianpublicschools wasaccompaniedby a riseinthepupil–trainedteacher kindergarten Nadeauetal. (2010) summarise theevidence onthecontributionofECDprogrammes tochildren’s well-being in Early childhood 58 There isalsostrong evidence (UNESCO, 2008). in recent years, withanaverage of22:1 in2005 education pupil–teacher ratiosinpre-primary Worldwide, there hasbeenanimprovement in torise(UNESCO,started 2011). in theaftermathoftransitionbuthave subsequently enrolment ratiosdeclined between 1999and2004 incentral particularly Asia andtheCaucasus, gross of preschool educationuniversal. Insomecountries, in enrolment reflect atrend towards makingone year In middle-income Latin American countries, increases are below 5%(ibid.). Chad, MaliandNiger, enrolment pre-primary rates 2011). Inthepoorest countries, suchasBurundi, significantly tobetween 40%and50%(UNESCO, and São Tomé andPríncipe, enrolments have risen income African countriessuchasSouth Africa (ibid.; Garcia etal., 2008). Similarly, inothermiddle- the schoolsreceived agrantfor every childenrolled educationinpublicschools,kindergarten whereby 2005 following theintroduction oftwo years offree enrolment jumpedfromprimary 40%to55%in There are exceptions, suchasGhana, where pre- low –14%and17%respectively (UNESCO, 2008). the Middle EastandNorth Africa remains extremely for educationinsub-Saharan pre-primary Africa and point. lowa very starting The gross enrolment rate In much oftheworld, these increases have beenfrom Latin America andtheCaribbean(UNESCO, 2008). west Asia, sub-Saharan Africa and, toalesserextent, The increase isduemostly togainsinsouthand 25.6 million, between 1999and2008, to148million. schools worldwide increased by nearly 21%, or The number ofchildren enrolled inpre-primary such askindergartens, andsowe focus onthisarea. attendance atpreschool educationalinstitutions, Most dataavailable concernyoung children’s How hasprogress inECDbeenachieved? Ethiopia (seeSection3.6). the generalexpansionofeducationsystem, asin in provision teachers, ofpre-primary of oftenaspart 59 This reflects increasing investment 3 Progress on key child-sensitive sectors 41 Significant rich–poor differentials differentials rich–poor Significant to less likely much are children poorer Overall, programmes education part in preschool take example, For counterparts. better-off than their the highest pre-primary which has in Ghana, wealthiest the Africa, in sub-Saharan levels enrolment as to be enrolled times as likely four are children However, 2011). (UNESCO, children the poorest (UNESCO, not universal are these inequalities publicly provide countries principally Some 2007). – children to poorer subsidised ECD programmes Child Development Integrated India’s example, for families wealthier from children System – whereas are as Chile, such Others, attend private preschools. efforts in provision making significant to close gaps socio-economic groups different among and uptake ECD programmes NGO Many (see Case Study 5). Data on disadvantaged children. for also cater mainly are in NGO provision servednumbers or on trends not available. some striking are although there In most countries, is relatively in enrolment the gender gap exceptions, and which gender is favoured at less than 10%, low, In the pre-primary gross 2007). varies (UNESCO, by ratio gender parity index recorded enrolment Arab in the ratio was found the lowest UNESCO, to males (thus discriminating at 0.92 females States, very 0.99, Africa showed sub-Saharan against girls), and the highest America at 1, Latin close to equal, Asia and in east found girls are rates favouring Asia at 1.02 and central the Caribbean at 1.01, 2011). (UNESCO, Quality quality is necessary so ECD programmes Improved contribution to improving a greater can make and later educational well-being health, children’s such as measures This can involve prospects. children’s increasing teacher–pupil ratios; reducing educational opportunities to use age-appropriate activities in play-based including more resources; teacher engagement with increasing some contexts; and less educative (so ECD becomes more children and integration of health and nutrition custodial); aspects into ECD programmes. and 60

61 Donor spending on pre-primary education in Ghana rose from 0.7% of total education allocations in 2004 to 5% from Donor spending on pre-primary education in Ghana rose NGO and private, by Africa in 2004 was accounted for in sub-Saharan A total of 64% of pre-primary enrolment the volume of aid has increased in recent years after years in recent has increased of aid the volume 13). partfalling in the early (see Figure of the decade in enrolment of the growth A significant proportion private by been driven have may that has occurred this could not be but investments, sector and NGO available data. the from verified Some countries, such as Ghana, Mauritius and Mauritius such as Ghana, Some countries, – and then implemented – developed have Namibia, This has been part ECD. for plans sector development financing that has increased of an integrated process for goals of meeting agreed with the objective levels will and technical Political 2008). et al., ECD (Boakye and implement these plans forward to drive capacity been crucial. have Significant rural–urban differentials Significant rural–urban differentials in enrolment in most points 10 and 30 percentage At between to less likely much with rural children countries, the reflect these differentials 2007), attend (UNESCO, provision lack of both public and private preschool This countries. (particularly lower-income) in many marginalised in more children means that many A few little or no access to preschool. contexts have Colombia such as Chile (see Case Study 5), countries, 2010) have (Tinajero, 2009) and (Vargas-Baron, special serviceseither universalised or developed in remote ECD programmes to provide initiatives rural areas. Ongoing challenges Ongoing of access to levels overall Increasing in ECD programmes and enrolment particularly in the poorest This is a major challenge, 5% of the population has less than where countries, pre-primary education. any Data on trends in government expenditure in ECD expenditure in government trends Data on however, available; not consistently are provision challenges in financing on below as the discussion extremely are levels expenditure overall indicates, in extending an important role has played Aid low. as Ghana, such in some countries, provision How have these reductions been financed? been reductions these have How in 2006 (Akwetey, 2007). 2007). in 2006 (Akwetey, 2008). et al., (Garcia provision religious 60 61 42 progress in child well-being 2000 64 63 62 Source: OECD-DAC data, authors’calculations. Colombia (UNESCO, 2007). 0.5% intheformer Soviet Unionand0.2%in 1% ofGDPonECDprogrammes; for example, even middle-income countriesspentlessthan government spendingonECDislow. In1999–2004, In mostlow- andmiddle-income countries, Financing andaidfor ECD school; inthosewithenrolments ofunder10%, only 69%did. found that, incountrieswithpreschool enrolment ofover 60%, 85%ofchildren completedfive years ofprimary education(aswell asanobjectiveprimary initsown right). JaramilloandMingat (2003; 2006inGarcia etal., 2008) disadvantaged children, there are soundreasons for extendingECDprovision asatoolfor achieving universal or widerhealthprogrammes elsewhere. health andnutrition programmes contextsare thatmightbeclassifiedasECDincertain considered withMNCH 0.04% in Angola [ibid.]). lower (eg, 0.01%inSenegal, 0.03%intheCongo and middle-income countries, expenditure waseven (Naudeau etal., 2010). educational spendingintheperiod1999–2004 preschool educationconstitutedlessthan1%of schooling.primary Inmostofsub-Saharan Africa, data, itconstitutedlessthan10%ofspendingon expenditure; inmostcountriesfor whichthere were education isalsolow asaproportion ofeducational However, given thecontributionECDcan make toincreasing enrolment andcompletion ratesamong These are few amongthe very countriesfor whichsuchdataare available. However, thesefigures vary betweenreflect thefactthatclassifications ofexpenditure countries, andsome Figure 13: 0 1 2 3 4 5 Aid to ECD 63 Expenditure onpreschool as 62 Inlow- andlower- a proportion ofeducation 2005 not apriorityfor financinginpractice. whereas inprinciplebut ECDisseenasimportant education,and increasingtosecondary support education commitments touniversalising primary past few years. This may reflect donoremphasison as Figure 13shows, with asmallincrease over the low. Furthermore, theoverall trend isdownward, considered separately, thisfigure isstillextremely sector. Even iffundsfor healthaspectsofECDare broadly mirror low government allocationstothe to education(UNESCO, 2007). These figures education,to primary onaverage 0.5%ofallaid ECD programmes lessthan10%offundsallocated 1999 and2004, 19outof22donorsallocatedto aid toeducationECD(seeFigure 13). Between smallproportion of Most donorsallocateavery aid , 2000–10(%) 2010 Asia the Caribbean and Latin America Sub-Saharan Africa Global 64

3 Progress on key child-sensitive sectors 43

Global Sub-Saharan Africa Latin America and the Caribbean Asia 65 2010 Figure 14 shows trends in aid to ECD in 2000–10, in 2000–10, to ECD in aid trends 14 shows Figure It regions. developing the main for and globally of aid to the volume years, in recent that, indicates with the region Africa, to sub-Saharan ECD disbursed grown. has levels, enrolment the lowest for ECD could ‘financing gap’ of a No calculations the other unlike be because, This may be found. is no agreed there this report, issues discussed in on The Dakar Framework for ECD. quantified target and “expanding mandates All simply Education for and childhood care early comprehensive improving and the most vulnerable for especially education, disadvantaged children”. 2005 2009 $ million) by region (constant ECD to 0 50 100 150 200 14: Aid Figure 14: www.unesco.org/education/efa/ed_for_all/dakfram_eng.shtml (accessed 1 October 2011). www.unesco.org/education/efa/ed_for_all/dakfram_eng.shtml 2000 65 Source: OECD-DAC data, authors’ calculations. data, OECD-DAC Source: The majority of bilateral aid to ECD supports aid to of bilateral majority The three. over children for programmes centre-based programmes Support home-based programmes, to and interventions delivered under three children for smaller scale while on a sector, the health through to likely is more ECD, to centre-based than that Aid to 2007). agencies (UNESCO, UN come from middle- towards been skewed ECD has typically levels greater reflect this may income countries; and extended ECD when improved of demand for or close to is universal primary school coverage (ibid). universal 44

paragraph splithere standfirst: toshorten OK? progress in child well-being services, for childassessmentsandinterventions focus andtheprovision ofparent education, nutrition ECD provision inChile isnotablefor itsholistic socially vulnerablefamilies(Umayahara, 2006). looking for work, female headsofhouseholdand on adolescentmothers, mothers whowork orare disadvantaged families. There focus isaparticular quintiles) andhomevisitsparentingfor support were(91% offamiliesserved inthelowest income on children from toagefour livinginpoverty birth fill gaps inJUNJI’s provision, focus withaparticular schools.nursery INTEGRAwassetupin1990to (Vargas-Baron, 2009), through seasonalandmobile indigenous familiesandinremote ruralareas to reach thegeographically disadvantaged, suchas During the1980s, there were increasing efforts 15% ofplaces(Peralta, 2011; Umayahara, 2006). and whichisregulated by thestateandprovides profit privateagency which receives publicfunding nurseries andkindergartens, andINTEGRA, anon- of Education–whichrunsandoversees state Council Programme oftheMinistry (JUNJI) –part Schools education inChileare theNationalNursery The two mainagenciesproviding preschool in Chileispublicly funded. provision continues, 83%ofECDprovision investment inECD. While privateandNGO government emphasison puttingparticular democratic governments, withtheBachelet Pinochet dictatorshipandsubsequent in preschool educationunderboththe 1970s. There hasbeensustainedinvestment scale andmostly privatesectoruntilthe education (Peralta, 2011). This wassmall in ofpreschool Chile hasalonghistory in Chile Reducing inequalities–ECDprogrammes C 66 Seewww.crececontigo.gob.cl/sobre-chile-crece-contigo/que-es/. ase Study 5 (Umayahara, 2006). andimprovechild mortality children’s nutrition ECD provision inthe1980shelpedtoreduce (Umayahara, 2006). EvidencesuggeststhatNGO of theirchoice; andprivatefee-paying provision vouchers whichparents canuseatestablishments provision whichissubsidisedby thestatethrough municipal preschool provision; private/voluntary geographically remote households, there isalso focus onpoor,a particular indigenousand In addition totheseprogrammes whichhave needs ofchildren indifferent contexts. comprehensive thedifferent systemtosupport ECD areaswork toensure oncomplementary amore hasthusreflectedof theECDstrategy aneedto young childrenevolution –ChileCrece Contigo. The been folded intoanew umbrella programme for education inremote ruralareas; since2007ithas which provides parent support, nutrition andearly been theKnow Your ChildProgramme (CASH), A third pillarofChile’s ECDprogramme has Chile between 1990and1996(Umayahara, 2006). programme toimprove thequalityofeducationin and INTEGRAfacilitieswere includedinasix-year education;building blockfor primary hence, JUNJI (Vargas-Baron,kindergartens 2009). Itisseenasakey children withdevelopmental delays aswell as four tofive years ofage. Itwasdesignedinexplicit before untilthey entertheschoolsystemat birth tochildren’sand healthsupport development from system andprovides integratedfinancial, educational Chile CreceofChile’s Contigo ispart socialprotection Chile CrcContigo 3 Progress on key child-sensitive sectors 45 Enrolment in ECD centres increased by 240% by increased centres in ECD Enrolment Veramendi, (Urzúa and 2005 and 2007 between age four under children 800,000 while in 2009, 2011), Chile Crece under the programmes from benefited has been Uptake 2010). (ECLAC, umbrella Contigo 63% of four-year-olds children: older by principally in attended ECD centres and 87% of five-year-olds did (Urzúa under-threes 3% of only whereas 2006, the expansion of However, 2011). Veramendi, and children, nursery disadvantaged younger places for opportunities the whole age for and of preschool to change is likely which took place in 2008/09, group, enrolment in a gross to result this situation and with other well which compares 50%, rate of over 2011). (Peralta, countries in the region programmes, the JUNJI and INTEGRA Furthermore, been have quintiles, aimed at the poorest which are in children: younger in reaching effective more much clientele and 97% of INTEGRA’s 98% of JUNJI’s 2004, The main 2006). (Umayahara, years under four were not taking children – for the board – across reason belief that is their parents’ part in ECD programmes 2006). (Umayahara, not old enough are they rates in enrolment net and gross A presents Figure The small childhood education programmes. early emphasis the strong reflect decline since 2006 may as part of government years under two on children policy. quintiles income two in the lowest children In 1990, in the highest children as less than half as likely were By 2006, part in ECD programmes. quintile to take particularly efforts thanks to ongoing to reach had narrowed the gap disadvantaged children, with participation the rates of 33% for considerably, the top quintile (Urzúa quintile and 48% for lowest B). 2011) (see Figure Veramendi, and far to assess how available data were No recent has managed to further Contigo reduce Chile Crece inequalities in uptake. Impacts One of the main objectives of the main objectives One of the 66 All young children are offered free pre-primary free offered are children All young JUNJI, run by the programmes education through offered are their parents INTEGRA and CASH; radio programmes TV and classes. parenting part are of children aimed at engaging young this programme. system in the public health children All young antenatal offered are children) (75% of Chile’s monitoring and and subsequent growth care child health surveillance. 60% most of the aged under two Children day free eligible for vulnerable households are of low- and children 2008), nursery places (UNDP, free eligible for are parents income non-working of adolescent Children part-time nursery places. families or with mothers and in single-parent priority access to these have parents unemployed 1,800 2008 and 2009, Between (ibid.). nurseries built to serve these families. were nurseries new of Chile Solidario Families in receipt cash transfers such nursery eligible for automatically are places and access to social support networks. system is to provide Thus the social protection complementary an optimal services to achieve over children Vulnerable of support (ibid.). level also with disabilities, including children age two, education guaranteed access to preschool have The most vulnerable 40% of 2011). (Peralta, access to a specific grant households also have to support families until their child low-income and to housing improvement old, is 18 years etc training, preparedness work programmes, 2011). (Peralta, recognition of the fact that children’s development development that children’s of the fact recognition initiatives, series of links a and is multidimensional childhood on early services focused programmes and to responds that a support network to develop stages of needs at different developmental children’s their childhood. ’s programme offers differentiated differentiated offers programme ’s Contigo Chile Crece of children: groups support to different 1. 2. 3. programme is to equalise children’s development development equalise children’s is to programme opportunities of socio- erase the effects and to finish children the time by economic inequalities was a presidential Contigo Chile Crece primary school. Michelle Bachelet and continues priority of President president. under the new to be a priority programme 46 progress in child well-being Source: Urzúaand Veramendi (2011). Source: (2009), CASEN inPeralta (2011). 100 (0–6-year-olds),and care 1990–2008(%) Figure B: ECDenrolment byquintile, 1990–2006(%) Figure A: Net 10 20 30 40 50 10 20 30 40 50 60 70 80 90 0 0

Gross Net 1900 199219941996 I and gross attendance rates in early childhoodeducation II III 1998 2000200320062008 IV V 2006 1998 1990 3 Progress on key child-sensitive sectors 47 ECD can ECD can 67 2004 2006 2000 2002 help to reduce socio-economic inequalities only only inequalities socio-economic help to reduce are investments broader the longer term; over also needed. cadre of highly trained professionals dedicated to dedicated professionals trained of highly cadre Chile opportunities. ECD and extending improving to of commitment in its strength is also unusual children. opportunities the poorest for increasing still very high, in Chile are levels inequality However, 52.3 in 2009. coefficient of with a Gini , 1990–2006 , programmes ECD to 1994 1996 1998 ) expenditure on education total 1990 1992

