1 Save the Children submission to iERG 2015 Call for Evidence

Save the Children response to iERG Call for Evidence 2015

Contents 1. Introduction .................................................................................................................................... 2

2. Child health as a human right ......................................................................................................... 2

1.1. Focusing on Child Health at the UN Human Rights Council .................................................... 2

1.2. Increasing accountability through the Universal Periodic Review Process ............................ 3

1.3. Renewal of the Global Strategy process via the Human Rights Workstream ......................... 4

2. Newborn mortality (early childhood development) ....................................................................... 5

2.1. Pushing newborn mortality up in the global political agenda ................................................ 5

2.2. Influencing newborn plans at national level ........................................................................... 5

2.2.1. Working in coalition to end newborn deaths India ........................................................ 6

2.2.2. Supporting the decentralization of newborn policies in Indonesia ................................ 6

2.3. Influencing technical measures to save newborn lives .......................................................... 7

2.3.1. Bringing life-saving intervention to Ethiopian communities .......................................... 7

2.3.2. Applying free vaccination in Kenya ................................................................................. 7

2.3.3. Introducing Community Case Management in remote areas of Nicaragua ................... 8

3. Nutrition (early childhood development) ....................................................................................... 8

3.1. Increasing global accountability to end malnutrition ............................................................. 8

3.2. Pushing for nutrition policies at national level ....................................................................... 9

3.2.1. Embedding nutrition policy in Ethiopia........................................................................... 9

3.2.2. Highlighting the need for nutrition measures in Pakistan’s media................................. 9

3.3. Involving local communities to scale up nutrition ................................................................ 10

3.4. Prioritizing nutrition in the post-2015 Framework through a bottom-up approach ............ 11

3.4.1. Encouraging a nutrition focus in United States of America policies ............................. 12

4. Human and financial resources (right to equality) ....................................................................... 12

4.1. Ensuring every child has access to a skilled health worker .................................................. 12

4.1.1. Standardising Community Health Workers curriculum in Kenya ................................. 13

4.1.2. Towards the professionalization of health workers in Nigeria ..................................... 13

4.1.3. Recruiting more Lady Health Workers and vaccinators in Pakistan ............................. 14

4.2. Resourcing health care for every woman and child ............................................................. 15

4.2.1. Tracking the health budget in Bangladesh .................................................................... 15

4.2.2. Children campaign to increase the health budget in India ........................................... 15

2 Save the Children submission to iERG 2015 Call for Evidence

4.2.3. Advocating for an increased health budget in Zambia ................................................. 16

5. Preventing child marriage ............................................................................................................. 16

1. Introduction

Save the Children welcomes the opportunity to feed into the iERG’s third report.

Save the Children works in around 120 countries to inspire breakthroughs in the way the world

treats children and to achieve immediate and lasting change in their lives. Across all of our work, we

pursue several core values: accountability, ambition, collaboration, creativity and integrity.

In 2014 we reached over 35 million children through our work. The present document reports on the

four focus areas related to child survival and is illustrated by some key examples around the world1:

1. Child health as a human right 2. Newborn mortality (early childhood development) 3. Nutrition (early childhood development) 4. Human and financial resources (right to equality) 5. Preventing Child Marriage

2. Child health as a human right

1.1. Focusing on Child Health at the UN Human Rights Council Following on from previous years (see Save the Children iERG submissions from 2013 and 2014) in

2014 we have directly contributed to the development and adoption of the Technical guidance on

the application of a human rights-based approach to reduce and eliminate preventable mortality and

morbidity of children under five years of age2. The guidance is an important tool to mainstream child

health as a human right at country level, as it provides recommendations in areas such as planning,

budgeting, governance, coordination, legislation, monitoring and evaluation to be taken by Member

States to integrate a human rights-based approach to reducing child mortality.

Save the Children advocated not only for its adoption but also for the development of an

implementation report. Our call is reflected in the resolution adopted by the UN Human Rights

Council on 30 June 20143 which not only endorses the technical guidance but also the need to

1 Save the Children Annual Report 2014 provides more information on our work health and nutrition, available

here: https://everyone.savethechildren.net/sites/everyone.savethechildren.net/files/library/ASIA%20EOReport_2014%20LORES%20Singles.pdf 2 Save the Children contribution to the Technical Guidance is accessible in 1)

http://www.ohchr.org/Documents/Issues/Children/TechnicalGuidance/SaveChildren1.docx and 2) http://www.ohchr.org/Documents/Issues/Children/TechnicalGuidance/SaveChildren2.pdf 3 See Human Rights Council, “Annual report of the United Nations High Commissioner

3 Save the Children submission to iERG 2015 Call for Evidence

prepare a report on the practical application of the technical guidance, to be presented to the

Human Rights Council at its thirty-third session (September 2016)4.

This contribution was possible through close collaboration with our Save the Children offices around

the world. For example, a colleague from Save the Children India took part in an experts’ meeting of

Member States to review the technical guidance on child mortality as a human rights concern,

where he gave examples of how Save the Children is applying a human rights-based approach to

programming and advocacy on child health.

Although the rollout of the Technical Guidance on Human Rights and Child Mortality at country level

is only just beginning, Save the Children has witnessed a shift in focus within the Human Rights

Council to seriously consider and tackle the issue of child health as a human right. This has been

demonstrated through continuous consideration of this agenda item in sessions of the Council,

adoption of resolutions, side-events, and other activities. In parallel, the World Health Assembly has

been integrating health and human rights in its sessions.

Save the Children is currently engaged in the discussions around the upcoming implementation of

the Technical Guidance.

1.2. Increasing accountability through the Universal Periodic Review

Process In 2014 we continued to use other human rights mechanisms such as the Universal Periodic Review

(UPR) to strengthen national accountability for child survival and health. Save the Children takes part

in this process both by inputting our own learning and by supporting the participation of grassroots

human rights associations. In particular, Save the Children country offices use UPR submissions as

an accountability tool to raise awareness about the child rights situation in their country and make

specific recommendations to Member States on how they could improve child survival and health

outcomes.

