Thematic Report 2013

YOUNG CHILD SURVIVAL AND DEVELOPMENT

unite for children

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Contents Executive summary .................................................................................................................... 3

Strategic context ........................................................................................................................ 6

Results assessment ..................................................................................................................11

Key result area 1 ...................................................................................................................11

Key result area 2 ...................................................................................................................16

Key result area 3 ...................................................................................................................29

Key result area 4 ...................................................................................................................34

Resources .................................................................................................................................39

Financial implementation ..........................................................................................................43

Future workplan ........................................................................................................................46

Expression of thanks .................................................................................................................49

Acronyms ..................................................................................................................................50

Endnotes ...................................................................................................................................51

Cover image: © UNICEF / NIGB2010-00313 / Giacomo Pirozzi

Niger, 2013 — 21 September 2010, A health worker shows a young mother how to correctly breastfeed her baby at the local health centre in the village of Sarkin Yamma Sofoua, Madarounfa, Maradi region, South East of Niger. In low-income, food deficit Niger where child mortality and morbidity are high with one in eight children who dies before the age of five, only 27 per cent of mothers exclusively breastfeed their newborn babies up to six months. The early inclusion of complementary feeding as practiced by Nigerien mothers soon after they give birth, coupled with poor feeding practices and hygiene puts the child at risk of contracting childhood killer diseases due to the lack of clean water and increase the probability of children dying before the age of five. UNICEF and Niger's Public Health Ministry organize nationwide campaigns providing evidence on exclusive breastfeeding in an effort to discourage the traditional practice of giving babies water, juices and herbal liquids during the first six months. Health workers and midwives in rural health posts, as well as community activists in villages educate women on the benefits of exclusive breastfeeding as part of nationwide campaigns during the breastfeeding week organized each year.

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Executive summary Covering the global programme work of UNICEF in nutrition, health, water, sanitation and hygiene (WASH) and early childhood development (ECD), young child survival and development (YCSD) is the largest component of the UNICEF medium-term strategic plan (MTSP), 2006-2013, in terms of both budget and programmatic scale. In 2013, overall expenditure for YCSD was $1.99 billion, accounting for 55 per cent of overall UNICEF expenditure. The year 2013 was one of reporting on impressive gains for children. The number of deaths of children under five years of age fell to 6.6 million in 2012, nearly half of the 12.6 million young lives claimed in 1990. The prevalence of underweight in children dropped from 25 per cent in 1990 to 16 per cent in 2013 while the percentage of stunted children continued to fall. Between 1990 and 2012, 2.3 billion people gained access to an improved drinking water source, and almost 2 billion to improved sanitation facilities. However, these gains mask significant inequities between regions and countries, within countries, between wealthy and poorer children, between urban and rural dwellers and between those living in fragile and more stable contexts. Additional dimensions of inequities are revealed depending on the country or region, for example, ethnicity or caste. Equity and reaching the most disadvantaged are a priority that characterize the work of UNICEF in YCSD. In 2013, UNICEF leveraged its global leadership, expertise and presence in over 150 countries to convene partnerships, promote awareness and advocacy, guide policy and programming, and provide technical expertise to promote maternal, newborn and child health (MNCH), nutrition and development. At the global level, UNICEF continued to provide leadership for important partnerships and initiatives including: A Promised Renewed, a global movement aimed at reducing preventable deaths; development of 'Every Newborn: an action plan to end preventable deaths' with the World Health Organization (WHO); the integrated Global Action Plan for Pneumonia and Diarrhoea, also with WHO; and the Scaling Up Nutrition (SUN) movement. UNICEF also played an influential role in the Sanitation and Water for All (SWA) partnership, catalyzing commitments from Governments to take action on WASH. UNICEF also supported the launch of the Early Childhood Peace Consortium. UNICEF has been strongly engaged in the relevant debates on the post-2015 agenda, focusing on child rights and equity and advocating the centrality of child well-being and development to a sustainable, equitable and human-centred agenda. Specific sectors have engaged with partners to ensure that targets for ending preventable maternal and child deaths, nutrition, WASH and ECD are disaggregated so that progress can be monitored among the most disadvantaged groups. UNICEF was one of the lead agencies for the United Nations thematic consultations on water, health and addressing inequalities. The engagement of UNICEF in these processes resulted, for example, in a call for a goal to achieve universal access to water and sanitation in the report to the Secretary-General's High-Level Panel of eminent persons on the post-2015 development agenda. To accelerate progress towards Millennium Development Goals 4 and 5, UNICEF supported innovative approaches to deliver lifesaving interventions, collaborating closely with partners and pursuing an equity-based strategy to reach the most vulnerable children and families. A critical element of this approach involved building the capacities of Governments and partners to identify and respond to key factors impeding progress, including systemic human rights and gender equality dimensions of maternal and child health.

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Pneumonia and diarrhoea remain the top two killers of children under five years of age, together killing almost 5,000 such children every day. Undernutrition remains the most important underlying cause of under-five mortality. Under A Promise Renewed, UNICEF supports Governments in reviewing and sharpening existing plans to increase coverage of integrated services by strengthening health systems in order to combat these major killers. One key example of this work was the five-year Integrated Health System Strengthening project, part of the Catalytic Initiative to Save a Million Lives that was also supported by the Canadian International Development Agency. As a result of UNICEF advocacy in support of the project, which ended in 2013, 29 of 40 countries in sub-Saharan Africa now feature integrated community case management programmes, allowing for community-based delivery of antibiotics to treat pneumonia. At least 1,200 children under age five years die of malaria every day; 90 per cent of these deaths occur in sub-Saharan Africa, with Democratic Republic of the Congo and Nigeria accounting for 40 per cent of the cases. In more than 15 countries, UNICEF supported Governments throughout all phases of malaria programming – from developing plans and donor proposals to programme implementation. This included coordinating campaigns to distribute long-lasting insecticidal nets (LLINs), distributing antimalarial drugs and diagnostics, and developing procurement and supply management plans. UNICEF remains one of the world’s largest procurers of insecticide-treated mosquito nets. In 2013, UNICEF supported the procurement of over 29 million LLINs, 24 million anti-malarial treatments and over 11 million malaria rapid diagnostic tests (RDTs). Because 44 per cent of all deaths of children under age five years occur during the neonatal period, UNICEF and WHO established a global partnership around the Every Newborn Action Plan, which is due to be launched in mid-2014. In 2013, UNICEF provided guidance and technical support to 10 countries with high infant mortality rates. The main purpose was to conduct bottleneck analyses, sharpen national plans to scale up newborn care and increase access to lifesaving maternal and newborn health commodities. With UNICEF support, polio vaccine delivery and related communication efforts are changing polio eradication efforts from a single disease narrative to a platform for child survival. Working with local partners, the Global Polio Eradication Initiative (GPEI) has succeeded in stopping the transmission of the wild poliovirus in over 99 per cent of the global population. The success of the initiative now depends on sustaining these gains while stepping up delivery of oral polio vaccine (OPV) to the 1 per cent of children living in the remaining 'polio sanctuaries' in Afghanistan, Nigeria and Pakistan. In 2013, UNICEF scaled up its contributions to polio eradication programmes in these countries. In order to generate demand for the vaccine and increase acceptance rates, UNICEF relied on social mobilization networks to engage communities and families. These efforts contributed to a 60-per-cent reduction in polio cases in Afghanistan and Nigeria in 2013, compared to 2012. The UNICEF commitment to polio eradication goes hand in hand with the organization’s long-standing commitment to routine immunization and the introduction of new vaccines, particularly in countries that have the greatest inequalities. UNICEF continued to provide wide-ranging support for immunization to Governments, increasing its focus on immunization supply chain management, reducing inequities and communication for development (C4D). UNICEF also helped to introduce the pneumococcal conjugate vaccine and rotavirus vaccine into national immunization programmes, supporting more than 20 countries to introduce, scale up or prepare for the introduction of these vaccines. With funding from the GAVI Alliance, UNICEF facilitated the development and implementation of communication plans to introduce new vaccines in 19 countries in 2013.

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Undernutrition is the underlying cause in 45 per cent of deaths of children under five years of age. The SUN movement is a key platform that brings together Governments, United Nations agencies, non-governmental organizations (NGOs) and the private sector to stimulate interest and additional funding to scale up interventions in countries affected by high rates of undernutrition. Its leadership role in SUN remained a major focus for UNICEF in 2013, when 13 new countries committed to the movement, raising the total to 47. SUN is credited with attracting global attention to stunting, which, despite dropping from 40 per cent in 1990 to 26 per cent in 2013, still affects an estimated 162 million children worldwide. In 2013, global events and summits focusing on nutrition and hunger resulted in increased donor attention, commitments for nutrition-specific and nutrition-sensitive interventions, and support to national nutrition programmes. UNICEF supports nutrition programmes in over 70 countries, focusing on improved infant feeding, micronutrient supplementation and fortification, and the prevention and treatment of severe acute malnutrition (SAM). In addition, in 2013, UNICEF and WHO led joint advocacy efforts to mobilize support and resources to enable more mothers around the world to optimally breastfeed their children. Interventions in support of Millennium Development Goal 7 helped 4.3 million more households gain access to safe improved drinking water and 4 million households to improved sanitation in 2013. Building on the successful scaling up of the Community Approaches to Total Sanitation (CATS) approach, concerted advocacy efforts have resulted in greater recognition of the sanitation crisis at the highest levels. On World Water Day 2013, the United Nations Deputy Secretary-General announced his Call to Action on Sanitation, which is based on the UNICEF strategy for the elimination of open defecation. As more children continue to survive, far too many fail to thrive. By incorporating the 'ECD Index' within the multiple indicator cluster survey (MICS), UNICEF was able to estimate with greater precision the percentage of children who receive proper care and stimulation. The preliminary results from 2013 indicate that only 63.6 per cent of young children are developmentally on track. To promote ECD, UNICEF worked with partners such as the World Bank and WHO to roll out the 'Care for Child Development Package', which is designed to increase cognitive stimulation and psychosocial support to young children. Despite this progress, deeper analysis reveals persistent disparities in MNCH. Continuing its focus on equity, UNICEF expanded the use of its Monitoring Results for Equity System (MoRES) from 30 to 80 countries in 2013 in different sectors. This approach enabled Governments and partners to use data to uncover disparities, focus on priority bottlenecks that constrain results and track the effectiveness of interventions in underserved populations. UNICEF provided humanitarian support to all major emergencies in 2013. UNICEF supported 2.4 million severely malnourished children (86 per cent of the global target) through therapeutic feeding programmes, up from 2.1 million in 2012. Over 1.1 million of these children were in the Sahel region. The UNICEF health response in emergencies focused on providing services to address the most common causes of illness and death, including pneumonia, diarrhoea and malaria. UNICEF supported measles vaccinations for 24.5 million children in humanitarian settings, and at least 23 million children in Syrian Arab Republic and neighbouring countries were vaccinated against polio at least once. As a result of major humanitarian crises in 2013 and the ongoing need to address chronic emergencies in fragile States, the numbers of people provided with drinking water and sanitation were larger than ever. In 2013, UNICEF published and disseminated the 'Cholera Toolkit' (in English and French) to help countries prevent, prepare for and respond to cholera. ECD also continued to be a component of the UNICEF emergency response, promoting play-based psychosocial support to young children and caregivers through the deployment of ECD-in-emergency kits, 15,000 of which were distributed in 2013. These kits benefited more than 700,000 children affected by violent conflict. UNICEF

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continued its lead role in the Global Nutrition and WASH Clusters, working with a large number of partners for effective coordination, advocacy and adherence to standards in humanitarian situations. Thematic funding has been extremely beneficial to catalyze and jump-start emerging and cross-cutting areas of work. This includes development of technical guidance and providing expertise for scaling up MoRES in sectors such as WASH and ECD where application was previously progressing at a slower pace; undertaking studies and documenting operational experiences for policy advocacy; and having the requisite in-house technical expertise to interface with strategic agendas such as the post-2015 dialogue and newborn health. The largest resource partner to thematic funding for YCSD was the Government of Sweden, which provided 70 per cent of funding. Looking ahead, UNICEF work in the different sectors is articulated in the Strategic Plan, 2014-2017, which builds on achievements to date, brings focus to gaps and emerging issues and fully integrates the equity focus in all of the organization’s work. Existing sectoral strategies will be adjusted or updated based on new evidence and operational experience, and even greater efforts will be made to forge linkages between the sectors to maximize effectiveness of programmes, recognizing the interrelated and multiple deprivations children face. All sectors will strengthen resilience-building strategies and explore innovative ways of delivering quality results in fragile contexts, which reflects the conditions in many of the countries harbouring the highest burdens of child deaths, undernutrition and developmental deprivations. Specific examples of what is expected from the different sectors include:

• Development of a new nutrition strategy; • WASH will introduce risk management approaches to drinking water safety; address

sustainability through interventions focused on the enabling environment, climate change adaptation and water resource management; and place more emphasis on sanitation marketing to facilitate access to improved sanitation;

• Health will place greater emphasis on newborn and maternal health; • ECD will catalyze knowledge platforms and work to bridge the divide between science and

practice for more effective programming.

Strategic context Since 1990, the world has made great progress in reducing child mortality. The number of deaths of children under five years of age ('under-five deaths') has fallen by nearly half, from 12.6 million in 1990 to 6.6 million in 2012. Despite progress, however, around 18,000 young children died each day in 2012, 44 per cent of them during the neonatal period. Sub-Saharan Africa and South Asia together have the highest burden of child mortality and together account for four out of five child deaths globally. West and Central Africa deserves special focus for child survival as it is lagging behind all other regions and has seen virtually no reduction in annual numbers of child deaths since 1990. Global analyses also confirm that income – at national, subnational and household levels – is in general correlated with child mortality. The richer countries overwhelmingly having lower rates of child mortality than less affluent countries. Children born into the poorest 20 per cent of African households are at least 50 per cent more likely to die before their fifth birthday than their compatriots in the wealthiest 20 per cent of households, and in some countries the poorest children are more than twice as likely to die before age five. Deeper disaggregation of data is critical to reveal patterns of inequities within countries, and making progress with equity will require reaching all those children who are currently hardest to reach.

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Most child deaths continue to be from preventable causes: pneumonia, diarrhoea and malaria are the top three killers of children. In Africa, these illnesses account for 40 per cent of all under-five deaths. Pneumonia kills more than 3,000 young children every day, while another 1,600 are claimed daily by diarrhoea. Since 2000, increased global investment and the scale-up of malaria control interventions have saved more than 1 million lives, but malaria continues to kill more than 1,200 children under age five years every day. As noted in the figure below, the greatest proportion of child deaths occur during the first 30 days of life (the newborn, or neonatal) period and significant investments and efforts are needed to address this situation. A global partnership has come together around the Every Newborn Action Plan, with UNICEF and WHO playing a leadership role. Undernutrition is the main underlying cause of under-five deaths, accounting for 45 per cent of under-five deaths in 2011.