0 2 4 6 8 10 (% of Public resources devoted Figure C: Data from World Bank data bank: http://data.worldbank.org/country/chile (accessed 12 February 2012). bank: Bank data World Data from 67 Source: Urzúa and Veramendi (2011). Veramendi Urzúa and Source: Although coverage of young Chilean children is far children Chilean of young Although coverage sustained expansion of ECD that the universal, from political strong place since 1990 reflects has taken and a governments successive commitment from Figure C illustrates that progress in extending ECD in extending ECD illustrates that progress C Figure opportunities a small proportion in Chile has cost (though small constitutes a relatively of GDP and the education budget. of proportion growing) Financing 48 progress in child well-being 69 68 T fact thatmuch oftheworld isnow closetouniversal many regions (UNESCO, 2011). This may reflect the towards educationhasslowed universal primary in Over theperiod2004to2009, thepaceofprogress in 15largecountries(UNESCO, 2011). 69% ofthesechildren, whoare concentratedmostly however, thetwo regions togetherstillaccountfor children duringthisperiod;school primary-age South andwest Asia halved thenumbers ofout-of- one-third, despitealargeriseinthechildpopulation. Africa increased itsnetenrolment ratioby over Saharan Africa andsouthwest Asia. Sub-Saharan fell by 39million, with80%ofthisdeclineinsub- number agebutnotinschool ofchildren ofprimary school.enrolled inprimary Inthesameperiod, the From 1999to2008, anadditional 58millionchildren educationoveruniversal primary thepastdecades. There have beenrapid advancestowards thegoal of Trends education inprimary 3.6 Education 70 the Philippines, South Africa, and (UNESCO, 2011). Source: Adapted from UNESCO (2011). of out-of-school children of primary age. of out-of-schoolchildren ofprimary enrolment ratesandreductionsprimary innumbers summarises progress by region intermsofnet

www.unesco.org/education/efa/ed_for_all/dakfram_eng.shtml (accessed1October 2011). The regions inthe table follow thoseusedby UNESCO. These were Bangladesh, BurkinaFaso, Brazil, Ethiopia, Ghana, India, Kenya, Mozambique, , Nigeria, Pakistan, able 1: Region Central &EasternEurope Latin America &Caribbean & WestAsia South East Asia &Pacific Central Asia Arab States

Sub-Saharan Africa trends inprimary schoolenrolment byregion, 1998–2008 68 2008 Primary netadjusted Primary (%) Table1 94 95 90 95 94 86 77 69 enrolment ratio Change since 1999 (%) economic crisisfrom 2007onwards. in 2004–09may alsoreflect theeffects oftheglobal 2008 (UNESCO, 2011). The slowdown inprogress and 2004to1.6millionperyear between 2004and of-school children enrolling eachyear between 1999 progress acceleratedfrom around 1.4millionout- despite highratesofpopulationgrowth, therateof enrolment ratios–sub-Saharan primary Africa –and Box 7). Itisnotablethatintheregion withthelowest the ultra-poororinareas affected by conflict(see communities (seeCaseStudy6onEthiopia), among they live inthemostremote regions orinmobile eligible children challenging, isparticularly because education,primary andenrolling thelast5–10%of from therichesthouseholds go toschool, butinthe greater gaps appear. InPakistan, 85%ofboys andgirls intersect, suchasethnicity, wealth andlocation, even children (UNESCO, 2011). Where different dimensions intense, girlsaccountfor 59%ofout-of-school west Asia, where genderinequalitiesare particularly 1990. population (UNESCO, 2011), compared with60%in Globally, girlsnow make up53%oftheout-of-school The gendergap inschoolenrolment hasnarrowed. 14 11 31 – 1 1 1 1 322 70 However, insomeregions, suchassouthand (’000) 17,919 28,867 2008 1,148 2,946 7,869 6,188 Out-of-school children Change since 1999 (%) – – – – – – – 32 21 51 27 11 34 32 3 Progress on key child-sensitive sectors 49 1 16 50 41 12 45 46 – – – – – – 1999 (%) Change since Change out of school in out of school 71 325 72 lower secondary age lower 4,571 2,100 1,699 2008 (’000) 19,675 13,277 31,486 Out-of-school adolescents, Out-of-school adolescents,

73 and reductions in 1 14 20 13 22 21 11 2015 (UNESCO, 2011). 2015 (UNESCO, Trends in secondary school enrolment Trends and retention of lower of adolescents the proportion Globally, 19% by fell out of school secondary age who were In east 2011). 2008 (UNESCO, 1999 and between of out-of-school numbers the Asia and the Pacific, By contrast, period. this 9% over by adolescents fell was almost no there Africa overall, in sub-Saharan population growth because 2011), change (UNESCO, rates enrolment increased counteracted substantially (see Table 2). Despite progress, 68 million primary million 68 school-age progress, Despite 2008 and, in not in school were worldwide children growth with population continue, trends if current children be 72 million could there However, some African countries have made made countries have African some However, secondary in increasing school considerable progress 1999 (%) Change since Change Total secondary Total 34 68 97 77 54 89 88 (%) 2008 gross enrolment ratio (%) enrolment gross , 1999–2008 adolescents by region, -of-school Sub-Saharan Africa Arab states Central Asia Asia & Pacific East South Asia & West America & Caribbean Latin Central & Eastern Europe Region

rates enrolment gross Changes in secondary able 2: The regions in the table follow those used by UNESCO. those used by in the table follow The regions UNESCO (2011) provides two projections of the likely numbers of children out of school in 2015, based on the out of school in 2015, of children numbers of the likely projections two UNESCO (2011) provides Out-of-school children refers to children of primary in either primary to children school age not enrolled or secondary refers Out-of-school children T numbers of out

73 72 globally down has slowed that progress Given since 2004. trend since 1990 and the shorter-term long-term trend and such as India risen in some of the most populous countries, have numbers and out-of-school since 2004, if However, years. the next three over of trends indicative be more may years recent in more the trend Nigeria, be out of school in 2015. would an estimated 48 million children continued, trend the longer-term Source: Adapted from UNESCO (2011). from Adapted Source: 71 school. The ages of children concerned vary country children The ages of entry from to country ages for and depending on different school. lengths of the primary cycle. Progress has been particularly slow in conflict-affected in conflict-affected has been particularly slow Progress home to 18% of the world’s These are countries. but 42% of the world’s of primarychildren school age, out-of-school primary (UNESCO, school-age children one- Secondary are rates school enrolment 2011). countries than in those in conflict-affected lower third has been there However, conflict. by not affected to promote of initiatives as a result some progress 7). (see Box areas in conflict-affected enrolment poorest households, only one-third of girls go to girls go of one-third only households, poorest all 30% of in 2005, Yemen, In 2010). (UNESCO, school but in the poorest boys, were children out–of-school 2010). (UNESCO, 46% boys this rises to quintile, can exacerbate poverty of The multidimensionality in the wealthiest a boy in Guinea, such that inequalities, with an educated in an urban area quintile living to be in school than likely more mother is 126 times with quintile living in a rural area a girl in the poorest 2007). (UNESCO, an uneducated mother 50 progress in child well-being 2006, inUNESCO, 2011]). 1% compared with33%for allschools[Alidouetal., that thedrop-out ratefrom bilingualschoolswas language they understand (astudyinNigerfound issues oflanguagesothatchildren are learning ina year [UNESCO, 2011])andgreater attentionto rates amongchildren wholearntmore theprevious from andPakistanshows much lower drop-out These includeimprovements inquality(research Quality andcurriculum-related factors reduced drop-out. have ledtosignificantgrowth inenrolment and and schoolfeeding programmes (Bundyetal., 2009) 2009]), schoolscholarshipsandstipends(Bangladesh) Mozambique, Tanzania [UNICEFand World Bank, Measures suchasfee abolition(Ethiopia, Ghana, Reduced costsofschooling school sanitationhasalsohelped. Case Study6onEthiopia). Improving provision of reluctant for themtotravel longdistances(see ofgirls,particularly whoseparents are oftenmore impactonincreasingan important enrolments, Providing more schoolsinruralareas hashad Improvements toinfrastructure been achieved? How have improvements ineducation and poverty. rates are lower anddrop-out higherinruralareas) areopportunities greater), location(enrolment boys are more likely todrop outastheiremployment always biasedagainstgirls–insomelabour markets there are significantinequalities, by gender(not schoolenrolment andretention,As withprimary school enrolment indifferent countriesandregions. a more detailedanalysis ofprogress insecondary the lowest intheworld. Table A.8, Appendix 1gives ratesinsub-Saharan participation Africa are still by abolishingschoolfees. However, secondary commitments toexpandingeducation, including This reflects rising government revenues andstrong they have more thandoubled(UNESCO, 2011). Ethiopia (seeCaseStudy6), GuineaandUganda enrolment numbers have grown five-fold, andin enrolment. InMozambique, for example, secondary 74 http://docustore.wfp.org/stellent/groups/public/documents/newsroom/wfp236983.pdf. (WFP). substantially financed by the World Food Programme countries, schoolfeeding programmes are or partially among thepoorest (Bundyetal., 2009). Inmany universal, becauseenrolment ratesare always lowest reaching thepoorest wherever enrolment islessthan including amongthepoor, they facedifficultiesin themselves provide anincentive for higherenrolment, et al., 2009). While schoolfeeding programmes may in ofBasicEducation2008,by 23%(Ministry inBundy during thesameperiod, withenrolment for girlsup enrolment inschools withtheprogramme rose 20% programme rose 5.9%between 2006 and 2007, in publicandcommunity schoolswithoutthe show that, whilenationalschool enrolment rates for example, dataontheschoolfeeding programme enrolment orattendance (Bundyetal., 2009). InMali, of promoting nutrition andincreasing school School feeding programmes have thedualpurpose for school-age children Improving preventive healthcare andnutrition (3ie, 2009). in Ethiopia(seeCaseStudy6)andBangladesh has proved effective inraisinggirls’enrolment rates availability, financialincentives andsocialmobilisation marriage. A combinationofincreased school contexts, andareduction inpressures for early This relates togirlsinpatriarchal particularly parents putoneducation Socio-cultural change toincrease thevalue (UCW, 2011). higher schoolenrolment rates(seeSection3.2) CCT have significantly reduced poverty andledto transfers suchassocialpensionsandtheBolsaFamília employment for poorpeopleandcash opportunities where acombinationofeconomicgrowth, improved costs ofeducationmore affordable, asinBrazil, education. They have madethedirect andindirect likelihood thatthey willwork inpreference to costsofchildren’sopportunity timeandthe Increases inhouseholdincomehave reduced the Household poverty-related factors feeding programmes in62countries. 22.4 millionchildren were reached by school 74 According to WFP figures, in2010, 3 Progress on key child-sensitive sectors 51 Total aid to Total basic education aid to Total education 75 5.6 13.4 2009 , 2002–09 , education to 4.6 11.3 4.6 11.5 Despite increasing public expenditure on education, on education, public expenditure Despite increasing countries depend on aid for developing many sector either direct (through educational investments African 15 sub-Saharan In funding or budget support). one-quarter aid accounts for of education countries, Aid has been important 2011). spending (Abetti et al., to expand provision, countries in enabling developing abolish school fees, teachers, more train and deploy quality (see and improve reforms enact curriculum in trends 15 shows Figure Case Study 6 on Ethiopia). 2002–09. education for aid for and creating a policy environment favourable to favourable environment a policy and creating to an has contributed which in education, investment 2011). (UNESCO, in this investment increase Aid doubled to in 2009 had aid to education Overall, 2011). since 2002 (UNESCO, $4.7 million per year for commitments to Education reflects This increase All Fast The Education for 2000. All and MDG2 from Global Partnership the renamed (now Initiative Track multilateral Education) has become a global for significant financial It has provided education funder. helping 19 million children support to 46 countries, billion since 2002). attend school ($2.1 aid disbursements 4.1 10.6 2006 2007 2008 9.5 3.7 2005 and multilateral 8.6 3.4 8.3 3.1 bilateral otal 6.1 2.6 2002 2003 2004