Save the Children often leads or engages in child focused coalitions making UPR submissions. We

support the process with technical advice at country level and then influence UPR country

recommendations through advocacy meetings with diplomatic missions in Geneva.

Our efforts in 2014 included:

Albania: We facilitated the participation of children in the review of Albania5. Their report raised the issue of corruption in the health care system and the Government agreed to take

for Human Rights and reports of the Office of the High Commissioner and the Secretary-General”, Document A/HRC/27/31, 30 June 2014: http://www.ohchr.org/Documents/Issues/Children/TechnicalGuidance/TechnicalGuidancereport.pdf 4 See paragraph 10 of the Resolution on the “Promotion and protection of all human rights, civil, political,

economic, social and cultural rights, including the right to development”, Document A/HRC/27/L.23, 22, September 2014: http://www.un.org/ga/search/view_doc.asp?symbol=A/HRC/27/L.23 See operational paragraph 10. 5 Joint Submission 1, accessible here:

https://uprdoc.ohchr.org/uprweb/downloadfile.aspx?filename=843&file=EnglishTranslation

4 Save the Children submission to iERG 2015 Call for Evidence

actions to overcome this problem through strengthening the institutional and administrative capacity of its civil service.6

Cote d’Ivoire: Our child-informed submission called for increased number of health workers and improved access to healthcare for newborns.7 Based on these recommendations, the Government committed to improve access to, and the quality of, the health sector.8

DRC: We led a children focused coalition addressing the high number of infant, child and maternal deaths as well as the high malnutrition rates.9 The Government committed to implement policies to tackle under-five child malnutrition10.

Kenya: Our report highlighted Kenya’s need to increase its health budget, in line with the Abuja commitment11. The Government committed to include in the national action plan for the promotion and protection of human rights continued attention to and focus on children as well as an emphasis on ensuring their right to health12.

Further work is needed at the national level to increase the visibility of commitments made through

the UPR, and to reinforce accountability for implementation, something we are strengthening in the

context of our global campaign on child survival, EVERY ONE, and our programme work on children’s

rights and governance.

1.3. Renewal of the Global Strategy process via the Human Rights

Workstream Since 2014, we have taken part in the discussions on the workstream focusing on health and human

rights for the revision of UN Secretary General Global Strategy on Women’s, Children’s and

Adolescents’ Health with a view to strengthening accountability for child health through the use of

Human Rights mechanisms. Our international Chief Executive, Jasmine Whitbread is a member of

the Strategic and Coordination Group for the Global Strategy and several Save the Children staff are

members of the sub-streams dealing with Financing, Human Rights and Accountability, among

others.

6 Supported recommendation 104.81 proposed by Italy: “Continue strengthening the institutional and

administrative capacities of the civil service while expanding the action against corruption, especially in the health-care, education and judiciary sectors”: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G14/076/77/PDF/G1407677.pdf?OpenElement 7 Joint Submission 6, accessible here:

https://uprdoc.ohchr.org/uprweb/downloadfile.aspx?filename=802&file=FrenchTranslation 8 Supported recommendations 127.161 proposed by Venezuela: “Continue its efforts in the social field, in

particular for those most in need, especially in the field of nutrition, health and education” and 127.153 proposed by Mexico: “Conduct awareness campaigns to promote birth registration of all children and take the necessary measures to ensure easy and effective access to free birth registration for the newborn”: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G14/075/83/PDF/G1407583.pdf?OpenElement 9 Joint Submission 2, accessible here: file:///C:/Users/Isabel/Desktop/Borrar/SCI/JS2_UPR19_COD_F_Main.pdf

10 Supported recommendation 134.144, proposed by Ireland: Ensure the effective implementation of the

national strategy on maternal and child mortality, including through addressing root causes of under-5 mortality, such as poverty, under nutrition, harmful practices, and lack of access to safe drinking water, health-care services and education: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G14/075/47/PDF/G1407547.pdf?OpenElement 11

Joint Submission 1, accessible here: http://www.upr-info.org/sites/default/files/document/kenya/session_21_-_january_2015/js1_-_joint_submission_1.pdf 12

Supported recommendation 101.17, proposed by Saudi Arabia: “Include in the national action plan for the promotion and protection of human rights continued attention to and focus on children and an emphasis on ensuring their right to health and education”: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G10/144/88/PDF/G1014488.pdf?OpenElement

5 Save the Children submission to iERG 2015 Call for Evidence

2. Newborn mortality (early childhood development)

2.1. Pushing newborn mortality up in the global political agenda Save the Children was closely involved in the development of the Every Newborn Action Plan (ENAP).

We successfully advocated for the adoption of ENAP by 194 countries during the Sixty-sixth World

Health Assembly (WHA) in May 2014. We highlighted the importance of health workers in saving

newborn lives, and called for a target for universal coverage of skilled birth attendance in the ENAP.

Examples of our work include the launch of a newborn push in early 2014 as part of our global EVERY

ONE Campaign, which included convening events at the UN in New York and Geneva, national

events in key countries which asked senior officials to sign a five point newborn promise, and the

publication of our report Ending Newborn Deaths13 which built on the findings of our 2013 report

State of the World’s Mothers: Surviving the First Day14.

Over 25 Save the Children country offices and Members engaged in national advocacy in the lead up

to the WHA to call for the adoption of the Every Newborn resolution. We held a side event at WHA

with partners, hosted at the Canadian Mission, which included the Minister of Health of Afghanistan,

the Joint Secretary from India, our healthworker campaigner and others where they committed to

advancing efforts to save newborn lives. At the meeting the Minister of Health of Canada announced

a 36 million dollar financial commitment towards child and maternal health.

