Data Snapshot: How Do Donors Support Citizen Engagement in Tax Policy?

Written by Andrew Wainer, Director, Policy Research

This summer’s Addis Tax Initiative (ATI) conference in Berlin demonstrated that the ATI is increasingly open to civil society participation. It was a forum where donors and revenue authorities discussed how to better harness tax for development, but local and global NGOs also asserted the importance of accountability and equity in tax policy and administration.

The elevated voice of civil society on tax follows an increase in donor domestic resource mobilization (DRM) assistance to civil society, according to our analysis of OECD data[i].  For example, among ATI donors, the percentage of DRM assistance to civil society rose from 4% ($6 million) in 2015 to 10% ($21 million) in 2017 – an increase of 252%, the largest increase of any category of assistance (see Table 1).

Table 1: Percent Change DRM Disbursements Channel, 2015 to 2017

Channel Change (%)
Public Sector -20
NGOs & Civil Society 252
Public-Private Partnerships (PPP) 186
Multilateral Organizations 42
Teaching Institutions, Research Institutions, Think-Tanks 61
Private Sector Institutions 77*
Other -86

 * OECD CRS values reported only for years 2016 and 2017. Percent change calculated from these two years.

Nevertheless, donor investment in civil society on tax issues remains small within the bigger picture of DRM funding.  And even as the role of civil society in tax policy and administration increases, much more needs to be learned about the impacts of civil society participation

Norway Provides Half Its DRM Assistance to Civil Society
Analysis of the OECD’s Creditor Reporting System data reveals that, for 2017, the top five ATI DRM donors to civil society (by amount of US dollars) provided 95% of total DRM assistance to civil society among all ATI donors (see Table 2 below).

The UK provided the largest amount of funding for civil society – $9 million, or about a quarter of its total $37 million DRM budget for 2017. And the US – while providing the largest total amount of DRM assistance – provided the second largest amount to civil society – $5 million. But Norway is particularly notable for providing fully half of its total DRM budget to civil society – a far larger percentage than any of the other top 5 donors.

Table 2: Top 5 ATI Donors Providing DRM Assistance Channeled Through Civil Society, 2017

ATI Donor Country DRM Assistance to Civil Society (millions of USD)* Total DRM Assistance (millions of USD)* % of Total DRM Assistance Channeled through Civil Society
United Kingdom 9 37 24
United States 5 49 10
Norway 4 8 50
Denmark 1 5 20
EU Institutions 1 14 4

*USD Figures are rounded to the nearest million

 

Assistance Split Between Local and International NGOs
ATI assistance to civil society is clustered among five major donors, but what type of civil society organizations receive this assistance?

As Table 3 demonstrates, it’s split: In 2017, 40% of all ATI DRM assistance to civil society went to developing country-based NGOs, defined as: “An NGO organized at the national level, based and operated in a developing [country].”

While developing country NGOs received a substantial minority of the assistance, the same amount was disbursed to NGOs based in donor countries. These are defined as national-level NGOs based and operated in donor counties. Such organizations would include, for example, Oxfam America and Save the Children USA.

 Finally, almost 20% of this assistance to civil society was delivered to international NGOs, defined as, “an NGO organized on the international level. Some INGOs may act as umbrella organisations with affiliations in several donor and/or recipient countries.” Examples in this category include Doctors Without Borders and the Society for International Development.

Table 3: DRM Civil Society Assistance Delivery Channel, 2017

Delivery Channel Amount (millions of USD)* % of Civil Society DRM Assistance Received Through this Channel
International NGOs 4 19
Donor-county based NGOs 9 40
Developing-country based NGOs 9 40

*USD figures are rounded to the nearest million

 

Africa Receives More Than Half of All DRM Assistance to Civil Society
What part of the world is this donor assistance going to? In 2017, more than half ($11 million) went to Africa (See Table 4). Western Hemisphere nations were the second largest recipients – receiving almost a quarter ($5 million) of all ATI DRM civil society assistance. Asia, Europe, and  Oceana received very small percentages of this type of assistance totaling a combined 6% of all assistance to civil for tax work.

Table 4: DRM Civil Society Assistance to Recipient Regions, 2017

Recipient Region Amount (millions of USD)* % of Civil Society DRM Assistance Received by Region
Africa 11 53
Americas 5 23
Developing Countries, Unspecified 4 18
Europe 1 4
Asia <1 2
Oceania <1 0

 

How is DRM Assistance to Civil Society Used?
As Table 5 demonstrates, almost half of all assistance is directed toward capacity building. Tax advocacy is a complex and contested space, so civil society organizations often need help building the capacity to credibly engage on fiscal issues – particularly at the national level – so this large allocation makes sense. 

Table 5: Civil Society Uses for DRM Assistance, 2017

Function Amount (millions of USD)* % of Total Civil Society ATI DRM Assistance Spent on Function
Transparency 3 14
Technical Assistance and Support 2 10
Research 1 5
Capacity Building 9 43
Other 1 5
Unspecified 5 24

*USD Figures are rounded to the nearest million

 

Taxation and Gender Equity
Ensuring that tax policy and administration is gender-responsive is also an important component of ensuring tax equity. The OECD “tags” foreign assistance for gender equality by assigning activities as ones where gender equality is a “principal objective”, a “significant objective”, or where gender equality is not an objective. As illustrated in Table 6, according to the OECD data, only 13% of civil society DRM assistance in 2017 contained a gender equality component – activities where gender equality were either a principal or significant objective.