0 2 4 6 8 10 12 14 16 18 20 15: T Figure 15: 2009 $ billion) (constant www.globalpartnership.org/about-us/our-new-name/ (accessed 1 October 2011). www.globalpartnership.org/about-us/our-new-name/ 75 Source: Calculation based on OECD-DAC CRS in Abetti et al. (2011). Abetti et al. CRS in Calculation based on OECD-DAC Source: Government investment in education investment Government has been financed above discussed The progress in public investment of greater a combination by of national The share and aid. countries developing from globally increased on education income spent 1999 and 2009 (UNESCO, 2.9% to 3.9% between in rose spending on education capita Per 2011). in some (such marginally only although region, every education in Public spending on states). Arab as the 2000 29% between up by Africa went sub-Saharan of this Three-quarters 2010). and 2005 (UNESCO, of economic has been the result investment increased to improved attributable with the rest growth, of budgets in a redistribution collection and revenue uncertain Given global economic of education. favour 2000s and of the early levels the growth conditions, in education public investment thus of increasing converting Furthermore, cannot be assumed. to educational investment of growth proceeds prioritising continue political commitment to requires as implementing the as well education spending, For example, necessary public financial management. all and Rwanda have Mozambique Mali, Ghana, collection levels revenue succeeded in improving How have these reductions been financed? been reductions these have How 52 progress in child well-being Source: UNESCO(2011). more stringentenforcement ofageregulations behind thisenormousincrease were fee abolition, from 14%in1997to 87% in2007. The mainfactors children schoolattheofficialageincreased starting in thisarea. In Tanzania, for example, theshare of However, somecountrieshave mademajor progress schoolontime(ibid). primary Africa started 2011). In2007, only 56%ofchildren insub-Saharan likely tocompletefive years ofschooling(UNESCO, children uptotwo whostart years lateare 10%less Evidence from Senegal, for example, suggeststhat more likely tohave torepeat gradesanddrop out. likely tocompleteafullcycleofbasicschoolingand out early. Childrenschoollateare whostart less problems: childrenschoollateanddropping starting This requires addressing two mainsystem-related of basiceducation Ensuring children completeafullcycle Ongoing challenges of economiccrisis(UNESCO, 2011). donors reducing overall aidbudgetsinthe context programmes (Abettietal., 2011). This reflects some countries inwhichthey currently fundeducation are reducingtoeducationand/or theirsupport basic educationwillcontinue, asanumber ofdonors is notclear, however, whetherthispro-poor focus on Education for All andtheMDGs–have increased. It allocations tobasiceducation–thefocus of As Figure 15shows, both overall allocationsand to poorlearningoutcomes. Finally, theprimary given additional training toreduce drop-out related these centres. Teachers intheearly gradeswere school-agepopulationhadenrolled in primary education systeminGrade5. By 2006, 8%ofthe (8–13), allowing themtore-enter theformal alternative formal educationtoover-age children in Tanzania project 1), (Cohort whichprovides developed BasicEducation theComplementary children couldundermineschoolretention. Italso school, recognising thatasurge ofover-age seven years primary asthemaximum agetostart Tanzanian government in2001putaceilingof schoolfees wereAfter primary abolished, the Bo x 6: Reducing primary schooldrop -out in T children, girlsand theirfamilies, particularly who or longjourneys toschoolcontinue todeter the poorest 20%(UNESCO, 2011). Lackofschools 20% ofthepopulationare 10timeshigherthanfor In BurkinaFaso, completionratesfor therichest they neededtowork (Save theChildren, 2010c). children wereprimary-age notinschoolbecause completion. In Afghanistan, 70%ofout-of-school a significantbarrier, andschool tobothentry schooling costsmore affordable, poverty remains and chargesand/orpoverty reduction thathasmade Despite theprogress madeinabolishingschoolfees infrastructure barriers Addressing financial, culturaland approximately one-fifth(9/50). in justunderone-third (15/50)anddecreased in school have increased inhalf(26/50), remained stable are data, ratesuntilthelastyear ofprimary survival low- andmiddle-income countriesfor whichthere about progress inthisarea difficult. However, of50 out (ibid.). Dataconstraintsmake globalconclusions all out-of-schoolchildren insouthandwest Asia drop Saharan Africa every year (UNESCO, 2011). Halfof school-age children drop outofschoolinsub- grade,the finalprimary and10millionprimary sub-Saharan Africa andsouthwest Asia complete Overall, only 70%ofchildren whoenrol in schoolin ‘over-age’ children (UNESCO, 2011)(seeBox 6). and thedevelopment ofalternative provision for pass ratesinthegrade7examination. Grade 4examinationrequirement isthedeclinein 26% to17%. The downside oftheremoval ofthe From 2001to2006, thedrop-out ratefell from fell from 3.2million in1999to33,0002008. the number ofout-of-schoolchildren in Tanzania achieving children. As aresult ofthesemeasures, to progression gradesfor under- intolaterprimary andasabarrier support students neededfurther as adiagnostictoolfor identifyingareas where level. Inthepast, thisexaminationhadserved system toimprove progression attheprimary to Grade5wasremoved ofareform aspart Grade 4examinationrequirement for progression anzania 3 Progress on key child-sensitive sectors 53 to maintain basic services basic to maintain of episodes during support and violence post-conflict for strategies to education in aid effective More reconstruction. is crucial to speeding countries conflict-affected goals, All for meet the Education to up progress to achieve and primarysuch as universal education, can Humanitarian aid education. rights to children’s and during emergencies, help to maintain education assistance can support the long-term development reconstruct to governments efforts of post-conflict types different between continuity Greater education. is vital. of funding stream conflict of aid to countries in armed Although levels aggregate years, in recent markedly increased have distribution pattern of skewed aid data hide a highly to Most ODA 2011). countries (UNESCO, across together goes to which, states conflict-affected of the aid 38% for accounted Afghanistan, with and lower-middle- the 27 low-income by received the Recently, conflict. by income countries affected seen their countries have conflict-affected 16 poorest Aid to education in these aid rise. of overall share aid and faster than overall countries has increased the given Still, faster than global aid to education. levels low of out-of-school children, large number classroom of literacy and costs associated with low-income construction and teacher recruitment, countries face far higher costs conflict-affected their On average, countries. than other low-income $69, is around estimated per pupil financing gap Yet countries. all low-income with $55 for compared $16 receive countries conflict-affected low-income with compared per pupil in aid to basic education, with countries, other low-income for the $22 average (ibid.). the global average large variations around the international community past, In the recent has made important supporting commitments to conflict. by affected children education for and UNICEF the Children Organisations such as Save these prioritising education for for advocated have and humanitarian as partchildren of development Following policies included in peace agreements. debate on education in Assembly a UN General the G8 emergency and post-crisis situations in 2009, special attention to conflict-affected to pay promised All goal. the Education for to reach countries in order and UN agencies donors Efforts governments, by accessibility and improved led to increased have 2010c), the Children, quality of education (Save still needed. effortsalthough continued are Development assistance has a vital role to play to play assistance has a vital role Development It has the potential countries. in conflict-affected The 30 low-income and lower-middle-income and lower-middle-income The 30 low-income countries that experienced armed conflict during the home to 116 million children period 1999 to 2008 are countries, developing Among poorer 2011). (UNESCO, about one-quarter account for of the primarythey half of the out-of- school-age population but nearly survival to the last grade of Further, school population. primary countries conflict-affected school in poorer with 86% in other poor countries. is 65% compared ratios in secondary enrolment school are Gross countries than in conflict-affected 30% lower nearly conflict (ibid.). by in countries not affected Special challenges in conflict-affected in conflict-affected Special challenges countries Solutions include increasing the number of teachers – the number Solutions include increasing needed to teachers are 1.9 million additional 2011), primaryuniversalise education (UNESCO, teacher pupil-teacher ratios and reducing reducing to improve Major training programmes absenteeism. also and instruction quality are teacher knowledge as is extending teaching in languages children vital, of textbooks and other and the provision understand, unacknowledged The relatively educational equipment. and sexual violence against physical but widespread teachers and other perpetrated both by children also be students in schools must school staff and by 2010). International, (Plan addressed Addressing quality problems Addressing time and wastes children’s education Poor-quality that likely it more it also makes families’ resources; 2011). out of school (UNESCO, will drop children the quality of education remains Despite progress, particularly in rural countries, in most developing low and in schools serving (ibid). areas poor communities Corporal punishment and sexual abuse at school are are sexual abuse at school punishment and Corporal International, (Plan causes of drop-out other major and discriminatory This, 2011). UNESCO, 2008; minority ethnic from of children treatment raising through can be addressed communities, the general of the issues; teachers’ awareness by be addressed undervaluing of girls’ education may among awareness-raising stipends and gender-specific and communities. parents are concerned about security, as does lack of lack as does security, about concerned are these to address funding Additional toilets. is crucial. barriers 54 progress in child well-being 76 (2008) asreported inSave theChildren (2010d). 77 World Development Indicatordata, and data from Government of Afghanistan Central StatisticsOrganization of Educationenrolment Datafrom statistics, Ministry asreportedinSave theChildren (2009). of primary schoolchildren areof primary girls. from 42%in2002), meaningthataround one-third enrolmentfemale was67%(up tomaleprimary compared with60%for boys. In2009, theratioof education –hasfocused onincreasing particularly One ofitscomponents–community-based Education BetterFuture campaignin Afghanistan. In 2006, Save theChildren launchedtheBetter community-based educationin Afghanistan Example: girls’educationthrough supporting attacks by extremists whoopposegirls’education. 2010d). Schoolsare oftenvictims ofthreats and female teachers(Jones, 2008, inSave theChildren, teachers, butonly 4%dosoinschoolswithout of girlscompleteGrade6inschoolswithfemale are available, girls’enrolment ismuch higher: 15% demonstrated that, inschoolswhere female teachers of Education, 2007). A studyinBaghlanprovince Uruzgan (IslamicRepublicof Afghanistan Ministry in Kabulare female, thisfigure islessthan1%in with starkregional variations: while64%ofteachers 2007). Nationally, only 28%ofteachersare female, beyond age(around acertain 11years old)(HRRAC, in mixed schoolsandtobetaughtby maleteachers unwillingness toallow theirdaughterstobetaught especially for girls. Otherbarriers includeparents’ homes andschoolsisakey barrier toenrolment, tents oropenspaces. The longdistancesbetween buildings, sothataround halfofschoolingoccursin are categorisedin thecountry ashaving useable conflict hasslowed progress. Only 25%ofschools The damagetotheeducationsystemcausedby the in 2007, increasing from 770,000in2001toover 6million of theeducationsystem, enrolment withprimary there hasbeenhugeprogress intheexpansion (Samady, 2001). Sincetheoverthrow ofthe Taliban girls’ enrolment inmany provinces wasalmostzero began closingallgirls’schoolssuchthat, by 2001, ineducation.girls’ participation In1995, the Taliban government policiesofthe1990s, whichlimited school increased steadily untiltheMujahideen were girls, andthenumbers ofgirlsenrolled in by conflict. In1970, 14%of Afghanstudents girls, have historically beenlimited, andrestricted 1970s. Educationopportunities, for particularly Afghanistan hasexperiencedconflictsincethe Bo x 7: Education 76 withgirls’enrolment reaching 42% and conflictin Afghanistan 77

enabling greater equity inaccess. situation ofchildren in aconflict-affected country, significantly totransforming theeducational fromsupport donors, isabletocontribute authorities andlocalcommunities, withfinancial how anNGO, working closely withgovernment This exampleprovides aninteresting modelof difficult-to-reach groups. more widely toprovide accesstoeducationfor school education. Therefore, they couldbeused providing education toalevel atleastasgood as during themid-termevaluation were found tobe are lesspublicthanschools. The ALCs visited as, beingoftenheldinhomesormosques, they to women working incommunity-based classes becausetherepartly are fewer culturalbarriers community-based schoolsthaninformal schools, much higherproportion offemale teachersin the Children, 2010d)found thatthere wasa (SaveA mid-termevaluation ofthisstrategy local community andidentifyingthestudents. space, appointing ateacher(ormentor)from the councils. These are responsible for findingalearning establish community educationcouncilsorparents’ the Children alsoworks withthecommunity to (Savetheir partners theChildren, 2010d). Save visitsfromsupport Save theChildren staffand The mentorsare alsoprovided withongoing and learnerspaying thementors’salaries. providing carpetsandtextbooksfor theteachers theseclassesthroughsupports trainingofmentors, avoid longjourneys toschools. Save theChildren the smallcommunity-based structure andthey formal schoolsbecausethey have confidencein are more appealing togirlsandtheirfamilies than These classesdonotspecifically targetgirls, but set up455 ALCs (Save theChildren, 2009). Balkh, Jawzjan, Sar-i-pul, KandaharandUruzgan–to inKabulandfivewith localpartners provinces – Between 2008and2010, Save theChildren worked in oneyear (acceleratedlearningclasses[ALCs]). accelerated curriculum covering two years’ content curriculum andschoolyear andothersdeliver an local community. Somefollow thenormalschool mosques andtaughtby amentorselectedfrom the based classesare usually heldinlocalhomesor girls’ andboys’ accessinremote areas. Community- 3 Progress on key child-sensitive sectors 55 Male Female Secondary 2010 80 in secondary Progress education secondaryrates gross school enrolment In 1971, girls). and 1.8% for boys 3.73% (5.6% for only were in secondary has been a sustained increase There so decades, the past three over school enrolment was 34.4% rate enrolment the gross in 2009, that, boys). girls and 38% for (30% for enrolments are likely to rise significantly in the to rise significantly likely are enrolments of numbers increased as the vastly coming years primary on to attending now move children school secondary education. 79 2000 2005 rate for primary rate for 78

1995 tudy 6 Study ase 0

20 40 60 80 , 1995–2010 (%) in Ethiopia, education in primary rate enrolment Gross A: Figure 100 World Development Indicator database. Development World Indicator database. Development World Net enrolment figures for 1971 were not available. available. not were for 1971 figures Net enrolment schools in Ethiopia was 14%, with 20% of boys and with 20% of boys schools in Ethiopia was 14%, Primary has school enrolment 9% of girls enrolled. from growth with particularly strong risen steadily, have net enrolments the past decade, Over 2000. with girls’ 40% in 2000 to 83% in 2009, from increased those of boys. 5% below only rates now enrolment 79 80 78 Source: World Development Indicators. Development World Source: Between 1998 and 2006, Ethiopia reduced the reduced Ethiopia 1998 and 2006, Between 6.5 million from of out-of-school children number through largely 2011), to 2.7 million (UNESCO, which reached intake, the Grade 1 gross increasing 153% in 2008 (ibid.). In 1971, the gross enrolment gross the In 1971, in primary Progress education and secondarythiopia education in E apid and equitable expansion in primaryexpansion and equitable Rapid C 56 progress in child well-being Source: World Development Indicators. Source: World Development Indicators. Figure C: Ratio offemales Figure B: Gross secondary enrolment 10 15 20 25 30 35 40 10 20 30 40 50 60 70 80 90 0 5 0

1998 19992000 2000 2001 2002 2003 2001 to males in secondary enrolment 2002 2004 2005 , 1998–2009(%) 2003 200420052006 2006 2007 , 2000–09(%) 2007 20082009 2008 2009 3 Progress on key child-sensitive sectors 57 In Amhara region, a government-run a government-run Amhara region, In 81 82 Support by NGOs and international agencies: NGOs and international agencies: Support by of national and presence is a strong There international NGOs (such as Plan International and and international child-sensitive the Children) Save on education agencies (such as UNICEF) working focuses the Children Save example, For in Ethiopia. to education approaches on supporting innovative project funded by the UN Population Fund (UNFPA) Fund (UNFPA) Population the UN funded by project has provided marriage aiming to counter early in or to girls aged 10–14 to stay financial incentives the for unmarried remain to school if they return The government’s 2011). duration (PMNCH, project’s also helped to rural school-building programme the distances reducing by girls’ enrolment increase concerns about their and allaying had to travel they to school vulnerability to sexual violence en route 2010d). (ODI, included in-service quality have Efforts to increase language use of regional greater teacher training, pupil–teacher and pupil– instruction and reducing These extra provision. textbook ratios through with up to 60 children however, very high, remain between per teacher and one textbook shared ten children. Programmes to reach disadvantaged children, such children, disadvantaged to reach Programmes for programme Education Basic Alternative as an and programmes school feeding youth, out-of-school (UNICEF communities pastoral for mobile education particularly all helped 2009) have Bank, World and gain an education. to children disadvantaged the among risen sharply rates have Enrolment households poorest 56% of the only groups: poorest to school in 2001 children to send their could afford in 2008, in 2006 (Woldehanna, with 91% compared orphans rate for The enrolment 2009). et al., Tafere 2005 2000 and 60% to 90% between from improved 2010d). (ODI, Action to improve inequalities: Action on gender included publicity campaigns gender parity has of provision to educate girls; encouraging parents for girls and establishing girls’ clubs sufficient toilets as teachers of women targeted recruiting in schools; to address initiatives micro-level and administrators; strengthening specific needs of girls out of school; and making the school system monitoring; actions detrimental to the access and accountable for survival of girls. http://ddp-ext.worldbank.org/EdStats/ETHgmrpro04.pdf (accessed 14 February 2012). http://ddp-ext.worldbank.org/EdStats/ETHgmrpro04.pdf www.educationfasttrack.org/news/198/291/Ethiopia-s-Political-Leaders-Champion-Girls-Education/d,Stories/ www.educationfasttrack.org/news/198/291/Ethiopia-s-Political-Leaders-Champion-Girls-Education/d,Stories/ 82 81 (accessed 21 September 2011). Ethiopia’s large social Ethiopia’s Action on poverty: Net Safety scheme – the Productive protection some of the – has helped to address Programme Among the households to schooling. financial barriers 69% this programme, supportreceiving through longer in school children been able to keep have levels Poverty 2011). in UNESCO, 2006, (Slater, 29% of 49% in 1996 to an estimated declined from line in 2009/10 the population under the poverty is very low although the threshold 2010), (MoFED, 2010). (Dom, Abolition of school fees: Primary school Abolition of school fees: the 23% in 1995, by in Ethiopia increased enrolment Grades abolished for were after school fees year In 1995/96, 2009). Bank, World 1–10 (UNICEF and per grants capitation meant to receive schools were but in some cases fees, user designed to replace pupil, full shortages not receive of funds meant schools did some schools still make Furthermore, funding (ibid.). construction, sanitation, sports, charges for additional etc (ibid.). stationery, 9,000 new 9,000 new in school facilities: increase Massive 2004/05 and constructed between schools were Of these, bringing the total to 25,000. 2008/09, These 2010). (MoFED, in rural areas 80% were or donors – government by financed not fully were expected contributions were substantial community 2010). (Dom, Government spending on Government spending: Increased national budget 19.8% of the from education rose The 2010). in 2009/10 (MoFED, in 2004/05 to 22.8% education financing and increases decentralisation of grants to local administrations in central government Some often further education spending. boosted 50% of authorities) allocated over (local woredas However, 2010). their budgets to education (Dom, been plus aid funding have these increases even targets of the insufficient to meet the ambitious 2010). Plans (Dom, Education Sector Development Achieving universal primary universal Achieving emphasis: Policy part has been a central education of government Education Sector successive with three policy, 2002/03– Plans (1997/98–2001/02, Development 2010). (Dom, 2004/05 and 2005/06–2009/10) underpinning factors Key progress in areas the government has not reached. Rather war of 2000 and following the 2005 elections. By than providing direct services, it has strengthened contrast, government funding to basic services was ten local NGOs to become major education actors largely protected during these periods of resource by providing support and guidance in such areas as squeeze (ibid.). The Protecting Basic Services (PBS) capacity-building, networking and negotiating with programme was set up to overcome donors’ the government. unwillingness to provide direct budget support following the 2005 elections while not wishing to pull funding on aid for basic services. It is now the main Role of aid channel for aid to education, with 50–70% of funding channelled through PBS in 2006 (ibid.). Although it is Aid has supported a government-led process of difficult to derive an exact figure, approximately 38% educational expansion (ODI, 2010d). Aid to education of PBS funds go to basic education (ibid.). in Ethiopia increased substantially over the 2000s

progress in child well-being progress (Figure D), as donors which had not supported the Consistent with the government’s emphasis on first Education Sector Development Plan slowly universalising primary education, aid to education in came on board. However, given the country’s large Ethiopia has focused largely on primary education population, per capita aid continues to be well below (Figure D), with strikingly little devoted to secondary the average for sub-Saharan Africa – $11 compared education – less than to the tertiary sector. This with $23 for the continent as a whole (Dom, 2010).83 reflects both the preferences of certain donors, which Aid to education was affected by the temporary emphasise university and technical and vocational suspensions of aid on political and human rights education and training, and the government’s own grounds that occurred after the Ethiopia–Eritrea emphasis on expanding tertiary education.

Figure D: Aid to education in ethiopia, 2000–10 ($ million)

800

600

400

Admin and policy Facilities and training

200 Primary Secondary Higher Skills and vocational Early childhood Research 0 2000 2005 2010 Total

Source: OECD-DAC data; author’s calculations.

83 The largest donors over the period 1999–2006 were the International Development Association (IDA) (the World Bank), the US, the European Commission (EC) and the UK (Dom, 2010).

