Global 1997: Sustainability of the World Summit for Children Goals
Author: Chen, L. Singh, S.; UNICEF NYHQ
This paper was originally prepared as background for discussion at the workshop 'The World Summit Goals for Children: The Challenge of Sustainability', International Child Development Centre, UNICEF, Florence, Italy, June 1-2, 1995. It was, subsequently, revised to incorporate the main conclusions of the workshop.
Purpose / Objective
In this paper, we examine sustainability as it relates to the year 2000 and mid-decade goals as articulated by the 1990 World Summit for Children. Its purpose is to address the question: Which strategies in the second half of the 1990s would strengthen efforts to achieve the Summit goals in a sustainable manner?
The paper begins by examining the rationale of the goals and criticisms about the weak incorporation of sustainability concerns into UNICEF's policies and programmes. Available data and analyses are next reviewed on progress and setbacks in achieving the goals around the world. UNICEF's internal documents as well as independent external studies are scrutinised. Based upon available evidence, we conclude that significant progress is being achieved in some goals in some countries. Gaps and setbacks, however, are also apparent, and enormous diversity exists among different goals and between countries. Only preliminary conclusions can be drawn because of limited data of uncertain quality, the restricted sources of information, and methodological constraints of available studies.
Key Findings and Conclusions
How well has the developing world, with UNICEF's support, done in attaining the Summit goals? This is a tough question and the answer is not simple. Available evidence, however, would seem to support several broad conclusions.
First, enormous progress appears to have been made in some of the Summit goals in some places. Child mortality continues its unprecedented pace of decline around the world. UNICEF has claimed that UCI and other Summit goal activities have contributed to human longevity. UNICEF reported that four out of five of UCI 'successful' countries in 1990 have either stabilised or further improved their immunisation coverage (Appendix A). Advances have been reported in the global eradication of polio, which has been eliminated from the Western Hemisphere. Guinea worm disease reportedly has been reduced by 90 per cent worldwide; eliminated in some regions. In the past decade, the use of oral rehydration therapy has increased from virtually zero to 44 per cent. Of the 94 countries reporting on the elimination of iodine deficiency through salt iodization, 58 countries were 'on track' and 32 more countries with 'extra effort' were likely to achieve the mid-decade goal of universal iodization.
UNICEF reports on immunisation coverage parallel data from its sister UN organisation, the World Health Organisation (LaForce, 1995). Table 3 summarises WHO data on immunisation progress in the 1990s, classified according to a country's position at the beginning of the decade. The majority of countries that had attained UCI targets in 1990 were able to maintain or further improve their performance. Equally important, many countries that had not reached the 80 per cent level in 1990 have also been able to maintain or improve coverage. Altogether, 40 countries have maintained and another 32 countries have improved upon their 1990 performance levels.
Major gaps and shortcomings, however, persist. Of 91 countries listed in Table 3, 19 showed declines of 10 per cent or greater in immunisation coverage over the 1990s. About 20 per cent of the UCI countries in 1990 experienced deterioration and about 25 per cent of the lower immunisation coverage countries in 1990 slipped backwards. Slippage of immunisation coverage was reported in every developing world continent.
Information on immunisation appears to be more abundant than on progress of other Summit goals. Progress in the prevention and treatment of acute respiratory infections (ARI) has been reportedly mixed. Although recognition of the health significance of ARI has grown, field implementation has been slowed due, in part, to professional resistance (against paramedic prescription of antibiotics) and, in part, to prohibitive costs (expensive antibiotics). For some goals, data are simply unavailable (e.g., maternal mortality in sub-Saharan Africa). With a few goals, the solution may remain relatively unaffordable or the problem may be intractable to available technology (e.g., the high cost of drinking water systems in some regions and the weak progress on sanitation in virtually all regions).
Finally, a global perspective disguises the great diversity of progress and setbacks between and within nations. The Bangladesh and Nigeria cases illustrate the enormous range of national experiences, both positive and negative. This comparison can be multiplied many times over across the full spectrum of goals. Overall, the progress in immunisation appears to have been greater than among other goals, and performance has been stronger in Asia and Latin America than in sub-Saharan Africa.