Global distribution of deaths under age 5, by cause , 2012

Approximately 29 per cent of under-five deaths are vaccine-preventable. Each year, immunization averts an estimated 2 million–3 million deaths from diphtheria, tetanus, pertussis and measles – life-threatening diseases that hit children hardest. In 2012, 129 countries immunized over 90 per cent of infants against measles, resulting in a global drop of 78 per cent in measles between 2000 and 2012. Yet one out of five infants worldwide remains vulnerable, beyond the reach of vaccination campaigns. In 2012 alone, 1.5 million children died from diseases preventable by recommended vaccines. In response, UNICEF and its partners support immunization programmes in over 100 countries, part of an integrated approach to giving children the best possible start in life. Globally, significant progress has been made to increase access to water and sanitation during the Millennium Development Goal era. Indeed, the target for drinking water was achieved five years ahead of schedule. However, 768 million people still lack access to improved drinking water and of great concern is the fact that the world is unlikely to meet the target for sanitation; some 2.5 billion people do not use improved sanitation facilities, including over 1 billion who practice open defecation.

Diarrhoea (9%)

Neonatal (44%)

Pneumonia (17%)

All Other (24%)

Injury — 5%

Pneumonia (neonatal) — 5%

Preterm birth complications — 15%

Intrapartum-related complications — 10%

Sepsis/meningitis — 5%

Congenital abnormalities — 4%

Tetanus — 1%

Other neonatal — 3%

Diarrhoea (neonatal) — 1%

Meningitis — 3%

AIDS — 2%

Measles — 1%

Other 19%

Pneumonia 13%

Diarrhoea (9%)

Malaria — 7%

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Even among those with access to improved drinking water and sanitation, substantial disparities exist along conventional fault lines of place of residence and socio-economic status. For example, 82 per cent of the world's population without improved drinking water sources live in rural areas. And although data are more limited, analysis shows that in some countries sanitation coverage among minority ethnic or religious groups is less than half of the national average. In 2013, the global development community intensified its focus on nutrition. Increasingly, global leaders, donors, Governments, national stakeholders and the public and private sectors are recognizing the critical link between undernutrition and child mortality and morbidity, as well as the impact of nutrition on human productivity and national development. Notably, SUN and other initiatives have resulted in rising nutrition budgets, greater coverage and quality of nutrition programmes and more multisectoral approaches that incorporate nutrition. While progress to reduce stunting is ongoing, much is left to do. In 2013, there were 162 million stunted children worldwide, usually in the most marginalized populations; children in the poorest wealth quintile are twice as likely to be stunted as those in the richest quintile. In 2013, UNICEF produced and disseminated data from the ECD Index, which captures information on the developmental status of children in the areas of social, emotional, language, physical and cognitive development. Introduced in the fourth round of MICS, the initial analyses show that over one third of the world’s youngest children are not achieving their developmental potential. The survey also revealed positive developments in countries that are succeeding in reducing the number of young children left at home with inadequate care. Disparities in ECD are stark. Trends show that the poorest children receive on average four times less support for learning at home than the richest ones. These data reflect the interconnected nature of health, nutrition, WASH and ECD in terms of overall YCSD. A significant proportion of disadvantaged children suffer from multiple deprivations, and it is important to recognize that deprivations in one area impact others. The same holds true for interventions; those in one sector are critical for other sectors. For example, research has shown that chronic malnutrition affects cognitive development, and that early interventions which combine stimulation and nutrition have a significant impact on improving holistic well-being not just of children but also their caregivers. Another critical factor impacting children’s health and development is the education of their mothers, particularly access to and completion of the first years of secondary education. Furthermore, emerging evidence indicates an even greater impact of sanitation on malnutrition and the subsequent impacts on growth and cognitive development than previously thought. There are significant gains to be made by examining the breadth of interventions that may optimize a child’s well-being and transition from one point in the life cycle to another. Against this backdrop are analyses that put forth an investment case for YCSD and its component sectors. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater growth in gross domestic product through improved productivity, and prevention of the needless deaths of 147 million children and 5 million women, plus 32 million stillbirths, by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to an increase of 2 per cent above current spending. Globally, the annual economic cost resulting from the lack of access to water and sanitation has been estimated at $260 billion. While investment in the WASH sector has steadily increased in the past decade, it is not enough. External aid commitments to the WASH sector reached $10.9 billion in 2012 – almost double the investment in 2002. According to World Bank estimates in 2010, an additional investment of $10.3 billion per year would be required to end undernutrition globally. Yet official development assistance for basic nutrition still falls far short of that goal, with an increase of only $139 million (1.4 per cent of the identified need) since 2010. In order to meet its own commitments, UNICEF increased its overall organizational expenditure for nutrition by over $100 million in 2013, to $404 million.

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In spite of growing political support within national Governments for ECD programming, budgetary allocations remain insufficient – a major barrier to the efficient provision of integrated services for young children. Tracking budget allocations to ECD is difficult because the processes are sporadic and unsystematic. A clear method to track allocations and their use is required for this area. To respond to these issues and influence action at scale, UNICEF invested significant time and resources in 2013 to leveraging partnerships. In the global health architecture, UNICEF is a member of the International Health Partnership (IHP+); the Health 8 (or H8) group of heads of the world’s leading health agencies; and the 'H4+' agencies (UNAIDS, UNFPA, UNICEF, UN-Women, WHO, World Bank) that are providing core support for implementation of the Secretary-General's Global Strategy for Women’s and Children’s Health. In 2013, UNICEF co-chaired the Reproductive, Maternal, Newborn and Child Health Steering Committee; the Child Health Epidemiology Reference Group; and the Alliance for Health Policy and Systems Research. It is a founding partner of the GAVI Alliance, which has enabled UNICEF to enhance its capacity to analyze and reduce immunization-related inequities in 10 priority countries, and to monitor and track financial inputs for routine immunization. UNICEF is also one of the founders of the Measles & Rubella Initiative and GPEI. In 2013, UNICEF and WHO launched the Global Action Plan for Pneumonia and Diarrhoea, a framework for integrated country scale-up plans. Similarly, UNICEF and WHO convened partners to develop the Every Newborn Action Plan to strengthen integrated community-based maternal and newborn care and improve the quality of facility-based services. In the area of nutrition, UNICEF plays a leading role in SUN, the REACH initiative and the Standing Committee on Nutrition. Through the SUN movement, UNICEF has been able to raise the profile of nutrition, catalyze greater government commitment to taking action on stunting and malnutrition and provide technical expertise to shape a framework for tracking progress in countries. New partnerships and engaging with existing ones represented a key component of strategic support to country office WASH programmes. UNICEF is a significant player in the SWA partnership, hosting the secretariat and convening the biennial high-level meetings in 2010, 2012 and 2014. The SWA partnership, involving over 40 partner countries and 11 bilateral donors, facilitated tangible and measurable commitments by countries for achieving universal access, addressing inequalities and sustaining outcomes. Throughout 2013, UNICEF was very active in disseminating the results of an extensive WASH sector consultation on post-2015 targets and indicators that was facilitated by the WHO-UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. The outcomes of the consultation have been used by the United Nations system and others to provide substantive inputs to a number of key post-2015 deliberations. UNICEF employs innovative approaches that aim to deliver enhanced support for children and caregivers and to help build national capacities to provide equitable access to health services. For example, UNICEF convened new partnerships to reach more caregivers with accurate information about polio vaccination, and ultimately, reach more children with OPV. A group of Islamic scholars convened in Cairo in March 2013 to support polio eradication. UNICEF also helped establish a ‘Brain Trust’ of diverse technical experts to gather insight and solutions to unlock the final doors to eradication, emphasizing the need for local sources to find local solutions. In the field, greater emphasis has been placed on innovative approaches for cross-sectoral programming e.g., integrating WASH interventions with nutrition programming for improved nutrition outcomes. UNICEF explored the links between ECD interventions and peacebuilding, launching an innovative global partnership to promote ECD as an entry point for peacebuilding in conflict and post-conflict settings. Global monitoring of the safety of drinking water to date has been impractical due to the lack of cost-effective and standardized testing

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methods and the absence of nationally representative data. However, recent developments such as rapid, low-cost test kits were evaluated as part of MICS and Demographic and Health Surveys (DHS) in 2013. This development, together with ongoing work on practical indicators of risk management, has the potential to develop into a monitoring framework for assessing the safety of drinking water in all countries. As the world faces increasingly complex humanitarian crises, children in emergencies endure escalating challenges. In 2013, fragile political contexts – such as those in South Sudan and Syrian Arab Republic – and disaster-prone areas placed greater demands on the global community. UNICEF emergency response priorities are not only to meet immediate needs for nutrition, health, WASH and ECD, but to make communities more resilient to crisis. This includes ensuring that high-quality, broadly accessible services are available and that emergency preparedness plans are in place. Fragile States are home to 65 per cent of all those worldwide who do not have access to safe drinking water and 54 per cent of those without access to improved sanitation, according to World Bank estimates. Furthermore, increasing pressure on water-scarce areas – a result of climate change – elevates tensions and the risk of conflict with some countries identified as potential flashpoints for water-related crises. Aid for water and sanitation to fragile States has tripled over the last 10 years, and in 2010 was nearly $3 billion. UNICEF carries out WASH programming in almost every fragile State and is working and documenting innovations in programme approaches that are sustainable and focus on equity in such contexts; typically, about 45 per cent of WASH expenditure goes to emergency response, coordination and preparedness. In 2013, the United Nations led a year-long series of thematic consultations on the post-2015 agenda that focused on water, health, food security and nutrition inequalities, among other themes. UNICEF played an important role in a number of these thematic consultations and related discussions feeding into the post-2015 agenda. For health, UNICEF co-led the consultation with the United Nations Department of Economic and Social Affairs (DESA), with support from the Governments of Botswana and Sweden. The consultation report has strongly influenced discussions of the High-level Panel on the Post-2015 Development Agenda including those on the health goal and targets. UNICEF also contributed to the inter-agency technical support team for the Open Working Group of the General Assembly, including co-writing the paper for the session on health in mid-2014. UNICEF co-led the consultation on water with DESA, contributing to the emerging consensus that recognizes the importance of water and sanitation to sustainable development. The report of the High-level Panel called for a goal to achieve universal access to water and sanitation, which was echoed in other reports and forums. Similarly, through deploying high-calibre technical expertise, evidence-based advocacy and working with strategic partners, UNICEF contributed to raising the visibility of ECD in the post-2015 development agenda. Positive developments include a proposed goal and targets for ECD. In nutrition, the World Health Assembly (WHA) endorsed nutrition targets for 2025, serving as an anchor for advocacy for nutrition in the post-2015 agenda. The work on the post-2015 discussions will intensify in 2014 as the Open Working Group considers all proposals covering a vast range of issues. UNICEF and other child-focused partners will need to continue to develop a compelling and evidence-based case for investing in children. For UNICEF, equity and child-centred sustainable development will be at the heart of its advocacy. The organization will draw upon its experiences in areas such as MoRES, innovations in real-time monitoring and data use and enhancing social accountability to inform the post-2015 discussions on tracking inequities.

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Results assessment

KEY RESULT AREA 1: Support national capacity to ach ieve MDG 1 by improving child nutrition through improved practice s and enhanced access to commodities and services

Globally, about 99 million of all children under five years of age are underweight. Although the prevalence of underweight has decreased, from 25 per cent in 1990 to 15 per cent in 2013, progress has been slow in certain regions. In sub-Saharan Africa, underweight prevalence declined only 7 per cent, from 29 per cent in 1990 to 21 per cent in 2012. During this same period, underweight prevalence in South Asia dropped an impressive 20 per cent, from 52 to 32 per cent. While it remains a critical indicator, underweight prevalence alone does not offer the complete picture of nutritional status. For example, in Benin, Guatemala, Liberia, Malawi, Mozambique, Papua New Guinea, Rwanda, United Republic of Tanzania and Zambia, the prevalence of underweight children is lower than 20 per cent, while stunting rates are over 40 per cent. This is one of the factors that has shifted the global focus to stunting.

Trends in Global Underweight Prevalence over time ( 1990-2012)

Today, far more children suffer from stunting than from being underweight, with an estimated 162 million stunted children worldwide.1 Some 80 per cent of the world’s stunted children live in just 14 countries.2 In fact, one of every two stunted children worldwide lives in three countries – India, Nigeria and Pakistan. In Burundi, Madagascar, Niger and Timor-Leste – the four countries with the highest prevalence – more than half of all children under age five years are stunted. Efforts to reduce stunting have reaped positive developments. Over the last two decades, the prevalence of stunting in young children has declined by one third, dropping from 40 per cent in 1990 to 25 per cent in 2012. Every region has observed reductions in stunting over the past two decades, with the greatest declines occurring in East Asia and the Pacific. Some countries, such as Ethiopia, Haiti, Peru and Rwanda, have experienced declines in stunting within short

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20

40

60

80

100CEE/CIS East Asia and Pacific

Eastern and Southern Africa Latin America and Caribbean

Middle East and North Africa South Asia

West and Central Africa LDC

World

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time frames, demonstrating that success is possible even in challenging contexts. The world is rallying around the concept that stunting and the larger problem of undernutrition can be prevented, at relatively little cost, by scaling up delivery of an integrated package of interventions to children during the critical period of the first 1,000 days – from pregnancy to age two years.

Trends in global stunting prevalence over time (199 0-2012)

The global focus on nutrition continued to intensify in 2013 with the publication by The Lancet of a series on maternal and child nutrition, which reported that undernutrition is the underlying cause in 45 per cent of all deaths of under-five children, representing more than 3 million deaths per year. The journal modelled a package of 10 nutrition-specific interventions that are required to improve nutrition globally, and which concern maternal nutrition; infant and young child feeding (IYCF); micronutrients; and community management of acute malnutrition (CMAM). Also in 2013, the Group of Eight put nutrition high on its development agenda, and international news outlets and eminent individuals spoke out about the problem – all with strong input from UNICEF. Global events and summits focused on nutrition and hunger resulted in increased attention by donors to nutrition, resulting in commitments for nutrition-specific and nutrition-sensitive interventions. The SUN movement, which is credited with attracting global attention to stunting, unites local, national and international efforts, experience and resources to tackle stunting and other forms of malnutrition. UNICEF plays a major role in SUN at the global and country levels. The Executive Director chairs the SUN Lead Group, which is made up of leaders of SUN partners representing government, civil society, international organizations, donor agencies, businesses and foundations. The Lead Group, with members appointed by the Secretary-General, serves to improve coherence, provide strategic oversight, improve resource mobilization and ensure collective accountability. At the country level, UNICEF activities include coordinating efforts to advocate for nutrition; supporting implementation and monitoring of evidence-based nutrition interventions; and supporting the integration of nutrition goals across the health, WASH, social protection and other sectors. UNICEF also supports countries that want to join SUN in terms of providing guidance on required steps. By the end of 2013, SUN included 47 member countries.