58 3 Progress on key child-sensitive sectors Ongoing challenges Increasing enrolment in pastoral and semi- pastoral regions (Afar and Somali): The gross Population growth: Ethiopia’s population grew enrolment rate for primary education in Afar rose 2.6% per year between 1994 and 2004. This meant from 26.2% in 2004/05 to 58% in 2009/10. In Somali the population of children under 15 rose to 33 region, the gross enrolment rate rose from 32.7% to million in 2007, compared with 25 million in 2004, 62.8% over the same period (MoFED, 2010). These so the “education system has had to run to stand increases are attributed to an ongoing regional still” (Dom, 2010). The progression of children who focus in the goverment’s development programme: have moved through the primary system into the that is, mobile and community schools for pastoral secondary system will further strain resources. This areas and a national progrmame of alternative basic needs urgent policy and funding attention. education. However, enrolments in these areas lag far behind those for other regions, and gender Drop-out rates: The rapid expansion of primary disparities are often even more severe (girls’ primary enrolment and an associated decline in quality led school enrolment in Afar is half the national average to a decline in school survival rates – more than a (UNESCO, 2010, in ODI, 2010d)), indicating a need quarter of children dropped out in Grade 1 (MoFED for further effort and investments. data, in UNESCO, 2011). In 2009/10, the completion rate for the first cycle of primary school (Grades Financing: There continues to be a significant gap 1–4) was 78%, but it was only 46% for the second between the funding required to meet Ethiopia’s cycle (Grades 5–8) (MoFED, 2010), with a significant education sector goals (in particular, universalising discrepancy between richer and poorer children primary education and meeting the unmet demand (Tafere et al., 2009). However, there is some evidence for secondary education). One reason for this is of increased Grade 8 completion rates (Dom, 2010). the increasing share of government expenditure on tertiary education, which rose from 13% in 1996/97 Quality: The donor-supported General Education to 20% in 2000/01 (while the share devoted to Quality Improvement Programme, along with other primary education fell from 52% to 41% (Dom, strategic investment, is intended to tackle problems 2010)).84 With the demand for secondary schooling of education quality. The number of primary school increasing, budgets for secondary education have also teachers grew from 171,000 in 2005 to 290,000 in been increased at sub-national level. Futhermore, the 2009 (Ministry of Education data, in Berry and Bogale, share of federal government expenditure allocated 2011) in order to reduce pupil–teacher ratios. The to education is expected to fall, as the shares of number of secondary school teachers also increased other sectors, particulary health and agriculture, by over 20% from 2004/05 to 2008/09 (ODI, 2010d). are increased. Dom (2010) estimates that total aid Teacher certification rates have risen to 89% in to education would need to double to meet the Grades 1–4 and 71% in Grades 5–8 (MoFED, 2010). financing gap and to support continuing progress. It is too early to assess how effective this will be in addressing the trend towards deteriorating learning outcomes in some areas as revealed by national tests. In part, this decline may reflect the inclusion of children with more difficult learning conditions (Dom, 2010).

84 More recent data are not available.

59 60 progress in child well-being Source: UNICEFglobal databases, 2011. BasedonDHS, MICSandothernational surveys, 2000–2010 Data coverage wasinsufficienttocalculatea regional average for industrializedcountries. Note: Regionalestimates represent datafrom countriescovering atleast50%oftheregional population. * ExcludesChina section focuses onselectedareas ofchildprotection. and exploitedchildren (Save theChildren, 2003). This to find reliable statistics for the numbers ofabused violations ofchildren’s rights, itisextremely difficult of thehidden andcriminalnature ofmany these commit themthemselves (UNICEF, 2009b). Because are exposedtoviolentatrocities oreven forced to inthearmedforces,conditions orserve where they trafficked orabducted, and madeto work inharmful places suchasathomeandinschool. Many are worldwide faceviolenceandabuse, even in ‘safe’ neglect (UN, 1989). However, millionsofchildren the righttobefree from abuse, exploitationand in theUNCRC, whichstatesthatevery childhas Children’s rightstocare andprotection are outlined 3.7 100 in unionby Figure 16: Percentage of 10 20 30 40 50 60 70 80 90 0 Married orinunionatage 15orafterbutbefore age 18 Married orinunionatage 15 Child protection South Asia 18 46 West and Central Africa 14 41 ages 15 Saharan Africa Sub- 12 38 and 18, byregion Southern Eastern Africa women and 11 35 Caribbean America and the Latin aged 20–24 29 8 East Asia Pacific* and 18 3 years between 2003and2006. However, childmarriage ofsouth some parts Asia (BangladeshandNepal) increasing in47countries, withsteadyincreases in The medianageatfirstmarriage isgradually the ageof18(UNICEF, 2009b). reporting thatthey were married orinunionbefore third of)women aged20–24indeveloping countries populations, withmore than64million(over one- The practiceismostcommonamongpoorrural sub-Saharan Africa (UNICEF, 2005b)(seeFigure 16). child marriages take placeinsouth Asia, followed by developmental opportunities. Nearly 50%ofall pregnancy andtruncatededucational domestic abuse, early (andoftencomplicated) Child marriage putsgirlsatriskofsexualand Early marriage abuse andexploitation Progress inprotecting children from East and Middle North 18 4 who CEE/CIS 11 1 were firstmarriedor developed countries Least 17 47 Developing countries* 12 35 World* 12 35 3 Progress on key child-sensitive sectors 61 greatest in the Asia Pacific region (from 19% to region (from Asia Pacific in the greatest America and the Caribbean 14.8%) and in Latin 2010). to 9%) (Diallo et al., 16% (from armed conflict by affected Children of the world’s two-thirds 2002 and 2006, Between in – lived children child population – some 1.5 billion high-intensity conflict. violent, by countries affected than 8.8 million children It is estimated that more and another conflict, displaced by internally were outside their country’s 5.8 million sought refuge under The use of children 2007a). (UNICEF, borders place in one form to take 18 in hostilities continues 86 countries and territories or another in over in while armed groups 2008), (CSUCS, worldwide or kidnapped recruited at least 24 countries have part in to take forced are of whom many children, hostilities as fighters or spies or used as porters, most often are Such children cooks or sex slaves. Africa (Save of sub-Saharan in the armed forces found 2010b). the Children, has been some there Against this background, been have than 100,000 children More progress. since 1998 (UNICEF, demobilised and reintegrated and Leone), 2007a) (see Case Study 7 on Sierra has led some pressure international and community to ending child to commit themselves armed groups and such as in Côte d’Ivoire, recruitment, in implementation significant gaps However, Sri Lanka. either children and tens of thousands more remain, into armed recruited been newly in or have remain 2008). conflicts (CSUCS, Over 1 million new registrations of registrations million new 1 Over Tanzania: 2005 between achieved and adults were children and 2009. of BirthsThe Revitalisation and Deaths Uganda: in an almost 25% resulted Registration project 550,000 including over in registrations, increase 2006 and 2007. from under eight, children led to on specific groups A focus Vietnam: 66 minority from children of 19,000 registration in Quang Ngai province ethnic communities in Lang Son and Lai Chau and 10,000 children in 2007/08. mountainous provinces registration birth Universal x 8: Bo Over 7 million children and adults 7 million children Cambodia: Over birth certificates months of the received within 10 commencement. programme’s Nearly 6 million children and adults and adults 6 million children Bangladesh: Nearly Through 2003. official identities since acquired have Plan also mobilised with the government, work children 50,000 street nearly NGOs to record birth half of whom received in Dhaka – over certificates in 2008. Through its Universal Birth Registration campaign, Birth campaign, Registration its Universal Through partner alongside and NGOs Plan International, of facilitated the registration has governments, – in 32 children mainly million people – 40 over including: countries, Child labour of number the overall 2004 and 2008, Between 3% (from declined by worldwide child labourers of girls and the number 222 million to 215 million), by decreased work aged 5–14 in hazardous and boys in labour The reduction 15% and 10% respectively. 2000 and 2008 was between among 5–14-year-olds Birth registration and the legal identity and protection Birth registration, and is critical to is a basic human right, it secures, including social assistance, access to legal entitlements, education and inheritance in childhood and heathcare, of a degree it also provides of age, As proof later life. child labour and marriage, against early protection has Some progress conscription into armed forces. when 40% of births were been noted since 2002, Asia particularly in east 2002), (UNICEF, unregistered 8). and the Pacific (see Box Support for female genital mutilation/cutting Support genital mutilation/cutting female for in some parts(FGM/C) also declined significantly of and Eritrea Africa (such as Burkina Faso, sub-Saharan millions However, 2002 and 2007. Mauritania) between exposed to the risk of genital cutting, of girls remain of high incidence such as the particularly in areas 2009b). Africa (UNICEF, East and sub-Saharan Middle Female genital mutilation/cutting genital Female continues to affect significant numbers of girls significant to affect continues in of women than one third More 2009b). (UNICEF, marry during childhood. world the developing Source: Cody (2009). Source: 62 progress in child well-being paragraph splithere standfirst: toshorten OK? and employment programmes, were conducted reunification, interimand alternative care, education These activities, whichincluded family tracingand demobilisation andreintegration (DDR)process. UNICEF, coordinated activitiesinthedisarmament, Gender andChildren’s by Affairs andsupported ofSocial managed by theMinistry Welfare, 85 The ChildProtection Committee(CPCom), rehabilitated andreintegrated. formerly associatedwiththearmedforces have been Since thecessationofhostilities, many children children comprised25%ofthefighting forces. who were helplesstostoptherebels. By1998, were abductedinthepresence oftheirparent(s) from theirfamilieswhile fleeingtosafety. Some parents were killedorthechildren got separated abducted by therebels afteranattackwhere the and were easily targetedby recruiters. Mostwere who were already abused, exploitedorneglected were undertheageof12. Somewere children Nearly 30%ofallpeopleforced intorecruitment communities (ibid.). terrible atrocities –attimesintheirown they were often madetowitnessandcommit conscripted intothearmedforces, where between 5,000and10,000were forcibly targeted for rape andsexualslavery, and between theagesof10and14were widely in any conflict”(SLTRC, 2004). Children brutal violationsofhumanrightsrecorded children singledoutfor “some ofthemost characterised by extreme violence, with The 1991–2002conflictinSierra Leonewas Leone in Sierra P C government ministries. by UNICEFand comprising40membersfromsupported UNagencies, nationalandinternationalNGOs and A nationalnetwork implementingprogrammes ofpartners inChildProtection, coordinated by theMSWGCA, ost-conflict childprotection ase Study 7 85

into thecommunity, community-level childwelfare early/forced pregnancies. To ensure fullintegration child victimsofdrugabuse, sex-related diseasesor Educationalists alsoprovided medicalassistancefor NGOs suchastheForum for African Women kits(Brooks,training andbusinessstart-up 2005). and Employment Programme, whichprovided skills entered theNationalCommitteefor DDR Training 1,441 former childsoldiersaged15–17years children whohadnotbeensoldiers. Inaddition, 2,788 former childsoldiersbutalsoaccomodated (CEIP), whichprovided education, primarily for Community EducationandInvestment Programme education agencieshelpedtofundandcoordinate the communities, childprotection andspecialist In order tobetterintegratechildren intotheir traced were placedinfoster care. conflict orwhoseparents/guardians couldnotbe for Refugees(UNHCR). Children orphanedby the the RedCross andthe UNHighCommissioner by keysupported stakeholders includingthepolice, Programme (Brooks, 2005). This programme was families through theFamily Tracing andReunification 6,977 ofthesechildren hadbeenreunited withtheir UNICEF andchildprotection NGOs. By2003, sent tointerimcare centres underthecare of ex-combatants and30%separatedchildren) were of 7,141children under15(70%were demobilised peacefully intotheircommunities. By2002, atotal involved inarmedconflictandto reintegrate them working toovercome thestigmafacingchildren A key objective wascommunity mediation: government agenciesandpeacekeeping forces. by variousNGOs, internationalorganisations, 3 Progress on key child-sensitive sectors 63 Sierra Leone’s DDR process was largely seen as seen was largely process DDR Leone’s Sierra other and has serveda success a model for as 2008). and Ginifer, regions (Solomon post-conflict support insufficient to girls it provided However, quarterA of girls forces. with the armed associated sexual slavery for soldiers and targeted abducted by 30% of and an estimated or under, 12 years were their complex However, girls. child soldiers were as ‘bush wives’ situations (as servants and captive went largely forces within the armed as fighters) well of DDR participants 8% and only unrecognised, UNICEF In response, 2008). (CSUCS, female were supporting Left Behind Project, established the Girls in collaboration the DDR process by girls overlooked the such as Save and NGOs with the government Rescue Caritas and the International Children, Other issues such as drug use and Committee (IRC). the conflict stemming from psychological problems on a small scale, but only also been addressed have led to increases have and some of these problems girls and young children of street in the number 2008). (CSUCS, engaged in sex work Challenges

86 Thanks to Save the Children Sierra Leone for this observation. Bilateral and multilateral aid (administered aid (administered Bilateral and multilateral this observation. Leone for Sierra the Children Thanks to Save 86 by the World Bank and government of Sierra Leone through a Multi-donor Trust Fund) were provided provided Fund) were Trust a Multi-donor Leone through of Sierra and government Bank World the by USAID DFID, Bank (AfDB), African Development the Union (EU), the European Bank, World the by primarily 2003). Bank, and UN agencies (World Aid post-conflict Leone’s Sierra aid was critical to Foreign it encompassed 94% 2002 to 2004, from recovery: a and nearly budget, development of the country’s reintegration, quarter towards of this budget went (World programmes and recovery rehabilitation 2003). Bank, committees and children’ clubs were also set up, with with up, also set were clubs children’ and committees workers social NGO by visits follow-up periodic to capacity community on strengthening focused social roles. to their new to readjust enable children successful that so were committees welfare The child Child Leone under the in Sierra formalised were they and other CPCom Child War Act of 2007. Rights and psychosocial recreation partners provided as the focal UNICEF, children. affected healing for provided Welfare, partner of the Ministry Social for to materials and recreational learning teaching, and children, 3,000 over for fees schools in lieu of girl mothers who had not been 1,414 reintegrated (Committee DDR programme included in the original 2006). Child, on the Rights of the 64 progress in child well-being soldiers (seeCaseStudy7onSierra Leone). Study 8onIndia)andtodemobiliseformer child programmes toeradicate childlabour(seeCase has played role. animportant Examplesinclude problems, ofparticular importance focused action government, donorsandcivilsocietyconcerningthe Where there hasbeenaconsensusbetween Focused action laws hasbeenpatchy. However, implementationofmany childprotection unlawful recruitment ofchildren (UNICEF, 2009c). Commitments andParisPrinciplestoprevent the conflict andtheadoption by many statesofthe Paris mechanism onchildrightsviolationsduringarmed include implementationofamonitoringandreporting impunity for crimesagainstchildren. These efforts many countriesasaresult toend ofglobalefforts Pornography. Legalreforms have beenintroduced in the SaleofChildren, ChildProstitution andChild have signedandratifiedtheOptionalProtocol on Children in Armed Conflict. More than100countries on theRightsofChildInvolvement of acceded totheOptionalProtocol totheConvention Over three-quartersofstateshave signed, ratifiedor Organization’s (ILO’s) mostratifiedConventions. Age Convention isamongtheInternationalLabour Forms ofChildLabourConvention. The Minimum has beennear-universal ratificationofthe Worst marriage underage18inmany countries. There punishment inschools(Jones etal., 2008a)and maltreatment have beenbanned, suchas corporal child protection, forms ofchild andparticular Legal reform hassetaframework for actionon Legal reform been achieved? How hasprogress inimproving childprotection labour, ashas dedicatedfundingfrom ILO-IPEC. education hascontributedtothedeclineinchild India respectively). More broadly, aidtopoverty and (see CaseStudies7and8onSierra Leoneand contributed tosomeoftheimprovements witnessed donor allocationstosocialwelfare. However, aidhas child well-being examined, reflecting generally low it islikely tobelower thanfor theotherareas of promoting childprotection couldnotbefound, Although aggregated dataonlevels ofaidto Aid et al., 2003). of Korea, SriLanka, Taiwan and Thailand (Mathur associated withlatermarriage ageintheRepublic employment andeducationlevels have been been important. Improvements insocialwelfare, other factors, suchassocialmobilisation, have also to improvements inhouseholdincomes, although early marriage, whichare especially responsive on someissues, childlabourand inparticular Poverty reduction hascontributedtoprogress Poverty reduction early marriage (MackieandLeJeune, 2009). protection, reductions particularly inFGM/Cand contributed tosomeimprovements inchild practiceshavemobilisation againstparticular Awareness-raising onchildren’s rightsandsocial Social mobilisation and FGM/C(MackieLeJeune, 2009). attitudes, for examplewithrespect toearly marriage Civil societyhasoftenbeeninstrumentalinchanging NGO PlanInternational(Cody, 2009)(seeBox 8). wide-scale registration campaignsby theinternational progress registration onbirth islargely aresult of governmental capacity ormotivation. For example, society organisations, reflecting partly gaps in protection hasoftenbeenspearheadedby civil More sothaninotherareas, progress onchild Active role ofcivilsociety 3 Progress on key child-sensitive sectors 65 Since the project’s Since the project’s 87 inception in 1988, 486,000 children have progressed progressed have 486,000 children inception in 1988, education (2% of child labourers into mainstream occupations in hazardous working and 4% of children 2008 place between most of this has taken in India); 52% of Around 2010). et al., and 2011 (Satpathy non-formal from progressed have children enrolled has not Targeting education (ibid.). to mainstream 79% of sampled as only successful, been entirely and range (9–14), of the targeted age are children in the programme enrolment at the national level, is around not child labourers who are of children 30% (ibid.). the NCLP to all plans to extend The government 2009). 602 districts in the country 2012 (USDoL, by for 90% of funding plan, Under the 10th five-year to the NCLP (Satpathy child labour schemes went on the expenditure However, 2010). et al., from years, scheme has been declining in recent million Rs 1.57 billion in 2008/09 to Rs 927.1 large scale of despite the continuing in 2010/11, the problem. government by the INDUS (co-financed The six-year the US Department of Labor [USDoL] and of India, aimed to eliminate the initiated in 2004, ILO-IPEC), addressing of child labour in India by forms worst and in the NCLP and other national initiatives gaps Examples of the focus components. piloting additional income-generation activities for of INDUS were departments of government capacity-building parents, beneficiary and and tracking partners, civil society and the public to strengthen It also worked monitoring. schools in the project education system and formal Other activities included the 2006a). (ILO, areas occupations hazardous from of children withdrawal Impacts child 280,000 former approximately In 2010, occupations) hazardous from (100,000 labourers in the project. enrolled were