Studies of sustainability
Internal UNICEF documents show that the agency has accorded high priority to promoting sustainability as an integral part its work. This strategic priority is manifested in numerous UNICEF programme documents, agency reports to its executive board, and several independent studies. As an exhaustive review of relevant materials is not possible, this paper will cite several types of studies - internal documents, external studies of UCI and Bamako Initiative, and studies of sustainable social development. Especially reassuring are three independent external studies of the Bamako and the UCI initiatives. Taken as a whole, they suggest that implementation of the World Summit goals, at a minimum, has not been detrimental to sustainability and, at a maximum, may have provided a stimulus for sustained action.
There are several caveats to this generally positive assessment, however. First, the available data are limited and of questionable quality. Secondly, several external studies undertaken are methodologically restricted. The assessments mostly deal with the health sector, and two focus exclusively on immunisation; fewer studies have been done in other goal-related sectors. Thirdly, UNICEF's policy articulation about sustainability, however genuine, says little about how operational, personnel, and budgetary decision-making are actually made in a highly decentralised field organisation. It is possible to interpret the policy statements as strategic deflection of external criticism, even as internal operations ignore sustainability in favour of rapid, visible results. Sustainability is a vague concept for which practical field translation remains problematic. Even if decision-makers were to prioritise sustainability in field action, precisely how to do so remains unspecified. This practical problem of how to strengthen sustainability in programming actions deserves more future attention.
Finally, none of the studies squarely address the question of whether the Summit goals provide the most strategically-effective approach to sustainable progress for children. In other words, the studies do not pose the counterfactual question. Would similar investments in another strategy, besides the Summit goals, contribute even more to sustainable progress?
Strategies for sustainability
To guide strategic thinking, a conceptual framework that considers supply and demand of goal-related activities is presented. Sustainable achievements depend upon six factors: (1) ownership of goals, (2) political commitment, (3) the participation of the beneficiaries, and strengthening the capabilities and power of (4) human, (5) institutional, and (6) financial resources. No blueprint in managing these factors can be offered because practical application will be shaped by specific contexts. Sustainability fundamentally involves a way of thinking and decision-making about these factors in unique real-world situations.
Finally, three mutually reinforcing approaches to sustainability are explored:
- A systems approach basically adopts the earlier work on primary health care systems that focuses on effectiveness, continuity, and fiscal capacity. The approach is basically supply-oriented to enhance a delivery system's capacity for continuity of service provisioning.
- A child rights approach uses tools like the Convention on the Rights of the Child to mobilise public pressure for sustainable action. As such, the strategy is based on normative standards, can be political, and may involve social advocacy. One challenge to a rights approach is the assignment of responsibility for rights provision in circumstances where rights depend not only on governmental desistance from abuse but positive work to create an enabling environment where children's rights can be satisfied.
- An empowerment approach basically employs demand promotion. How can one endow capacity, resources and, thus, power to agents that will, for themselves, achieve sustainability of goals? Since very young children depend ultimately on the commitment and care of adults and their social organisations, one challenge of an empowerment approach is to identify ways of empowering women, men, families, and local communities to undertake actions for sustainability.
These issues were discussed at a workshop organised by UNICEF and Harvard University in Florence in June 1995. Participants felt that the achievement of sustainability required changes in relevant values to generate permanent demand for goal-related activities, the development of local capacities for implementation and research, and the ultimate transfer of ownership to the people and communities.
The ICDC Workshop participants proposed a host of sustainability processes that should be examined, including political will and commitment, mobilisation of resources, the capacity of people and their organisations, and the ultimate transfer of ownership of the goals. The identification of key indicators to gauge these processes is a major priority as these can guide programme design, monitoring and evaluation.
UNICEF's Executive Board policy review document stresses that for sustainability to be achieved, the demand for services must be created, and national capacity must be built. Both of these factors have to be translated into action at country level. In order to move forward, UNICEF must make a strong commitment to research and develop the demand side of its activities, as well as transfer ownership and priority setting of programmes to the specific countries. The ICDC Workshop illuminated these links that need further exploration, and form the basis of practical translation into programme management.
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