Table 6: Support for Gender Equality and Women’s Empowerment for Tax, 2017

DAC Gender Marker Score Amount (millions of USD)* % of Total Civil Society ATI DRM Assistance Dedicated to Gender Equality
(Gender is the principal objective) 0.6 3%
(Gender is a significant objective) 2 10%
Total:   13%

*USD Figures are rounded to the nearest million

 

Based on this analysis of the OECD data, we have a clearer – but still incomplete – picture of how ATI’s increasing DRM assistance to civil society is being used. We have little understanding of the impact of these funds.   

We need to continue to assess the impact of civil society in making tax policy and administration more accountable, participatory, and transparent. Data is key – donors and the OECD must ensure that data on donor assistance to civil society for DRM is reported and labeled accurately and that data is disaggregated, especially by age and sex. The analysis in this blog is a first step to outline the trends and contours of donor assistance for civil society engaging in DRM.  

As the Addis Tax Initiative develops its vision for 2020 and beyond, Save the Children continues to emphasize the role of local citizens in shaping tax policy and administration.  

In coming years, we hope that donor agencies will improve investments in country-based NGOs to strengthen local self-reliance, promote fairer tax allocations, and finance pro-development public expenditure. 

[i] Because the OECD continually updates the historical data in the CRS and these analysis were carried out over a period of months, calculations may vary. Like all large datasets, the CRS may also contain labeling and reporting errors that impact accuracy. Our analysis is based on an analysis of the OECD data as presented.

 

Why I Don’t Want Another Mother to Experience My Health Care Scare

Written by Soha Ellaithy
Senior Director, Strategic Foundation Partnerships and Senior Partnership Director, BASICS

I was born and raised in Egypt, a middle-income country that has a functioning healthcare system and universal healthcare coverage – albeit of often dubious quality.

In 2008, one in 10 Egyptians had chronic Hepatitis C, the highest rate of infection in the world. The direct cause of this catastrophic situation is a mass-treatment campaign conducted by the Egyptian government in the 1970’s and 80’s to eradicate schistosomiasis infection. The repeated use of needles resulted in Hepatitis C, a virus not yet known, being inadvertently spread to millions of people.

When, in 2011, my oldest son went on a school trip to Nepal, he contracted a diarrheal infection and had to be rushed to a local hospital to receive intravenous fluids. He called me and, to my horror, described stepping over pools of blood on the floor to get to a bed with no covering. My heart dropped – and to this day it still does when I think about that moment.

I knew exactly what the implications could be.

I’ve witnessed firsthand the terrible devastation of a healthcare-acquired infection on families and could not bear the thought of my son contracting Hepatitis C or HIV. It took a full three agonizing months of tests to clear my son of any possible infections that he might have picked up from a needle prick in an unclean hospital.

Photo courtesy of: FACEBOOK PAGE/ SO THAT HE'S NOT SURPRISED
Egypt’s doctors have been anonymously sharing pictures of the conditions they work in – with stray animals and overflowing sewage on display – after the country’s Prime Minister said he was “surprised” at the state of the country’s run-down hospitals. Photo courtesy of FACEBOOK PAGE/ SO THAT HE’S NOT SURPRISED via BBC

Despite a fairly strong medical education system and a tireless and dedicated medical staff, public health care systems in many countries like Egypt, continue to be plagued by poor adherence to proper hygiene standards and the devastating consequences that result.

As the Senior Partnership Director leading the submission to 100 & Change, when my colleagues first discussed with me the idea of eliminating this risk globally, I was immediately engaged. As we fine-tuned our idea in meeting after meeting, I became very excited that in BASICS (Bold Action to Stop Infections in Clinical Settings) we truly have a solution that will change the way healthcare is delivered across the world.

I feel very passionate about this project because it is inconceivable that in this day and age, we are still grappling with a problem whose solution is so simple: wash your hands, clean your working surfaces and be diligent in using sterilized equipment.

BASICS tackles the root causes of the problem and builds a solution that is self-sustaining. Using behavioral science to modify individual behavior so that simple hygiene routines can become “second nature,” we will build the supporting infrastructure and design a national system that ensures this new normal is part of a fully functioning and supportive national health system.

I dream of the day when no mother would ever take her child for a simple procedure only to go home with a child who has a life-threatening disease for absolutely no good reason!

 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings) is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%, visit savethechildren.org.

Photo credit: LJ Pasion/Save the Children

Expanding Education in the Philippines

“My mom lets me go to school only if there is extra money,” says Cristina, age 9. “I was able to attend before, but not anymore. Now I wash dishes for a small canteen where my mother works.”

Eight-year-old Ashly (pictured above) tells a similar story: “I used to go to school. I’m supposed to be in Grade 3. But I have to help Mama and Papa sell vegetables. I sell them in the street every day from noon until late at night. I have many cousins who also don’t go to school.”

There are 1.3 million children like Cristina and Ashly in the Philippines today who are not enrolled in school. But this is far fewer than the 2.9 million children who were out of school 20 years ago. In 1999, 1 child in 6 was out of school. Today, that figure has dropped to 1 in 16. After almost two decades of no progress, the Philippines cut the share of children out of school by about 60% in just the last 10 years.