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1990 1995 2000 2005 2010 2012

CEE/CIS East Asia and PacificEastern and Southern Africa Latin America and CaribbeanMiddle East and North Africa South AsiaWest and Central Africa Least Developed CountriesWorld

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Rwanda: Reducing stunting through consolidated nati onwide action

In 2005, more than half of Rwanda’s children under age five years – nearly 800,000 – were stunted. By 2010, just five years later, the prevalence of stunting had decreased from an estimated 52 per cent to 44 per cent. This success was achieved through government-led, multisectoral approaches and scaling up community-based nutrition programming throughout the country’s 30 districts. While Rwanda had been working to improve social services since the 1990s, strong evidence on the effectiveness of nutrition interventions persuaded the Government to invest in efforts to eliminate undernutrition. In April 2009, building on the previous community-based nutrition programmes and energized by the personal interest of the President, Rwanda initiated a National Emergency Plan to Eliminate Malnutrition (EPEM). This move created new momentum and opportunities to strengthen collaboration between sectors and support innovative programming. The EPEM addressed both acute and chronic undernutrition, focusing first on the most vulnerable. Village-level identification and treatment of SAM was scaled up in 2009. Around 30,000 community health workers (CHWs) received refresher training on how to screen, identify and refer cases for treatment. At the same time, additional preventive measures were initiated within communities to improve household food security and care practices. Interventions aimed at ensuring sustainable household food security included expanding kitchen gardens and increasing the availability of livestock. At the same time, behaviour change interventions helped promote optimal maternal and child care and feeding practices. By 2010, 85 per cent of infants aged 0–5 months were exclusively breastfed, and almost 80 per cent of infants aged 6-8 months received timely introduction to complementary foods. Growth monitoring was combined with nutrition programming in 15,000 villages, and monthly data collection and analysis supported monitoring of progress and improved planning. Lessons learned from the EPEM were incorporated into the subsequent National Multisectoral Strategy to Eliminate Malnutrition. The strategy’s emphasizes behaviour change communication to promote optimal nutrition practices during pregnancy and the first two years of a child’s life. Responsive planning and monitoring at the local level have been bolstered by improved information-gathering capacities. An electronic health monitoring and information system integrates nutrition data and other local information, such as demographic information and data on routine healthcare, allowing for evaluation of district-level performance. UNICEF has played a key role in the nutrition sector in Rwanda. An example is the successful piloting of RapidSMS (short message service/text messaging) in one district in 2009 which led to national level roll-out in all 30 districts with the support of UNICEF. By leveraging funds from other development partners in 2013, CHWs in almost all districts were trained in the use of SMS. By early 2014, RapidSMS will be operational in the entire country and efforts will focus on quality assurance, maintenance of the system and expanding its programmatic uses.

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Infant and young child feeding - complementary feed ing Studies show that receiving appropriate, adequate and safe complementary foods starting at six months of age leads to better health and growth outcomes. At the same time, breast milk remains an important source of nutrients, and thus it is recommended that breastfeeding continue until children reach the age of two years and beyond. In vulnerable populations, the majority of children (60 per cent) started receiving food at six months of age, but they often failed to receive the right frequency of meals or diversity of foods. Limited data demonstrated that only 4–24 per cent of children met the indicator of minimum acceptable diet, a composite indicator of food frequency and dietary diversity in countries that reported on this indicator. In conjunction, these countries also had a high prevalence of stunting, ranging from 33 to 58 per cent. UNICEF addressed the lack of available data on new, more sensitive indicators, such as minimum acceptable diet by adding complementary feeding indicators to the MICS. These included: minimum meal frequency; minimum dietary diversity; and the composite indicator, minimum acceptable diet. This will significantly improve the data and evidence needed to focus programming and investments in this area. In a growing number of countries, interventions to improve IYCF, which includes breastfeeding and complementary feeding, are now at the heart of strategies to prevent undernutrition. UNICEF continues to support the introduction, training and scale-up of community-based IYCF programmes. Thirty countries (compared to 23 in 2012 and16 in 2011) now use the UNICEF community IYCF counseling package, adapted to the local context. A new supervision, mentoring and monitoring module was developed in 2012 and ECD elements were integrated into the materials – an example of translating the science of the synergistic relation between nutrition and ECD into operational programme guidance. The package has a strong emphasis on counselling and negotiation with mothers on optimal complementary feeding. In sub-Saharan Africa, where there is a high rate of HIV, UNICEF has also taken the lead to integrate IYCF counselling and support within national HIV programmes, and to ensure that optimal infant feeding counselling and support are part of routine care for HIV-infected girls and women. In 2013, UNICEF conducted a series of workshops to reduce stunting through IYCF programming and planning in five countries, bringing the number of countries to 14 where such efforts took place. The countries assessed the status and gaps in their stunting reduction and IYCF strategies, discussed the latest thinking on programming paradigms and design, and developed plans to address the gaps. Improving complementary feeding featured prominently in these workshops, including the use of: a new decision tree to determine effective strategies to fit the context; tools (such as 'ProPAN') to help with programme design; and multisectoral approaches aimed at improving the key indicator for complementary feeding, the minimum acceptable diet. ProPAN is a systematic, comprehensive and ready-to use tool that helps countries assess, analyze and develop tailored interventions on IYCF practices, thus contributing to the reduction in stunting. In 2013, the entire ProPAN package (manual and software) was made publically available (in English, French and Spanish) by UNICEF, the Pan American Health Organization, the United States Centers for Disease Control and Prevention (CDC) and Emory University. UNICEF supported the roll-out by training national nutrition institutions and universities from Ethiopia, Kenya, Somalia and South Africa. These countries then developed concrete plans to integrate components of ProPAN within existing nutrition assessment systems for sustainability and scale of uptake. The e-learning component of IYCF programming – a capacity development initiative co-produced by UNICEF and Cornell University – has been widely successful. As of 2013, over 6,500 people from 167 countries registered for this free course, 85 per cent of them from

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government and partner organizations. The UNICEF IYCF programming guide, upon which the e-learning is based, was widely disseminated in 2013, and its principles for comprehensive IYCF programming are increasingly used to guide the efforts of Governments and global partners. MoRES is an approach that sharpens programme design and leads to better monitoring of the effectiveness of programme strategies. Indicators related to priority bottlenecks are tracked more frequently, especially at decentralized levels, so that implementation can be adjusted to on-the-ground reality and deliver better results. As of 2013, 31 countries were using MoRES to improve nutrition programmes. In Malawi, for example, MoRES has improved national capacities to improve access, coverage and quality of nutrition interventions, and real-time data collection and analysis have been critical to this success. An expanded global nutrition data collection tool that includes aspects of MoRES was launched in 2013; it will provide key information on the status of country-level nutrition interventions and guide follow-up actions.

Proportion of households consuming adequately iodiz ed salt (percentage), 2007–2011

Micronutrient powders and fortification programmes UNICEF continues to play a leading role in scaling up home fortification programmes, which use micronutrient powders to improve the quality of complementary foods and combat anaemia. In 2013, UNICEF and CDC supported 14 countries in the Central and Eastern Europe and Commonwealth of Independent States and Middle East and North Africa regions to design and implement home fortification programmes. The number of countries receiving support for home fortification has increased rapidly in the last five years, with over 60 countries now implementing or planning this important intervention. Forty-three countries have home fortification programmes using micronutrient powders, 16 of them with nationwide implementation. In order to meet the growing demand for technical support, UNICEF works with a home fortification technical advisory group to support country-based efforts. The advisory group's efforts include developing a home fortification toolkit, launching an online community of practice website (http://network.hftag.org/categories), and planning a series of webinars in 2014 for programme implementers. UNICEF continues to promote fortification of food with iron and folic acid, important micronutrients that improve birth outcomes and prevent birth defects. UNICEF and its

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partners have been building alliances with Governments, international agencies, the wheat and flour industries and consumer and civic organizations, with the aim of having 80 per cent of the world's roller milled flour be fortified with at least iron or folic acid by 2015. Currently, 78 countries worldwide fortify wheat flour (comprising 34 per cent of all flour produced), 12 countries fortify maize products and five countries fortify rice. In 2013, UNICEF worked to ensure sustainability of salt iodization programmes by: supporting their integration within national policies; strengthening national public-private coordination mechanisms; fostering national ownership; improving and expanding supply and delivery of quality iodized salt; increasing public demand for iodized salt; and establishing or strengthening regulatory and monitoring systems. Today, an estimated 76 per cent of all households globally consume adequately iodized salt. The East Asia and the Pacific region has surpassed the universal salt iodization target of 90 per cent, but in West and Central Africa, only half of all households consume adequately iodized salt. Further intensified work is needed in these countries as part of an overall effort to improve the nutrition status of children and the general population.

KEY RESULT AREA 2: Support national capacity to ach ieve MDGs 4 and 5 through increased coverage of integrated pack ages of services, improved practices and an enhanced policy environme nt

In 2013, UNICEF support to ending preventable child deaths and accelerating progress towards Millennium Development Goals 4 and 5 continued to include innovative approaches to delivering interventions and an equity-focused strategy to reach the most vulnerable children and families. This section of the report covers high-impact interventions in health, nutrition, WASH and ECD, all of which have contributed to reducing child mortality and improving children’s growth and development. Pneumonia and diarrhoea Pneumonia and diarrhoea remain the leading causes of death among young children, together killing almost 5,000 children under five years of age every day. These are diseases of the poor and nearly three quarters of global pneumonia and diarrhoea deaths occur in just 15 countries.3 Under the banner of A Promise Renewed, UNICEF supports the Governments of these countries to increase coverage of integrated health services, and to strengthen health systems in order to tackle these preventable causes of death. One important example is the five-year Integrated Health System Strengthening project, part of the Catalytic Initiative to Save a Million Lives that was supported by the Government of Canada. The project aimed to train and equip front-line health workers to deliver a package of essential, high-impact interventions and services, with an emphasis on treatment for pneumonia, diarrhoea and malaria. (See text box below.) Additional funding from the Canadian Government will enable UNICEF to scale up activities in Ethiopia and Niger, and kick-start treatment activities in Kenya and United Republic of Tanzania, where pneumonia and diarrhoea are the main causes of mortality in children under age five years. UNICEF support is driving progress across sub-Saharan Africa, where 29 of 40 countries now have policies to allow community-based delivery of antibiotics for pneumonia treatment as part of integrated community case management (iCCM) programmes (up from seven countries in 2007 and 23 in 2010).

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Catalytic Initiative strengthens community-based he alth services for mothers and children in Niger

2013 was the final year of the five-year Integrated Health System Strengthening project, part of the Catalytic Initiative to Save a Million Lives that was supported by the Government of Canada. The five-year project aimed to strengthen community-based health service delivery in countries that were not making sufficient progress to meet Millennium Development Goal 4. Implemented in Ethiopia, Ghana, Malawi, Mali, Mozambique and Niger, where child survival interventions were urgently needed, particularly among the most vulnerable populations, the project emphasized training and equipping of front-line health workers to deliver a package of essential, high-impact interventions and services, with an emphasis on treatment of malaria, pneumonia and diarrhoea –the major killers of young children. In recent years, unprecedented progress has been made in strengthening community-based, front-line child health services, which have made important contributions towards accelerating child survival and reducing under-five mortality. The project strongly influenced national policies for community-based approaches to child health, allowing for fully integrated community case management programmes, and in some countries it was a major impetus for overall revitalization of national community strategies. Thematic funding complemented these gains, helping to amplify progress. In Niger , the project was launched shortly after the Government's introduction of a new policy eliminating health service fees for all pregnant women and children under five years of age. This free health care initiative would not have been effective without the project's support, which ensured the system’s functionality through training, supplies and supervision, thus increasing access to health care for women and children. The package of interventions included the training of CHWs in iCCM; the provision of essential drugs and supplies to prevent and treat the main causes of under-five mortality; promoting the use of LLINs and key family care practices; training of nurses and doctors in integrated management of childhood illness and immunization techniques; and immunization outreach activities. Implemented at a national scale, the project served over 17 million people. Although Niger’s Ministry of Health initially expressed reluctance about the provision of care via CHWs, UNICEF demonstrated how successful this model can be through two pilot programmes, thus securing the Government’s endorsement and adoption of the iCCM policy. By May 2013, when the project ended, 2,560 CHWs had been trained in iCCM, focusing on curative care for the three main childhood diseases and the management of acute malnutrition. The project also invested in training CHWs and nurses in immunization techniques and helped to organize sessions about providing optimal vaccination coverage in-hard-to reach areas. In total, CHWs provided 6.1 million treatments for sick children over the course of the programme; nearly 30 per cent of these treatments (1.8 million) occurred during the final year (2012-2013), showing that rapid scale-up is possible. An estimated 63,600 lives were saved as a result of the Catalytic Initiative. The initiative also strongly influenced how iCCM programmes are monitored by establishing mechanisms and processes for data collection, analysis and reporting

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Increasing coverage of services also increases the distribution of lifesaving commodities. For example, as part of the Catalytic Initiative programme, UNICEF supported the distribution of 46.9 million sachets of oral rehydration salt sachets, 39.4 million zinc tablets, 15.1 million amoxicillin tablets and 688,000 doses of amoxicillin syrup. A 2013 review of results showed that over 8.7 million children under age five years were treated by CHWs over the five-year period of the programme. More than 3 million of these treatments were provided in 2013 (compared to 1.8 million in 2012), demonstrating that rapid scale-up is possible once there is an established CHW network. Malaria Every day, at least 1,200 children under five years of age die of malaria, with 40 per cent of cases occurring in Democratic Republic of the Congo and Nigeria alone. UNICEF supported Governments in more than 15 countries in all phases of malaria programming, from developing plans and donor proposals to implementation. This included coordinating LLIN campaigns, distributing mosquito nets through routine systems (immunization and antenatal care), distributing artemisinin-combination therapies (ACTs) and RDTs, and developing procurement and supply management plans. UNICEF supports countries in securing funding from the Global Fund to Fight for AIDS, Tuberculosis and Malaria, which requires that the organization be actively engaged in national strategic planning for malaria; support the collection of data; reinforce procurement and supply mechanisms; participate in country coordinating mechanisms; and provide technical assistance to ensure a continuous flow of resources. In Madagascar and Zambia, with funding from the Bill and Melinda Gates Foundation, UNICEF supported innovative approaches to incorporate pneumonia diagnosis and treatment in ongoing malaria activities. As part of the Malaria Initiative supported by National Committees for UNICEF, which remitted over $1 million last year and is currently in its third phase, UNICEF supports 10 priority countries to scale up use of LLINs, ACTs and RDTs and to strengthen their national malaria control programmes. UNICEF has been a leader in the roll-out and scale-up of seasonal malaria chemoprevention in Sahelian countries, including identifying financing for countries such as the Gambia. In 2013, UNICEF led the response to malaria outbreaks in Chad, Cameroon, Democratic Republic of the Congo and Niger. Country-level engagement takes place in the context of global malaria partnerships, in which UNICEF also plays a key role. UNICEF remains one of the world’s largest procurers of insecticide-treated mosquito nets, and often supplies logistical and operational support to planning campaigns to distribute nets. In 2013, UNICEF procured over 29 million LLINs for 38 countries, 24 million anti-malarial treatments in 27 countries and over 11 million RDTs in 24 countries. Over half of this procurement was financed with UNICEF resources, as opposed to procurement services on behalf of Governments. Maternal and newborn health In 10 countries with a high neonatal mortality rate, UNICEF provided guidance and technical support to conduct a bottleneck analysis and also helped to sharpen national plans to scale up newborn care and increase access to lifesaving maternal and newborn health commodities. UNICEF also supported countries to identify and document best practices and innovative approaches to address challenges and increase access, quality and use of maternal and newborn health services Paediatric HIV By ensuring better integration of the management of health and HIV programming, UNICEF has contributed to eliminating new HIV infections in children and keeping their mothers alive. In 2013, UNICEF provided technical support to high-burden subnational areas, such as Kaduna