At the launch of the ENAP the Partnership for Maternal, Newborn and Child Health (PMNCH) global

forum in South Africa in June 2014, Save the Children co-hosted a side event where guests and

speakers pledged their support to the plan. We also used the meeting to bring civil society

partnerships back into practice for newborn survival.

As a result of this work, carried out in partnership with several other organisations, we have been

able to raise the profile of newborn survival. However, underlying structural issues such as universal

access to skilled birth attendants, which Save the Children has identified as critical to this strategy,

were not fully addressed by ENAP. The plan is weak on empowering women, and does not include

an accountability mechanism.

2.2. Influencing newborn plans at national level Through our work as co-chair of the ENAP Advocacy Working Group together with PMNCH and the

UN Foundation, Save the Children has been supporting and following-up on country consultations to

ensure country governments integrate evidence-based newborn health interventions and necessary

systems into country RMNCH plans and budgets.

Following the adoption of the ENAP, we have supported a number of high-burden countries (see

below case studies from India, Indonesia and Kenya) to plan and launch their own national version of

ENAP.

13

Ending Newborn Deaths, February 2014: https://everyone.savethechildren.net/sites/everyone.savethechildren.net/files/library/CalltoAction_EndNewbornDeaths(Africa)_0.pdf 14

State of the World’s Mothers: Surviving the First Day, May 2013: http://www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf

6 Save the Children submission to iERG 2015 Call for Evidence

More work needs to be done to influence Finance and Planning Ministries and the offices of heads of

state and government if the interventions are to be adequately financed. The priority is to ensure

ENAP is fully financed and implemented through funded country plans for newborns.

2.2.1. Working in coalition to end newborn deaths India

The India Newborn Action Plan (INAP) was launched in September 2014 at a high-level event in New

Delhi. This represents a renewed commitment by the Government of India to tackling infant

mortality and is a landmark for Save the Children’s advocacy and campaign efforts in India, where

we have been working towards ensuring that robust plans are in place to respond to high newborn

mortality rates. Through our role as Secretariat to the government sponsored RMNCH+A

(Reproductive, Maternal, Newborn and Child Health plus Adolescents) Coalition15, Save the Children

was part of a core drafting committee for the Plan, ensuring that key priorities were reflected in the

document – including expanded coverage of targeted, low-cost interventions. INAP sets target to

reduce deaths per live births from the present 29 to below 10 by 2030 and credits ENAP in its

introductory chapter 16.

2.2.2. Supporting the decentralization of newborn policies in Indonesia

In Indonesia, Save the Children gave financial support to the Government to participate in the ENAP

regional consultation in Nepal in 2013, where the Ministry of Health was invited to present a

bottleneck analysis on newborn survival. Our advocacy work continued in 2014 and the Government

of Indonesia adopted a newborn action plan -the Rencana Aksi Nasional tentang Neonatus (RAN)-

which aims to reduce maternal and newborn mortality rates in Indonesia by 25% by 2035. Save the

Children provided technical advice to the Government on the development of the plan, through our

participation in the Ministry of Health working group for newborn health. We also presented our

recommendations on newborn survival to key government ministers. The roll-out of the plan has

begun in the six provinces with the highest newborn mortality rate.

To enhance the effective decentralization of the plan, Save the Children facilitated the collaboration

between the Ministry of Health, the Indonesian Paediatrician Association and the Indonesian

Obstetrics and Gynaecology Society, whose representatives work at provincial and district level to

develop district action plans to implement the newborn plan. 39 districts in the 6 provinces have

adopted action plan documents and we are pushing for the effective implementation of the plan at

district level. Local governments from two districts have enacted a local regulation and approved

budget allocations to the plan. Save the Children is closely working with local civil society coalitions

to make local governments accountable for implementation of the newborn plan.

In 2014, Indonesia also started to develop a five-year national development plan and Save the

Children attended a number of consultations, contributing to the health and nutrition aspects of the

plan. Save the Children specifically presented recommendations on newborn survival based on the

15

Save the Children has played a leading role in getting the RMNCH+A coalition formed and formalised, creating a platform for future action and ensuring accountability. Such partnership comprise organisations that have the capacity to exert considerable influence on both national governments and international governmental organisations and serves to work with the civil society community to raise awareness and action for newborn health and stillbirths using parent groups, women’s organizations and other activists at all levels. 16 Indian Newborn Action Plan available at: http://ibnlive.in.com/news/indian-launches-plan-to-drastically-reduce-newborn-death/500079-3.html

7 Save the Children submission to iERG 2015 Call for Evidence

key suggestions from the Ending Newborn Deaths report. Following our recommendations, the

Ministry of Health and National Planning Bureau committed to engaging in a continuous effort to

improve the knowledge of all stakeholders on newborn health. They also committed to improving

the quality of data systems, to strengthening the health care system and to ensuring that Civil

Society Organisations play a role in decentralisation of policy by connecting policies at the central,

provincial and district level.

2.3. Influencing technical measures to save newborn lives The EVERY ONE campaign has not only helped to mobilise communities to claim and achieve better

child health on the ground, but also to channel technical assistance and support to end preventable

child deaths in high burden countries. In many cases, including the examples from Ethiopia, Kenya

and Nicaragua shown below, Save the Children operational know-how has been incorporated into

the execution of national MNCH plans, as implementing partners and as participants of advising

committees.