Girls in particular have benefited from this progress. The out-of-school rate for school-aged girls has fallen by 69% since 1999, compared to 55% for boys. This means, however, that boys are now much more likely to be out of school than girls, especially older boys.

Progress in the Philippines is reducing inequalities. The poorest children have made by far the greatest gains at every level of education.

Photo credit: LJ Pasion/Save the Children
Aldrin, 7, poses for a portrait at the spot where reading camp sessions are held in their community in Barangay 176, Caloocan City. In this small space, he and at least a dozen more children take part in activities such as reading, writing, and drawing facilitated by Save the Children partners. (Photo by LJ Pasion/Save the Children)

The Philippines Department of Education (DepEd) has implemented an intense and continuous campaign to reduce the number of children quitting school. It has incentivized school attendance with feeding programs and cash transfers based on school attendance.1  DepEd has also piloted a wide range of alternative schooling models to offer flexibility for students’ differing circumstances and address the specific needs of learners.2 

For children who still are not in school, Save the Children has adapted its successful Literacy Boost approach to provide learning opportunities outside the classroom. Christina and Ashly both participate in Reading Camps where they engage in fun, play-based activities to develop their literacy skills and habits.

“I learned how to read, write and draw,” said Ashly. “They teach me and tell stories and then we all read together.”

Since it was launched in the Philippines in 2012, the Literacy Boost program has been implemented in seven cities and provinces throughout the country. In 2018 alone, it reached 31,560 girls and 33,080 boys.

To learn more about the work Save the Children has done to support child literacy and help set children up for success, visit our website.

1. and 2. Changing Lives in our Lifetime: Global Childhood Report 2019 

Photo credit: Charlie Forgham-Bailey / Save the Children, Oct 2018

Getting to 2030 Vision to End Preventable Child and Maternal Deaths: Building on the global progress for women and children

Written by Smita Baruah, Senior Director, Global Health and Development Policy, Save the Children

Children today have a better chance than any time in history to grow healthy, be educated and be protected, as noted in Save the Children’s latest report, Changing Lives in our Lifetime: Global Childhood Report. Today there are 49 million fewer children stunted, a form of malnutrition that impacts a child’s ability to survive and thrive than two decades ago. There are 4.4 million fewer child deaths than they were in the year 2000.

These successes are not by accident.  Strong and increased political leadership at both global and national level have greatly contributed to changing the lives of women and children around the world in addition to scaling up of proven interventions and innovation.

The United States is one donor government who deserves much credit for accelerating progress on women and children’s health, beginning with its leadership at the first child survival resolution in 1982 through hosting the Child Survival Call to Action meeting in 2012 that set the stage for the vision to end preventable child and maternal deaths by 2030.

Critical Role of US Leadership in Reducing Maternal and Child Deaths
Last month, USAID launched its 5th annual progress report, Acting on the Call: A Focus on the Journey to Self-Reliance for Preventing Child and Maternal Deaths.  The report notes that in 2018 alone, USAID helped reach 81 million women and children access essential — and often life-saving — health services. USAID’s contributions have led to significant reductions in child mortality in many countries such as in Bangladesh where child deaths were reduced by 63% since 2000 and in Uganda, which experienced a 66% in reduction of child deaths during the same time period.

The report demonstrates the ways in which USAID has also helped increase national political will. Since the Child Survival Call to Action forum in 2012, governments in more than half of USAID’s priority countries for maternal and child survival have increased their domestic budgets for health.  In Uganda, for example, USAID worked with the Ministry of Health to increase the percentage of the allocated budget for health from 79% to 97%. 

Bangladesh, a USAID maternal and child health priority country, is an example of how donor assistance coupled with national political will, creates change for women and children. According to the Global Childhood Report, Bangladesh has had a sustained commitment to improving child health despite changing leadership. With donor and their own investments, Bangladesh has focused to strengthen health systems and scale up proven solutions for mothers, children and newborns with a focus on equity. However, focusing on health interventions alone did not contribute to Bangladesh’s success.  Women and girls’ education and empowerment are also key factors driving progress as well as the engagement of civil society, including children and young people.

Getting to 2030
In 2015, the United States and other world leaders and stakeholders committed to a set of global goals which includes the ambitious goal of ending preventable and child and maternal deaths by 2030. There is indeed much to celebrate.  To continue on the path to achieve the global goal of ending preventable child and maternal deaths, U.S. and other stakeholders must continue to focus on continuing to invest in maternal and child survival programs and designing and implementing highest-impact evidence based interventions. 

This also includes investing more resources in areas that are becoming the greatest contributions to child deaths: newborn health, pneumonia and addressing malnutrition.  Without increased focus on malnutrition, Save the Children’s report notes that in 2030, 119 million children will still find their physical and cognitive development stunted by malnutrition, with the poorest children at highest risk. Addressing pneumonia must also be prioritized. According to the Global Childhood Report, childhood pneumonia is the leading infectious cause of deaths in children under age 5 and it kills more children than diarrhea, malaria and HIV combined.