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and Anambra states in Nigeria and health zones in Katanga province, Democratic Republic of the Congo, to improve planning that integrates data about HIV and health district data. This involves troubleshooting system bottlenecks that cut across the health and HIV domains. This approach is proving particularly useful for countries that are making the transition to new lifelong antiretroviral therapy protocols using a 'test and treat' approach for prevention of mother-to-child transmission of HIV, which requires renewed efforts to strengthen primary health care systems. With funding from the Government of Sweden, UNICEF provided technical support to Côte d’Ivoire, Democratic Republic of the Congo, Malawi and Uganda for this transition by building district capacities to better plan, manage and monitor for results. UNICEF also fosters integration of paediatric HIV care within broader child survival programmes, by, for example, adapting iCCM, newborn and well-child training for CHWs in settings with high HIV prevalence. HIV and immunization staff are exploring the possibilities of using immunization contacts for infant HIV testing. At the global level, UNICEF has been closely involved in the development of normative guidelines for paediatric HIV care and treatment. UNICEF was one of the conveners of a group of global experts for the integration of paediatric HIV and tuberculosis in iCCM; helped to draft global guidelines on opportunistic infections and co-trimoxazole prophylaxis; and was one of the authors of the 'Roadmap for childhood tuberculosis'. To further advance global advocacy for paediatric HIV and for scaling up programmes at the country level, UNICEF, WHO and the Elizabeth Glaser Pediatric AIDS Foundation convened a high-level ministerial meeting which endorsed the ‘Double Dividend’, a global framework which seeks to improve health outcomes of children born to HIV-positive mothers by aligning paediatric HIV with the broader child survival agenda. More detailed information on UNICEF work in this area is available in the thematic report on MTSP focus area 3, HIV/AIDS and children. Immunization In the area of immunization, UNICEF has continued to provide wide-ranging support to Governments but in 2013 increased its focus on immunization supply chain management, reducing inequities and C4D. Increased funding in 2013 from the GAVI Alliance bolstered the capacity of UNICEF at global and regional levels, particularly in terms of strengthening routine immunization systems, data management, cold-chain logistics, C4D and tracking financial resources. In addition, through its Business Plan 2013-2014, the GAVI Alliance provided funding to staff positions in 10 priority UNICEF country offices. These will enable UNICEF to better monitor bottlenecks to coverage, inform advocacy and support efforts to leverage resources to reduce inequities. Similarly, funding from the Bill and Melinda Gates Foundation enabled UNICEF to strengthen its capacity to support routine immunization and supply chains. Kenya and Lao People's Democratic Republic conducted formative research to inform and enhance C4D activities and integrate immunization within broader child survival interventions, promoting key family practices. Pilot projects to track resource flows for immunization have also started in Indonesia, Nigeria and Uganda, with results expected in 2014. In 2013, UNICEF facilitated the development and implementation of coordinated communication plans supporting the introduction of new vaccines in 19 countries and six regions. In addition, baseline knowledge, attitude and practice surveys concerning immunization completed in Sierra Leone and Zambia will be used to monitor the impact of future communication and social mobilization activities. Eleven 'Effective Vaccine Management' assessments took place, raising to 69 the total number of assessments conducted (64 of which were in GAVI- eligible countries). The assessments, conducted by UNICEF and WHO, show that none of the countries assessed have achieved the minimum standards necessary for delivering safe and effective vaccines to meet the disease control goals. An examination of each of the nine assessment criteria shows that less than half of the countries meet these minimum standards, underscoring the urgent need to address

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supply chain problems in many countries. Recognizing these shortcomings, UNICEF supported the implementation of systematic stock and temperature monitoring systems in 11 countries, and provided technical support to complete or update cold- chain equipment inventories in 16 countries. In Kenya and Mozambique, UNICEF tested a pilot process examining the redesign of the cold chain and logistics system. The pilots demonstrated that the decision-making process for cold-chain system design is complex and requires coalition-building among many stakeholders, including partners outside the Ministry of Health. In Kenya, the result was that Government recognized the need to build local capacities to use system design, including transfer of technology and methodologies to local experts, and has included this in its application to GAVI in order to secure funding for this work. To improve coordination between UNICEF and WHO country support, the two agencies launched a virtual immunization supply and cold chain logistics hub to serve as a repository for experience, best practices and lessons learned. In its first year, coordination through this virtual hub mechanism offered support to over 30 countries. In addition, UNICEF is co-leading the development of a GAVI Alliance end-to-end supply chain strategy. Another new area of work was introduction of the Human Papillomavirus vaccine (HPV), with UNICEF beginning to look at how introducing the HPV vaccine can provide opportunities to reach adolescent girls with other relevant interventions. UNICEF conducted equity assessments in 9 of the 10 GAVI focus countries (excluding Central African Republic). Based on these assessments, UNICEF provided technical support to Liberia, Mozambique, Madagascar and Yemen to develop and complete their equity plans. Staff from 13 countries and all regions collaborated and shared country best practices to reach a consensus on equity-reduction approaches and producing country-specific roadmaps. The maternal and neonatal tetanus elimination programme reached a major milestone in early 2013, when more than 50 per cent of priority countries eliminated the disease. UNICEF supported tetanus elimination in more than half of the high-risk countries, and nearly 13 million women of reproductive age were vaccinated. Significant progress was noted in the introduction of the rubella vaccine, and rubella elimination activities have provided opportunities to improve routine immunization service delivery, particularly in India. For the first time, all regions had measles elimination goals in 2013, and Burundi, Kenya and Sao Tome and Principe introduced the recommended second dose of measles vaccine. Finally, Ethiopia, Nigeria and Sudan conducted mass campaigns for meningitis A vaccination. Despite this progress, immunization programmes continued to face a number of challenges. Efforts to assess and alleviate inequities in immunization coverage were delayed by broader external factors. For example, the ongoing conflict in the Central African Republic limited the operational capacity of UNICEF. In such situations, recruitments for key positions and the fielding of support missions can be delayed or cancelled. Low-level security risks in certain settings have created new challenges. Sub-optimal funding to implement programmes remains a serious constraint in many countries, resulting in low-quality immunization activities, despite support efforts by UNICEF and its partners. Recurring measles outbreaks, for example, or poorly implemented communication strategies to introduce a new vaccine are evidence of such shortcomings. Polio UNICEF maintained the hard-won progress towards polio eradication in 2013, while fostering a new understanding of polio immunization in the remaining underserved communities. With UNICEF support, the delivery of polio vaccine and related communication is changing from a single disease narrative to a platform for child survival. Rather than attempting to generate demand for OPV as a single intervention, communications in 2013 incorporated polio within

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routine immunization, or within the broader scope of child survival and development interventions. For example, in Nigeria, in response to demonstrated demand among mothers for nutrition and therapeutic feeding programmes, thousands of community mobilizers in the field previously trained with polio-specific skills are being trained to measure mid-upper arm circumference and help track and refer children with malnutrition to the appropriate health facilities for nutritional and other child health services. UNICEF and its partners in GPEI continue to tackle the underlying causes of refusal and create sustainable demand for OPV by building local trust and empowering communities as stewards of their own health. For example, UNICEF no longer conducts mass polio communication campaigns in Pakistan and Nigeria. Instead, community mobilizers work behind the scenes to identify and support local leaders to be the face of the programme. Innovative programming, improved data collection and regular monitoring have contributed to enhanced performance, including marked reduction in refusals as well as timely delivery of the appropriate type of polio vaccine during polio campaigns. However, security risks continue to hinder polio vaccination campaigns in Nigeria and Pakistan, where frontline workers have been targeted in direct attacks. UNICEF and WHO co-chaired the Immunization Management Group (IMG), which is coordinating the introduction of the inactivated polio vaccine (IPV) in routine immunization systems in over 120 countries by the end of 2015; it also plans to improve routine immunization using the polio eradication infrastructure in 10 of these countries. The IMG partnership has been successful to date in advocating the agenda and making preparations to assist countries with IPV introduction and strengthening of routine immunization. UNICEF also continues to be a core partner of the Measles & Rubella Initiative, and under this umbrella provides technical support and funding to countries to increase protection against these two diseases.

Polio: Fast -tracking innovation

The UNICEF contribution to polio eradication is built on innovation. This includes exploring new partnerships to reach more caregivers with accurate information about vaccination, and ultimately, reaching more children with OPV. For example, a group of Islamic scholars convened in Cairo in March 2013 to support polio eradication. In Islamabad in June 2013, UNICEF helped to convene a consultative meeting of religious scholars and health specialists that resulted in the Islamabad Declaration, a commitment to support polio eradication and the healthy future of children in Pakistan. UNICEF is also contributing to polio eradication through the innovative use of new tools and technologies. Polio eradication campaigns are fast moving and data-oriented, and real-time data collection and analysis can better inform planning of future campaigns. By allowing immediate, direct communication with frontline health workers, innovations including use of SMS technology are revolutionizing social mobilization, monitoring and response efforts. In Nigeria, the social mobilizer network uses smartphones to transmit data from the field to streamline information-sharing and improve management and monitoring of field-level activities. Mobile payments are being used to ensure that social mobilizers are paid on time. In Lebanon, SMS technology is being used to target specific messages to Syrian refugees, one of the groups at the highest risk for polio transmission in the Middle East. Other innovations, including the use of computer tablets to show training videos or mobile projectors to play informational videos, can help reach, inform and engage children and caregivers, even in the world’s hardest-to-reach places.

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Increasingly, sharing best practices across countries and with convening partners across a broad range of sectors promotes integrated health services and systems that respond to the needs of children and their families. In Angola, Chad and India, for example, UNICEF-supported polio programmes were linked with routine immunization, WASH and nutrition interventions; lessons learned from these efforts will guide linked programme delivery in the polio 'sanctuaries'. Through a UNICEF partnership with the Harvard School of Public Health, scientifically rigorous, rapid polls are being conducted to gauge public perceptions of OPV and of the polio programme overall. The data will be comparable across countries through a standardized approach that can also be adapted to specific country contexts as needed. In general, UNICEF supports increased availability of scientific evidence on MNCH, from gathering and synthesis to dissemination and publication. Enhancing policies and strengthening systems UNICEF seeks to standardize and improve the quality of monitoring and evaluation of MNCH programmes and supports district health system strengthening. In 2013, UNICEF helped to build local capacities to collect and analyze data in more than 20 countries. The health system strengthening work in one district of Botswana, for example, revealed that only 28 per cent of women and newborns were receiving post-natal visits. Once the reason for the bottleneck was identified – a lack of midwives – post-natal visits were delegated to appropriately trained nurses and as a result, the proportion of women and newborns receiving postnatal visits increased to 55 per cent. UNICEF also supported and conducted global evaluations, generating data that already have been used to sharpen country programmes and to attract funding for similar work in other countries. For example, as a result of documenting and evaluating the barriers and challenges to the Catalytic Initiative Integrated Health System Strengthening programme, Ethiopia and Malawi are now using mobile technologies to track supplies to avoid stock outs. The process also helped secure a new $20 million grant from Canada's Department of Foreign Aid, Trade and Development for iCCM implementation and scale-up in Ethiopia, Kenya, Niger and United Republic of Tanzania. Evaluations have also informed UNICEF advocacy at the global level, helping to keep MNCH prominent in the post-2015 development agenda. Vitamin A supplementation Coverage of vitamin A supplementation, often combined with immunization campaigns during Child Health Days, remained high (70 per cent) in all programme countries. UNICEF has been instrumental in promoting the integration of vitamin A supplementation with routine health service delivery, supporting several countries with national planning. As a result, 63 countries have implemented vitamin A supplementation as part of their national health programmes. In many programme countries, especially where coverage by the routine heath system is weak, vitamin A supplements are delivered to children during Child Health Days. This allows for the periodic delivery of key child survival interventions including vitamin A supplementation, particularly in sub-Saharan Africa. Countries that have adopted this approach have managed to sustain high coverage of vitamin A supplementation even in hard-to-reach areas. Globally, 70 per cent of children received two doses of vitamin A, and coverage of vitamin A supplementation was highest in East Asia and the Pacific and West and Central Africa.

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Percentage of children 6–59 months old reached with two doses of vitamin A, 2012

Management of severe acute malnutrition UNICEF supports community-based management of SAM in more than 60 countries. Preliminary data indicate that some 2.87 million children aged 6–59 months received lifesaving treatment for SAM in 2013, compared with 2.64 million in 2012. This is a small increase, but much of the global burden of SAM lies in parts of the world – particularly Asia – where SAM treatment and prevention programming is still in its infancy and requires massive scale-up. At the SUN Movement Global Gathering in September 2013, UNICEF and partners organized a side event to raise awareness among Governments and donors about the threat of acute malnutrition, particularly in non-emergency contexts and within the broader set of nutrition interventions. UNICEF continues to work with WHO as co-chair of a task force to ensure that countries and development partners have adequate guidance and tools to integrate SAM management in existing health systems, promoting ownership and sustainable scale-up. UNICEF also collaborates with the World Food Programme (WFP) for treatment of moderate acute malnutrition (MAM) to prevent further deterioration. In Yemen, UNICEF worked with WFP to link MAM and SAM treatment to ensure continuous service and follow-up. A series of consultations UNICEF conducted in all regions helped to improve capacities to design SAM treatment programmes. These consultations focused on programme monitoring and technical guidance regarding product specifications for ready-to-use therapeutic food. UNICEF contributed to strengthening information systems, enabling them to better monitor and support the scale-up of SAM treatment by strengthening the web-based Global SAM Management Update. UNICEF received global recognition for the innovative RapidSMS, a platform for data gathering and group communication using text messaging on mobile phones to tackle the problem of slow data transmission within the food security surveillance system. First used in Malawi, RapidSMS has expanded to many countries, allowing them to promptly analyze and address nutrition surveillance as well as nutrition screening, supply monitoring and other sectors (i.e., monitoring distribution of LLINs, birth registration).

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Exclusive breastfeeding Despite the compelling scientific evidence of breastfeeding’s unique and wide ranging benefits for newborn, infant and child survival, growth and development, global progress in exclusive breastfeeding has been modest. Global rates increased from 38 per cent in 2000 to 41 per cent in 2012, with the most significant increases taking place in least developed countries (from 38 per cent in 2000 to 50 per cent in 2012). The increase in exclusive breastfeeding can be seen across all regions, although there are no data for the Middle East and North Africa. Behaviour change is known to be complex and require time. However, success has been seen in 25 countries, with recorded increases of over 20 percentage points over 10 years. Such achievements confirm that with comprehensive, large-scale and well-designed programmes, significant progress is possible, even in challenging circumstances.

