Progress towards achieving the MDGs Dr Mickey Chopra, Chief of Health, UNICEF

The progress towards MDG 4 is insufficient globally Sub-Saharan Africa, Southern Asia and Oceania is not on track

Under-five mortality rate by region, 1990 and 2009 Source: IGME 2010

U5MR reduction - Progress has not been evenly distributed among regions This graph illustrates the progress by region. Currently (2008 data) about half of the 8.8 million children dying every year live in Africa, while only 22% of worldwide births occur on that continent. Around 40% of all child deaths occur in Asia. In Sub-Saharan Africa, 1 child out of every 7 children will die before the age of 5 (U5MR 2008: 144 per 1000)! In South Asia one out of every 13 (U5MR: 76 per 1000). Compare that to the industrialized world, where the same will happen to 1 child in every 165 children (U5MR 6 per 1000). That all goes to say that we have made a lot of progress, but that the progress has not been evenly distributed among countries and regions. And that we must work hard, especially in Africa and South Asia to save more lives if we are to achieve MDG4. 4

MDG 5: Progress but still too high

Total aid to MNCH (constant 2008 USD) Non-Countdown countries 68 Countdown countries --ODA to MNCH for the 68 priority countries more than doubled between 2003 and 2008, rising from about $1.8 billion to over $4 billion. --Between 2003 and 2008, ODA to child health increased by 120% and ODA to MNH increased by 130%. --Funding to child health has remained a steady 70% of total funding to MNCH. What does this mean for individual countdown countries? and for individual children? ODA to MNH per birth ODA to MNH

68 priority countries: Levels of ODA to CH per child, 2008 Population-weighted Average: $6 per child Unweighted Average: $16 per child Only two countries have experienced an overall decreasing trend over the 6-year period: Brazil and Iraq. Nonetheless, significant volatility remains. Despite the overall increasing trend, 17 countries received less aid in real terms in 2008 compared with 2007. Moving on to maternal and neonatal health . . .

68 priority countries: Levels of ODA to MNH per birth, 2008 Unweighted Average: $31 per birth Population-weighted Average: $11 per birth Six countries have, however, experienced an overall decreasing trend over the 6-year period: Brazil, Iraq, Burundi, Ghana, Eritrea, and Morocco. And despite the overall increasing trend, 23 countries received less aid in real terms in 2008 compared with 2007.

Funding gap still large Global Strategy for Women and Children 2010

Unequal Progress to MDG’s Under Five Mortality 2/3 countries that have made progress in reducing U5MR have shown worsening inequalities (i.e gaps between better off and worse off have increased) Indicates : delivery and financing of health and nutrition services as well as demand / use of these favor the better off This first slide, taken from the Progress for Children, shows trends in under 5 mortality reduction, and the gap between richer and poorer children in around 37 countries. Dots in red and green, on the left, represent countries that have reduced under 5 mortality. Dots in red, on the top left, are countries that have done so but in which the gap between the poor and the rich children, in terms of under 5 mortality, has widened. Green dots, on the left bottom corner, are countries in which under 5 mortality has been reduced and in which equity has improved, in other words, under 5 mortality has come down more in the worse-off than in the better-off children. The red dots, those with worsening inequity, amount to 2/3rd of the countries that have made progress toward MDG 4. In these countries, the delivery and financing of health and nutrition services as well as the access to and use of these services favor the better off. That is “the bad news “ and it reflects a broader trend, as the Progress For Children 2010 shows.   However, the good news is that 1/3rd of the countries that have made progress toward MDG 4, have done so by improving equity (green dots). This fact questions the conventional wisdom – that it is too costly and too difficult to go into poor, hard to reach communities; that it is easier and more cost-effective to reach better-off children. UNICEF Progress for Children 2010

In South Asia, the richest 20% are 23 times more likely to use improved sanitation than poorest 20%

Education marginalization – inequalities within countries The case of Nigeria 14 C. A. R. Chad Bangladesh Cameroon Honduras Indonesia Bolivia Cuba Ukraine 12 10 years 10.3 years 9.7 years Rich, rural boys Urban Rural 10 Rich, urban boys Richest 20% Rich, rural girls Boys 8 Girls Average number of years of schooling Nigeria 6.7 years 6.4 years Poor, urban boys 6 Average number of years of schooling varies between countries Within Nigeria, richest have more years than poorest, Within each category, boys have more schooling than girls, The worst off are poor, rural girls from the Hausa tribe 4 Education poverty Poorest 20% 3.5 years 3.3 years Poor, rural girls 2.6 years 2 Extreme education poverty Rural Hausa Poor, rural Hausa girls 0.5 years 0.3 years

Targeting CH aid Equatorial Guinea Afghanistan Chad Niger Just to note - Botswana has been excluded as an outlier with over $150 per child Here I have plotted the U5 mortality rate against the aid to child health per child in 2008. The intention is to show whether aid is being targeted towards those countries with the greatest needs, though other interpretations are possible and I welcome your thoughts and interpretations of this graph. I have included a logistic trendline, which shows some degree of fit to the data, although there is, as you can see, very significant variation in levels of funding for a given level of U5 mortality. Equatorial Guinea, for example, receives over $50 per child and has an U5MR around 150. Niger has a somewhat higher U5MR and receives about 1/3 the aid per child. Chad’s U5MR is higher still, and yet it receives less than $10 per child. Finally, I have included Afghanistan, whose child mortality rate is the highest of all 68 countries; it receives just over $26 per child. Chad Niger

Targeting MNH aid Equatorial Guinea Afghanistan Niger Chad Looking at funding to maternal and neonatal health, we can again see a similar picture when aid per birth is plotted against the MMR. Again, I should note that Botswana has been excluded as an outlier with over $400 per birth A logistic trendline shows some degree of fit, but there is a lot of variation – indeed, even more than for child health. We see the same four countries occupying rather similar positions as for child health – Equatorial Guinea, like Botswana, receives several times more aid per child than countries of similar – or even much higher – MMRs. Chad and Niger have very high MMRs and do not receive proportionately higher aid. Niger Chad

Equity-driven programming can deliver better results, more equitably, at a lower cost per life saved in Pakistan Locally-developed strategy can obtain similar or better results at a lower cost