While much progress has been made in increasing national governments’ political will to reduce child and maternal deaths, resources must follow this commitment. The U.S. should work with national and local governments to continue to increase its own domestic investments in health, particularly for maternal and child survival interventions. This also includes working with national and local governments in ensuring that these resources are reaching the hardest to reach populations. Women and children who are furthest behind must be identified and prioritized in terms of investments, service provision and decision making. US should also work with governments to ensure that all women and children, especially excluded women and children, are counted to measure progress towards reducing child and maternal deaths. 

Going beyond just working with the Ministries of Health is critical.  U.S. and other stakeholders must continue to engage local civil society in the efforts to change the lives of women and children. In Ethiopia, for example, Kes Melakeselam Hailemnase, a 64 year old Orthodox Priest and head of Embaalaje Woreda Orthodox Churches Forum, reached more than 8.000 individuals with maternal, child, newborn health messages during regular sermons and other religious festivities after receiving training on Community Based Newborn Care, organized for faith-based leaders.  Kes’ efforts helped Abeba Mesele, a 21 year old mother of two, learn the importance of going to a health facility for antenatal check up and early post natal check ups.  

Change often happens at the local, community level. As USAID works with countries in their journey to self-reliance, development plans must be made in consultation with recipient country governments and civil society.  To ensure sustainability and self-reliance, development must be owned by the people of the countries receiving foreign assistance.

As the 2019 report shows, USAID has greatly contributed to building in country capacity by training health professionals including community health workers. This may not be enough. With increased natural disasters and the resurgence of pandemic threats such as Ebola, U.S. should work with governments and other stakeholders in helping to build resilient health systems. 

Finally, continued U.S. partnership and assistance is critical to a country’s success in improving the lives of women and children around the world. USAID should maintain evidence-based, highest-impact interventions and a comprehensive approach to addressing maternal and child survival and continue to provide robust resources.

Photo credit: Susan Warner / Save the Children

Taxation with Representation: Citizens as Drivers of Accountable Tax Policy

Written by Andrew Wainer, Director, Policy Research  and Sadie Marsman, Research Assistant
Photography credit: Susan Warner / Save the Children

Protests by citizens against their government’s tax systems have not just occurred across cultures and centuries, but have led to revolutions.

In 18th century America, for example, the British crown’s assertion of its right to tax colonists without consent led to the Boston Tea Party and, eventually, the American Revolution. “No taxation without representation” is perhaps that revolution’s most famous slogan. Since then, it’s been played out in countless other parts of the globe.

Throughout history, taxation has been controversial and often dramatically contested. Yet today it is accepted as one of the primary ways for governments to increase domestic revenue in order to better meet the basic needs of citizens.

Save the Children’s new report, Taxation with Representation: Citizens as Drivers of Accountable Tax Policy, analyzes the evidence on citizen tax advocacy in developing countries in order to garner insights, and identify trends, on how civil society organizations (CSOs) contribute to accountable and progressive tax policies within the framework of equitably financing the Sustainable Development Goals (SDGs).

The report, being launched this week in Berlin at a meeting of the Addis Tax Initiative, is intended to:

  • Provide additional guidance to policymakers seeking to support pro-development and accountable DRM in developing countries, and
  • Contribute to the growing evidence base on the role of CSOs in tax policy

A Tax and Governance Virtuous Circle?
Tax policy isn’t just about tallying revenue collection numbers and tax-to-GDP ratios. It’s also about ensuring revenue collection is pro-development, and contributes to enhanced governance. A broad representation of citizens’ voices must be included in that tax policy’s development and execution including marginalized and vulnerable groups.   

To create a tax system that is representative of broad societal goals, factors such as gender, ethnicity, geography and language must all be considered. While technical experts should, and will, continue to play a central role in tax policymaking, domestic resource mobilization (DRM) will fail to achieve its potential as a key source of finance to achieve development goals if it’s pursued without citizen input, and without prioritizing equity.

With this in mind, the report analyzes a series of cases in the research and policy literature on civil society engagement in tax policy at the national and subnational levels. The goals of our analysis are to illustrate what has worked and what is needed to support citizen engagement for more accountable tax policies.

 Citizen Engagement at the Subnational Level: Burundi
A 2014 World Bank study in Rutegama, Burundi, found that fostering partnerships between civil society and local administrators was necessary for successful citizen engagement, given the low levels of civil society capacity and state administrative capacity in fragile contexts.

Capacity building had to happen with citizens and the state, together.

World Bank researchers found that, “Within the Burundi context [it]…must be done in tandem with encouraging state developmental responsiveness.” In Burundi, as in other instances analyzed in the report, international donors–in this case primarily the Swiss Agency for Development and Cooperation (SDC) and the German Agency for International Cooperation (GIZ) – facilitated the decentralization process, encouraging engagement between CSOs and local fiscal officials.

In Rutegama, the municipal administrator created a partnership with local civil society, in which they were involved in discussions on budget and tax collection. Burundian law facilitated more equitable participation of women because gender balance is enshrined in law at both the local and national levels.

For example, communes in Burundi are governed by a council of 15 members that must also reflect a degree of gender balance (by law, at least 30% must be women).

For its part, matching the local government commitment, civil society raised awareness among taxpayers on the links of taxation to public expenditure. At the time, the public already had access to budget expenditures, but many citizens were unable to read the documents in French or make sense of the budget’s complicated format, so additional taxpayer education was conducted.