Changes in exclusive breastfeeding rates over time (2000-2012)

UNICEF conducted a landscape scan of breastfeeding in 2012, aiming to better understand why the compelling scientific evidence of its benefits and the effective interventions available to make breastfeeding a viable practice has not translated into strong commitment and significant progress. The landscape scan highlighted and reaffirmed a number of issues and factors that have created hurdles. These include: insufficient global leadership; low prioritization and financial commitment by donors and policymakers; a lack of policy consensus and unity; and insufficient advocacy and communication tools that employ compelling, current information and effective approaches. Consequently, in 2013, UNICEF and WHO invited multiple partners – including United Nations agencies, civil society organizations and the donor and foundation communities – to increase attention, investment and support for breastfeeding within the critical first 1,000 days of a child's life. The central aim of this joint advocacy effort is to mobilize support and resources to enable more mothers around the world to optimally breastfeed their children. Specifically, the initiative calls for scaling up programmes in the following strategic areas: (a) support for mothers by skilled health care providers; (b) community-based support by peer counselors and other community workers; (c) culturally-sensitive education and communications; and (d) protective laws and policies, including laws and regulations enforcing the International Code of Marketing of Breast-milk Substitutes and all relevant subsequent WHA resolutions, and providing maternity protection.

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Around 2000 Around 2012

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UNICEF continued to use multiple strategies to promote exclusive breastfeeding. At the country level, UNICEF supports Governments to implement the priorities outlined in the Global Strategy for Infant and Young Child Feeding, ensuring that policies and legislation that support breastfeeding are not only formulated but enforced. UNICEF also provides support at the health system and community level by providing, for example, training for health workers and facilitating mother-to-mother support groups. As of 2013, 86 countries had laws incorporating all or most of the provisions of the International Code of Marketing of Breast-milk Substitutes and subsequent WHA resolutions, with a further 19 countries having adopted at least some of the provisions into law.

Case study: Protecting breastfeeding through legislation in Vie t Nam

Hindered by inadequate maternity leave provisions and the aggressive promotion of breast milk substitutes, Viet Nam’s exclusive breastfeeding rates have remained stagnant at about 17 per cent since 1997. A 2011 study by Alive & Thrive, an initiative promoting good infant and young child feeding practices, cited 'returning to work' as one of the main reasons mothers stopped exclusive breastfeeding. At the same time, poor regulation of marketing of breast milk substitutes made artificial feeding extremely popular in the Asia- Pacific region. The region accounts for 31 per cent of the global retail value of baby food sales, compared with 24 per cent in Western Europe and 22 per cent in North America. In support of breastfeeding, Viet Nam’s National Assembly recently enacted legislation that extends paid maternity leave and bans advertising of breast milk substitutes for infants up to 24 months. The new legislation is the result of an advocacy strategy implemented by partners involving the Vietnamese National Assembly’s Institute of Legislative Studies, the Ministry of Health, UNICEF, WHO, Alive & Thrive and others. The partners drew attention to the 1981 International Code of Marketing of Breast-milk Substitutes, subsequent WHA resolutions and the 2000 International Labour Organization Maternity Protection Convention and Recommendation. These international regulatory frameworks were used to persuade legislators to protect the nutritional and breastfeeding rights of mothers and their babies. Also highlighted were the Government’s obligations under the Convention on the Rights of the Child, which addresses breastfeeding specifically in article 24. As a result of these advocacy efforts, the National Assembly passed a Law on Advertisement banning the promotion of breast milk substitutes for children up to age two years. A provision in the Labour Code extending paid maternity leave from four to six months also passed by an overwhelming majority. Both provisions received more than 90 per cent of the votes. These victories were the result of combination of strategies, including:

• Identifying key operational partners to influence policy dialogue and generate evidence;

• Using stakeholder mapping to identify key coun¬terparts, including the Ministry of Health; the Ministry of Labour, Invalids and Social Affairs; the Women’s Union; the General Confederation of Labour; and the Institute of Legislative Studies;

UNICEF Viet Nam / 2013 / Truong Viet Hung

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• Monitoring progress from counter¬parts, including daily updates prior to approval of the law, which helped spur timely action;

• Preparing evidence-based advocacy materials to illustrate the problem; these explained the harmful health, social and economic impact for individuals, families, communities and the nation as a whole associated with low breastfeeding rates, and provided information about regula¬tory solutions within the context of internationally agreed instruments;

• Relying on face-to-face advocacy with counterparts to provide consistent messages, evidence, facts and statistics to support breastfeeding.

There was some resistance – especially from stakeholders who were hesitant to expand the advertising ban in the face of rising concerns among interest groups. But partners dispelled accusations presented by these groups, ensuring that the proposed measures were not a violation of international trade laws. They also emphasized that adop¬ting the proposed measures would improve the country’s efforts to fulfil its obligations under the Convention on the Rights of the Child. In addition, the partnership provided evidence revealing harmful marketing practices, its impact on child development and the extent to which Viet Nam was lagging behind the rest of the world in terms of protection, promotion and support of breastfeeding. There was also some resistance to expanding maternity leave. Yet a survey conducted by the General Confederation of Labour found that 80 per cent of employers and nearly 90 per cent of female workers supported six months of paid maternity leave. The Government confirmed there were sufficient funds to cover the cost, buoyed by estimates showing the positive impact breastfeeding has on children’s health – a gain that could help Viet Nam save millions of dollars in long-term health care costs.

Additional key family care practices In keeping with its target on family care practices, UNICEF seeks to increase the proportion of families with caring practices which improve young child survival, protection, growth and development, with an emphasis on disadvantaged groups. Some of these practices such as exclusive breastfeeding and use of insecticide-treated nets have been covered earlier in this section. In 2013 there was greater integration of handwashing as part of WASH programming, specifically in sanitation and WASH in Schools. The success of large media campaigns such as ‘Global Handwashing Day’ – which in 2013 was celebrated in 60 countries – has without doubt brought the importance of handwashing to the attention of decision makers and communities alike. Yet encouraging the habitual practice of handwashing continues to be a challenging programming area. However the, use of a proxy indicator for handwashing that can then be readily assessed through household surveys is contributing to a growing database that will enable progress to be more easily measured. Through MICS and DHS, there are now data sets from 35 countries, and these will continue to grow. The existing data, combined with studies and other observational evidence, were the basis for the monitoring and evaluation toolkit for handwashing promotion programmes, which was developed in collaboration with the University of Buffalo. Published in 2013, the toolkit has already been disseminated to UNICEF country offices and training has been conducted through webinars. UNICEF and WHO continued to co-host the International Network to Promote Household Water Treatment and Safe Storage (HWTS). The annual meeting of the Network, held in India in

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October 2013, reviewed: the status of national policy development; the evidence supporting integration of HWTS with other health interventions; an international scheme to evaluate HWTS; and the potential to link HWTS with the water safety plan concept. New evidence published in 2013 reported that in Kenya, the use of HWTS led to significant reductions in diarrhoea and HIV mortality. The Network also organized a West Africa workshop on integrated interventions and national HWTS strategies; supported implementation of national HWTS action plans in Ethiopia, the Gambia and Zambia; and saw the inclusion of HWTS within the WHO/UNICEF integrated Global Action Plan for Pneumonia and Diarrhoea and Pneumonia. The most recent data indicate that more than 30 per cent of young children are not receiving sufficient care and support from a responsible parent or caregiver. To address this gap, UNICEF continued to increase ECD investments in 2013, including both programmatic and policy advocacy initiatives in development and humanitarian contexts. The innovative UNICEF/ WHO Care for Child Development (CCD) Package offers families the skills and knowledge they need to care for their infants and young children. Using play and communication, parents foster their children’s development by being responsive, stimulating development and providing the safety and security they need to thrive. Since 2012, the CCD package has been rolled out globally, and in 2013, coordination among partners implementing this flagship programme ensured wider and systematic implementation of CCD within existing health, nutrition and other family support systems. By the end of 2013 the model was being implemented in 14 countries in three regions, with further roll-outs planned in the Middle East and North Africa and other regions in 2014 and beyond. Building the capacity of stakeholders who work with and for young children and their families is an organizational priority. UNICEF provided technical support through capacity-building and training initiatives to improve the quality of teaching and learning in early childhood care and development centres globally. In 2013, 89 UNICEF country offices reported that the host countries' national development plans included targets for scaling up improved family and community care practices for mothers and children, up from 40 in 2005. In 51 countries the UNICEF country programme conducted a gender analysis within the current programme cycle to identify gaps/challenges in family and community care practices, up from 25 countries in 2005. In Ethiopia, following the development of a comprehensive parental education training manual, 10,227 education and health professionals received training (7,617 of them in 2013). Some 365,000 parents and caregivers were also trained on childcare, parenting and early stimulation (137,550 in 2013). In Malawi, capacity development in basic ECD pedagogical skills was provided to caregivers in the four completed UNICEF community-based childcare model centres. UNICEF is also supporting the Ministry of Gender to develop a framework to guide the development of a national ECD training strategy. These operational experiences are being documented and assessed for good practices and lessons learned which can then be shared for context-specific scale up of such programmes. In Bangladesh, India, Liberia, Malawi, Myanmar, Rwanda and South Africa, UNICEF made significant contributions to reviewing, developing and/or implementing ECD policies. In Rwanda, UNICEF played a key role in promoting and disseminating an ECD policy to key stakeholders. This led to the creation of the first ECD and family centre, which will inform the roll-out of government-supported modelling across the country. In South Africa, through evidence-based advocacy, the State is preparing to take over the provision of ECD. A new ECD policy and programme encapsulating a full range of services for children up to age four years is being developed with UNICEF support. In Bangladesh, UNICEF aided the development of a comprehensive early childhood care and development policy, which was approved by the Government in 2013. Similarly, in India, the first national early childhood care and education policy was approved and a policy framework was developed together with UNICEF and the Ministry of Women and Child Development. In Indonesia, UNICEF technical support to Governments implementing ECD policies has been catalytic, expanding services to some 300,000 children.

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Review of community -based care services reveals benefits for children, parents and communities

An increasing body of evidence suggests that early childhood care and education services provide a foundation for children to thrive in many facets of life. Yet children who stand to gain the most are least likely to participate in formal education programmes. Factors such as poverty, ethnicity, place of residence and disability create barriers that often prevent the most disadvantaged children from gaining access to any form of organized early learning and care programmes. To address this disparity, UNICEF considers the scale-up of effective community-based childcare programmes to be a critical means of enhancing opportunities for the most disadvantaged children to receive holistic support. Community-based childcare is one approach that is being adopted across low- and middle-income countries to address this equity gap. This strategy involves an array of stakeholders –NGOs, faith-based and community groups – and programming is frequently influenced by the values of primary caregivers, educators and the community. In 2013, UNICEF commissioned a literature review of community-based childcare services for the most vulnerable young children in developing countries, examining three primary models: Centre-based services: This model is facility-based, and tends to target children aged 3–6 years, with a focus on school readiness. In some programmes, feeding and hygiene interventions may also be incorporated. The service providers involved in these programmes are primarily trained community workers and volunteers. Outreach services : This model tends to target all young children from birth through age eight years, as well as parents and caregivers, with a holistic focus. It is often used when targeting 'hard-to-reach' populations, such as nomadic or indigenous children. Other hubs : This model tends to be used primarily for parenting education programmes, focusing on parents of children from birth through age two years. These services are delivered at locations that typically belong to other sectors (hospitals, clinics or social security centres), and service providers are most often the trained staff from that sector. The benefits young children gain from these programmes include improved school readiness and better cognitive and motor development skills. Community-based programmes also had a positive impact on children’s social and emotional development and, where integrated services were available, their nutrition and health status improved. Indeed, although results vary due to programme quality, location and other context-specific programme characteristics, the review reveals important instances in which integrating initiatives from the ECD sector with those of other sectors – including nutrition and WASH – can lead to greater results for young children and their caregivers. In addition to the benefits to children and caregivers, the review was designed to assess outcomes at the community level, including productivity, income generation, community relationships, children’s safety, advocacy and evidence-based policy making and planning. It found that effective community-based childcare services contribute to the development of a sense of collective responsibility for preparing children for school, and have had a positive impact on the development of local and national policies.

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In India the poorest 40% of the population hardly benefited from improvements in sanitation between 1995 and 2008

UNICEF work with partners on improving demand for services and adopting key practices for children’s well-being is underpinned by the work of the various sectors with the C4D team. In 2013 UNICEF, with the United States Agency for International Development (USAID) and other leading organizations, facilitated, a systematic evidence review on social and behaviour change interventions for child survival. The review brought together more than 100 researchers, academics and practitioners to identify the most compelling evidence to date, as well as gaps that need to be addressed in order to strengthen country level interventions for maternal and child health. These findings are contributing to a growing evidence base that will continue to inform advocacy with . policymakers. Also in 2013, global guidance on evidence-based communication strategies for MNCH was disseminated. Six countries in the East Asia and Pacific region are already reviewing their national behaviour and social changes interventions based on the new guidelines. This more evidence-based approach to social and behaviour change will accelerate the achievement of sustainable results in YSCD

KEY RESULT AREA 3: Support national capacity to ach ieve MDG 7 by increasing access to and sustainable use of improve d water sources and sanitation facilities The 2013 progress update on safe drinking water and sanitation produced by the indicated that 768 million people still lack access to improved drinking water, and 2.5 billion are without access to improved sanitation, including 1 billion people who still practice open defecation. Even among the population with access to improved drinking water and sanitation, substantial disparities are evident. The increasing availability of data allows the JMP to report on a range of inequalities, including access to water and sanitation by wealth quintile, which is now available for more than 70 countries (see box on the case of India). In the future, the growing number of data sets will also enable analysis of access at subnational levels by ethnicity and even religion. This analysis can be used to support sectoral planning, particularly to improve the targeting of resources to unserved populations. At the global level, UNICEF successfully influenced the dialogue on the post-2015 WASH goals and targets. Several influential reports drew significantly on the JMP consolidated proposal and communication materials, and on the United Nations thematic consultation on water that was co-led by UNICEF. The report of the High-Level Panel called for a goal to achieve universal access to water and sanitation, which was echoed in other influential reports and forums. These included 'Corporate Sustainability and the United Nations Post-2015 Development Agenda', prepared by the United Nations Global Compact; reports of the Sustainable Development Solutions Network; the Budapest Water Summit Statement; and the UN-Water recommendation for a post-2015 global goal on water.

