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CORE Group Spring MeetingApril 2013

US Government Action Plan for Children in Adversity

New Science for Old Problems Neil Boothby

USG Special Adviser and

Senior Coordinator for the USAID Administrator Children in Adversity

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A diverse portfolio of assistance

PL 109-95

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A legislative requirementPublic Law 109-95: The Assistance for Orphans and Other Vulnerable Children in Developing Countries Act of 2005

Requirements:

International assistance to highly vulnerable children is comprehensive, coordinated,

and effective, and built on evidence-based practices.

• Special Advisor (appointed or delegated by the Secretary of State)

• Interagency strategy to determine strategic priorities

• Whole-of-government M&E system

• Annual reports to Congress

• USAID is the lead agency (Senior Coordinator to the USAID Administrator)

• $2.85 billion per annum

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From evidence to actionResults of the U.S. Government Evidence Summit on Children Outside of Family Care (December 2011):

• 150 experts participated• 3,500 articles were reviewed• Senior interagency leaders committed

to developing a strategy, published in Lancet

• 60 authors contributed to 7 papers published in Child Abuse and Neglect: The International Journal

• One year later (December 2012), the U.S. Government Action Plan on Children in Adversity was launched at the White House

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U.S. Government Action Plan

The first-ever strategic guidance for U.S. government assistance to children overseas

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Children in Adversity: who are they?

25%live in

extreme poverty

1.9 billion children in LMIC

Adversity: Serious deprivation or danger

Poor health and nutrition

Low education attainment

Outside of family care

Exposure to violence, exploitation, abuse

United Nations Population Division World Population Prospects 2010UNICEF State of the World’s Children 2012

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Critical Pathways and Investments

compromised

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Action Plan Objective

Promote Evidence-

BaseIntegrationStrengthen

Systems

Put Family Care First

Protect Children from Violence, Exploitation, Abuse, and

Neglect

Build Strong BeginningsPRIORITY

SUPPORTING

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White House LaunchDecember 19, 2012

"And every child — no matter where they live, no matter the circumstances into which they are born — should have the opportunity to survive and thrive… And so while we know that our future prosperity and our security are intimately tied into the results we deliver for children today, we also know that we have within our power today to ensure that all children survive and get healthy food, all children grow up in a family, and all children are safe from the violence and terror that sometimes erupts in our world.”

USAID Administrator Rajiv Shah, December 19, 2012

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“It is easier to build strong children than to repair broken men.”Frederick Douglass

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U.S. Government CommitmentGoal: The U.S. Government will help ensure that children under five not only survive, but also thrive by supporting comprehensive programs that promote sound development of children through the integration of health, nutrition, and family support.

Outcomes: Increase the percentage of children achieving age-

appropriate growth and developmental milestones.

The number of USG-funded programs that integrate health, nutrition, developmental protections, and caregiving support is increased.

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The global burden

• 6.9 million children under the age of 5 worldwide die each year.

• More than 25 times that number -- over 200 million children -- survive, but do not reach their developmental potential.

• As a result, their countries have an estimated 20 percent loss in adult productivity.

Grantham McGregor, S. et al., (2007). Developmental potential in the first 5 years for children in developing countries. Lancet, 369:60-70

WHO and UNICEF. Care for Development.

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109

891

Expected to diebefore their5th birthday.

Expected to livepast their

5th birthday.

Approximately 1/3 are notexpected to reach their

developmental potential

Grantham-McGregor et al. Lancet. 2007January 6; 369(9555): 60–70

In Sub-Saharan Africa, for every 1000 children born in 2011…

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The importance of early intervention

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Adversity impairs development

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The economics: breaking the poverty cycle

Rates of return on investments made during the early childhood years average between 7 and 10 percent, greater than investments made at any other time in the life cycle.

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What works?Healthcare Standard health screenings for pregnant women Skilled attendants at delivery Childhood immunizations Well-child visits

Nutrition Breastfeeding promotion Salt iodization Iron fortificationEarly Learning Parenting programs (during pregnancy, after delivery and throughout early childhood) Childcare for working parents (of high quality) Free preprimary school (preferably at least two years with developmentally appropriate curriculum and classrooms,

and quality assurance mechanisms)

Social Protection Services for orphans and vulnerable children Policies to protect rights of children with special needs and promote their participation and access to ECD services Financial transfer mechanisms or income supports to reach the most vulnerable families (could include cash

transfers, social welfare, etc.)