Due to the government’s commitment to transparency and social accountability, and gender equality, citizens placed more trust in their government and were more willing to pay taxes. After the program was implemented in 2010, Rutegama experienced increasingly larger revenue collections each year for the next three years.

Recommendations
Based on the analysis of the country cases, the report presents recommendations on how to support citizen engagement in DRM including:

  • Support subnational-to-national links through donor DRM programming. Donors can build national-level civil society tax advocacy through supporting more developed subnational work. Local level civil society advocacy can be foundational for building broader national campaigns and serve as the training ground for tax policy advocacy.
  • Support government and civil society co-design of tax policy. Engaging civil society and governments together – particularly at the local level – has a track record of success. The citizen-state compact can be strengthened when capacity needs are addressed together, rather than only building the capacity of government.  Confrontations between citizens and government tend to occur when there is no platform to engage on tax issues.
  • Engage in the full budget cycle. Over the last decade, civil society organizations across the world have advocated for effective and equitable provisions of services through the budgeting process. In so doing, they have gained expertise as well as become agents of change able to influence budget allocations at all levels of government. Combining tax advocacy, with budget advocacy, civil society can be more effective in advocating for accountable and equitable revenue collection and spending on public services

To ensure that a tax policy is pro-development, and contributes to enhanced governance and social inclusion, a broad representation of citizens’ voices must be included.  Otherwise, DRM will fail to achieve its potential as a key source of finance for development around the world. We look forward to presenting that case to our ATI partners this week in Berlin.

 

 

Photo credit: Caroline Trutmann Marconi / Save the Children, Nov 2018

Mexico’s Progress in Ending Child Labor Is a Father’s Story of Progress As Well

The latest child labor estimates tell a story of real progress and of a job unfinished, as outlined in Save the Children’s Global Childhood Report: Changing Lives in our Lifetime. Child labor rates and the global number of child laborers have declined dramatically in recent years. Globally, rates are down 40%, and 94 million fewer children are working now than in 2000. But progress has slowed and the world remains far from the 2025 target to end child labor in all its forms. 1

Much of the decline in child labor in recent years has been credited to active policy efforts to extend and improve schooling, extend social protection, expand basic services and establish legal frameworks against child labor.2

Mexico has made impressive progress against child labor, cutting its rate by 80%. This progress deeply personal for many families with young children who hope for a better future for their sons and daughters, free from child labor. 

Amador is one such parent.

The father of five school-age boys himself, Amador dropped out of school to work and make money when he was about 10. “My dad was disabled and I was the last child,” he said. “I did not have an education. I still don’t read very well.”

Amador’s story was much more common in 2000 than it is now. Just a generation ago, 1 of every 4 Mexican children aged 5 to 14 was engaged in child labor.5  Today, Mexico has cut its child labor rate from 24% to 5% – a remarkable decline. This progress saves an estimated 4 million children a year from child labor.6

Data suggest Mexico’s progress has been broad-based, benefiting both male and female children, children from urban and rural areas, and children from all regions. Progress has been strong among the poorest households, and equity gaps are shrinking.7

The Mexican government regularly collects and disseminates information on child labor.8 It has also invested in education and provided incentives for children to attend school rather than work. Education reforms in the 1970s and 1980s helped create a new generation of more educated parents less inclined to send their children to work.9 The Prospera program, launched in 1997, offers small cash payments to impoverished parents to keep children in school and attend workshops on nutrition, hygiene and family planning.10 Improvements in living standards and an overall reduction in poverty also contributed to the decline in child labor, as did the movement of jobs away from the agricultural sector.11

Save the Children Mexico has partnered with the sugar industry to better comply with Mexico’s child labor laws and make changes in the way business is done. This alliance, established in 2012, identifies child labor risks throughout the sugar supply chain, finds alternatives for at-risk children and supports community work to prevent child labor in the fields. The partnership also advocates for better child labor regulations and has working groups to promote best practices.

There are still an estimated 3.2 million child laborers in Mexico, 134 so increased attention on this problem is needed, especially in rural areas. Amador is determined that his five boys will not be among that statistic. “I’m giving my children an education… so they can study and be someone in life.”

1. El Instituto Nacional de Estadística y Geografía. “3.2 Milliones de Niños y Niñas y Adolescentes de 5 a 17 Años Trabajan en México: Módulo de Trabajo Infantil (MTI) 2017”

2. Understanding Children’s Work Programme. Understanding Trends in Child Labour: A Joint ILO-UNICEF-The World Bank Report. (Rome: 2017)

3. ILO. Global Estimates of Child Labour: Results and Trends, 2012-2016. and ILO. Global Child Labour Trends 2000 to 2004. (Geneva: 2006)

4. ILO. Marking Progress Against Child Labour: Global Estimates and Trends 2000-2012. (Geneva: 2013)

5. Includes household chores for at least 21 hours. 

6. National estimates for 2017 suggest child labor rates have declined further, to 3.6% of children aged 5-14. Source: El Instituto Nacional de Estadística y Geografía. “3.2 Milliones de Niños y Niñas y Adolescentes de 5 a 17 Años Trabajan en México: Módulo de Trabajo Infantil (MTI) 2017” (2018) 

7. Understanding Children’s Work Program. The Mexican Experience in Reducing Child Labour: Empirical Evidence and Policy Lessons. (2012) 

8. UNICEF. Child Rights in Mexico.

9. Understanding Children’s Work Program. The Mexican Experience in Reducing Child Labour: Empirical Evidence and Policy Lessons.