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UNICEF hosts the SWA secretariat in coordination with the Water Supply and Sanitation Collaborative Council. In 2013, the secretariat supported the SWA shift to increase dialogue at country level in the periods between High-level Meetings. One key outcome was greater mutual accountability in the sector, with all partners reporting back on progress on the commitments made at the 2012 High-level Meeting. The secretariat facilitated the global tracking of these commitments; produced a global progress update, which was endorsed by the Deputy Secretary-General; developed national advocacy tools available to all stakeholders; and supported advocacy in the form of joint letters from the SWA chair and the Deputy Secretary-General to Heads of State of partner countries, urging attendance at the 2014 High-level Meeting and the formulation of new commitments. The secretariat strengthened the partnership by facilitating partners' contributions to key strategic decisions, including opening SWA to new types of partners, contributing to the dialogue on the post-2015 agenda and advancing the aid-effectiveness debate in the WASH sector. Additionally, the secretariat played a key role in facilitating the alignment of SWA with regional initiatives, such as AfricaSAN (an initiative of the African Ministers Council on Water) and the South Asian Conference on Sanitation, and global monitoring initiatives such as the Global Assessment and Analysis of Sanitation and Water. Increasingly, the UNICEF global WASH programme focuses on country-level efforts to address ‘upstream’ or enabling environment problems in order to achieve at-scale transformational change. In 2013 the SWA National Planning for Results Initiative (NPRI) was launched in six countries (Chad, Mauritania, Niger, Sierra Leone, South Sudan and Togo). The NPRI brings together representatives from donor and developing country Governments and other sector partners to support the constituent elements of an effective sector framework or planning process. These include political will, sector coordination, an overall strategy for sector development and an institutional capability to monitor and respond to bottlenecks impeding effective performance. Participating countries have used the recently developed UNICEF WASH Bottleneck Analysis Tool to develop investment plans to address bottlenecks. The tool contributes to the organization-wide application of the MoRES approach for achieving greater equity-focused results. Since the roll-out began in the second half of 2013, 10 countries have used the tool to undertake national or subnational analyses. Elsewhere, UNICEF has embraced opportunities to support transformational change through active engagement in sector-wide approaches (SWAps) (see text box below).

Ethiopia: ONEWASH National Programme

Ethiopia officially launched the ONEWASH programme in September 2013 as a SWAp to achieve Millennium Development Goal 7 and meets the Government's growth and development targets. ONEWASH brings together the Ministries of Water Resources, Health, Education, and Finance and Economic Development to modernize the way water and sanitation services are delivered to the people of Ethiopia; improve their health; decrease school drop-out rates; and make WASH financing more effective. UNICEF was requested by the Government to lead the development of the programme’s five-year plan. This represents an opportunity for UNICEF to influence and leverage large financial and technical resources in the SWAp for the neglected areas of the WASH sector, targeting underserved communities to reverse the equity gap. Toward this end, UNICEF will focus on 'gap areas' of the SWAp; WASH in small towns; technological innovation; developing the capacities of institutions and agencies; and creating an enabling environment that will pave the way for greater private sector involvement.

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Building on the successful scaling up of the CATS approach to sanitation programming, concerted advocacy efforts have resulted in greater recognition of the sanitation crisis at the highest levels. On World Water Day in 2013, the Deputy Secretary-General announced his Call to Action on Sanitation, which is based on the UNICEF strategy for the elimination of open defecation. He subsequently met with the UNICEF Executive Director and other high-level decision makers to discuss the urgent need to invest in sanitation (see text box below).

A Matter of Life – Investing in Sanitation

With one seventh of the world’s population still practicing open defecation, bringing safe sanitation practices to underserved communities is a matter of life and death. With 1,600 young lives claimed by diarrhoea every day, improving sanitation is fundamental to boosting child survival and promoting development. By eliminating open defecation, deaths caused by diarrhoea – the second greatest killer of children – could be cut by one third. UNICEF advocacy efforts to address the global sanitation crisis were amplified in 2013 by the Call to Action on Sanitation, which was launched by Deputy Secretary-General Jan Eliasson in April. Following the launch, Eliasson joined UNICEF Executive Director Anthony Lake, World Bank Group Vice President of Sustainable Development Rachel Kyte, and American Standard Vice President Jim McHale for an online conversation with key global decision makers about the economics and politics of sanitation. The World Bank responded to the Call to Action on Sanitation by committing to help people 'climb the sanitation ladder' by providing support to knowledge, finance and leveraging funds at scale. As UNICEF continues to scale up community-based interventions to promote safe sanitation practices in underserved communities, the Call to Action and ensuing discussion among global decision makers reflects the success of the organization's upstream efforts to attract attention and investment to this global crisis.

Bringing and sustaining WASH services to the most vulnerable and marginalized communities remains central to UNICEF efforts to address the needs and rights of children everywhere. In 2013, more than 4 million households were provided with access to improved drinking water through direct support from UNICEF. Reaching the unreached requires innovation and knowledge-sharing to identify cost-effective solutions that enable access to sustainable and safe drinking water. In 2013, new partnerships to achieve these goals were established with the Stockholm International Water Institute to address water governance; the Rural Water Supply Network to support a South-South network on manual drilling for more cost-effective water supply; and Tufts University to undertake research on water safety planning. Sustainability checks originally developed in Eastern and Southern Africa were introduced to West and Central Africa. These were further developed to become a ‘sustainability compact’, identifying explicit commitments for sustainability among key stakeholders. Nine countries in West and Central Africa used the MoRES determinant framework to analyze sustainability bottlenecks and develop the sustainability compacts, which were signed by the relevant line ministries. Approximately 4 million households gained access to improved sanitation in 2013 as a result of UNICEF direct support. The CATS approach to sanitation is now firmly established as a best practice and continues to influence thinking around national sanitation strategies. By mid-2013, the cumulative ‘open defecation free’ population had reached an estimated 116 million as a result of direct and indirect support from UNICEF. Indirect support includes, for example, the

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provision of technical assistance for development of policies and standards, advocacy, training of partners, monitoring and the coordination of CATS programming which is being implemented and paid for by government and other partners. Throughout 2013, innovation and development of the CATS approach and concept were very much in evidence. An important complementary component to the demand that CATS ‘awakens’ is to address the supply of materials and other technical assistance, primarily through the private sector. To address this issue and build capacity, UNICEF developed the Sanitation Marketing Learning Series in collaboration with the University of California, Davis. Two cohorts of sanitation marketing training were completed (in English and French) and were well attended across all regions. In some countries a hybrid approach has been developed, combining some of the basic concepts of school sanitation and hygiene education with the participatory methods that underpin CATS. At the heart of the school-led total sanitation approach is the premise that schools are a respected and permanent community institution, and through the mobilization of children's clubs, change agents and participatory techniques, community members are motivated to abandon the practice of open defecation and build and use a latrine (see box below).

School -led total sanitation in Sierra Leone

Fourteen-year-old Memunatu is a student at TDC Primary School in Sierra Leone’s Tonkolili District. She lives with her mother, who grows fruit to sell at the local market. Her father mines gold and lives in Kabala to support his family. Memunatu enjoys attending school, and is looking forward to going to secondary school if she passes her exams this year. Memunatu has been an active member of the school Health Club, applying what she has learned to improve hygiene and sanitation at school and in her community. Her school is one of many in Tonkolili District that has been involved in the WASH in Schools Project that is helping to provide schools with child friendly-WASH facilities, and to promote school sanitation and hygiene education and outreach within the community through school-led total sanitation. Before this programme began, Memunatu and her classmates were exposed to numerous risks associated with poor sanitation and hygiene, both at school and within their communities. “I sometimes missed school due to severe diarrhoea and had to travel to the Makkrugbe clinic for treatment,” she said, adding that defecating in the bush also has its dangers. She got an infection in her foot after standing on a thorn, and one of her brothers was even bitten by a snake. Memunatu is one of the 12 children in her school’s Health Club, which is supported by two teachers and the School Management Committee. All members are committed to ensuring that hygiene and sanitation practices are upheld at school as well as within the community. The dedication of club members has been very effective; households began building latrines and handwashing facilities as a result of their influence. Masaka village has now been declared Open Defecation Free, but Memunatu says that the work of the School Health Club will continue, reminding people to clean up and sharing hygiene and sanitation messages. “My brother used to get sick, but after my family built our toilet, he has not fallen sick again. Neither has anyone else in our household,” said Memunatu. “That is why I like our School Health Club so much.”

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One example of innovation is in Zambia, where a mobile-to-web surveillance system was introduced in 2013 to collect data and monitor CATS implementation. The new surveillance platform was introduced in 15 districts and usage of the data collection tool has already begun. Rapid deployment continued through 2013, and all 20 districts will be covered before the end of February 2014 (see box below).

Real-time monitoring of hygiene and sanitation with mobile-to-web system (Data collection flow from household to Ministry of Local Government and Housing The 'Three Star Approach for WASH in Schools' was launched at a global WASH in Schools meeting in August 2013. WASH professionals from UNICEF discussed strategies for scaling up national WASH in Schools programmes. Participants shared bottleneck analyses of their national programmes and reviewed the commonalities facing countries. There was broad agreement that the Three Star Approach of prioritizing the most essential actions for achieving the health and education goals of WASH in Schools is not only a solid programming strategy, but is also a powerful tool for advocating the realignment of resources and focus on what matters most for children. Under the Three Star Approach, schools and communities are encouraged to take simple steps to make sure that on every school day, students wash their hands with soap, have access to drinking water and have clean toilets. Three key principals underpin the approach: to encourage hand-washing as a habitual practice, children need to practice handwashing with soap at school every day; that expensive WASH infrastructure in schools in not necessary to meet health

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goals; and that WASH in Schools programming should be simple, scalable and sustainable. The approach was developed based on the long-term comprehensive programming experience of UNICEF in over 95 developing countries, and on the German Agency for International Cooperation 'Fit for School' initiative in the Philippines and other countries. The second virtual conference on menstrual hygiene management (MHM) took place in November 2013, co-hosted by Columbia University and UNICEF, and attracted more than 150 virtual participants. The conference presented 16 studies from around the world on MHM, including four case studies from the UNICEF country offices from Burkina Faso, Nepal, Niger and Pakistan. The presentations focused on: (a) the tools/instruments utilized to explore MHM requirements of schoolgirls; and (b) the tools/instruments utilized for monitoring MHM interventions for schoolgirls. An emerging conclusion from both the conference and debate within the growing movement on MHM indicates that not only do significant gaps remain in the evidence base itself, but also that the research methodology must find innovative approaches to include quantitative methods. Building on the success of the virtual conference, new research funding of $7.5 million was secured that will focus specifically on developing the MHM evidence base. Initiatives to further develop cross-sectoral work were undertaken, particularly between WASH and nutrition. For example, the SWA secretariat organized a high-level meeting during the General Assembly to discuss linkages between nutrition and WASH. The meeting was chaired by H.E. John Kufor, former President of Ghana, and H.E. Ellen Johnson Sirleaf, President of Liberia, and attended by leading figures from the SUN Movement, and other high-level decision makers. Additionally, WASH staff worked with the UNICEF Nutrition Section and USAID to develop technical guidance on integrating WASH and nutrition programming. Another important cross-sectoral initiative was collaboration with the UNICEF Disability Section, which included supporting the development of a thematic brief on WASH and children with disabilities, and contributing to the State of World’s Children 2013: Children with Disabilities, as well as developing tools to support inclusive programming such as a guidance note, webinars and an advocacy video on WASH and disability for country offices.

KEY RESULT AREA 4: In humanitarian situations (both acute and protracted), every child is covered with lifesaving interventions, in accordance with the UNICEF Core Commitments for Chi ldren (CCCs) in Humanitarian Action.

UNICEF plays a vital role in strengthening the capacities of countries and partners to reduce excess mortality, malnutrition and other deprivations in disasters and target the most vulnerable population with appropriate interventions. Globally, UNICEF supported 2.4 million severely malnourished children aged 6–59 months (86 per cent of the global target) through therapeutic feeding programmes. This demonstrates an increasing trend, up from 2.1 million in 2012 year and 1.8 million in 2011. Over 1.1 million of these children were in the Sahel region. To support scaled-up, quality programming, there was a focus on improving global information and knowledge for better evidence-based programming. UNICEF worked with Action Against Hunger-UK in 2013 on a technical paper comparing direct estimates of SAM treatment coverage and indirect estimates to better understand coverage data. Other work included a global consultation involving UNICEF, donors and NGOs, held in London in 2013, to accelerate the agenda for scaling up SAM treatment globally. The consultation resulted in greater commitments to improve nutrition information to drive better

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evidence-based programming. To strengthen information and knowledge management, UNICEF supported the CMAM Forum, a platform for information-sharing and dissemination on acute malnutrition to support practitioners and policymakers. Finally, the annual online gathering of key information on country programmes to treat SAM has been continued and expanded to include micronutrient interventions and IYCF programming. The online data will guide programme support, resource mobilization and advocacy in 2014. In terms of country support, humanitarian support was provided in 2013 to all major emergencies and to all appeals. Country-level nutritional support was provided to Angola, Central African Republic, Democratic Republic of the Congo, Guatemala, Honduras, Mauritania, Nigeria and Viet Nam. The Global Nutrition Cluster provided strong support to the field, conducting missions to Afghanistan, Kenya and the Philippines in 2013. Programme cooperation agreements were developed and signed with the International Medical Corps, Save the Children-UK, Action Against Hunger and World Vision International to recruit and deploy staff for rapid response teams. In 2013, rapid response teams were deployed to the three Level 3 emergencies (Central African Republic, the Philippines and the Syrian subregional crisis), as well as to Chad, Pakistan and Somalia, with a total of 10 staff deployed. UNICEF continues to work to improve emergency response as a member of the Strategic Advisory Group of the Global Nutrition Cluster, contributing to the three-year strategic plan to guide the Cluster's work. UNICEF co-led a partners' forum on nutrition to promote information-sharing, strategic planning and the development of tools and guidance together with Action Against Hunger. The CCCs for health address the major causes of maternal, neonatal and child mortality. Injuries or violence may immediately account for a substantial number of deaths, but in protracted humanitarian situations, most deaths are attributable to common health conditions prevalent in the community, such as malnutrition, pneumonia, diarrhoea, measles, malaria (in malaria-endemic areas) and neonatal causes. UNICEF is committed to supporting the continuum of care across the maternal, newborn and early childhood periods at the household, community and health-facility levels, with an increasing emphasis on community health approaches. In 2013, the UNICEF health response in emergencies focused on providing services to address the most common causes of illness and death, including pneumonia, diarrhoea and malaria in endemic areas. UNICEF also supported prevention of disease outbreaks through scaling up its contributions to polio eradication programmes and measles immunization campaigns in emergencies. Globally, UNICEF supported measles vaccinations for 24.5 million children in humanitarian settings, and 67.7 million children aged 6-59 months received vitamin A supplements worldwide through UNICEF support. In addition, UNICEF published and disseminated the UNICEF Cholera Toolkit (in English and French) to help countries prevent, prepare for and respond to cholera, and has provided technical support and supplies to cholera outbreaks globally, including oral cholera vaccines. UNICEF and WHO supported the development of the global Every Newborn Action Plan, which will includes a draft package for newborn care in humanitarian emergencies, including a newborn kit. UNICEF has started work on community case management (CCM) in emergencies to collect the evidence base and to influence guidance on CCM in fragile and crisis settings as a strategy to increase access to health care.