2.3.1. Bringing life-saving intervention to Ethiopian communities

A strong evidence base and policy analysis has been key to secure influence to save newborns’ lives

in Ethiopia. Between 2007 and 2013 Save the Children conducted research on Community-based

Interventions for Newborns in Ethiopia (COMBINE) that revealed the potential of measures applied

locally in reducing newborn deaths by 30% in the country17. This evidence fed into advocacy with

the government: the results of the report were presented to the Ethiopian authorities who agreed to

expand neonatal sepsis management from the facility level to the community level by Health

Extension Workers (HEWs). The measure was introduced in 2014 in the new Community-Based

Newborn Care (CBNC) program, an initiative the Federal Ministry of Health has implemented in

seven zones, with the support from three implementing partners including Save the Children. Our

role within the CBNC has been very diverse as we have not only supported the adaptation of training

materials from COMBINE, but also intervened in the monitoring and evaluation system. The Ministry

of Health aims to scale-up the CBNC programme nationally.

2.3.2. Applying free vaccination in Kenya

The Kenyan Government has been developing a three-year maternal and newborn health plan which

- responding to civil society advocacy - prioritizes the three leading causes of newborn mortality:

prematurity, asphyxia and sepsis. While the national plan was started before 2014, it has aligned

with ENAP.

Save the Children contributed to growing momentum on newborn health through technical

advocacy with the Ministry of Health, and awareness raising activities around the International Day

of Midwives (in partnership with the Midwives society of Kenya), World Prematurity Day (organised

with UNICEF in partnership with Ministry of Health, to raise awareness of the importance of

Kangaroo Mother Care) and Malezi Bora, celebrated in Wajir County to raise awareness and catalyse

uptake of high impact interventions, like routine immunisation.

17

Ethiopia: Saving Newborn Lives Project / Community-Based Interventions for Newborns in Ethiopia (COMBINE) Project, by Save the Children and John Snow Inc., 2007-2013, accessible here: http://www.jsi.com/JSIInternet/IntlHealth/project/display.cfm?ctid=na&cid=na&tid=40&id=2001

8 Save the Children submission to iERG 2015 Call for Evidence

The Government of Kenya made the rotavirus vaccine freely available in all public hospitals from July

2014. This measure is a milestone for the Technical Working Group on Rotavirus that has been

influencing decisions on vaccines during the last two years and of which Save the Children is

member.

2.3.3. Introducing Community Case Management in remote areas of Nicaragua

The introduction of a Community Case Management (CCM) approach since 2006 in several regions

of Nicaragua has helped to reduce under-five mortality from pneumonia, diarrhoea, and dysentery

by 50%. CCM is an integrated approach between child protection and health introduced by Save the

Children via the Nicaraguan Ministry of Health to deliver life-saving curative interventions through

brigadistas- an existing cadre of volunteer community health workers - to sick children under five

living in remote communities lacking access to health facilities.

In 2014, 360 brigadistas and 120 Ministry of Health staff were trained in delivering or supporting

CCM. These brigadistas treat about 5000 episodes of illness annually. The introduction of CCM has

been a major innovation in Nicaragua as it has transformed the role of brigadistas, not only

equipping them to deliver case management, but also enhancing their credibility when promoting

high-impact preventive interventions, such as immunization, breastfeeding and complementary

feeding and antenatal care.

3. Nutrition (early childhood development)

3.1. Increasing global accountability to end malnutrition In November 2014, we participated in the Second International Conference on Nutrition (ICN2)18

with the aim of securing a policy framework to address global nutrition challenges and enhancing

international cooperation on nutrition.

As part of the ICN2 civil society liaison group, Save the Children reached out to other organisations

to strengthen the place of direct nutrition interventions and nutrition sensitive interventions in the

agenda.

The preliminary programme for ICN2 did not focus on accountability nor was planning to produce

any follow guidance after the meeting. Save the Children advocated for a framework for action to be

included in the outcomes of the conference19, and participated in the revision of the Nutrition Policy

Briefs launched at the event20. The Framework for Action21 which was endorsed includes specific

recommendations on breastfeeding, stunting and accountability and is the most important outcome

of the meeting. It is now being used as a starting point for discussions on nutrition in the post 2015

18

The ICN2 was organised by the Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO) in cooperation with a number of key agencies: http://www.fao.org/about/meetings/icn2/en/ 19

More information available here: http://blogs.savethechildren.org.uk/2014/11/this-weeks-international-conference-on-nutrition-we-have-concerns/ 20

Nutrition policy briefs available here: http://www.who.int/nutrition/topics/globaltargets_policybrief_overview.pdf 21

The ICN2 Framework for Action proposes 60 recommendations divided into 16 cross-cutting chapters affecting nutrition levels: http://www.fao.org/3/a-mm215e.pdf

9 Save the Children submission to iERG 2015 Call for Evidence

agenda and Save the Children will use it as check list tool to guide advocacy on nutrition at country

and donor level.

During ICN2 we co-hosted a side event on nutrition results and accountability22 to maintain nutrition

as a political priority not only in high burden countries but also in donor countries. The event

provided an opportunity for government representatives and civil society organisations to highlight

the importance of prioritising accountability in nutrition interventions, and improve coordination.

We secured sponsorship to the event from the Governments of Brazil, Canada23 and Ireland.

3.2. Pushing for nutrition policies at national level Although there has been a significant increase in political attention towards nutrition since the

Nutrition for Growth conference in 2013, further progress is needed to translate this into changes in

national policy and practice. Our work in Ethiopia and Pakistan highlights two different ways in

which Save the Children technical advocacy at country level contributed to the development of

nutrition policies.

3.2.1. Embedding nutrition policy in Ethiopia

The Government of Ethiopia committed to reduce stunting by 20% by 2020, at the 2012 Nutrition for

Growth conference, to increase its budget for direct nutrition services by USD15M annually to 2020,

and to improve nutrition coordination. In 2013, Ethiopia launched a revised National Nutrition

Programme (NNP) envisaging a multi-sectorial, life-cycle approach. Save the Children took part in the

reduced and strategic National Steering Committee and provided technical and financial

contributions to the NNP revision, consultative workshops and NNP launch, and engaged six experts

in different NNP working groups. In 2014, Ethiopia organised different taskforces, in which Save the

Children has been involved, to draft the next National Nutrition Programme (2016-20).