10. Dávila Lárraga, Laura. How Does Prospera Work? Best Practices in the Implementation of Conditional Cash Transfer Programs in Latin America and the Caribbean. (Inter-American Development Bank: April 2016)

11. El Instituto Nacional de Estadística y Geografía. “3.2 Milliones de Niños y Niñas y Adolescentes de 5 a 17 Años Trabajan en México: Módulo de Trabajo Infantil (MTI) 2017”

Investing in Maternal and Child Health: Development Impact Bonds

Written by Andrew Wainer, Director, Policy Research and Jill Carney, Associate Director Global Health and Development

The global decrease in child and maternal deaths is one of the great achievements in international development in recent decades. Child mortality rates have fallen by more than half, from 12.7 million under-5 deaths in 1990, to 5.6 million in 2016. American leadership and foreign assistance played instrumental roles in this achievement, saving the lives of millions of children around the world

Nevertheless, preventable maternal and child deaths are still too high. Globally, 15,000 children continue to die each day from causes that are often preventable, such as pneumonia, diarrhea, and malaria.

The global health community knows how to reduce maternal, newborn, and child deaths, but a persistent financing gap impedes more progress. Current levels of international development assistance are not enough to achieve the Sustainable Development Goal (SDG) 3 target of ending preventable child deaths by 2030. According to the World Bank, achieving SDG 3 will require an additional $33 billion annually. To close this gap, development actors are increasingly exploring innovative financing tools that engage the private sector – and unlock new resources.

A new mother cradles her newborn baby in the neonatal ward at Queen Elizabeth Hospital, Malawi. She was being taught the KMC (Kangaroo Mother Care) method to use on her baby. Photo credit: Jonas Gratzer/Save the Children, Feb 2016

Due in part to the SDG financing gap, over the last few years, Save the Children has complemented its policy and advocacy work on bilateral assistance with a focus on identifying alternate ways to close the financing gap for poverty-focused development and humanitarian programs, including maternal, newborn and child survival.

Supported by the Bill and Melinda Gates Foundation as part of our commitment to researching and advocating for innovative financing tools for child survival, Save the Children produced a report on development impact bonds (DIBs) for maternal and child health that was launched during the 2018 United Nations General Assembly.

This report is part of Save the Children’s focus on ensuring that governments are providing funding for vital services to give children a chance at a bright future – such as health, education and nutrition.  This includes policy and advocacy work to increase domestic resource mobilization at the country level, especially increased public financing for health and education.

DIBs are one financing mechanism through which we can attract private capital to social projects, and for private investors to earn a profit if the development outcome is achieved. By offering a potential profit to investors, plus guaranteeing the security of impact for outcome, DIBs have the long-term potential to attract additional public and private stakeholders to international development. They are analyzed at length in our report, which focuses on two DIBs intended to improve maternal and child health:

Fine-Tuning a new Development Finance Tool
More DIBs are set to be launched in coming years, providing stakeholders with additional cases to observe and gather evidence. In the wake of the launch of the Save the Children report at UNGA73, discussion on the potential and challenges of DIBs has escalated in the United States and globally.

Through our continuing discussions with DIB stakeholders and development finance experts, we’ve continued to hone in on how to make DIBs more efficient and effective. The following are some of the key learnings we’ve gathered though discussions with our DIB research and analysis partners:

Building a DIB is Challenging
Given its complex legal and financial structure, DIBs require more effort design and stand up in comparison with traditional grant-based assistance. Organizations interested in participating in DIBs must be “DIBs ready” – prepared for the patience and flexibility needed to craft a DIB with multiple partners over months and years. Building a DIB is a complex undertaking and service providers need to ensure that their systems and structure are appropriate before embarking on one. It’s also important that stakeholders use the DIB tool because it’s the most appropriate for the development problem being addressed rather than bypassing that analysis and diving into the DIB structure without assessing its appropriateness to addressing the problem.

More Evidence
There are still few completed DIBs and very limited evidence with which to judge them, thereby leaving DIBs as an “open case” as to whether it can help reduce the financing gap for maternal and child survival. More evidence is needed for potential DIB stakeholders to adequately assess risks and benefits. Multiple DIB experts have discussed the need for more transparency and sharing of evaluation data and other learnings. 

More Education
More evidence is a tool for additional education. In spite of growing buzz around the DIBs model, there are still relatively few investors and outcome funders involved in DIBs, in part due to a lack of understanding needed to determine potential risk and reward. Part of the solution is streamlining the DIBs process, where the costs and benefits are explicitly stated to potential future stakeholders. To achieve this, more stakeholders need to be educated on DIBs and results-based performance tools generally. In addition to identifying more outcome funders and investors, explicitly sharing the model’s risks and the incentives in these roles could facilitate broader interest and participation. 

Financing the SDGs
The private sector has the potential to make major contributions to achieving the SDGs, with some estimates that that there is $85 trillion, “parked in long-term investment vehicles, including sovereign wealth funds, pension funds, and insurance funds” that could be harnessed toward development goals.