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The UNICEF Cholera Toolkit

Cholera is on the rise, claiming over 100,000 lives each year and infecting 3 million–5 million people. Children are particularly vulnerable to the disease, and children under five years of age account for more than half of all cholera-related deaths worldwide. While cholera has remained endemic in some Asian countries for centuries, it has become endemic in an increasing number of African countries, and has recently returned to the Americas with ongoing transmission in the Dominican Republic and Haiti. Adding to this threat is the emergence of new, more virulent and drug-resistant strains and the frequency of large protracted outbreaks with high fatality rates. This growing public health emergency has caused UNICEF to invest resources and expertise in cholera prevention, preparedness and response. In 2013, UNICEF launched its Cholera Toolkit in English and in French, a process that included a thorough review of existing guidance and internal global consultation, along with valuable contributions and peer review from external global experts and partners in the fight against cholera. The purpose of the toolkit is to provide UNICEF offices, counterparts and partners with one source of information for prevention (or risk reduction) and control of cholera outbreaks, preparedness, response and recovery – including integration with regular development programmes. The cholera response is a truly integrated approach – one that, by definition, needs to focus on the most disadvantaged populations. Programming for cholera goes beyond the confines of health and WASH to include communication, nutrition, education and protection. Disease outbreaks reflect broader inequities, impacting the poorest populations. The launch of the toolkit, and the organization's reinforced efforts to fight cholera, are in keeping with the UNICEF focus on equity and multisectoral approaches.

ECD continues to be an important component of the UNICEF emergency and post-conflict response. Since it was launched in 2009, more than 65,000 ECD kits for emergencies have been distributed by UNICEF country offices. Over 15,000 kits were distributed in 2013, most of them in Syrian Arab Republic and the surrounding countries. These kits benefited more than 700,000 children who have been affected by the violent conflict. The use of the kits in such large numbers clearly indicates the high level of demand for ECD interventions in emergency and crisis contexts. In response to a compelling need in South Sudan, an ECD programme was initiated in four refugee camps targeting 8,800 children between aged 3–5 years – all of whom had been affected by violent conflicts. By the end of 2013, 18,471 refugee children living in refugee camps were enrolled in ECD classes. In 2013, UNICEF strengthened the linkages between ECD and peacebuilding, promoting the role of young children and families as agents of change. Several country offices stepped up efforts to promote peace and social cohesion among young children and their families. In Liberia and South Sudan, the ECD curricula were revised to include the promotion of 'peace multipliers' such as trust, confidence, tolerance and respect. In Ethiopia, UNICEF is conducting research on parenting education and socialization through quality parent-child interactions to promote peacebuilding and social cohesion.

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Access to safe water, sanitation and hygiene in eme rgencies As sector and cluster lead and a Strategic Advisory Group member, UNICEF continued to play a key role in shaping the global WASH landscape during humanitarian actions in 2013. The organization's WASH expertise and field presence have resulted in its leadership and co-leadership role during humanitarian preparedness and response, enhancing partnerships and participation in the rapid response and rapid assessment teams to ensure timely action. UNICEF co-led the WASH cluster with the Government of Philippines after Typhoon Haiyan/Yolanda, and together with the Office of the United Nations High Commissioner for Refugees (UNHCR) continued to lead WASH sector/cluster response to the Syrian crisis. UNICEF led the cluster in Central African Republic and South Sudan. UNICEF continued to work with countries to strengthen national humanitarian WASH coordination and response as a result of the growing caseload and the long-term sustainability of the cluster system during and after humanitarian action. Afghanistan, Bangladesh, Ethiopia, Ghana, Haiti, Indonesia, Kenya, Mali, the Philippines, Sudan and Zimbabwe are among the countries that took concrete steps to strengthen national capacities for humanitarian WASH coordination, preparedness and response. As noted above, the UNICEF Cholera Support Team continued to provide technical assistance to cholera outbreaks in Haiti and other countries in Africa. Incorporating WASH services in UNICEF-supported nutrition centres complemented efforts to address nutritional crises in countries such as Mali and Yemen. The development and implementation of ‘WASH in Nut’ – a minimum package of WASH and nutrition interventions – was conducted in nine countries. In 2013, UNICEF helped to maintain access to drinking water for 24 million people, sanitation for 7 million people and hand-washing facilities for 13.1 million people. UNICEF activated its corporate emergency procedures for three Level 3 emergencies, in addition to responding to humanitarian situations in a total of 83 countries. In total, UNICEF deployed 111 surge support experts through the WASH roster and the humanitarian support personnel mechanism. UNICEF continued to influence WASH sector/cluster learning and capacity-building for humanitarian response. UNICEF and UNHCR have taken concrete actions to upgrade UNICEF training on WASH in emergencies for United Nations and standby partners. With the increasing concern for humanitarian WASH response in urban settings, UNICEF, the United Nations Human Settlements Programme (UN Habitat) and UNHCR agreed to an operational framework for humanitarian WASH in urban settings. In 2013, UNICEF conducted a review of the response to Typhoon Haiyan after one month to identify what went well, areas needing improvement, and to generate critical recommendations to improve the UNICEF WASH response to major emergencies.

Humanitarian response to Typhoon Haiyan: YCSD was c entral to the UNICEF response

Typhoon Haiyan (know locally as Yolanda), one of the strongest cyclones on record, struck the Philippines on 8 November 2013 This devastating event affected 14.1 million people, including 5.9 million children, and caused the deaths of more than 6,000 people. Responding to the emergency was immensely challenging due to the geographic spread of the affected areas, and the fact that the country was recovering from two other recent emergencies – the escalation of conflict in Zamboanga, Mindanao in September, which

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displaced 120,000 people; and a 7.2 magnitude earthquake that struck Bohol province of the Visayas Islands in October. The cross-sectoral response included comprehensive health, nutrition and water and sanitation interventions. The disruption of basic services caused by Typhoon Haiyan, crowding in displacement shelters and population movements all put children, particularly newborns, at increased risk of illness and death from common causes such as pneumonia and diarrhoea, as well as outbreaks of measles and water-borne and vector-borne diseases endemic to the region. UNICEF supported priority life-saving interventions including:

• immunization, particularly a mass measles vaccination campaign, with polio immunization and vitamin A supplementation, integrated with nutrition screening (measurement of mid-upper arm circumference)., As part of these efforts, UNICEF supported re-establishment of the cold chain and restoration of routine immunization services;

• providing emergency health services; • IYCF and treatment of acute malnutrition; • preventing outbreaks of water- and vector-borne diseases.

In the first four months of the response more than 83,200 children under five years of age were vaccinated against measles and more than 82,100 against polio, and 55,300 received vitamin A supplementation and were screened for malnutrition. Efforts focused on the areas most at risk areas, including evacuation centres and communities with confirmed and suspected cases of measles. The Department of Health led the campaign with support from WHO, while UNICEF replenished stocks of the measles and polio vaccines and vitamin A. From December, the strategy shifted to the re-establishment of routine immunization. An important aspect of the strategy was to rebuild a resilient cold chain – for example by equipping 50 health centres with solar-powered refrigerators, a 'climate-smart' move to avoid disruptions in case of power outages. In the acute phase of the response, UNICEF also prepositioned diarrhoeal disease kits as a preparedness measure, with supplies to treat up to 1,400 cases of Shigella dysentery and up to 7,000 moderate to severe cases of diarrhoea. When new cases of dengue were reported, UNICEF worked with the Government, WHO and other partners on field guidelines for response and treatment of acute watery diarrhoea and dengue, combining this effort with training for health workers. The nutrition response aimed to reduce the risk of excessive mortality and morbidity by maintaining the nutritional status of vulnerable groups at pre-crisis levels. IYCF interventions focused on 81 municipalities, targeting 250,000 pregnant women and caretakers of children aged 0-23 months (95 per cent of the total) for a period of one year. Action on prevention of acute malnutrition focused on 62 severely affected municipalities targeting a total of 145,000 boys and girls aged 6-59 months. Programmes to treat acute malnutrition reached 27,000 boys and girls 0-59 months, and 11,000 pregnant and lactating women in 52 mother- and child-friendly spaces. These spaces offer counselling on breastfeeding and complementary feeding for women. Now that families have moved to transition sites or back home, the focus has shifted to the community level, with UNICEF building the capacities of partners on the ground to deliver micronutrient supplementation, deworming and screening and referral for children with acute malnutrition.

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An estimated 200,000 residents in and around Tacloban went days without portable water for drinking, hand washing and cooking, leaving survivors of the storm vulnerable to disease. With a major water treatment plant damaged in the storm, UNICEF worked with partners to restore water points for residents throughout the city. Together, UNICEF, USAID and the relevant Philippine government departments were able to open up more than 30,000 water points throughout the city to deliver portable water. Before the water points had been restored, UNICEF had been trucking and airlifting water and sanitation supplies to Tacloban to reduce the threat of diarrhoea and other water-borne diseases. In total, some 930,000 people were provided with safe water and more than 231,000 children received school hygiene kits.

Resources From 2006 to 2013, several resource partners chose to give flexible funding to thematic pooled funds for the five focus areas of the UNICEF MTSP and humanitarian response. In 2013, UNICEF received $64 million in thematic contributions for YCSD, amounting to 18 per cent of the total thematic contributions received in 2013 ($359 million) for the five focus areas and humanitarian response.

What is thematic funding?

Thematic funding was created after the adoption of the UNICEF MTSP 2001–2005 as an opportunity for resource partners to support the goals and objectives of the MTSP and to allow for longer-term planning and sustainability of programmes. While regular resources continue to be UNICEF’s preferred type of funding, thematic contributions are the next best option because they have fewer restrictions on their use than traditional ‘other resources’. From 2006 to 2013, resource partners could allocate thematic funds to the five MTSP focus areas and humanitarian response as follows:

• Focus area 1: Young child survival and development • Focus area 2: Basic education and gender equality • Focus area 3: HIV/AIDS and children • Focus area 4: Child protection from violence, exploitation and abuse • Focus area 5: Policy advocacy and partnerships for children’s rights • Humanitarian response

Thematic contributions are provided at the global, regional or country level. Contributions from all resource partners to the same focus area are combined into one pooled-fund account with the same duration, which simplifies financial management and reporting for UNICEF offices. As funds are pooled, UNICEF cannot track individual resource partners’ contributions. A single annual consolidated narrative and financial report is provided that is the same for all resource partners. Due to reduced administrative costs, thematic contributions are subject to a lower cost recovery rate: 5 per cent (compared with the standard 7 per cent) during the 2006-2013 MTSP period.

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Thematic contributions to MTSP focus areas and huma nitarian response, 2013: $359 million

Due to the extraordinary response to the funding appeals for the Syrian crisis and South Sudan in the latter half of the year, two fifths of thematic funding in 2013 went to humanitarian response, with the majority of contributions made to the new 2014-2017 thematic funding pool which opened on 1 October 2013. Total thematic funding for the five MTSP focus areas in 2013 was $211 million, 6 per cent more than the corresponding funding in 2012. This narrow funding base continues to be a challenge for UNICEF, as resources and efforts have necessarily shifted to preparing project proposals and reporting for earmarked contributions. The thematic funding received for YCSD in 2013 represented an increase of 57 per cent from the $41 million received the previous year. In 2013, 74 per cent of the contributions were from Governments, 25 per cent from National Committees for UNICEF, with private sector fundraising by field offices and Goodwill Ambassador Tetsuko Kuroyanagi accounting for the remaining 1 per cent. The largest resource partner to thematic funding for YCSD was the Government of Sweden, which provided 70 per cent of funding, followed by the Korean, Italian, Spanish and Netherlands Committees for UNICEF and the Government of Luxembourg. Sweden and the United Kingdom Committee for UNICEF have been the top two resource partners, the first providing reliable annual support. The Korean and Italian Committees, the United States Fund for UNICEF and the Government of Spain have also been important to the delivery of results in this focus area.

Basic Education and Gender Equality

$112m — 31%

Child Protection from Violence, Exploitation and Abuse

$17m — 5%

Young Child Survival and Development

$64m — 18%

Policy, Advocacy and Partnerships for Children's Rights $8m — 2%

HIV/AIDS and Children

$10m — 3%

Humanitarian Response

$148m — 41%

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Thematic contributions by resource partners to youn g child survival and development, 2013

Resource Partner Type Resource Partner Amount (in US$)

Government

Sweden 44,531,818

Luxembourg 2,306,645

Flanders International Cooperation (Belgium) 331,565

Canada 5,502

National Committee

Korean Committee for UNICEF 3,900,000

Italian Committee for UNICEF 3,064,305

Spanish Committee for UNICEF 2,764,962

Dutch Committee for UNICEF 2,468,856

Norwegian Committee for UNICEF 1,025,676

Portuguese Committee for UNICEF 794,315

Belgian Committee for UNICEF 408,266

Danish Committee for UNICEF 393,122

United States Fund for UNICEF 339,118

Australian Committee for UNICEF Ltd 319,284

United Kingdom Committee for UNICEF 233,814

Slovakian Committee for UNICEF 66,885

French Committee for UNICEF 55,558

Swiss Committee for UNICEF 52,259

Luxembourg Committee for UNICEF 50,857

Canadian Committee for UNICEF 38,948

German Committee for UNICEF 25,510

Swedish Committee for UNICEF 21,966

Polish Committee for UNICEF 18,808

Irish Committee for UNICEF 10,451

Turkish Committee for UNICEF 7,689

New Zealand Committee for UNICEF 5,270

Austrian Committee for UNICEF 4,135

Private Sector Field Office Fundraising

UNICEF Malaysia 240,000

UNICEF India 121,036

UNICEF Thailand 48,649

UNICEF Bosnia and Herzegovina 17,906

UNICEF United Arab Emirates 10,000

UNICEF China 6,000

Other Goodwill Ambassador Tetsuko Kuroyanagi 200,884

Grand Total 63,890,059

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Top 15 resource partners to thematic Focus Area 1: young child survival and development, 2006-2013*

Resource Partner 2006 2007 2008 2009 2010 2011 2012 2013 Total 2006-2013

in US$ thousands

Sweden 382 546 587 314 482 12,567 11,124 44,532 70,534

United Kingdom Committee for UNICEF

3,823 1,675 4,886 3,810 5,420 550 3,692 234 24,090

Korean Committee for UNICEF 850 853 1,399 1,450 1,903 1,727 8,283 3,900 20,365

Spain

17,789

17,789

Italian Committee for UNICEF 1,881 410 4,395 2,198 274

4,649 3,064 16,871

United States Fund for UNICEF 5,013 3,621 2,087 2,335 166 380 238 339 14,179

Luxembourg 711 973 1,362 1,247 2,381 2,394 2,259 2,307 13,634

Portuguese Committee for UNICEF

619 1,869 1,317 2,002 200 2,387 704 794 9,892

Spanish Committee for UNICEF 330 293 530 1,067 546 199 1,237 2,765 6,967

Dutch Committee for UNICEF

1,050 354 387 2,180 2,469 6,440

Japan

2,809 3,086

5,895

Andalusia, Spain

2,711

2,365

5,076

Belgian Committee for UNICEF

780 846 583 335 408 2,952

Danish Committee for UNICEF 231 234 427 354 367 340 543 393 2,889

Australian Committee for UNICEF Limited 309 172 43

584 483

1,591

*Change in accounting policy from United Nations System Accounting Standards to International Public Sector Accounting Standards on 1 January 2012 does not allow comparison between 2012 figures and prior years.