tudy 8 Study ase

The following data were collected when only 250 districts were participating in the NCLP. 250 districts were collected when only data were The following 87 The NCLP is India’s largest programme aimed at largest programme The NCLP is India’s It is implemented through eradicating child labour. 266 the Ministry across and Employment of Labour child labour is most markedly of the districts where and works 2011), endemic (Department of Labour, hazardous from children and rehabilitate to withdraw primarily focus The projects 2004). occupations (ILO, Special schools provide education. on non-formal and non-formal with formal child workers former supplementary training, vocational education, stipends and health examinations, monthly nutrition, into mainstreamed eventually are and children ordinary schools or employment. In addition to action on factors underlying to action on factors underlying In addition the and education, poverty such as child labour, ILO including NGOs, and its partners, government committed have and US Department of Labor, in the to tackling child labour substantial resources first country India was the to join past 20 years. the Elimination of for the International Programme and has since launched in 1992, Child Labour (IPEC), including the various anti-child-labour programmes, the (NCLP) and National Child Labour Project (INDUS). Indo-US Child Labour Project India is home to the largest population India is home to under 14 in the world: of child labourers 2007b), 2007a, 12.6 million (NCPCR, over of the global population of 7% or nearly million Two 2006b). (ILO, children working in hazardous employed are of these children engaged and the majority are industries, occupations and hazardous in exploitative to their development detrimental that are rights. and undermine their basic human be considerably may involved The numbers to be estimated there NGOs have higher: children million working 25 and 115 between 2007b). in India (ILO,

hild labour in India labour Child C 66 progress in child well-being duplicated heading? transitional educationcentres achieved (ILO, 2007a). (against atargetof40%), withgenderparityin from vocational trainingare now ‘gainfully employed’ figure. Around 57%ofadolescentswhograduated (USDoL, 2009). This was20,000more thanthetarget more than100,000children from hazardous work By 2009, the$40millioninitiative hadwithdrawn Impacts (ILO, 2006a). operating buthandedwork over toINDUS states; in6ofthesedistrictstheNCLPwaspreviously Labour andEducationin21districtsacross 5major initiatives of by bringingtogethertheDepartments on andcomplementtheNCLPothernational social mobilisation(USDoL, 2009). Itsoughttobuild stipends, vocational trainingandawareness-raising/ supplementation, healthcare, primary monthly and provision oftransitionaleducation, nutritional 88 www.unicef.org/india/child_protection_2053.htm 2012). (accessed 14February children’s income. prevalent, reflecting family dependenceon continues tobeculturally acceptedandwidely labour (aswell aswork inhazardous conditions) Labour Act in2006. Nevertheless, childdomestic in thehospitalitytradewere appended to the Child children or under14working asdomesticservants sectors (NCPCR, 2007a). banson Supplementary 90% ofthelabourforce isemployed inunorganised only organisedsectorsofproduction, whereas over hazardous industrialchildlabour; however, thiscovers Labour Prohibition andRegulation Act addresses the Worst Forms ofChildLabour. Its1987Child India hasnotyet ratifiedILOConvention 182on Challenges 88 3 Progress on key child-sensitive sectors 67 Donor funding to 90 Taking action Taking requires children in protecting progress Greater fronts: action numerous of and understanding visibility for Greater child protection of enhanced the necessity to invisible is simply Much child maltreatment data Without reliable and donors. policy-makers of its causes and consequences, and understanding small-scale as a relatively it can often be dismissed development. overall to and/or insignificant problem on child protection, focus without a greater However, the MDGs will achieving towards global progress example, For 2010). (EveryChild, be hindered the education MDGs (2 and 3) requires achieving (including the educational inclusion of all children in extended family girls and children married young violence in addressing and prison or work) care, the health MDGs towards progress For schools. on sexual abuse action effective more 5 and 6), (4, early and preventing and exploitation of children is vital (ibid). marriage policy emphasis on and Greater child protection for resources on and agencies working ministries Government underfunded, often grossly are child protection with other and their allocations minimal compared only that found one review example, For sectors. Asia Pacific budgets in the 4% of social protection (ADB, dedicated to child protection were region child donors, Among many 2010). in EveryChild, 2007, priority than concerns is also a lower protection a recent example, For and healthcare. such as food continues that child protection UNICEF report found underfunded in emergencies. to be significantly to to respond $129 million was required In 2009, the UN Central in emergencies by child protection of this was but less than one-third Emergency Fund, 2011). et al., (Lilley received ILO-IPEC has been cut in recent years, including a years, ILO-IPEC has been cut in recent $60 million 2008 to 2009 (from from 20% reduction 2010b). to $53.7 million) (ILO, Only 93 countries have banned corporal 93 countries have Only 89 This is compared with $7 billion received for all sectors. all sectors. for with $7 billion received This is compared In 2002, an estimated 150 million girls and 73 million boys under 18 had been raped or suffered other forms of other forms or suffered under 18 had been raped 150 million girls and 73 million boys an estimated In 2002, 90 89 sexual violence (Krug et al., 2002, in Plan International, 2008). in Plan International, 2002, sexual violence (Krug et al., Violence against children in schools children Violence against punishment, including corporal School violence, school authorities and teachers, sexual abuse by is a pervasive problem other pupils and bullying, (Plan International, the world all over children for 2008). Child labour million about 215 labour, on child Despite progress the in some capacity, work worldwide children Africa (where in sub-Saharan majority concentrated Pacific Asia and labourers) are 25.3% of all children 70% Around labourers). are children 13.3% of (where and 91 million are aged 5–14 years, (153 million) are involved million) are than half (115 More under 11. or such as dangerous situations work in hazardous vulnerable to physical, or are environments, unhealthy labour or forced psychological or sexual abuse, engaged in illicit activities with some children slavery, Furthermore, work. such as drug trafficking or sex involvement overall in the has been an increase there 7%) and of older children in labour (by of boys (Diallo 16%) (by work (aged 15–17) in hazardous 2010). et al, Birth registration all births – 36% of 48 million children An estimated The majority unregistered. – remain worldwide Asia and populations in south poor come from respectively 64% and 62% where Africa, sub-Saharan 2012). (UNICEF, unregistered go Ongoing challenges challenges Ongoing punishment in schools, and the law is often not and the law punishment in schools, Research 2008a). et al., (Jones enforced effectively 2003 and 2005 in a range of conducted between one-fifth that between countries found developing reported (Zambia) of children (China) and two-thirds bullied in the previous or physically being verbally 2008). (Plan International, 30 days 68 progress in child well-being attention toproblems ofcorruption ifnecessary. capacity inthepoliceandcriminaljusticesystem, with and Maher, n.d.). Tackling theserequires enhanced forces (UNICEF, 2009c)andchildtrafficking(Skinner child rightsabuse, includingenlistment intoarmed organised crimerings, are involved insomeforms of Powerful interests, suchasthoseofmilitiasor Addressing powerful interests child protection initiatives (Jones andHolmes, 2011). protection programmes, suchascashtransfers and potentially through stronger linkagesbetween social be betterintegratedintoactiontoprotect children, (eg, Mathuretal., 2003), andanti-poverty actionmust including childlabour(ILO, 2010a)andearly marriage Poverty underpinsmany childprotection problems, Action onpoverty LeJeune, 2009). these entrenched andsensitive issues(Mackieand been successfulinmobilisingsocialchange, even on intervene. Awareness-raising campaignshave, however, it isbeyond thepower ofthestateorNGOsto abuse –isoftenseenasafamily matter, oneinwhich Child maltreatment physical –particularly andsexual FGM/C (Pinheiro, 2006; UNICEF, 2005b; 2009b). against children, childlabour, childmarriage or Entrenched culturalnormsoftencondoneviolence Action onentrenched culturalnorms et al., 2010). offeredsupport toaffected children (Wulczyn can beprevented more effectively andmore holistic protection systemssothatabuseandexploitation actionisneededtostrengthenFurther child inseveraloften needsupport areas simultaneously. ignoring thefactthatabusedandexploitedchildren focused onindividualforms ofchildmaltreatment, Much actiononchildprotection isfragmented, Strengthening childprotection systems accounts for theirrelatively smallscale. few key agenciesactive inchildprotection, which on programming. Successeshave beendriven by a conduct for theirstaff, ratherthananenhancedfocus have ofteninvolved area theimportant ofcodes Donor responses tochildprotection concerns OF ACROSS differentdimensions and improving educationandhygiene. improvements, poverty reducing householdmonetary outcomes inBrazilhave beenachieved by, among other girls’education);(particularly andbetternutritional have beenlinked toimprovements ineducation sectors. For example, improvements inchildmortality strengthened through synergieswithprogress inother how somesector-specific have interventions been Some ofthecasestudiespresented earlierhave shown elementssimultaneously.on thevariouscontributory investment ofresources andfocused policyattention action toenhancechildwell-being requires nature ofchildwell-being andthefactthateffective holistic manner. This reflects the multidimensional to improve childwell-being inacomprehensive and ofmaximisingsynergiesbetweenimportance sectors are tochildren, important we now focus onthe Having analysed progress inspecificsectorsthat REDUCTION and 3.8 improve thesituationofminorityethnicgroups. among theKinhmajority, despiteprogrammes to children. However, progress hasbeenconcentrated social well-being for households, for andparticularly a plannedapproach towork ondifferent areas of except nutrition. This progress hasbeenfuelled by progress across mostchildwell-being indicators the countriesthathave madethemostimpressive This lastcasestudyfocuses on Vietnam, oneof Multidimensional poverty child well-being progress

3 Progress on key child-sensitive sectors 69 Child poverty rate Child poverty Urban Rural 32.6 5.5 Vietnam 26.7 42.8 was estimated to have fallen to 9.4% (AEF, 2010). The 2010). fallen to 9.4% (AEF, have was estimated to in recent dramatically rate has reduced child poverty 65% in 1993 to 26.7% in 2004 (Nguyen, from years: A). 2008) (see Figure monetary from suffering of children The number decades, in recent dramatically has dropped poverty B). rate (Figure in line with the national poverty it is higher than the national poverty However, households tend to have rate because poorer than other children and thus more larger families, in poor households. live population groups 9.7 36.4 53.1 14.2 46.4 71.9 30.3 1993 1998 2002 2004 65.2

tudy 9 Study ase

0 , 1993–2004 (%) /urban residence, by rural rate Child poverty A: Figure 10 20 30 40 50 60 70 80 Source: VLSS 1992/93, 1997/98, VHLSS 2002, 2004 in Nguyen (2008). (2008). 2004 in Nguyen VHLSS 2002, 1997/98, VLSS 1992/93, Source: The country of has far exceeded the MDG goal than $1 of those living on less halving the proportion 40% in 1993 to 4% in 2008. from it reducing per day, line the national poverty The population living below 58% in 1993 to from 80%: over by has decreased By 2010 the proportion 2010). 14.5% in 2008 (SRV, Vietnam has exhibited one of the sharpest Vietnam has exhibited in the world poverty declines in absolute global despite the decades and, in recent continue levels poverty economic slowdown, 2009a). Bank, to decline (World positive impacts on children in impacts on children positive multi-sectoral development with with multi-sectoral development xceptional poverty Exceptional and reduction C paragraph split here to shorten standfirst: OK? to shorten split here standfirst: paragraph 70 progress in child well-being 56 to14per 1,000 live(ODI, births 2011c), fulfilling and 2008, under-five ratesdeclined from mortality amongpoorpopulations.particularly Between 1990 Child healthoutcomeshave improved dramatically, Health in previous years (SRV, 2009a). which wasat92.5%in2008, after constantincreases significant onpreschool enrolment of3–4-year-olds, countries inthesub-region. Progress hasalso been enrolment put Vietnam inaleadingpositionamong (VASS, 2006). school These increases insecondary 90% in2004, from 7%to63% anduppersecondary enrolment wentsecondary upfrom 30%in1993to in 1991to95%2006(ODI, 2011c). Netlower schoolenrolment roseNet primary from 89% Education fromsupport UNICEF. sensitive development strategy, drawn upwith achievements reflect inpart anexplicitly child- towards achieving theMDGs(ODI, 2010c). These terms ofbothabsoluteandrelative progress ranksinthetop10worldwide in The country child poverty reduction Multidimensional Source: VLSS 1992/93, 1997/98, VHLSS 2002, 2004, inNguyen (2008). Figure B: Childmonetary poverty rate in Vietnam, 1993–2004(%) 10 20 30 40 50 60 70 0 1993 58.1 65.2 1998 37.9 46.4 2002 28.9 36.4 to 15per1,000livein2008(SRV, births 2009c). also decreased, from 21per1,000livein2003 births (UNICEF, 2010b). among children Infantmortality ranking above any butthehighest-incomecountries the government’s 2010targettwo years early and with a38%increase intheproportion ofthe improved watersources between 1995and2008, with regard toprogress onsecuringaccessto Vietnam wasoneoftheworld’s top10countries W affected (UNICEF, 2010b). ethnic groups inremote ruralareas theworst of Vietnamese children, highrate, avery withminority Van Anh, 2011). Stuntingcontinues toaffect one-third worldwide for underweight children (Jones and Thi remains oneofthe10most-affected countries 1997 to0.91in2006(ODI, 2010c). However, Vietnam ratio ofunderweight children underfive, from 1.13in 2009). hasalsoreduced themale–femaleThe country decline inunderweight: from 49.1%to34%(Nguyen, deprived Highlandregion experiencedthegreatest in 2008(ODI, 2011c). Between 2001and2005, the five years olddecreased from 45%in1994to20% The prevalence ofunderweight inchildren under Nutrition ater,sanitation 2004 19.5 26.7 and hygiene rate Child poverty poverty rate National 3 Progress on key child-sensitive sectors 71 Equitable land 92 financing government government financing 93 and agricultural sector reforms in recent decades in recent and agricultural sector reforms underpinned growth, have in Vietnam, nutritional programmes are heavily heavily are programmes nutritional Vietnam, in creating below), (see donor funding on dependent across of coordination agenda and a lack a limited (Jones underfunded generally are and they ministries, and Anh, Thi Van 2011). in the addressed are and sanitation Clean water Growth Reduction and Poverty Comprehensive Supply Water Strategy Rural Clean and the National which aims to achieve and Sanitation Strategy, sanitation services water and to safe access universal Water Rural five-year Vietnam’s 2020. by in rural areas Programmes Target and Sanitation National Supply meeting targets. in been effective have integrated into has been on children A focus and sector- strategies national development National Three specific plans and targets: been have Children Action for of Programmes These establish time-bound implemented since 1991. education nutrition, health, children’s for objectives and for and access to clean water and hygiene, with specific of children in the numbers reductions and those children vulnerabilities such as street abuse and trafficking sexual HIV/AIDS, by affected plans are These child-sensitive 2007a). (UNICEF, the Programmes, Target integrated with National policy. government for main implementation vehicles for Programme Target include the National They which supports access to basic Reduction, Poverty exemption school fee through including services, These are 2009). (MOLISA et al., and reduction a range of specific programmes complemented by situation of particularly the aimed at improving disadvantaged children. and longstanding orientation A strong government The pre-1990 equity: income towards in education. substantially invested investment in education, healthcare and general healthcare in education, investment 2011c). (ODI, reduction poverty been has also The fiscal decentralisation process with provinces since 2006, equitable and pro-poor: of levels lower headcount ratios, higher poverty of minority ethnic presence greater local revenue, rose from 10% in 1993 10% in 1993 from rose 91 this progress High education levels have in turn contributed to sustained economic progress and helped to attract large in turn contributed to sustained economic progress have High education levels benefiting with minority ethnic communities among the Kinh majority, has been concentrated however, This, That is, double-vault composting latrines, ventilated pit latrines, pour/flush-water sealed latrines and septic tank pit latrines, ventilated composting latrines, double-vault That is, 92 93 91 08/2005/QD-BYT). latrines used in the household (MoH Decision No. 730,000 people (although this accounted for employed FDI projects (FDI). investment direct of foreign volumes state revenue. 2002 contributed $480 million towards and by 2006, by 1.5% of workers) only 2009c). Bank, (World reduction poverty little from In addition to major investments in the health in the health to major investments In addition Poor the Fund for such as the Health Care system, with international Vietnam has a worked (HCFP), specific organisations such as UNICEF to improve the EPI has In the past 15 years, health indicators. 90% of the population against vaccinated over (UNICEF, measles and diphtheria tuberculosis, tetanus and maternal and neonatal Polio 2009b). Vietnam has and 2008), been eradicated (Le, have deficiency micronutrient also begun to control 2005).The National Nutrition Bank, diseases (World child Strategy on improving (2001–10) has focused enhancing food through and maternal nutrition disease, nutrition-related security and reducing An anti- particularly among minority ethnic groups. has under five children for programme malnutrition The 2006). (IMF, province been implemented in every prevention malnutrition child on programme 2001–05 all the National among the most effective was ranked consistent with relatively Programmes, Target Health 2009). Vietnam (Nguyen, throughout achievements public sector spending as with much However, ? been achieved commitment government strong has been There with policy commitments to social investment, example, For programmes. translated into concrete Reduction and Growth Poverty the Comprehensive the the Secondary Education Master Plan, Strategy, Plan (2001–10) Education Strategic Development All campaign and the National Education for primary all emphasised universalising and have secondary education. has How population (to 94%) using improved drinking water drinking improved 94%) using (to population over improved also to sanitation Access 2010c). (ODI, with of the population the proportion this period: latrines hygienic access to to 32% in 2004 (VASS, 2006). Most schools now have have now Most schools 2006). 2004 (VASS, to 32% in and 73% and latrines (80% sources water improved meet national not yet do many although respectively), 58% of By 2005, 2007). (UNICEF and MoH, standards water and had improved areas clinics in poor rural 2005). (SRV, sanitation facilities 72 progress in child well-being 2. 1. decade. For example, in expenditure onkey socialsectorsover thepast Financing: There have beensignificantincreases 3. 2. 1. For example: reflected inbudgetsandconcrete programmes. disadvantaged children’s hasbeen accesstoservices A strong policyfocus onsecuringpoorand sharing taxproceeds nationally (World Bank, 2009b). minimum expenditure needsare alsoexempted from the centralgovernment. Provinces which cannot meet districts receive largerpercapita fiscaltransfers from communities andmore geographically disadvantaged for children. its commitmenttoexpanding healthcoverage children undersix(UNICEF, 2010d)tosupport put $25milliontowards healthinsurancecards for Further, between 2005and2006, thegovernment 9.3% between 2000and2008(WHO, 2011b). government expenditure) rose from 6.6%to Health expenditure (asapercentage oftotal (World Bank, 2005). schoolteachersalariesnearly doubled primary education. Between 1999and 2002, spendingon (SRV, 2009a), withmost spendingonprimary 2002 to2006(VND15billion150billion) The educationbudgetincreased 10-fold from (UNICEF, 2010d). families are now entitledtofree medicalservices sick children from economically disadvantaged six hadbeengrantedfree medicalcards, andmany 2009; SRV, 2008). By2006, 96%of children under through healthcare cards orinsurance(Nguyen, andessentialdrugs free accesstohealthservices from thegovernment’s HCFP, whichprovides whom children are over-represented) benefited In 2004, 84%ofthepoorpopulation(among of education. (which are oftenthemostexpensive component reported exemptions from schoolcontributions secondary; more than50%and30%, respectively, school tuitionfees, asdid60%for lower received completeexemption from primary Targeted Programme for Poverty Reduction A totalof95%beneficiariestheNational for difficult-to-access regions schools experimented withalternative primary ofEducationand The Ministry Training has ethnic groups, includingearly childhoodeducation. disadvantaged children andthosefrom minority are committedtoensuringeducationalaccessfor Three of Vietnam’s key development strategies h a n, 2010). Thi VanAnh, unsustainability ofsomeprogrammes (Jones and This contributestothedonordependencyand ad hocandgenerally poorly fundedfrom thestate. Vietnam’s socialprotection systemisfragmented, for Poverty Reduction(2006–10)(SRV, 2009b). 8.5% offundingfor theNational Targeted Programme Areas (Programme 135-II)isprovided by donors, asis Communes inEthnicMinorityandMountainous Socio-economic Development ofExtremely Difficult 30% oftheNational Targeted Programme for the on socialhealthcare (UNICEF, 2010b). For example, contributed 27percentofthetotalmoney spent development aid, andin2006, thestateonly national AIDS response isfundedby international financing gaps insomesectors. Sixtypercentofthe Aid hasplayed role animportant inbridging 3. Ongoing challenges and areas. disadvantaged households attention toparticularly This underlinestheneedfor continued focused socio-economic groups have increased (ODI, 2010c). malnutrition ratesbetween thepoorest andrichest In recent years, and disparities inchildmortality the richesthouseholds(Leetal., 2008; UN, 2011). likely todiebefore theageoffive thanchildren from the poorest householdsare two tothree timesmore critical determinantofchildoutcomes. Those from better-off households: Householdincomeisa Reducing disparitiesbetween poorand programmes tothese hard-to-reach areas. andotherdevelopmentextend socialservices greater, socontinued commitmentisneededto are generally higherandtheinfrastructuralchallenges of reaching suchgeographically isolatedcommunities for 39%of Vietnam’s poor(Nguyen, 2008). The costs comprise only 12.6%ofthepopulation, they account (Le etal., 2008)and, althoughminorityethnicgroups and urbanareas onallchildwell-being indicators significant persistentdisparitiesbetween rural rural andminorityethniccommunities. There are become increasingly concentratedamongremote areas: Asoverall poverty ratesoffallen, poverty has Concentration ofpoverty indisadvantaged (Nguyen, 2009). $1.87 millionin2000to$2.672004 prevention programmes increased from The statebudgetallocationtochildmalnutrition 4 Drivers of progress