DIBs are a tool to do just that, but Save the Children’s research on DIBs and our consultation with experts reveals that channeling that private sector funding into development is not easy or quick. The movement from rhetoric on “billions to trillions” to the actual sustained investment of private dollars into development will require new and sometimes uncomfortable partnerships and new ways of analyzing and thinking about development finance.

And it is important to keep in mind that DIBs are one tool among many to finance development. While their introduction has facilitated important conversations on development finance, Save the Children is exploring multiple channels for financing child survival. We’ve conducted research on development impact bonds – a new and mostly untested financing tool—as an example to illustrate the use of alternate sources of financing.

Save the Children is grateful to our DIB research and advocacy partners for lending their hard-earned expertise to us, helping make certain that our analysis and findings are grounded in the complex realities of forging innovative finance solutions to child survival.

Illnesses Don’t Discriminate: Vaccines Work

Co-authored by Carolyn Miles, President & CEO, Save the Children and William Moss, MD, MPH, Interim Executive Director, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health

Parents work hard to help their children stay healthy. Try as we might, hand washing, good nutrition, and flu shots are sometimes no match for “what’s going around.” A cough. A fever. A stomach bug. If you feel like these illnesses are everywhere – you’re right.

And families around the world are battling the same illnesses. But in some places it’s far from a fair fight. Illnesses that are easily preventable and treatable in the United States can take the life of a child in Africa. More than 1.3 million children die each year from pneumonia and diarrhea, two of the leading killers of children in poor countries.

It surprises many people to learn that pneumonia and diarrhea, not HIV, tuberculosis or malaria, are the leading cause of death in young children around the world. While diseases like HIV and malaria take a toll, pneumonia and diarrhea take more lives of children under age five than all these diseases combined.

In the U.S., routine immunization helps protect against these common sicknesses. Hib (Haemophilus influenzae type b) and pneumococcal conjugate vaccines protect against pneumonia, and the rotavirus vaccine protects against one of the most common and serious stomach bugs. These vaccines have drastically reduced the number of children who suffer from these illnesses. A 2017 study found the rotavirus vaccine cut nearly in half the number of young children hospitalized for diarrhea, saving more than $1 billion in health care costs over five years. Similar benefits have been documented with the vaccines that prevent pneumonia.

Though germs are everywhere, health care sadly is not. Parents around the world share a common goal of protecting their children, yet too many families still lack access to, or even awareness of, vaccines and medicine that could save their children’s lives. As a result, the stomach bug that means a few days off school and a trip to the pediatrician for a child in Maryland can mean severe dehydration and even death for a child in Kenya. The respiratory infection that goes around at a preschool in Atlanta causes life-threatening pneumonia for young children in Ethiopia. What separates parents around the world is not the illnesses their children face, but how the health care systems they have access to are equipped to battle them.

While some may dismiss the challenges parents in poor countries face as inevitable and unfortunate consequences of poverty, this is simply not the case. This is not only a battle worth fighting, it’s also one we can win. We know how to prevent these deaths, and in many places, we are already succeeding. India, Nicaragua, Tanzania and many other countries have increased immunization rates and have saved lives as a direct result. Since 2000 the number of children’s lives lost to pneumonia and diarrhea has been more than cut in half – from 2.9 to 1.3 million deaths annually.

Every year, fewer children lose their lives to preventable diseases. We should be encouraged—but not satisfied—with the progress we’re making. We can do better. We can increase resources to equip families and health care systems around the world with the tools they need to battle our shared infectious foes. We can find new ways to deliver lifesaving vaccines and antibiotics to make sure no child dies from a cough, the stomach bug, or a mosquito bite. And we can muster our political courage and give voice to the needs, worries, and love of parents who, like germs, are the same everywhere.

Ethiopia’s Children Deserve to Have a Childhood

Written by Carolyn Miles, President & CEO, Save the Children

As we drove into the camp area for those displaced from home, the sea of people, goats and cows on the dusty, potholed road parted and flowed around our vehicles, each intent on going somewhere fast. The entrance to the children’s area of the camp was a piece of tin in a fence of sticks and tarps and when it swung open, we could see hundreds of children running and playing and a circle of girls dancing.  This is Gedeb, Ethiopia, a few hours south of Hawassa, where more than 13,000 people have come to escape violence.  

In this rather sad place, we visited the happiest corner, full of children playing and learning in a Save the Children supported area. Small children learned their letters in a huge tent, with local teachers and volunteers coaxing them to the front of the room to practice at posters tacked to the canvas walls. There were few books, and even fewer toys, but the children were intent on learning and squealed in delight when one of us came to the front of the room to “help” with the lesson.

Outside, girls danced and sang in a tight circle and in the large field dozens of older kids were engaged in a lively game of soccer. Even in the worst of circumstances, children just wanted to play, have fun and learn like any child anywhere. 

As we walked through the camp, through crowded rows of tiny huts made of tarp, sticks and dried banana leaves, the delight of the children nearby seemed even more amazing. Inside one of the shelters, I stopped to talk with a mom named Biritu, a mom of five who is pregnant with her sixth child. This was her second time coming to the camp from her home further north, where violence and looting had caused her to flee with her children. The space they were living in was about the size of a basic bathroom here at home, with tarps on the floor of mud and two tiny spaces for sleeping and living. Even on a cool day, it was steamy inside. When I asked when she thought she might go back home, she just shook her head sadly and held up her hands – a universal sign of “who knows.”