Child Protection Mandated birth registration Job protection and breastfeeding breaks for new mothers Specific provisions in judicial system for young children Guaranteed paid parental leave of least six months Domestic violence laws and enforcement Tracking of child abuse (especially for young children) Training for law enforcement officers in regards to the particular needs of young children

Source: World Bank. Strategic Evaluation Impact Fund.

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Two birds, one stone

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Sustained results

0%

1%

2%

3%

4%

5%

6%

7%

height weight

% i

ncr

ea

se o

f m

ea

nco

mp

are

d t

o c

on

tro

lgro

up

Supplementation

Maternal tutoring

Both

Source: Van der Gaag, J. School Performance and Physical Growth of Underprivileged Children: Results of the Bogotá Project at Seven Years. (1983). World Bank, Washington D.C.

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What does success look like?• The percentage of children achieving age-appropriate

growth and developmental milestones is increased.

National surveillance through DHS and MICS (data is collected but as yet not analyzed)

Project-level indicators (WHO, UNICEF, World Bank, and NGOs have models. USAID has as yet not adopted any).

• The number of USAID-funded programs that integrate health, nutrition, developmental protections, and caregiving support is increased.

Reported through annual reports to Congress required by PL 109-95.

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“Any proposed programs should respect the primacy of the family.”

James J. Heckman, Nobel Laureate in Economics

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U.S. Government CommitmentGoal: U.S. Government assistance will support and enable families to care for their children, prevent unnecessary family-child separation, and promote appropriate, protective and permanent family care.

Outcomes: Increase the percentage of children living within appropriate,

permanent, and protective family care.

Reduce the number of children living in institutions.

The percentage of families providing adequate nutrition, education opportunities, care, and protection for their children is increased.

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The global burden

The most vulnerable children in the world – children outside of family care – have fallen off the statistical map.

Global estimates:• 17.8 million children have lost

both parents• 2-8 million children may be living

in institutional care• 1.1 million children are trafficked

for forced labor• 1.8 million children are victims of

sex trafficking or pornography• 300,000 children are associated

with armed forces or groups

All children count, but not all children are counted.

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Children are at high risk of growing up without a biological

parent, usually their father

Percentage of children under 5 living with their biological mother but w/o their biological father

Percentage of children under 5 living with their biological father but without their biological mother, and

Percentage of children under 5 living without both biological parents (x-axis)

Source: UNICEF. Inequities in Early Childhood Development: What the data say - Evidence from the Multiple Indicator Cluster Surveys. February 2012. Figure 5, Page 9.

Note: This analysis included 40 countries.

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The importance of family• Optimal support for child health, nutrition, and development

comes through protective and permanent caregiving in a family environment.

Children outside of family care often experience higher prevalence of abuse, neglect, lack of stimulation, poor health, and inadequate nutrition with negative long-term outcomes.

• Most children (approx. 80%) are institutionalized as a result of extreme poverty rather than parental death or abandonment.

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The effects of caregiving• Institutionalization can lead to serious developmental, cognitive,

emotional delays and challenges. Children placed in appropriate family care by age 2 recover

normative growth and development by age 8. Children removed from institutions after age 2 do not reach

normative ranges.

EEG level: Institutionalized children EEG level: Never-institutionalized children

• Placing children in protective family care results in better child outcomes and is significantly less expensive than institutional care.

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What works?

• Household economic strengthening plus support for caregivers

Employment, savings and loans programs, cash transfers Positive parenting: reducing harsh discipline, substance abuse HIV prevention and treatment Child care

• Genuinely free and equally accessible primary education

• Family tracing and reunification in emergencies

• Family reunification, foster- and kinship-care

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What does success look like?• The percentage of children living within appropriate, permanent,

and protective family care is increased. National surveillance through a new measurement tool

(currently under development, to be piloted in 2 countries)

• The percentage of children living in institutions is reduced. National surveillance focusing on 6 priority countries

• The percentage of families providing adequate nutrition, education opportunities, care, and protection for their children is increased.

Project-level indicators monitored within targeted sub-populations.

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“Safety and security don’t just happen; they are the result of collective consensus and public investment. We owe our children, the most

vulnerable citizens in our society, a life free of violence and fear.”