3.2.2. Highlighting the need for nutrition measures in Pakistan’s media

With the adoption of Multi-Sectoral Integrated Nutrition Strategies (MSINS) in 2013 in all Pakistan’s,

in 2014 our work focused on the definition of specific nutrition policies to implement the plans. Our

technical advocacy towards local authorities dealing with health, family, social affairs and

agricultural policies was done in coordination with Development Partners for Nutrition and helped

to ensure the adoption of new policies in areas including breastfeeding promotion, infant feeding

guidelines and maternal nutrition. Last year, each province also approved a PC1 (Planning

Commission document) on nutrition and budgetary allocation is in progress24.

22

We co-hosted the event in partnership with the Governments of Brazil, Canada, Ireland and United States together with the Children’s Investment Fund Foundation (CIFF), 1000 Days and the Pan American Alliance for Nutrition and Development. Called “Accelerating Progress to End Malnutrition: Action, Results and Accountability”, a summary of the event is accessible here: https://everyone.savethechildren.net/articles/accelerating-progress-end-malnutrition-save-children-jointly-hosts-event-discuss-results 23

Canada’s speech during the event, available here: http://www.international.gc.ca/media/dev/speeches-discours/2014/11/20b.aspx?lang=eng 24

The most important achievement in 2014 has been the allocation of specific resources to make the nutrition plans a reality: 1) The Government of Balochistan enacted a Protection and Promotion of Breastfeeding and Child Nutrition Act in 2014 and approved a PKR 1492.62 million line for the Enhanced Mother and Child Nutrition Programme includes PKR 298.52 million from the provincial budget. 2) The Government of PK

10 Save the Children submission to iERG 2015 Call for Evidence

Although the new nutrition-related policies do not provide a formal accountability mechanism for

nutrition, each provincial breastfeeding law includes the setting up of an Infant Feeding Board to

monitor violations of the Breast Milk Substitute Code. The Board reports violations, recommends

investigation against manufacturers, distributors or health workers and advises the Government on

policies or guidelines for the promotion and protection of breastfeeding. Infant Feeding Boards have

been established in the federal area (ICT), Punjab and Sindh. Save the Children is member of the

Punjab Board.

The fact that all provinces have adopted laws on nutrition demonstrates the increasing attention

that Pakistan is paying to this problem. The use of media (and in particular TV) has been a prominent

element of our EVERY ONE campaign in Pakistan, which involved raising awareness and securing on-

camera commitments from policymakers, through to documentaries and talk shows. Save the

Children’s messages about the need to recruit trained, equipped and remunerated health workers

and a specific cross-cutting budget for nutrition were covered by media articles and reports at the

national and provincial level, which generated debates demanding budgetary allocations for health

programmes and child survival. The team underpinned this media focus through regular contact with

editors who benefitted from training on nutrition advocacy and field visits25.

3.3. Involving local communities to scale up nutrition In 2014, we reinforced our contribution to national civil society initiatives to improve child nutrition,

through the Scaling Up Nutrition movement (SUN) in 54 countries26. Save the Children hosts the SUN

Civil Society Network global secretariat and is the vice-chair, and in this capacity we strengthened

the support available for and the capacity of national Civil Society Alliances. Through the global

secretariat, we encourage the alignment of Civil Society Organisations’ strategies, programmes and

resources with country plans for scaling up nutrition and we coordinate them at national level27.

Save the Children also provides technical assistance and support to the Network in a range of areas,

including social protection and budget tracking work. Since April 2014, four SUN Communities of

Practice (CoP) have emerged as a method for ensuring that countries can access technical support

more easily and share best practices28. Save the Children is contributing to the implementation and

rolling out of national costed plans and the monitoring of the delivery of those plans through our

enacted the same act and allocated for the first time a budget line of PKR 1129 million for nutrition interventions that also foresees the establishment of “Nutrition Coordination Cell” and the recruitment of a Nutrition Officer at every District Head Quarter. 3) The Government of Sindh allocated resources for implementation of health sector interventions under Nutrition Support Program Sindh (NPS). 4) The Government of Punjab adopted its Nutrition Strategy and the promotion of breastfeeding act, establishing an Infant Feeding Board, already in place. 25

Save the Children Pakistan also used social media as a dissemination, interaction and outreach tool was used effectively to communicate through the EVERY ONE Campaign Facebook account (17,995 followers) and Twitter account @Every1Pak (767+ followers). 26

Check the SUN Movement 2014 Annual Report for more information, available here: http://scalingupnutrition.org/wp-content/uploads/2014/11/SUN_Progress-Report_ENG_20141024_web_pages03.pdf 27

Save the Children leads CSA platforms in DR Congo, Ethiopia, Guatemala, Myanmar, Nepal, Nigeria, Pakistan, Sri Lanka and Tanzania and we are engaged in the CSA formed in Bangladesh, Kenya, Malazi, Niger, Senegal, Zambia and Zimbabwe. 28

SUN CoPs: http://scalingupnutrition.org/about/strengthening-capacity-to-deliver#.VUIaNyHtmko

11 Save the Children submission to iERG 2015 Call for Evidence

guidance and technical assistance to the first CoP focused on “Planning, Costing, Implementing and

Financing Multi-sectoral Actions for Improved Nutrition”. In 2014, our contribution helped to cost

nutrition plans in three SUN countries: Malawi, Niger and Zambia.

Save the Children has also assessed the impact of social protection on nutrition in Bangladesh. Our

analysis, published on the Malnutrition in Bangladesh report29, explains how to develop social

protection across the lifecycle – with a greater focus on nutrition behaviour change, adolescent girls,

early marriage, empowering women and the 1,000-day window of opportunity between a woman’s

pregnancy and her child’s second birthday. The report makes recommendations for policy

development and an integrated approach to tackling malnutrition through social protection in

Bangladesh and internationally.