This section explores the critical economic, resourced sectoral strategies, in both human and political, socio-cultural and technological financial terms, mobilising donor support where drivers of progress identified through our necessary.94 Sustained policy commitment in the analysis of progress in different areas of medium term through changes of government and children’s well-being, the wider literature dedicated civil service capacity have underpinned on development progress and the country improvements, as they reduce the risks of programme discontinuation and capacity gaps that arise with case studies. For an aggregated analysis of political change. This is critical to child well-being progress in different areas of child well-being because change takes time – particularly among the such as this, it is difficult to make quantitative poorest children, where disadvantage is entrenched. estimates of the contributions of different Among our case studies, continued commitment to drivers of progress, such as aid, growth, reducing child mortality in Bangladesh across several the political economy, etc. Our quantitative governments stands out. analysis probed the role of aid, rather than The space that civil society organisations have in comparing its role with that of other factors which to act can also be critical to child well-being. (see Appendix 2). Therefore, our analyses In some sectors, for example child protection, in this section rely principally on qualitative NGOs have helped to extend provision, particularly assessments of the roles of different factors in geographically isolated areas and to socially in the achievements discussed in Section 3. marginalised groups. They have frequently developed innovative approaches to provision that address social or financial barriers to service use (see Box 7 4.1 A supportive political on education in Afghanistan) and found ways to AND policy environment better protect extremely vulnerable children (such as child workers or former child soldiers – see A supportive political environment is one of the Case Study 7 on Sierra Leone). NGO advocacy also most important factors underpinning progress for has an important role to play in helping to build children. In most cases where sustained progress has accountability of both public and private service been achieved on a significant scale, the leading role providers. Success has been driven principally, of the state has been crucial, providing direct policy however, by a state that is strong both as a provider support, creating an enabling environment, financing and as a regulator (as in Chile’s ECD programmes), initiatives or allowing the space for NGOs and reflecting state capacity to provide services on a donors to fill government gaps. Mehrotra and Jolly’s large scale; NGOs can often only fill gaps in state (1997) analysis of 10 “well-performing” countries on or private sector provision. human development found that the state had played a critical role in ensuring that the vast majority of the Where service delivery is decentralised, local population had access to basic services. Our sectoral governance structures are sufficiently strong and and case study analysis in Section 3 bears this out. adequate implementation capacity exists, devolution of resources and decision-making power has Progress has often been driven by high-level contributed to region- or state-level improvements political commitment to a particular area (eg, health, in child well-being (Mehrotra, 2004; Case Studies nutrition and poverty reduction in Brazil; education 6 and 9 on Ethiopia and Vietnam, respectively). The in Ethiopia), with the development of adequately rise of a social accountability movement, embodied

94 This contrasts with a common situation where leaders express their support for the MDG agenda or for child well-being without putting in place policies, strategies and programmes to articulate this support.

73 74 progress in child well-being IMPLEMENTEDprogrammes 95 coverage. The casestudiesinSection3looked at capacity for effective implementation, reach and encompasses issuesaround design, financing, programmes andinterventions. Effectiveness only whenimplementedintheform ofeffective frameworks leadto progress inchild well-being Study 9)examplesbearthisout. Coherent policy not. OurBrazil(CaseStudy2) and Vietnam (Case severe childdeprivation ratesthanthosethatdo within andoutsidefamilies–generally have lower childrenrange ofpoliciesinplacetosupport –both UNICEF, 2011a)suggeststhatcountrieshave a At anaggregate level, recent analysis (e.g. ODI, 2010c; 4.2 be immunised. inconflicttoceasehostilitiessoinfantscan parties Days have beenbasedonagreements between all instance, innovative approaches suchasImmunisation and programmes. Inconflict-affected states, for the Afghanistan exampleinBox 7)todeliver services and civilsocietyworking withlocalauthorities(see quick-changing regime. Another exampleisNGOs formulti-actor initiatives support inthecaseofa work withdifferent politicalstakeholders togarner Some inroads have beenmade, for example, through circumvents difficultieslinked to weak governance. benefit children have tobedeveloped inaway that provision (OECD, 2008). Therefore, to interventions government solutionsandtoalternative, non-state control ofservices, gives greater prominence tolocal humanitarian anddevelopment financinganddeclining resources, exacerbatedby poorcontinuity between conflict. The resulting problem ofdiminishedcentral willingness orthebreakdown ofsocialorder through lack ofgovernment capacity, lackofgovernment may ofsocialservices the delivery beimpaired by investment isanadditional challenge. Incentives for and sustainpolicycommitmentstosocialsector achieving sufficientpoliticalstabilitytoinitiate In fragilestatesandconflict-affected countries, Case Study2onBrazil). insomeplaces(Worldpublic services Bank, 2004; see helped toimprove thequalityandaccessibilityof monitoring, advocacy andcitizenscorecards, hasalso in initiatives ontherighttoinformation, budget activities inNigeria. Seefor example, Jones etal. (2011), whodiscussthelow levels ofgovernment fundingtochildprotection Well-planned and

Children, 2011c). and 3.5millionhealthworkers are needed(Save the schoolteachers(UNESCO,1.9 millionprimary 2011) of teachersandhealthworkers: globally, anadditional remain, suchasmeetingtheneedfor largernumbers funding toinfrastructure. However, criticalchallenges providing atlocal level, services aswell asincreased andagreatersupport number offront-line staff has comprisedbothadministrative/managerial into effective programmes in Vietnam). Resourcing 9 for anexampleofconverting policycommitments and 3.6for examplesoneducationandCaseStudy and bridge[meaning?]are crucial(seeSections3.5 properly resourced policies sectorplanstoarticulate associated casestudies, ambitious, detailedand Further, asillustratedby sectoranalyses andthe for achievements inchildwell-being. ofsuccessfulprogrammeimportance implementation both policiesandprogrammes, stressing the governmental contributions. and donorcommitmentsoftenoutweigh provided directly by donors)thangovernments, of children andwithgreater resources (often issues, they are oftenreaching largernumbers that, where NGOsare active onchildprotection so low, inlow- andmiddle-income countriesalike, child protection, where government funding isoften provided by governments. A key exception isin funding for improving children’s well-being has been Even inthepoorest countries, themajorityof of theinternationalcommunity. commitments by countries, with thesupport sharing andtheestablishmentofconcrete channel financialandhuman resources, knowledge- as Educationfor All, have generatedmomentumto educationthroughuniversal initiatives primary such multilateral fundsandNGOs, orthepromotion of HIV/AIDS backed by donors, individualcountries, commitment tosomeareas, suchasthefightagainst sanitation) (UN, 2011). Inaddition, high-level and,child mortality toalesserextent, waterand reduction, education, primary HIV/AIDS, reducing investment insomeMDGsandtargets(eg, poverty associated withtheMDGshave ledtoconsiderable The politicaltractionandresource mobilisation 4.3 Resourcing 95