Nelson Mandela

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U.S. Government CommitmentGoal: The U.S. Government will facilitate the efforts of national governments and partners to prevent, respond to, and protect children from violence, exploitation, abuse, and neglect.

Outcomes: Reduce the percentage of children who experience

violence, abuse, exploitation, and neglect.

Increase the percentage of children who receive care and protection.

Obj 3 - Protect Children

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The global burden• Between 133 million and 275 million children are

estimated to witness domestic violence annually.• 25-30% of children experience severe forms of

punishment.• 150 million girls and 73 million boys under 18 experienced

forced sexual intercourse or other forms of sexual violence in one year.

• 36 percent of girls and 29 percent of boys globally have been sexually abused.

• 115 million children are engaged in hazardous work; 5.5 million are in forced labor.

• 1.8 million children are victims of sex trafficking or pornography.

• An estimated 300,000 children are associated with armed forces or groups.

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The lasting effects of adversity

CDC. Adverse Childhood Experiences.

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Health impacts:violence against children

Health-risk behaviors• Sexual promiscuity• Sexual perpetration• Alcohol abuse• Illicit/injected drug use• Smoking

Mental health and well-being• Depression, post-traumatic

stress disorder (PTSD)• Aggression• Anxiety • Somatic complaints• Attempted suicide• Social ostracism• Anxiety• Academic achievement• Re-victimization• Unwanted pregnancy

Disease and injury• STDs, including HIV• Gynecological problems• Heart disease• Diabetes• Stroke• Cancer• Suicide

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Association between childhood sexual violence and selected health conditions,

females 13–24 years old, Swaziland, 2007

STDs

Pregnancy

Complications

Alcohol U

se

Unwanted Pre

gnancy

Suicidal Id

eation

Feelin

g Depre

ssed

Attempted Suici

de

Difficu

lty Sleeping

Cigarette U

se0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

3.73.5

3.0 2.9

2.3 2.32.0 1.8

1.2

Adj

uste

d od

ds ra

tio*

HIV /

*Adjusted for age, community setting, SES, and orphan status

Source: Jim Mercy, CDC

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What works? • Developing nurturing relationships between children and caregivers

• Strengthening the economic status of households

• Reducing access to and use of alcohol, illegal drugs, and weapons

• Promoting gender equality to prevent violence against girls and women (addressing violence against women and children together)

• Changing cultural norms and social attitudes that promote violence; integrating violence prevention into sector programs

• Support programs for survivors and initiatives to reverse under-reporting of violence, exploitation, abuse, and neglect

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What does success look like?

• The percentage of children who experience violence, exploitation, abuse, and neglect is reduced. National surveillance through the Violence Against

Children Surveys.

• The percentage of children who receive appropriate care and protection after experiencing violence, exploitation, abuse, or neglect is increased. Project-level indicators monitored within targeted sub-

populations.

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Outcome

Reduce % children not meeting growth and developmental

milestones

Reduce % children living outside of family care (COFC)

Reduce % children who experience violence or

exploitation

Existing Data

Stunting and Poverty (DHS) [used as ‘proxy’ indicators]

COFC living *in* HHs(DHS, MICS)

CDC VACSDOL/ILO Child Labor Surveys

Missing

Cognitive Delays, Developmental Milestones

COFC living *outside* of HHs

USG Funding for VACS

Filling the Gap

Measurement Experts Group

Measurement Experts GroupMethods Development/Grand

Challenge

Promoting VACS and CLS in Priority Countries

Measurement Challenges 3 outcomes6 countries

5 years

Results-based Approach

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Build Strong Beginnings

Protect Children

Put Family Care First

Outcomes for Rwanda 40% reduction in the number of children under the age of five with cognitive delays

– Integrate cognitive & social stimulation into existing child health and nutrition programs – Coordinate with faith-based actors in their application of caregiving programs

75% reduction in the number of children living outside of family care – Prevent child-family separation through provision of nutrition, care, education and protect– Close all orphanages in all provinces. De-institutionalize 3,400 child from orphanages to family care– Strengthen national surveillance system for children living outside of family care

50% reduction in violence against children in target populations – Incorporate anti-violence counseling for children into current projects reaching 60,000 children & families– Support national childhood violence surveillance systems

Elimination of exploitive child labor from tea industry – Remove 4,000 children from tea industry supply chain through transition into service work & schools– Implement an integrated child labor monitoring system