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Top resource partners to thematic Focus Area 1, you ng child survival and development, 2006-2013*

*Change in accounting policy from United Nations System Accounting Standards to International Public Sector Accounting Standards on 1 January 2012 does not allow comparisons between 2012 figures and prior years.

Financial implementation

Expenditure by funding type for young child surviva l and development, 2013

Funding type Expenditure (in US $ million) Expenditure (%)

Regular resources 393.7 19.8%

Other resources–regular 935.9 47.0%

Other resources–emergency 662.2 33.2%

Total 1,991.8 100%

- 10 000 20 000 30 000 40 000 50 000 60 000 70 000

Sweden

United Kindom NC

Korea NC

Spain

Italy NC

United States NC

Luxembourg

Portugal NC

Spain NC

Netherlands NC

Japan

Adalusia, Spain

Belgium NC

Denmark NC

Australia NC In US$ thousands

2006 2007 2008 2009 2010 2011 2012 2013

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Total expenditure by MTSP focus area, 2013 (all fun ding sources)

MTSP focus area Expenditure (in US $ million) Expenditure (%)

Young child survival and development 1,991.8 55.5%

Basic education and gender equality 712.6 19.9%

HIV/AIDS and children 111.9 3.1%

Child protection: preventing and responding to violence, exploitation and abuse

399.3 11.1%

Policy advocacy and partnerships for children's rights 294.6 8.2%

Other 77.4 2.2%

Total 3,587.5 100%

Total expenditure by MTSP focus area, 2013 (in US$ millions)

Total expenditure: $3,587.5

Young Child Survival and Development

56%

Policy Advocacy and Partnerships for Children's Rights

8%

Other — 2%

Child Protection: Preventing and

Responding to Violence, Exploitation and Abuse

11%

HIV/AIDS and Children — 3%

Basic Education and Gender Equality

20%

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Total expenditure by region and funding source for young child survival and development, 2013

Region

Regular resources

Other resources (regular)

Other resources (emergency)

Total expenditure

Total expenditure (%)

(in US$ millions)

Eastern and Southern Africa 99.4 316.1 191.2 606.7 30.5%

West and Central Africa 138.8 296.0 162.4 597.2 30.0%

South Asia 63.2 133.5 60.4 257.2 12.9%

Middle East and North Africa 35.2 54.5 193.0 282.7 14.2%

East Asia and the Pacific 20.9 55.5 30.3 106.8 5.4%

UNICEF headquarters 24.7 39.5 .5 64.6 3.2%

Latin America and the Caribbean 6.4 27.3 23.6 57.3 2.9%

Central and Eastern Europe and the Commonwealth of Independent States

5.1 13.5 .7 19.3 1.0%

All regions 393.7 935.9 662.2 1,991.8 100.0%

Expenditure by region and funding source for young child survival and development, 2013

,0

100,0

200,0

300,0

400,0

500,0

600,0

ESAR WCAR ROSA MENA EAPR HQ TACR CEE/CIS

Regular Resources Other resources (regular) Other resources (emergency)

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Expense by key result area for young child survival and development, 2013

Key result area Expenditure (in US $ million)

% of focus area expenditure

KRA1 - Support national capacity to achieve MDG 1 by improving child nutrition through improved practices and enhanced access to commodities and services

96.8 4.9%

KRA 2 - Support national capacity to achieve MDGs 4 and 5 through increased coverage of integrated packages of services, improved practices and an enhanced policy environment

1,211.0 60.8%

KRA 3 - Support national capacity to achieve MDG 7 (target 7. C) by increasing access to and sustainable use of improved water sources and sanitation facilities

263.2 13.2%

KRA 4 - In humanitarian situations, (both acute and protracted), every child is covered with lifesaving interventions (as per UNICEF Core Commitments for Children in Humanitarian Action)

383.9 19.3%

Cross cutting* 36.7 1.8%

Total 1,991.8 100%

*Figure includes funds used in a cross-thematic manner or to cover operational costs. Without such cross-thematic and operational usage, outcome area results would often be compromised or not achieved

Future workplan Under the banner of A Promise Renewed, in 2014 UNICEF will continue to support national efforts to mobilize public and private support for the goal of ending preventable maternal, newborn and child deaths. Several countries, including Namibia, Nepal, the Philippines and United Republic of Tanzania, have already announced plans to launch A Promise Renewed in 2014. In preparation for these launches, UNICEF will continue to support government-led efforts to sharpen national strategies for maternal, newborn and child survival, set costed targets and mobilize the public, private and civil society sectors to fulfil the commitments made on behalf of women and children. UNICEF will also continue to help Governments develop and implement country scorecards for reproductive, maternal, newborn and child health. The country scorecards provide Governments with a practical tool for demonstrating progress and strengthening public accountability for national targets. Although A Promise Renewed is global in focus, UNICEF will intensify collaboration with the African Union in 2014, following the regional body’s recent endorsement of a continental road map for ending preventable child deaths across Africa. The high-level recognition of the importance of this goal lends additional political credibility to A Promise Renewed and opens up new channels for social mobilization across the continent. To help countries eliminate unnecessary child deaths, UNICEF will reinforce national efforts to identify and scale up high-impact interventions. For example, the Integrated Community Case Management Symposium in March 2014 gave UNICEF the opportunity to synthesize data on

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the impact of iCCM and share progress and guidance across more countries. In every area of health, UNICEF will continue to strengthen the visibility and momentum around A Promise Renewed and its goal of ending preventable child deaths. Strengthened political commitment, accountability and national capacities to legislate, plan and budget with the aim of increasing access to health interventions will be a key output. For child health, the coming years present an opportunity to further consolidate evidence and learning on iCCM and CHW service delivery, and use this information to address barriers to scale up and improve the effectiveness and efficiency of community-based treatment programmes. For paediatric HIV, the focus will be on consolidating evidence around HIV burden within the context of other childhood morbidities, and effective models of care to enhance uptake of services. Within the new Strategic Plan, 2014-2017, UNICEF will focus on delivering enhanced support for children and caregivers, from pregnancy to adolescence, for improved healthy behaviours, while also supporting increased national capacities to provide access to essential high-impact maternal and child health interventions. Following the launch of the Every Newborn Action Plan in mid-2014, a key priority will be to provide guidance and technical assistance to countries to implement the Action Plan. UNICEF will focus on leveraging resources and evidence to support programmes linking maternal and newborn care, including breastfeeding, with health system strengthening. UNICEF will also continue to support countries to strengthen national MNCH plans and leverage new funding opportunities, while also improving district health systems; the latter will include building capacities to identify and tackle priority bottlenecks, and to routinely monitor progress. Working to build national capacities and increase coverage of services for women and children applies in humanitarian situations as well. In the area of immunization, work will focus on the 10 countries with the greatest inequalities among districts; this will include support for programme design, implementation and monitoring, and building sustainable local capacities to leverage funds to scale up interventions. For the polio eradication programme, 2014 is a critical year with the target of halting circulation of the wild poliovirus. Looking beyond the end of polio to the wider health agenda, UNICEF will accelerate programme convergence at headquarters and country levels, particularly concerning routine immunization. The expedited introduction of IPV in the many countries where UNICEF has a central mandate to support routine immunization represents a window of opportunity for the organization to use its expertise to strengthen systems. UNICEF will also take a risk management approach to prevent further polio outbreaks, applying innovative approaches to further enhance coordination and support to countries. In 2014, UNICEF will develop a new nutrition strategy for 2014-2025 to mobilize action at the global, regional and country levels. The strategy will focus on increasing equitable access to high-impact nutrition interventions, and define the UNICEF approach in emerging areas, such as maternal nutrition and childhood obesity, and emphasize liaising with partners across sectors to develop nutrition-sensitive approaches. UNICEF will continue to play a leadership role in global and regional forums, including its Cluster Lead Agency function for nutrition. Multisectoral linkages will be strengthened, following up on UNICEF collaboration in 2013 with USAID and WHO to develop guidance on how to integrate WASH within nutrition programming, based on evidence and case examples. UNICEF will invest in partnerships to promote knowledge management and develop practical guidance required for programming that leads to improved nutrition outcomes, such as, for example, developing risk- informed programming in fragile States. UNICEF will build on its foundational collaboration with other sectors to ensure greater convergence of efforts to prevent and treat malnutrition. Country-level support will emphasize mainstreaming of MoRES and accelerating progress in strategic countries with a high burden of undernutrition.

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In 2014, UNICEF plans to increase the number of children experiencing positive, responsive, sensitive and nurturing parenting. For the programming phase 2014-2017, there will be a strategic shift to address the demand-side bottlenecks identified for ECD services in order to achieve equity in ECD outcomes, as measured through the ECD index. As families are the strongest advocates for their children, UNICEF will prioritize their empowerment, supporting mothers, key caregivers and their communities to demand the best for their children. UNICEF will ensure that the latest evidence informs programming at the country level. This process will be supported by established programming tools, including the CCD approach; early learning programmes, including preschool and community-based programming; and the ECD kit for emergencies, conflict and humanitarian settings. UNICEF will continue to rely upon ECD as a critical entry point for peacebuilding programming in conflict and post-conflict affected communities Continuing its convening role, UNICEF plans to host a high-level neuroscience consultation early in 2014 to learn about the latest in brain development in the earliest years. This greater understanding of science and evidence will help to sharpen ECD programme strategies. ECD is gaining momentum globally, and the opportunity cost of not engaging now is very high. ECD’s cross-cutting nature and influence is reflected in the Strategic Plan with ECD indicators integrated across the nutrition, education, child protection and social inclusion outcome areas. In the Strategic Plan, 2014-2017, WASH outcome areas include the introduction of risk management approaches to drinking water safety, and addressing sustainability through interventions focused on the enabling environment, climate change adaptation and water resource management. Efforts will continue to scale up CATS, but will give more emphasis to sanitation marketing to strengthen the supply side, and make handwashing a more integral component. The findings of the global evaluation of CATS , expected in 2014, will help to fine tune programming. Engaging with key global partnerships is a fundamental part of the WASH strategy to achieve transformational change. Toward this end, SWA and the JMP remain the two most important partnerships. UNICEF will continue to play a key role in the Global WASH Cluster and Strategic Advisory Group response to existing and new emergencies, engaging with various humanitarian WASH coordination and technical forums. Best practices, new technologies and innovations will be documented, and development of technical notes will continue in 2014. The joint UNICEF/UNHCR WASH in emergency training will be rolled out and a UNICEF/UN- Habitat/UNHCR operational framework for humanitarian WASH in urban settings will be defined. On cholera, UNICEF will develop two regional platforms in Eastern and Southern and West and Central Africa to support dissemination and use of the Cholera Toolkit. The organization also continues to play a key role in responding to the cholera outbreak in Haiti. UNICEF will engage with donors, universities and sectoral partners to strengthen national humanitarian WASH coordination, preparedness and response. An overall framework for support and decision-making will be developed and country assessments conducted in Ethiopia, Guinea, Haiti, Mali and Sudan in 2014. As noted above, all YCSD sectors will build on the gains made to date, use the latest evidence to inform programming and explore strategies that achieve results in fragile and humanitarian contexts that affect millions of children. With the majority of children living in countries classified as middle-income, ways of leveraging domestic resources to best reach the unreached with key YCSD interventions will be a growing area of work. Where basic services are available, a focus on their quality will be important, especially in relation to how they are delivered to the most disadvantaged and marginalized populations. In addition, recognizing the importance of a life-cycle approach and need to preserve and nurture the gains made in the early years to adolescence and beyond, the YCSD sectors will be exploring ways to support this stage of development. Given the data and epidemiology, areas of work such as non-communicable diseases will also grow with UNICEF defining its niche area vis-à-vis those of other partners.

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Expression of thanks UNICEF expresses its sincere appreciation to all resource partners contributing to the work on YCSD throughout the 2006-2013 MTSP period through this thematic funding window. Thematic funding provides greater flexibility, longer-term planning and sustainability of programmes. It reflects the trust resource partners have in the capacity and ability of UNICEF to deliver quality support under all circumstances and has made possible the results described in this report. Special thanks go to the Governments of Sweden, Spain, Luxembourg, Japan and Andalusia (Spain) for their generous contributions and partnership, as well as the National Committees, particularly the United Kingdom and Korean Committees for UNICEF, for their consistent support to YCSD.

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Acronyms

ACT Artemisinin-combination therapy (anti-malarial) C4D Communication for development CATS Community Approaches to Total Sanitation CCCs Core Commitments for Children in Humanitarian Action (UNICEF) CCD Care for Child Development CCM Community case management CDC United States Centers for Disease Control and Prevention CHW Community health worker CIDA Canadian International Development Agency CMAM Community Management of Acute Malnutrition DESA United Nations Department of Economic and Social Affairs DHS Demographic and Health Survey ECD Early childhood development EPEM Emergency Plan to Eliminate Malnutrition (Rwanda) GPEI Global Polio Eradication Initiative HPV Human Papillomavirus vaccine HWTS Household water treatment and safe storage iCCM integrated community case management IMG Immunization Management Group IPV inactivated polio vaccine IYCF Infant and young child feeding JMP WHO-UNICEF Joint Monitoring Programme for Water Supply and Sanitation LLINs Long lasting insecticidal nets MAM Moderate acute malnutrition MHM Menstrual hygiene management MICS Multiple indicator cluster survey MNCH Maternal, newborn and child health MoRES Monitoring of Results for Equity System MTSP medium-term strategic plan NGO non-governmental organization NPRI SWA National Planning for Results Initiative OPV Oral polio vaccine RDT Rapid diagnostic tests (for malaria) SAM Severe acute malnutrition SUN Scaling Up Nutrition Movement SWA Sanitation and Water for All SWAp Sector-wide approach UNAIDS Joint United Nations Programme on HIV.AIDS UNFPA United Nations Population Fund UN-Habitat United Nations Human Settlements Programme UN-Women United Nations Entity for Gender Equality and the Empowerment of Women UNHCR Office of the United Nations High Commissioner for Refugees USAID United States Agency for International Development WASH Water, sanitation and hygiene WHA World Health Assembly WFP World Food Programme WHO World Health Organization YCSD Young child survival and development

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ENDNOTES

1 Global and regional estimates reflect those consistent with the UNICEF, WHO, World Bank Joint Child Malnutrition Estimates

from analysis of the joint Global Nutrition database from 1990 to 2011. The data presented here supersede relevant historical data published by UNICEF and WHO. Further details of the harmonized methodology are available at: http://www.childinfo.org/malnutrition.html

2 Improving Child Nutrition- The achievable imperative for global progress. UNICEF 2013

3 Angola, Afghanistan, Burkina Faso, China, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Mali, Niger, Nigeria, Pakistan, Uganda, United Republic of Tanzania,.

United Nations Children’s Fund 3 United Nations Plaza New York, NY 10017, USA www.unicef.org © United Nations Children’s Fund June 2014