NARROWING THE GAPS TO MEET THE GOALS An equity-focused approach to child survival and development

1. NARROWING THE GAPS TO MEET THE GOALS An equity-focused approach to child survival and development

2. Children’s rights, our mission

3. Equity for children is… An equal opportunity for all children to survive, develop and reach their full potential.

4. … a human rights imperative... Based on principles of universality, non-discrimination and participation enshrined in the Convention on the Rights of the Child, CEDAW and other major instruments..

5. … and fundamental to UNICEF’s mission… In everything we do, the most disadvantaged children and the countries in greatest need have priority. “ ” UNICEF Mission Statement

6. The facts on Child survival and beyond

7. Success in reducing child deaths in national averages… Trends in the under-five mortality rate (per 1000 live births), 1990 to 2009 The global under-five mortality rate has fallen by one third since 1990. This is one of the greatest success stories in international development.

8. …is masking growing inequalities within countries • Two-thirds of the countries that have made strong progress in reducing the under-five mortality rate have shown worsening inequalities since 1990. • In short, gaps between better off and worse off have increased. • This suggests that the delivery, financing, and use of essential health services for children favor the better off.

9. 1.0 – 17.5 17.6 – 20.0 20.1 – 238.1 Missing data The case of Brazil: Moderate national average National level On the basis of the national average alone, Brazil’s under-five mortality rate is moderate. Legend: Under-five mortality rates (deaths per 1,000 live births)

10. 1.0 – 17.5 17.6 – 20.0 20.1 – 238.1 Missing data The case of Brazil: Significant intra-state disparities State level Disaggregating under–five mortality by states shows a more mixed picture of child death, with much higher rates in some states compared with the national average. Legend: Under-five mortality rates (deaths per 1,000 live births)

11. 1.0 – 17.5 17.6 – 20.0 20.1 – 238.1 Missing data The case of Brazil: Wide disparities among municipalities Municipal level Disaggregating further to the municipal level shows even greater disparities, even in some of the states that have among the best aggregates for under-five mortality. Legend: Under-five mortality rates (deaths per 1,000 live births)

12. Inequity beyond health: Birth registration In some regions, children from the richest households are 2-3 times as likely to be registered as those from the poorest Percentage of children under 5 years old who are registered, by household wealth quintile Note: Estimates are based on a subset of 80 countries, covering 60% of the world population (2000-2009). Estimates for the Middle East and North Africa cover 47% of the population of this region. The graph illustrates differentials by wealth quintiles; these estimates should not be used for comparison with other data sets. Source: UNICEF global databases, 2010.

13. Inequity beyond health: Stunting Urban / rural disparities around the world

14. Inequity beyond health: Sanitation Sub-Saharan Africa: 75% of the richest quintile use improved sanitation facilities; only 15% of the poorest do

15. Inequity beyond health: Education Case study: Nigeria Average number of years of schooling 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 6.7 years Nigeria Ukraine Bangladesh C.A.R. Bolivia Honduras Cameroon Chad Cuba Indonesia extreme education poverty education poverty

16. Inequity beyond health: Education (cont..) Case study: schooling disparities in Nigeria Average number of years of schooling 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 extreme education poverty education poverty 6.7 years Nigeria 3.5 years 9.7 years Poorest 20% Richest 20% 0.5 years 3.3 years 9.5 years 6.4 years 10 years Urban Rural Rural Hausa Rural Urban girls 6.4 years 2.6 years 10.3 years 0.3 years boys Poor rural Hausa girls Poor rural girls Poor urban girls / boys Rich rural boys

17. Inequity beyond health: Child marriage In developing countries, girls from the poorest households are 3x more likely to be married before age 18, compared with those from the richest.

18. The causes

19. Obstacles to equity geographical location income racial, ethnic, religiousor other cultural affiliation minority status disability gender

20. resulting in: Many children: high mortality morbidity malnutrition illiteracy exploitation intergenerational cycle of poverty are not reached by services have no access to information suffer multiple deprivations, which compound one another (e.g. poor nutrition / education) are vulnerable to exploitation and abuse have limited opportunities for development

21. The global context

22. Global Economic Crisis .. Global economic crisis • Deepest since 1930s • Shows little sign of abating • Household and public finances under strain Fiscal consolidation • Austerity measures in EU • Belt-tightening in developing world • Less funds available for ODA Food price uncertainty • Recent spike in food prices, which are almost back to 2008 high • The poor will be hard hit again.

23. Urbanization and demographics • Rapid urbanization is swelling the ranks of slum dwellers and the urban poor. Slum prevalence is highest in the poorest developing regions, sub-Saharan Africa and South Asia, which are both experiencing rapid rates of urban growth. • At the same time, the rural poor are being left behind, with few economic opportunities and less access to core services.

24. Climate change • Global environmental trends disproportionately threaten the poorest and most marginalized communities and countries. • The children of the poor are particularly vulnerable to the impact of climate change, due to living in homes with inadequate shelter, and greater susceptibility to vector borne diseases known to be highly sensitive to climatic conditions.

25. Humanitarian crises • Intensifying natural disasters and ongoing armed conflict are exacerbating penury and exclusion for millions of children. • It is estimated that low- and lower-middle-income countries account for 97% of global mortality risks from natural disasters. • Of the estimated 100 million primary school aged children not in school, 70 million live in the 33 countries affected by armed conflict.

26. The challenge

27. Reaching the most disadvantage and vulnerable The children currently excluded, the poorest and the most marginalized must be reached: to achieve universality (e.g. in primary education or eradication of disease) to reduce child mortality (MDG 4), as most child deaths occur among the most deprived populations to break the cycle of poverty, discrimination, disadvantage and violence that affects girls by new technologies and interventions (such as immunizations and mother-baby packs) which particularly benefit the poorest

28. Conventional wisdom says equity approaches are too costly Conventional wisdom is that is too costly and too difficult to go into poor, hard-to-reach communities. Extending services to easier to reach children is surely more cost effective.