Our involvement in strengthening the SUN movement has also looked at the issue of adolescent

nutrition. In some countries up to a half of adolescents are malnourished. Urgent action is needed to

address adolescent malnutrition in low- and middle-income countries, especially given the high

numbers of adolescent girls who give birth and of girls under 18 who get married. Save the Children

has published Adolescent Nutrition, a report30 targeted specially at ministers in SUN countries who

are responsible for the welfare of adolescent girls, programme implementers and policy-makers in

SUN+ countries, and officials in donor governments and agencies. The report goes on to describe

promising interventions to address adolescent nutrition. It explores policies and programmes

directly aimed at adolescent nutrition as well as those designed to improve it indirectly, as one of a

number of other intended impacts.

3.4. Prioritizing nutrition in the post-2015 Framework through a bottom-

up approach Save the Children has actively been advocating for a standalone goal for food and nutrition security

within the SDGs and welcomes the proposed goal 2: End hunger, achieve food security and improved

nutrition, and promote sustainable agriculture31. We are now advocating for the relevant nutrition

indicators to be integrated throughout the framework.

In 2014, Save the Children also published the Nutrition Sensitivity report32 which examines and

explores how nutrition can be prioritised within agricultural policies, strategies and investment

29

Save the Children Malnutrition in Bangladesh report, February 2015: http://www.savethechildren.org.uk/resources/online-library/malnutrition-bangladesh 30

Save the Children Adolescent Nutrition report, March 2015: http://www.savethechildren.org.uk/resources/online-library/adolescent-nutrition 31 Proposed SDG 2 sets two targets: target 2.1) by 2030 end hunger and ensure access by all people, in

particular the poor and people in vulnerable situations including infants, to safe, nutritious and sufficient food

all year round, and target 2.2) by 2030 end all forms of malnutrition, including achieving by 2025 the

internationally agreed targets on stunting and wasting in children under five years of age, and address the

nutritional needs of adolescent girls, pregnant and lactating women, and older persons. Accessible here:

https://sustainabledevelopment.un.org/sdgsproposal 32

Nutrition sensitivity: how agriculture can improve child nutrition, 2014: https://everyone.savethechildren.net/sites/everyone.savethechildren.net/files/library/SCI_ADV_NutritionSensitivityReportLowRes_EN.pdf

12 Save the Children submission to iERG 2015 Call for Evidence

plans, and demonstrates the power of agricultural bio-diversity, social behavioural change,

enterprise diversification, and women’s empowerment in improving nutrition in rural areas.

3.4.1. Encouraging a nutrition focus in United States of America policies

In 2013, the US Government recommitted to the 1,000 Days initiative on nutrition, to reduce

stunting by two million by 2017, and signed the Nutrition for Growth compact that includes specific

global commitments to reducing malnutrition.

In 2014 the US Government released a ten-year Nutrition Strategy. The strategy strongly links

nutrition with the goal of ending preventable maternal and child deaths. Save the Children fed into

drafts – providing expert comments and feedback on the draft, specifically advocating that the

strategy needed to be more results orientated. Moreover, Congress increased nutrition funding as

part of Fiscal Year 2014 Global Health budget, over the Obama Administration’s requested level.

Despite the tough budget environment, funding for maternal, newborn and child health and

nutrition was increased in Fiscal Year 2015.

On 25 June 2014, USAID announced specific targets and funding at, Acting on the Call: Ending

Preventable Child and Maternal Deaths. The US is now committed to saving 15 million children’s

lives and 600,000 mothers’ lives by 2020. Save the Children led direct engagement and high-level

dialogue with USAID to ensure that the June 2014 event included concrete outcomes and objectives.

Save the Children co-chaired a civil society advisory group to help shape the June 2014 report and

event and leveraged their leadership role to urge the inclusion of nutrition as a key intervention as

well as concrete targets.

4. Human and financial resources (right to equality) A joint 2014 UNICEF, WHO and Save the Children report Universal Health Coverage: a commitment

to close the gap33 identified policy options to strengthen health systems for sustainable gains. Early

2015, Save the Children presented a specific analysis on the impact of inequalities on the reduction

of child mortality. Through the Lottery of Birth report34 we collected disaggregated data from 87 low

and middle income countries around the world and showed widening disparities between the

highest mortality groups and the lowest mortality groups.

4.1. Ensuring every child has access to a skilled health worker Advocating for an increased focus on Human Resources for Health (HRH) by funding and supporting

frontline health workers directly addresses a big part of the problem of maternal and child mortality.

The outbreak of Ebola has increased pressure on health workers and health structures in affected

countries in West Africa, also highlighting the need for strengthened health systems.

Following campaigning and advocacy by Save the Children, HRH is now well established on the

political agenda in Norway. For example the White Paper Education for Development launched in

33

Save the Children Universal Health Coverage 2013 report: a commitment to close the gap report: http://www.savethechildren.org.uk/resources/online-library/universal-health-coverage-commitment-close-gap 34

Save the Children Lottery of Birth 2015 report: http://www.savethechildren.org.uk/resources/online-library/lottery-birth

13 Save the Children submission to iERG 2015 Call for Evidence

June 2014 has a strong focus on the education of health workers as an important component of

Norway’s global health policies. The state budget for health and immunisation in 2014-2015

increased by approximately $30 million, and included commitments to strengthening health systems

and supporting the recruitment of health workers.

We have made extensive use of media to push HRH up the policy agenda among donor

governments. The media visibility achieved through the REAL awards (showcasing the vital role that

health workers play in ensuring good health outcomes)35 resulted in more than 29,000

communications to US policymakers in support of health workers in developing countries. USAID

committed to development of a whole-of-government health workforce strengthening strategy for

the US Government, which is currently in development. Health workforce capacity building is now

deeply embedded in USAID’s new vision and framework for ending preventable child and maternal

deaths: Acting on the Call: Ending Preventable Child and Maternal Deaths. Save the Children US has

also developed the Global Health Workers Awards to build awareness and support for its health

workers advocacy aims.