We visited the health post in the camp, which is also run by Save the Children. Here there were doctors from a nearby hospital who work 15 day rotating shifts. Mothers lined up on wooden benches waiting to get babies checked for malnutrition and for their children to receive vaccinations or treatment for illnesses. Adults were receiving services too, but the biggest focus was on pregnant women and children, trying to keep them healthy. 

The plight of the internally displaced people (IDPs) in Ethiopia is largely unknown. Yet there are more than one million people in just these two southern regions of Ethiopia and 3.2M country-wide who have been displaced. Many of them live in camps like the one we visited and even more live in the surrounding communities, sometimes with relatives until the resources and goodwill run out and they find themselves in the streets or back at a camp.

The conditions, despite the services offered by Save the Children and other aid agencies, are harsh. There is worry that as the rainy season approaches, this camp will be flooded. The latrines and water points may not hold out and these people could be moved yet again from this place to another. For many this might be the third or fourth move in just the past year. The children can’t go to formal school and the cases of scabies, malnutrition, pneumonia, and diarrhea are growing every day. Save the Children has reached more than 470,000 of the IDPs in this region with distributions and services, but there are still hundreds of thousands of displaced around the country unreached by any aid. With a world full of crisis and disasters, the suffering of these children and their families is largely ignored. 

Ethiopia is a country of great progress – one of the only countries in the world to meet the Millennium Development Goal for two-thirds reduction in child mortality from 2000 to 2015 and a country with strong GDP growth. But that progress and the opportunities it affords children is at risk of being set back for millions of children who can’t get regular access to services, especially to health services and school.

As part of our Return to Learning initiative, Save the Children has been working for the past three years to get refugee children access to school within a few months of being displaced. We’re working to ensure the world pays more attention to the importance of education for refugee children. I came away from this trip to Ethiopia convinced that we need to do the same for IDP children here in Ethiopia and around the world. We can’t afford to let millions of children lose out on the opportunity to go to school for years on end due to displacement. Whether they are refugees in another country or displaced within their own, they deserve the chance to grow up healthy and to get an education.  

 

 

Newborn babies and their mothers receive care in a health center located in Malawi where Save the Children supports proven programs, such as Kangaroo Mother Care. Photo credit: REDD BARNA / JONAS GRATZER

Customizable Hospital Furniture for the Smallest Babies in Malawi: A Potential Disruptive Innovation

Written by Bina Valsangkar, MD, MPH, FAAP

© 2015 | Kristina Sherk Photography 

Bina Valsangkar, MD, MPH, FAAP, is a pediatrician, adviser at Save the Children and a changemaker for children. She leads a team of health experts, industrial engineers and industrial designers under a Save the Children innovation grant to re-design newborn hospital units in Malawi to deliver family-centered care. In previous roles at Save the Children, she drafted policy, conducted research and developed newborn health programs in Africa and Asia. 

While many aid agencies, academic institutions and traditional and non-profit companies work to ensure access to essential medical equipment in low-income countries, less attention has been paid to the importance of suitable medical furniture. In the newborn units of Malawi, where Save the Children has been working to improve quality of care for the last several years, a well-designed chair, neonatal crib and staff workspaces have the potential to make care more family-centered, comfortable and safer. Well-designed furniture can improve patient, family and health worker comfort, but can also improve health outcomes. A well-designed chair for the newborn unit, for example, can facilitate greater amounts of skin-to-skin time between a mother and her newborn infant—which can be life-saving for infants born prematurely in Malawi. Well-designed workspaces and neonatal cribs can improve patient flow and visibility and reduce infection risk.

Malawi currently buys and imports the majority of its hospital furniture from India and China. While these pieces offer a relatively affordable option for hospital furniture with basic function, the furniture does not fully suit the needs of patients, families and health care workers in Malawi. Hospitals there face a different patient profile, medical demands, space limitations and set of cultural beliefs and practices.

Customizable hospital furniture offers a potential solution to the problem of functional fit. Headway in this market, however, has been largely made in high-income, high-end markets, with little or no market share in low-income countries.

With seed funding from the Save the Children Innovations Council as well as Purdue University’s I2D Lab, our team of experts in health, industrial engineering and design led by Professors Yuehwern Yih and Steve Visser, is working to create a set of space-saving furniture with accompanying layout design to allow for greater family-centered care and meet the needs of patients, families, and healthcare workers at Ntcheu district hospital in Malawi. The set includes a stacked neonatal crib, lounge chair for mothers and babies to be in skin-to-skin contact together and a mobile nurse’s station. Our project was born out of research and experience from the Saving Newborn Lives (SNL) program, a now 19-year old newborn health project at Save the Children.

While getting the individual furniture pieces and layout just right and within budget for the hospital is of utmost importance, it is the process of customization in the low-income setting, and creating and using customizable blueprints to make locally-sourced pieces with learnings from prior users that we hope will be a new market foothold in Malawi, with the potential to move across markets and upmarket to other countries and regions.

To learn more about Save the Children’s changemakers, visit our website.