29. The premise: equity approaches can be cost effective Since the needs are greatest amongst the unreached… …and new, innovative, efficient strategies and tools exist to reach them… …might the benefitsof concentrating on them outweigh the additional costs of reaching them?

30. Investing in marginalized children may be cost-effective because: Marginalized populations generally have higher fertility rates and higher rates of child mortality. More children die of preventable or treatable diseases within poor and excluded groups. Most excluded populations have limited access to cost-effective mass interventions reducing the impact of major childhood diseases and conditions.

31. The approach

32. Examining the evidence UNICEF examined data, literature and country experience on equity approaches to young child survival and development; HIV/AIDS; basic education and gender equality; and child protection. Countries with sufficient data available to analyze different levels of deprivation and sub-national patterns of inequity were chosen to test a new equity focused approach. From low-income, where most children experience high levels of deprivation to middle-income with less deprivation but significant inequality between the most deprived and more affluent.

33. The 15 selected countries Bangladesh Benin Ghana Honduras Kenya Mali Niger Nigeria Pakistan Philippines Rwanda South Africa Uganda Viet Nam Zimbabwe

34. Equity approach Aims to accelerate progress, reduce disparities and lower out-of-pocket expenditures for the poor: Upgrade facilities (especially. maternal and neonatal), expand maternity services, including ‘waiting homes’. Overcome barriers preventing access to available services; expand outreach; eliminate direct user charges; extend cash transfers; use mass communication to boost demand and usage. Focus on task-shifting: basic outreach through community health workers. Support enhanced community involvement in promoting health and behaviour change. 1 2 3

35. Testing the strategies 180,000 variables later… The UNICEF research team tested the model using a Marginal Budgeting for Bottlenecks (MBB) simulation. Widely applied to international health research, MBB focuses on eliminating the barriers to supply and demand of essential services

36. The findings

37. An equity-focused approach … accelerates progress towards the health MDGs fasterandmore cost-effectivelyacross all country types especially effective in low-income, high-mortality countries: every additional $1 million invested can save 60% more lives than the current path

38. … could bring major potential gains for children in health… Projections based on an analysis of 15 countries: Bangladesh, Benin, Ghana, Honduras, Kenya, Mali, Niger, Nigeria, Pakistan, Philippines, Rwanda, South Africa, Uganda, Viet Nam and Zimbabwe.

39. …is most cost effective in low-income, high-mortality countries…

40. …but also has better results in reducing U5MR in all country types *Niger, Mali, Rwanda, Uganda Per $1m additional invested - equity-focused strategies can avert more child deaths *Benin, Kenya, Nigeria, Zimbabwe, Ghana *Philippines, Vietnam South Africa *Honduras, Bangladesh, Pakistan

41. The implications

42. An equity-focussed approach addresses... • Societal factors i.e. social norms, behaviours, practices impeding access to services or fuelling discrimination and deprivations • services and systems i.e. why are services not reaching those who are most in need ? What are the barriers to access and what systems constraints are there? • political and “ideological” issues i.e. what are the governance, accountability, policy, legislative etc issues that are not favouring equal opportunities for the disadvantaged children and communities • transnational issues i.e. market failures that impede access to new technical solutions (e.g. new vaccines) by poor countries

43. …and what it does not mean… • Starting from scratch - a radically new approach or completely new goal for the organization • Abandonment of the human/child rights approach • A move towards more service delivery and away from policy advocacy (‘swimming downstream’) • “Pilot equity projects”

44. External, broader policy implications Identify the most deprived children and communities Invest in proven, cost-effective interventions Overcome bottlenecks and barriers Partner with communities Maximize the impact of available resources

45. Can an equity approach garner sufficient political will? UNICEF United Nations Governments NGOs Advocates Academics

46. Internal, UNICEF implications Analytical • Process of model testing, refinement and external review • Model based on primary health care  extended to education, child protection Programmatic • Equity tracker • Country office guidance Advocacy • September 2010: Launch • October-December 2010: Roadshow (Washington, Beijing, India, Europe?)

47. Implications for country level programming Data, evidence, monitoring and evaluation • Improve generation, presentation and use of disaggregated data to better target programmesand policy-related work • Increase understanding of the drivers/causes of exclusion and inequities Policy and programming • Understand the national policy environment and developments on equity issues • Ensure alignment between programme focus/strategies with equity profile and national / local context • Re-assess existing programme strategies using the equity lens • Promote integrated strategies – e.g technical sector strategies with social protection, community empowerment; coherence between programmes and operations

48. Implications for country level programming Partnerships • Creativity in partnerships to reach the disadvantaged • Leverage national partnerships to focus on equity – engage them in the evidence-based analysis, defining barriers/bottlenecks, solutions and resource allocation, accountability systems • Regional think-tanks, academia – sourcing external partners Monitoring and Evaluation • Innovations and adaptations in monitoring, measuring results and evaluations; sensitivity to determine outcomes for disadvantaged children General • Determine priority capacity / resource gaps • Mobilize entire office around equity on a few key issues that will yield a high impact

49. Sharpening our equity focus • Generating the momentum - Innovative study - High level advocacy – MDG Summit etc - Global Leadership Meeting and Follow-up • Field Focus - Gaining Traction - Going to Scale - Proof of concept – showing results • Sustaining political will, external mobilization - showing results - advocating, communication and convening role - focused knowledge management and sharing

50. The equity agenda is… Broader than UNICEF Requires support from international and national partners Demands incremental investment and additional financial Necessitates committed political support Will take courage and dedication from staff and supporters