At the national level in high burden countries, including Kenya, Nigeria and Pakistan, we have

advocated for investment in health workers to expand children’s access to life-saving health care:

4.1.1. Standardising Community Health Workers curriculum in Kenya

With other like-minded partners, Save the Children provided technical support for the development

of the Health Workers Work Load Analysis report, which was endorsed and launched by the

Government of Kenya and will be critical in identifying recruitment gaps for health workers in the

respective counties. Following the Work Load Analysis report, Save the Children is working to

influence the County Budget process to grow investment in health.

In 2014, Kenya’s Ministry of Health also finalised the Human Resources for Health country profile

reflecting the situation of health workers recruited in 2013 in 47 counties. Save the Children has

been involved in the revision and validation of this work. Given recent strikes in some counties

among nurses, and the high turn-over of health workers in marginalised areas, the analysis is an

important tool to help guide investment in health worker recruitment and training, and to inform

deployment. Save the Children has been also closely involved in the definition of the curriculum for

Community Health Extensions Workers (CHEW) in Kenya, we developed and disseminated the

training curriculum in several counties involving CHEW and Community Health Workers.

4.1.2. Towards the professionalization of health workers in Nigeria

Save the Children has worked with a large network of organizations within the Maternal, Newborn

and Child Health Coalition in lobbying for the Health Act over the past few years. The National

Health Bill was passed by the Nigerian Senate in February 2014 and by the House of Representatives

in July 2014. It finally became law in December 2014. The new Act will release funds from the federal

level down to the state level for primary health care and has the potential to save the lives of

millions of mothers and children across Nigeria by putting a trained and skilled health worker within

reach.

35

The REAL Awards: http://www.therealawards.com/

14 Save the Children submission to iERG 2015 Call for Evidence

A key success coming out of the 3rd Global Forum for Human resources for Health was a set of new

commitments made by the Nigerian government, including developing a costed HRH plan. These

commitments were influenced in part by Save the Children and its partners’ strong advocacy,

stemming also from its role as a key member of the Nigerian government’s federal-level HRH

Technical Committee. In 2014, the Committee supported the Government of Nigeria in creating the

National Health Workforce Registry. In addition, a review of the Nigerian Health Workforce Profile

was carried out by the HRH unit of the Federal Ministry of Health that counted on Save the

Children’s expertise in reviewing the findings of research on the minimum data sets required to

design the Registry.

At state level, in Gombe, a final draft of the state version of the National HRH policy was created in

2014, with Save the Children’s input, and has been submitted to the Commissioner for Health. In

Zamfara, the State Coordinating Committee for HRH has been inaugurated to drive the push for

adopting the national HRH policy. Katsina State government has approved the recruitment of 50

doctors, 89 midwives and nurses, and 49 tutors for the Health Training Institutions. In 2014, Katsina

and Gombe States joined Jigawa in establishing HRH desk offices.

4.1.3. Recruiting more Lady Health Workers and vaccinators in Pakistan

In 2014, the fear of redundancy of 98,000 health workers across Pakistan was successfully turned

around into a win-win situation through joint advocacy and campaigning with the Lady Health

Workers (LHW). Nearly 52.1% of Pakistani births occur at home in the presence of unskilled birth

attendants. Save the Children has engaged closely with parliamentarians and officials, and the

media, to argue for formal recognition of LHWs and their regularisation. As a result, provincial

governments have set up the terms and conditions of employment of 48,000 LHW in Punjab, 13,500

in Khyber Pakhtunkhwa (KP) and 13,000 in Sindh. LHW wages have also increased by almost 50%.

The Punjab LHW Program is now in the process of recruiting an additional 12,000 LHWs while KP is

processing the addition of 3600 LHWs. Balochistan has earmarked and purchased PKR 10 million

medicines for LHWs through provincial budgetary allocations.

These measures have enhanced the working conditions of LHW. Since 2013, we have celebrated the

Lady Health Worker Awards in all four provinces of Pakistan. This recognition has been extended in

2014 to skilled birth attendants and 12 Community Midwife Workers (CMW) were nominated to the

International Midwifery Award – one of them was among the top five contestants.

In addition, Save the Children’s multi-pronged approach, creating spaces for dialogue and influence

by working with Provincial governments, has contributed to the development of the Khyber

Pakhtunkhwa (KP) government’s campaign Sehat ka Insaf, to ensure immunisation for children.

Under this campaign, 500 additional vaccinators have been included in the KP government’s Polio

Campaign. Both Balochistan and KP provincial governments have also recently committed to

allocating two vaccinators per union council, which has meant that the total number of vaccinators

for KP will increase from 1,375 to 2,080. In Balochistan, in 2014, 198 new positions for vaccinators

were created and trained, while 1,993 Lady Health Workers were trained in routine immunisation.

Punjab province will be filling 345 vaccinator vacancies.

15 Save the Children submission to iERG 2015 Call for Evidence

4.2. Resourcing health care for every woman and child In order to track whether we are making progress in tackling one of the major underlying causes of

child mortality, Save the Children undertook a study on budget transparency and child nutrition in

five African countries. The aim was to identify important transparency gaps, and to encourage civil

society to advocate more effectively for budget accountability on nutrition interventions to reduce

under five mortality.

The report36 focused on Kenya, South Africa, Uganda, Zambia and Zimbabwe and showed low levels

of budget transparency in relation to child nutrition across the five countries. The countries had

higher levels of transparency when it came to information about policy and planning for child

nutrition. However, countries scored low regarding public participation in governments’ child

nutrition decisions. We are also continuing to strengthen our health budget tracking at national and

local levels, including in Bangladesh, India and Zambia.