4 Drivers of progress 75

97 Education 24.1% Health 16.1% 13.8% programmes Population maximum impact on children at a relatively low cost cost low at a relatively children on impact maximum children’s to advancing to be critical will continue countries. particularly in the poorest well-being, has increased aid to child well-being Overall aid Bilateral decades. in recent substantially services to basic social commitments (education, than doubled and sanitation) more water health, $3.2 billion to 2004 (from 1995 and between Spending on primary education $7.1 billion). in 2005 to $3 billion $2.3 billion from increased top 10 world’s the 2006 and 2008, Between in 2009. $13.7 billion in assistance donors contributed ($1.8 billion of which went to the health sector services) of basic healthcare – an increase toward data). 1990 (OECD-DAC $11.8 billion since bilateral and average total annual In 2007/08, aid commitments to water and sanitation multilateral 2003 and 2008, Between amounted to $7.2 billion. aid to clean water both bilateral and multilateral 2010). (OECD, 15% and 4% respectively by increased, on the contribution of aid to The literature is surprisingly in social well-being improvements did not find of the literature and our review limited, demonstrating a causal link compelling evidence children. for outcomes aid and positive between , 2005–08 (%) , by sector social sectors to WASH 14.9% WASH have limited many low-income low-income many limited have 96 Government and civil 31.2% Government 17: ODA ODA Figure 17: For example, median health sector expenditure per person across sub-Saharan Africa in 2011 was $13.4 (up from Africa in 2011 was $13.4 (up from sub-Saharan per person across median health sector expenditure example, For a health aid produces per capita 2009 study which finds that doubling Exceptions include Mishra and Newhouse’s Effective programmes need to be affordable in a need to be affordable programmes Effective minimising leakages requires which sustained manner, government Increasingly, and wastage of resources. in resources seeking to invest and donors are within outcomes that can yield positive programmes in terms of Progress of costs. a manageable level in the use of public funds and in the transparency of interventions has enabled a better evaluation some programmes for use of resources overall in Case Study 2). (see discussion of Bolsa Família a that can have programmes policies and Developing countries’ ability to provide services either that are ability to provide countries’ quality or of high enough to their goals near enough notable progress Niger’s example, For to be effective. and maternal of child very high levels in reducing absolute very by low mortalityhampered has been in middle- Even 2010a). the Children, (Save resources of the quality and availability income countries, on their contribution to services can be a brake Case Study 2 on example, For well-being. children’s cash transfer the Bolsa Família Brazil suggests that in improving as it could has not been as effective of a lack of and poor- because nutrition children’s in some rural areas. quality health facilities 96 97 $9.4 in 2001), with 33 countries spending less than S$33 on health (WHO, 2011a). 33 countries spending less than S$33 on health (WHO, with $9.4 in 2001), which is small but significant. in health spending per capita, and a 7% increase in infant mortality, 2% reduction Source: OECD-DAC data. data. OECD-DAC Source: Across the areas analysed, low absolute levels levels absolute low analysed, areas the Across of expenditure 76 progress in child well-being been thecaseinEthiopia. contribute tobetterpolicyoutcomes, ashasalso enabled qualityimprovements to delivery inservice sector), ithasprovided additional fundingthathas Section 3.6). Inothers(suchasBangladesh’s health aid fundsconstitute25%oftheeducationbudget(see some sub-Saharan African countries, suchasEthiopia, sectors(seeCaseStudies1,particular 3, 6and7). In aid hasbeensignificantinindividualcountriesand Our casestudiesillustratethatthecontributionof more in-depthanalysis. See Appendix 2for fullmethodologicaldetailsanda financing socialexpenditure (Gomaneeetal., 2003). through promoting economicgrowth orthrough of aidonsocialwell-being indicators, whether that there isaggregate evidence for apositive effect summarised inBox 9, andtheliterature doessuggest improving thelives ofchildren. Key insightsare the pastdecadealsomademostprogress in that countriesreceived themostaidover However, dataanalysis demonstrates ourprimary 98 The prevalence ofunderweight inchildren under5wasusedas anindicatorofchildmalnutrition. most progress inimproving children’slives? countries that Bo reduced childhoodmalnutrition We found thattheaverage high-aidcountry See Appendix 2for fulldetails. Our analysis wasrestricted tosub-Saharan Africa. is considerablevariationaround theseaverages. treated withappropriate caution. Moreover, there determine acausalrelationship, andthusmust be These are descriptive statistics, notanattemptto outcomes over thesameperiod. the average annual improvement inchildhood the lastdecadefor whichdataare available, and of aidpercapita received by eachcountry, over relationship between theaverage annual quantity To answer thisquestion, we have estimatedthe 2.7m children would nolongerbemalnourished. 2 percentage pointsacross allofsub-Saharan Africa, country. Ifmalnutrition ratesfell by anadditional the decade, compared withthe average low-aid additional 2percentage pointsover thecourseof x 9: Keyinsights from primary data received the 98 by an most services (seeCaseStudies1,services 6, 8and9). implementation ofeffective programmes and already existandcanstrengthen andfacilitatethe where nationalcommitmentstochildwell-being In bothcontexts, aidismosteffective for children and Uganda). other developing countries(eg, Malawi, also provided toestablishCCTsin support for designandimpactevaluations. Donorshave providing andtechnicalsupport financialsupport these initiatives have beenscaledup, withdonors outcomes (Barrientos anddeJong, 2006). Someof poverty reductionmonetary andchilddevelopment which have contributedsignificantly toimproving originated inLatin America (seeCaseStudy2)and dissemination ofexperiencesCCTs, which sharing ongood practices. Oneexampleisthe essentially catalytic, helpingtopromote knowledge In many middle-income countries, therole ofaidis countries was6.5children per1,000population. of childHIVinfection in this group ofhigh-aid with initially highinfection rates. The average rate of good progress by agroup ofhigh-aidcountries population over thepastseven years, as aresult of children livingwithHIVby 1.4children by 1,000 hadreduced thenumbertypical high-aidcountry the rest ofsub-Saharan Africa, we found thatthe Study 3). Comparinghigh-and low-aid countriesin inBotswana (seeCase important particularly recently stabilisedafterasharprise. Aid hasbeen In Southern Africa, childinfection rateshave The caseofchildhoodHIVismore nuanced. infant lives eachyear. all ofsub-Saharan Africa thatwould save 63,000 fell bymortality anadditional 4per1,000across the average low-aid country. Iftherateofinfant over thecourseofdecade, compared with by anadditionalmortality 4deathsper1,000 The average reduced infant high-aidcountry aid analysis: have also made the 4 Drivers of progress 77 major increases in school enrolment in Ghana, Mali, Mali, in Ghana, enrolment in school increases major (UNESCO, example for and Rwanda, Mozambique has been growth cases, in all these Critically, 2011). social progress. used to stimulate without place can take progress much However, particularly in health, growth, economic rapid explain is estimated to growth economic where in in healthcare improvements less than half the (Mishra the last 50 years countries over developing in A 1997 study of progress 2009). and Newhouse, that ten high-performing found human development Cuba, Costa Rica, Botswana, countries (Barbados, the Republic Mauritius, , state (India), Kerala made had Sri Lanka and Zimbabwe) of Korea, 50 years and education over advances in health in the industrialised 200 years that took nearly of economic growth Although their levels world. varied income poverty and success in reducing these countries made significant considerably, on child and infant mortality and basic progress population (Mehrotra, almost the entire education for generally, America more in Latin Similarly, 2004). public sector social spending has resulted increased but no indicators, human development in positive to a stagnating owing in growth, parallel increase and (Ocampo economic volatility and labour market some countries with high Furthermore, 2012). Vallejo, on little progress seen relatively rates have growth in Nigeria the numbers some social indicators (eg, in the absence grown, have of out-of-school children into growth to convert programmes of effective particularly context of high in the social investment, population growth). such as of child well-being, some areas Finally, than to growth less responsive are malnutrition, Egypt, countries (eg, middle-income Several others. of stunting high levels have Peru) Libya, Guatemala, after Likewise, 2011). UNESCO, 2009c; (UNICEF, India is still home to half decades of growth, two and has been malnourished children the world’s countries with than slowly its rate more reducing (UNESCO, rates half of India’s economic growth This highlights the importance of planned 2011). interventions that combine medical-nutritional causes of with action on the underlying measures insecurity and food such as poverty, malnutrition, gender inequality. but most agree that pro-poor policy that pro-poor but most agree 99 of growth ole R For example, Filmer and Pritchett (1997) argued that public spending has little effect on child mortality, and on child mortality, Filmer and Pritchett (1997) argued that public spending has little effect example, For 99 particular income, combination of per capita each country’s by that health outcomes can be explained entirely Yontcheva while Masud and and religion, of ethnic fragmentation level education, women’s distribution of income, infant mortality and better overall to reduced related is directly capita per (2005,) argue that health expenditure health outcomes. Economic growth can play an important role in important an role can play growth Economic greater and financing income poverty both reducing in which can result services, in social investment growth for However, children. for importantprogress increasing avoid also it must poverty, to reduce a inequality, In countries with less income inequality. below those reduced growth 10% rise in economic wide but in countries with 9%, line by the poverty produced only the same growth income inequality, must Growth 2000). et al., (Hanmer a 3% reduction active this requires achieving be pro-poor; therefore Economic growth governments. management by with a governments is expected to empower which can be directed of financing, sustainable source policy is pro-poor, if government at social investment 2010). (Durairaj and Evans, social welfare increasing and its relationship of economic growth The role is thus complex and with human development contested, 4.4 Economic growth has been an important has been driving Economic growth in most of the thematic areas progress for force In the main, and in our case studies. analysed occurred have well-being in children’s improvements periods of economic growth during or following in all cases, However, 6 and 9). 2, (see Case Studies 1, often planned, by has been accompanied growth dedicated which have programmes, multifaceted to resources and human resources both financial has expanded the resource Growth goals. achieving but, these programmes and facilitated envelope use of the fruits of policies to make without active not have would of progress the same level growth, Suri et al (2011) argue that human been achieved. is necessary growth: sustained to reach development policies in human development, without investment In will fail. economic growth aiming to increase high and which has achieved example, for Mauritius, the since independence, sustained economic growth inequality has also managed to keep government and effective redistribution through low and poverty This in turn provision. spending on social welfare educated population has helped maintain a healthy, 2011d). (ODI, growth and underpinned continued revenue improved As discussed in Section 3.5, has contributed to in tandem with growth, collection, is at least as important as growth. is at least as important as growth. 78 progress in child well-being majority ofthepopulation. reduction thathave madeiteasiertoreach the to underlying processes ofurbanisationandfertility health outcomes, nutrition and poverty reduction ofBrazil’sattribute part notableimprovements in some contexts. For example, Victora etal. (2011b) Broader socialchange hasalsofacilitatedprogress in on Bangladesh. in children’s well-being, asshown inCaseStudy1 also contributetoreducing genderdifferentials UNESCO, 2011). Empowerment ofwomen can reduce by 9%(Caldwell, childmortality 1986, in Indeed, eachadditional year ofgirls’educationcan nutrition andchildprotection (eg, Brazil, Bangladesh). have beencriticaltoimprovements inchildhealth, example, improvements ingirls’educationrates effect across different areas ofchildwell-being. For Increased genderequalityhashadastrong positive 4.5 critical (Save theChildren, 2011b). evidence-based policiesandprogrammes isequally far aschildwell-being isconcerned, acommitmentto undermine progress), theevidence suggeststhat, as stagnation oreconomicdeclineare likely to continues tobedebated(anditisclearthat While therole ofgrowth indevelopment progress Social change eliminating corruption. Africa, improving programme efficiency by cards forsmart cashtransfer insouthern delivery (pioneered by theGrameenBank)andbiometric to remote areas, suchasbankingviamobilephone advances have contributedtoextendingservices education have alsobeenvital(ibid.). Technological and capacity touseitthrough increased levels of preventable diseases. Increasing accessto information AIDS, from mortality malariaandimmunisation- and have played acriticalrole inreducing HIV/ have spread rapidly across theworld (Kenny, 2011) technologies thatcandramatically reduce mortality ideas hasplayed role. animportant Very cheap health Finally, insomeareas, DISSEMINATION thespreadand oftechnology ofideas KEYtechnology 4.6 Increased availability and

of

5 Conclusions and recommendations

There has been much progress in children’s importance. Our case studies of reducing child well-being globally over the past 20 years. mortality in Bangladesh (1), expanding access to Child mortality rates have fallen by over and quality of education in Ethiopia (6), eliminating one-third and there has been a significant hunger in Brazil (2) and extending ECD provision, decline in the numbers of children affected particularly for disadvantaged young children, in Chile by HIV. The numbers of children receiving (5) exemplify this confluence of factors. at least primary education and, in many Greater investment, facilitated by economic countries, also junior secondary education growth and development assistance have increased greatly. There has also been Progress has required significant financial investment, some progress in reducing severe and usually through a combination of increased moderate malnutrition, extending access to investment by national governments, and more aid. water and sanitation, and reducing children’s Increased government commitments have been risk of abuse and exploitation. The scale of facilitated by economic growth (Bangladesh, Brazil), progress has varied considerably, however, and by prioritising particular areas within government from region to region, country to country. expenditure (eg, education in Ethiopia received an Nevertheless, child mortality rates globally remain increasing share of the budget over a key period). very high: 7.6 million children under five died in 2010. Aid has been important in lower-income and lower There are 67 million primary school-age children still middle-income countries, and also in some upper out of school. Progress on reducing malnutrition has middle-income countries for specific issues (eg, in been slow. An estimated 2.5 billion people are still helping to address the particularly high HIV rates without improved sanitation, with major implications in Botswana). Our quantitative analysis found some for child health. The world as a whole is not on track evidence of the potential contribution of aid to to meet most of the child-related MDGs, although improving nutrition, reducing child mortality and certain regions and countries are on track to meet tackling HIV. Effective aid has often been aligned particular goals. with government-led sector development (eg, in Bangladesh and Ethiopia). Development assistance plays a key role in improving How do we move forward? children’s well-being, particularly in low-income countries. Our analysis demonstrates that those Government commitment countries in sub-Saharan Africa that received the Significant progress has usually been driven by several most aid over the last decade also made the most factors simultaneously. Strong political leadership progress in child well-being. Countries that received (often from the president) has been crucial. This large amounts of aid typically reduced childhood has led to a particular issue being institutionalised malnutrition by an additional two percentage points as a policy priority, and to governments being given over ten years, and infant mortality by four deaths mandates and resources (financial and human) to per 1,000. Replicating this progress across all of achieve clear goals. Coherent, widely accepted sector sub-Saharan Africa would prevent 2.7m children strategies, behind which donors have aligned (in from becoming malnourished and save 63,000 young aid-recipient countries), have been of fundamental children’s lives each year.[1]

100 These findings are based on a correlation and are not proof that aid caused these improvements. Nevertheless, there is clearly an association between aid and improved child well-being.

79 80 progress in child well-being agencies andmultilateral andbilateraldonorscan governments, NGOs, communities, international Continued commitment andenhancedactionsby achievements reach allchildren. by children butrathertowork toensure that ‘by half’ The goal shouldnotbetoreduce theproblems faced other becausetheeconomicpay-offs are enormous. standpoint –achildrightsperspective –andon the this are compelling, ontheone handfrom anethical beyond thatrequired for theMDGs. The reasons for be agreater mobilisationofresources andaction achieve amore ambitiousimprovement), there must aiming only tohalveratherthan childmortality Because theMDGsare inmany ways modest(eg, maximising theuseofdevelopment assistance. to makinginvestments more manageableandto budget planswithastrong childfocus cancontribute or sectorsupport). Well-designed policiesand have beenshown tobemosteffective (eg, budget governments tomake investments, inmodalitiesthat Development assistancecancontinue tofinance sectoral actionplans. budgets arecoordination between neededtosupport across sectors, whichimprove outcomes: specific planning hasoftennotaccountedfor synergies so figures areby country. bestascertained Policy estimating thegaps have generateddifferent results, education andsanitation. Varied methodologiesfor meet thechild-related MDGsinhealth, nutrition, There are significantgaps infinancingandactionto education andlower childandinfantmortality. include reduced populationgrowth through women’s economies. Indirect impactsoneconomicgrowth population, whichisacriticalcomponentofstronger and canleadtogreater productivity amongthe terms ofeconomicgrowth. Itdevelops humancapital Investing inchildwell-being hassignificantpayoffs in and services. the implementationofeffective programmes development assistancecanstrengthen andfacilitate child well-being already exist. Inthesecircumstances, effective for children where nationalcommitmentsto In bothcontexts, development assistanceismost promote knowledge sharingongood practices. income countries, aidisessentially catalytic, helpingto the educationbudget. Bycontrast, inmany middle- African countries, aidprovides asmuch as25%of progress across different sectors. Insomelow-income afford toallocateenoughresources tomake significant Many low- andlower-income countriesare unableto emerging knowledge are crucial. learning andsharingenhancedcapacity toacton some areas, suchaschildprotection, betterlesson- are widely acceptedascriticalways forward. In The Lancethave identifiedpackagesofinterventions) in thehealthandnutrition fields, where WHOand Evidence-based consensusonprioritiesfor action(as lessons ofhow achievements have beenmade. lead topositive outcomes, drawing ongood-practice intergenerational poverty cycles. greater socialcohesion. Itcanalsohelpbreak – cancontributetoreducing inequalityandfoster which focuses resources onthemostmarginalised Well-designed investment inchildwellbeing –one rights simultaneously. of childwellbeing andfor theachievement ofmany are optimalfor progress inthemultiple dimensions water andsanitation. These cross-cutting investments simultaneous investment ineducation, healthcare and poverty reduction. Vietnam shows thepayoffs from nutritional andchildhealthadvice, andcontributedto ofmothersabletoacton led toaneducatedcohort facilitated by itspriorinvestment ineducation, which payoffs. For example, Brazil’s progress innutrition was either insequenceorsimultaneously, hashadstrong Investment inseveral aspectsofchildwellbeing, implemented programmes Multi-dimensional andwell-planned, targeted, and been leftbehindby progress amongmiddle-income attending school, andinmany countriesthey have the mostriskofearly death, malnutrition andnot age offive. Worldwide, the poorest children are at are stillatanotably greater riskofdyingbefore the insouth in somecountries(particularly Asia) they globally, withrespect particularly toeducation, and many countries. However, girlsremain disadvantaged and accesstoeducationhasnarrowed significantly in services. The gendergap inchildhealth, nutrition are alsonotoriouslyby underserved allsocial populations. Inmany countries, urbanslumchildren areas, sometimesamongmobile orminorityethnic conflict-affected countriesorlive in remote rural schoolare increasinglyprimary concentratedin enrolment,increasing primary children notattending as many countrieshave mademajorstridesin among themostdisadvantaged. For example, Child ‘ill-being’ isbecomingincreasingly concentrated also becost-effective children isnotonly amoralimperative: itcan A greater focus onthemostdisadvantaged 5 Conclusions and recommendations 81 New technologyNew and innovation have innovations and programmatic Policy and contributed to monetary reduction poverty of wellbeing, other areas across improvement These and nutrition. health particularly education, of better- include wider coverage innovations such as the policies, designed social protection focused programmes scaling-up of cash transfer particularly of human development, on promoting and children. women the opportunity for has also offered Technology efficiencies and greater and for impact, multiplied development accountability along the spectrum of in of telecommunications, growth The rapid work. dissemination of key the has promoted particular, and in children, such as the value of investing ideas, It has also helped health. example, for of self-help on, particularly – in the most remote livelihoods improve capacity The growing and underserved communities. solutions and local development local innovation for of change. scalable driver is a true, to global problems groups. Our case studies of Bangladesh (1) and of Bangladesh case studies Our groups. of equitable examples concrete (2) provide Brazil have improvements where strategies, development Vietnam our the poorest; among been concentrated to targeted approaches (9) outlines some case study participation educational among minority improving ethnic communities. Where the majority lack a basic service, investment investment the majority lack a basic service, Where in extending that service is critical (as in the example Once the vast majority of education in Ethiopia). will focus that the it is likely served, are of children need to shift to particularly disadvantaged children such as children support, additional who require ethnic or marginalised areas in the remotest Progress in child well-being has often been greatest often been greatest has well-being in child Progress on explicit emphasis has been an there where the situation to and improving resources directing The most marginalised groups. and of the poorest are lives wisdom has been that more conventional countries and enhanced in poor protected saved, closer individuals who are on those focusing by or a particular development line, to the poverty that this is not is evidence there However, target. by Importantgains can be achieved the case. always marginalised on the most vulnerable and focusing populations within excluded example, for because, of a large proportion have countries generally or a larger to higher fertility rates, owing children, die of in these groups of children proportion Examples in the diseases. or treatable preventable strategies where report of equitable development been concentrated among the have improvements Vietnam. include Brazil and poorest and better-off groups. Finally, the poorest children are are children the poorest Finally, groups. and better-off of the violations risk of severe at the greatest often as abuse and exploitation. such protection, rights to references

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Figure A.1: Decline in under-five mortality rate by region, 1990–2010 (%)

75

67

63

57 55 52 53 50

44 42

35 35

31 30

25

0

World Oceania NorthernAfrica Eastern Asia Western Asia Caucasus and Southern Asia Central Asia the Caribbean Latin AmericaSouth-eastern and Asia Sub-Saharan Africa Developing regionsDeveloped regions

Source: UNIAGCME (2011).