Save the Children has also complemented this work on health and nutrition budgeting with analysis

of domestic resource mobilisation and the scope to finance progress towards ending preventable

child deaths by reducing illicit financial flows. Our report Tacking tax and saving lives: children, tax

and financing for development37 presented new findings on this issue.

4.2.1. Tracking the health budget in Bangladesh

In 2014 Save the Children and the Bangladesh Department of Development Studies published a new

report, National Budget Tracking in Child Related Ministries38 to investigate trends in allocation,

implementation, coverage and output of the education, health and social protection sectors. Cross-

country comparison shows that Bangladesh’s per capita health expenditure is much lower than

South Asian neighbours. The report captured the current situation, and proposed steps for designing

a more child-focused budget, and a guideline for analysing budgetary allocations for children.

The report was presented to Bangladeshi authorities and influenced the Government’s commitment

to rolling out a child budget in 2015/16. As a result, the allocation for the Ministry of Health and

Family Welfare has increased around $20 million (a 0.18% percentage of the national budget). Apart

from those nominal increases, a specific child budget will feature children more centrally in the

planning and allocation process allowing tracking resources and its impact of children, and helping

ensuring no child is left behind.

4.2.2. Children campaign to increase the health budget in India

Save the Children India successfully mainstreamed children’s voices in partnership with the Nine Is

Mine campaign39, which is calling for 9% of Indian GDP to be devoted to health care and education.

Nine is Mine started in 2013 ahead of the annual budget announcement, and the child advocates

36

Save the Children Budget Transparency and Child Nutrition 2013 report: http://resourcecentre.savethechildren.se/library/budget-transparency-and-child-nutrition 37

Tacking tax and saving lives: children, tax and financing for development, March 2014: https://everyone.savethechildren.net/sites/everyone.savethechildren.net/files/library/TacklingTaxandSavingLives.pdf 38

National Budget Tracking in Child Related Ministries in Bangladesh: http://resourcecentre.savethechildren.se/library/national-budget-tracking-child-related-ministries-bangladesh 39

Nine is Mine campaign: http://www.nineismine.in/home

16 Save the Children submission to iERG 2015 Call for Evidence

who have fronted the campaign generated significant public attention. In the subsequent budget

announcement the Government announced plans to increase the national health budget from 1.02

to 2.5 percent of GDP in the period 2013-2017.

Save the Children India has decided to build on this success by partnering with Nine Is Mine on a

campaign to strengthen the focus on maternal and child health, education, poverty and hunger in

Indian political party manifestos during last year’s elections, and to reflect this in the Indian

negotiating position on the post-2015 international development framework. At the 2013 UN

General Assembly in New York, 14 children from India met with heads of civil society and UN

organisations and the Indian mission to carry these messages.

4.2.3. Advocating for an increased health budget in Zambia

Save the Children participated in the analysis of the 2014 Budget under the Zambia Tax Platform,

which showed that the allocation to the health sector has declined from 11% to 9.9% of the total

budget. Save the Children worked with the Zambia Tax Platform on submissions to the Ministry of

Finance, Members of Parliament and the Economic Association of Zambia during the annual CSO

post budget dialogue, to highlight the drop in the budget allocation. Our analysis was presented to.

Through this engagement, alliances were formed with lawmakers to make amendment to the 2014

budget. These amendments were not adopted by government, and are being pursued again in the

context of the 2015 budget.

5. Preventing child marriage Save the Children is working at the national level, and in Africa at the regional level, to prevent child

marriage, both as a major child protection and girls’ education issue, and as a major factor in

adolescent pregnancy and maternal and newborn mortality. As a member of Girls Not Brides40, Save

the Children is advocating on this at the UN level: we are part of the New York based NGO working

group focused on child early and force marriage that helped shape and influence the UN Resolution

on Child, Early and Forced Marriage41 that was adopted by 116 Member States. Similarly, in Geneva

Save the Children fed into an OHCHR report42 on prevention child marriage in 2014 and carried this

issue into our submissions on the Human Rights Council’s Universal Periodic Reviews, for example

for Yemen.

In Yemen we successfully advocated for increasing the age of marriage to 18 in the new Constitution

during the constitutional review process in 2014. In 2015 we are focusing on working with the

Yemeni Parliament to pass this law, conduct meetings with Ministry of Human Rights and to run

awareness campaigns about the same issue.

40

Girls not brides: http://www.girlsnotbrides.org/ 41

UN passes historic resolution on ending child marriage, WHO, November 21, 2014: http://www.who.int/pmnch/media/events/2014/child_marriage/en/ 42

See Human Rights Council, Report of the Office of the United Nations High Commissioner for Human Rights “Preventing and eliminating child, early and forced marriage”, Document A/HRC/26/22, 2 April 2014: www.ohchr.org%2FEN%2FHRBodies%2FHRC%2FRegularSessions%2FSession26%2FDocuments%2FA-HRC-26-22_en.doc&ei=n7VLVb21BMq5UZTxgJAL&usg=AFQjCNEkzO3n2RRWoSONct592EOVsTw0GA&sig2=Gi3YtdcmE31ubaHU0IfEMA&bvm=bv.92765956,d.d24

17 Save the Children submission to iERG 2015 Call for Evidence

We have also engaged in the issue of child marriage in emergency situations. Save the Children

published the Early marriage in Jordan, Too Young to Wed report43 in 2014, focusing on early

marriage in the Syrian refugee camps in Jordan.

At the African Union (AU), we have collaborated closely with the African Union Council (AUC) and

with the AU ambassador on child marriage, including by convening a side event at the January AU

summit that brought together first ladies and ministers of AU member states.

For any further information, please contact shani.winterstein@savethechildren.org

43

Early marriage in Jordan, Too Young to Wed report, 2014: http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/TOO_YOUNG_TO_WED_REPORT_0714.PDF