89 90 progress in child well-being Source: UNIAGCME (2011) Source: MICS, DHSandothernationalsurveys of infants undersixmonths(%) Figure A.3: Countries and mother’s educational status, 2000–10 Figure A.2: Under-fivemortality rate bysocio-economicquintile, location 120 150 30 60 90 African Republic 20 40 60 80 0 Central 0 (1994, 2006) 3

23 Poorest Uzbekistan (1996, 2006) 121 3 26 (1993,Senegal 2005) Second 114 6 34

(1996,Lesotho 2004) Middle Wealth 16 101 increasesinexclusivebreastfeeding with significant 36 (1995,Pakistan 2008)

16 Fourth 37 90 (1996, 2006) Mali 8 Richest 38

(1998, Turkey2008) 62 7 40 (1996, 2006) Benin 10 43 Colombia (1995, 2005)

12 Rural 114 Residence 47 (1999, Guinea2008) 11 Urban 48 67 (1998, 2008)

To g o 10

48 Cambodia (2000, 2006) 12 60 (1996,Zambia 2007) None 19 ?? Mother’s education 61

(1997, 2008)Ghana Primary 7 91 Madagascar 63 (1992, 2004) Secondary

38 or higher 67

51 (2000,Sri 2007)Lanka 53 76 Figure A.4: Targeting of aid for MNCH by income and under-five mortality rate

GDP ODA for maternal, newborn and child health per capita ($) per capita ($)

Less than 500 0.02–6.40

500–1,000 0.24–6.90

More than 1,000 0.04–28.40

Under-five mortality rate ODA for child health (per 1,000) per child under age 5 ($)

More than 200 4.0–28.7

150–200 4.5–225.7

100–149 2.7–18.9

Less than 100 0.3–12.9

Source: Greco et al. (2010) in Countdown (2010).

Figure A.5: Trends in stunting prevalence in Africa and Asia, and examples of countries where prevalence has decreased by over 20 percentage points

70 68 63

60 57 57

50

44 42 40 40 38 38 36 36 34 33 30 30 29 27

22 20

11 10

0 Africa Asia Developing countries China Eritrea Bolivia Vietnam Around 1990 Bangladesh Mauritania (1993, 2002) (1992, 2007) (1983, 2006) (1990, 2008) (1989, 2008) (1990, 2005) Around 2008

Note: the trend analysis is based on a subset of 80 countries with trend data, including 75 developing countries covering 80% of the under-five population. All trend estimates are calculated according to the NCHS/WHO reference population. Source: MICS, DHS and other national surveys around 1990 to around 2008

91 92 progress in child well-being Source: Author calculations; basedonOECD-DAC CRSdatabase. Note: ‘Population programmes’ includes aidfor HIV Source: Authors’ calculationsbasedon World Bankdata. WASH Figure A.7: Aid globally Figure A.6: Trends inunderweight prevalence inchildrenunderfive, civil society Government and 20 40 60 0 1995 programmes Population and byregion, 1995–2010(%) allocations 2000–2004 2000 2005 to different socialsectors, 2000–04 Education nutrition Basic Health civil society Government and WASH programmes Population 2005–2009 2010 and 2005–09 South Asia Central Asia MENA East Asia andPacific Latin America Sub-Saharan Africa Education nutrition Basic Health Figure A.8: Expansion in secondary enrolments, by region (%)

Niger Chad Burkina Faso Mozambique Rwanda Uganda Malawi Nigeria Eritrea Senegal Liberia Ethiopia Democratic Republic of Congo Guinea Cameroon Mali Lesotho Sub-Saharan Africa Zimbabwe To g o Zambia Gambia Swaziland Ghana Kenya Namibia Botswana Mauritius South Africa

Mauritania Sudan Morocco Syrian A. R. Oman Occupied Palestinian Territory Arab States Kuwait Tunisia Qatar United Arab Emirates Bahrain

Tajikistan Kyrgyzstan Armenia Georgia Mongolia Kazakhstan Central Asia Uzbekistan Azerbaijan

Solomon Islands Cambodia Lao PDR Myanmar Marshall Islands Malaysia China Samoa Fiji Philippines

East Asia and the Pacific East Macao, China Brunei Daruss. 0 10 20 30 40 50 60 70 80 90 100 110 1999 2008 (decrease since 1999) 2008 (increase since 1999)

continued overleaf

93 94 progress in child well-being Source: UNESCO(2011). Note: Only thosecountrieswithgross enrolment ratiosbelow 97%ineither1999or2008are included. Figure A.8: Expansion insecondary enrolments , byregion(%)continued

2008 (increase since1999) 2008 (decrease since1999) 1999 Central and Eastern Europe North America Latin America and the Caribbean South and and Western West Asia Europe Dominican Republic TFYR Macedonia Trinidad/Tobago Czech Republic Venezuela, B. R. United States Rep. Moldova Luxembourg Iran, Isl. Rep. Switzerland Bangladesh Bolivia, P. S. El Salvador Guatemala Saint Lucia Costa Rica Nicaragua Argentina Colombia Dominica Lithuania Bahamas Paraguay Romania Hungary Maldives Uruguay Bulgaria Ecuador Slovenia Slovakia Ukraine Panama Jamaica Guyana Croatia Belarus Estonia Greece Bhutan Mexico Cyprus Turkey Serbia Aruba Latvia Belize Israel Cuba Chile India Peru Italy 0 10 20304050 60 708090 100 110 Appendix 2 Primary data analysis

Our primary data analysis seeks to answer could have reported more statistically significant the question: have countries that received result had we not done this. the most aid also made the most progress We performed population-weighted cross-country improving the lives of children? regressions of the average annual change in the To answer this question, we have calculated the outcome over the period 1999–2008 on the average relationship between the average annual quantity of annual quantity of aid per capita over the same period. aid per capita received by each country, over the last Our data on child outcomes come from the decade for which data are available, and the average World Bank Development Indicators dataset. For annual improvement in childhood outcomes over malnutrition, we used weight for age, defined as the the same period. We have restricted our analysis percentage of children under age five whose weight to sub-Saharan Africa because other regions lack for age is more than two standard deviations below sufficient available data or have too few countries the median for the international reference population for convincing cross-country analysis. aged 0–59 months. Infant mortality is defined as the We report the relationship between aid and three number of infants dying before reaching one year of childhood outcomes: infant mortality, childhood age per 1,000 live births in a given year and children malnutrition and the number of children living living with HIV refers to the number of children aged with HIV.101 0–14 who are infected with HIV. Rather than base our analysis on total ODA or the When analysing childhood malnutrition and infant subset of aid targeted specifically at the outcome in mortality, we used a constructed aid variable question, for example using aid allocated to maternal intended to capture total aid resources mostly likely and child health in the case of infant mortality, we to affect these outcomes. This was the sum of aid have used a broader measure of aid, intended to allocated to the following OECD-DAC sectors: capture all forms of aid that are mostly likely to affect health, reproductive health, water, sanitation and the outcome in question. Infant mortality is likely to hygiene, support to NGOs, food security, general respond to access to clean water and investments in budget support, government and civil society and strengthening civil society, for example, and excluding social infrastructure. In our analysis of childhood aid for these purposes from the analysis would yield HIV, we used just aid allocated to reproductive misleading results. health, which is where all efforts to combat HIV are accounted for. Controlling for other categories We decided to weight the data by population. The of aid in our regression does not qualitatively alter rationale for this was that we wanted to avoid our results. Population data came from the Penn multivariate analysis, yet suspected that country size World Table. may affect the relationship between per capita aid and outcomes. We wanted to report relationships So, we have chosen to report correlations and between aid and outcomes that represent the leave interpretation to the reader. To illustrate what experience of the majority of people living in Africa, this means, consider again the positive correlation rather than a relationship driven by the experience between aid and the average annual reductions in of very small countries. This is not standard: most infant mortality across countries in sub-Saharan analysis weights countries equally. In some cases, we Africa. This relationship certainly fits with the story

101 We judged these to be the most direct indicators of childhood well-being with sufficient data to perform the analysis. We have not cherry-picked the best-looking results – some of the relationships we report are not statistically significant, and we found positive significant relationships between aid and indirect outcome indicators like access to sanitation and immunisation. We found no relationship between aid and primary schooling outcomes, but positive relationships between aid and secondary school enrolment.

95 96 progress in child well-being childhood malnutrition. So anadditional $1ofaidwasassociatedwith 0.011percentage pointchangeintheaverage annual reduction in 103 102 receiving anadditionalcountry $20annual aidper The relationship we estimatesuggestsatypical for doingso. malnutrition, buttherejustification isnoparticular relationship between aidandreductions inchildhood analysis would leave astronger, statistically significant terms. Removing thesetwo countriesfrom the although bothare majoraidrecipients inabsolute without receiving much aidinpercapita terms, bottom-left cornerofthegraph) madegood progress countries, SudanandEthiopia(thetwo bubblesinthe the relationship isnotstatistically significant. Two progress inreducing childhoodmalnutrition, but more aidpercapita have tendedtomake more Over thepastdecade, countriesthathave received Childhood malnutrition improving thelives ofchildren? recent years alsomadethemostprogress intermsof have countriesthathave received themostaidin provide someinformative descriptive dataanalysis: the scopeofthisreport. Ourintentionhere isto to differentiate between thesestoriesisbeyond up’ growth, for reasons unrelated toaid. Attempting improvements becausethey have experienced ‘catch- and thesecountrieshaving seenthegreatest most aidhaving beengiven tothepoorest countries, reducing infantmortality, butitisalsoconsistentwith that aidhashelpedcountriestomake progress on The estimatedcoefficientfrom apopulation-weighted regression was-0.011 withastandard error of0.010. Clemensetal. (2011) isanup-to-dateaccessiblereview oftheseproblems inthecontextofaidgrowth research. of lookingatcorrelations. Correlation doesnot In thisreportwe have taken thesimpleapproach is contentiousandoftenunconvincing. aid effectivenesslevel, atthecountry theiruse exist, butespecially whenseekingevidence of A varietyoftechniquestodealwiththisproblem is associatedwithlow levels ofchilddevelopment. aid where needisgreatest, thedatawillshow aid these isnon-randomallocation. Ifdonorstarget development facemany problems; thegreatest of relationship between foreign aidandchild Researchers lookingfor evidence ofacausal Correlation and causation 102 2 percentage points. prevalence ofchildmalnutrition by anadditional $20 percapita annually willhave reduced the a decade, receiving anadditional thetypicalcountry 0.2 percentage points peryear. So, over the courseof prevalence ofchildhoodmalnutrition by anadditional inthedata)reducedand alow-aidthe country capita (roughly thedifference between ahigh-aid balance ofprobabilities. of feasible hypotheses andmay shifttheperceived proof ofeffectiveness, butthey canrestrict theset course, correlations shouldnever beregarded as that would bedoingwell intheabsenceofaid. Of and are notsimply givingmore aidtocountries that donorsare targetingcountriesinneedofhelp, of aideffectiveness whencombinedwiththebelief infant mortality, thismightberegarded asevidence positive correlation between aidandreductions in about theworld. For example, ifthedatareveal a be informative, whencombinedwithotherbeliefs demonstrate causation. Butcorrelations may still mortality soheavilymortality skewed by theexperienceof be misleadingtoleave ouranalysis ofaidandinfant large inabsoluteterms. Inthis case, we thinkitwould was smallrelative totheirlargepopulations, itwas may beatwork here; althoughaidtothesecountries It isinteresting tospeculatethateconomiesofscale (inthebottom-leftcornerofgraph).mortality yet have made good progress inreducing infant which bothreceived littleaidinpercapita terms heavily by two largecountries, NigeriaandEthiopia, the population-weighted relationship isinfluenced relationship between aidandinfantmortality. But At firstglance, there doesnot appear tobea Infant mortality malnourished. region, 2.7millionchildren would nolongerbe fell by anadditional 2percentage pointsacross the malnourished (ouranalysis). If malnutrition rates (UNICEF data): onaverage 24%ofchildren were 137 millionchildren underfive insub-Saharan Africa 103 In2009, there were roughly Figure A2.1: Sub-Saharan Africa – aid and trends in childhood malnutrition

2

1

0 0 20 40 60

–1

–2

X-axis: Average annual aid 1999–2008, constant dollars per capita. Y-axis: Average annual change in percentage of children that are malnourished, 1999–2008. Bubble size = population

Source: World Bank, WHO, OECD DAC, PWT7.0

just two countries. If we repeat the analysis without Childhood HIV weighting by population, or if we remove Ethiopia and Nigeria from the sample, a strong statistically Southern Africa has been in the grip of a dreadful significant relationship emerges between aid and HIV epidemic, with infection rates only recently infant mortality in the remaining countries.104 starting to stabilise (as illustrated in our Botswana case study). These countries are coloured red in Based on this estimated relationship, a typical Figure A2.4. As can be seen, infection rates have (smaller) country receiving an additional $20 of aid been rising, and there is no clear relationship with per year, roughly the difference between a high-aid aid in these countries. Botswana is the red circle in and a low-aid country in the data, reduced infant the bottom-right, the only southern African country mortality each year by around an additional 0.4 to have reduced child HIV infection rates and the deaths per 1,000 births so, over the course of a recipient of the most aid. decade, will have reduced infant mortality by an additional 4 deaths per 1,000. In 2009, there were Throughout the rest of sub-Saharan Africa, progress roughly 15.7 million births in sub-Saharan Africa has been more encouraging, and a strong relationship (UNICEF data), and the (unweighted) average rate between aid and reductions in infection rates is of infant mortality was 46 deaths per 1,000 (our evident. In this case, we have looked at changes in analysis). If the rate of infant mortality fell by an infection rates between 2002 and 2009 and we also additional 4 per 1,000 across the region, this would use aid specifically targeted at fighting HIV.105 save 63,000 infant lives each year.

104 The estimated slope coefficient in an unweighted regression is -0.039 with a standard error of 0.014, and the estimated coefficient from a population-weighted regression, as illustrated in Figure A2.3, is -0.046 with a standard error of 0.011. 105 Trends in infections rates have tended to follow an inverted U shape, so had we looked at the whole decade, the simple linear trend estimates we use would be misleading. HIV infection rates started to stabilise or trend downwards in most countries around 2002, meaning a linear approximation is likely to give an acceptable estimate of trends since then, which is why we look at whether countries that received the most aid have made the most progress since 2002.

97 98 progress in child well-being Source: World Bank, WHO, OECDDAC, PWT7.0 Source: World Bank, WHO, OECDDAC, PWT7.0 trends ininfant mortality Figure A2.3:Sub-SaharanAfrica Figure A2.2: Sub-Saharan – frica A Excluding NigeriaandEthiopiafrom thesample Bubble size=population Y-axis: Average annual changeininfantdeathsper1000births, 1999–2008. X-axis: Average annual aid1999–2008, constantdollarspercapita Bubble size=population Y-axis: Average annual changeininfantdeathsper1000births, 1999–2008. X-axis: Average annual aid1999–2008, constantdollarspercapita – – – – – – 0 2 6 4 2 0 2 6 4 2

0 0 20 4060 20 4060 – aidand Nigeria Ethiopia and excluding aid and trends ininfant mortality The estimated relationship between aid and Figure A2.5 reveals two loose clusters of countries; childhood HIV infection rates, excluding southern those that received under about $4 per capita Africa, suggests that a typical country, outside of annually, and those that received above this. southern Africa, receiving $10 additional annual aid Figure A2.6 plots the time trend of average infection per capita, roughly the difference between a high-aid rates within these two clusters, and for southern and a low-aid country in the data, reduced childhood Africa. The pattern is clear: infection rates have infection rates by 0.2 children per 1,000 population rocketed in southern Africa. Donors have targeted (not per 1,000 children; we could not find these data), aid at countries with initially high infection rates, so between 2002 and 2009 reduced HIV infection which have made good progress since around 2002, by an additional 1.4 children per 1,000.106 This is whereas the group of countries that received less aid a big number in this context: in 2009, the average had lower infection rates to begin with. The average rate of infection in the group of southern African annual per capita quantity of aid targeted directly at countries was 9 children per 1,000 population; fighting HIV over the decade 1999–2008 was $6.3 in in the rest of sub-Saharan Africa, it was 2.5 children the high-aid cluster with high infection rates and per 1,000 population and 6.5 in the cluster of $1.8 in the low-aid cluster with low infection rates. high-aid countries.

Figure A2:4: Sub-Saharan Africa – aid and trends in childhood HIV

.2

0 0 10 20 30

–.2

–.4

–.6

X-axis: Decade-average aid allocated for HIV, dollars per capita Y-axis: Average annual change in children with HIV, per 1000 population, since 2002. Bubble size = population Black circles: South Africa, Mozambique, Namibia, Botswana, Lesotho, Swaziland

Source: UNAIDS, WHO, OECD DAC, PWT7.0

106 The estimated slope coefficient from a population-weighted regression , excluding southern Africa, was -0.02 with a standard error of 0.004.

99 100 progress in child well-being Source:UNAIDS, WHO Source: UNAIDS, WHO, OECDDAC, PWT7.0 – – Southern Group isSouth Africa, Botswana, Lesotho, Swaziland, Namibia, Mozambique Population-weighted means Y-axis: Numberofchildren livingwithHIVper1000 of population. Figure A2.6: Sub-Saharan –children Africa 0 2 4 6 8 Figure A2.5: ExcludingSouthern – Africa Excluded from sample: South Africa, Mozambique, Namibia, Botswana, Lesotho, Swaziland Bubble size=population Y-axis: Average annual changeinchildren withHIV, per1000population, since2002. X-axis: Decade-average aidallocatedfor HIV, dollarspercapita .1 .2 .1 0 1995 0 2000 5 aid with HIV and 2005 2010 trends inchildhoodHIV 10 Low aid High aid Southern 15