1. CORE Group Spring Meeting
April 2013
US Government Action Plan for Children in
Adversity
New Science for Old Problems
Neil Boothby
USG Special Adviser
and
Senior Coordinator for the USAID Administrator
Children in Adversity
1

2. A diverse portfolio of assistance
2
PL 109-95

3. A legislative requirement
Public Law 109-95: The Assistance for Orphans and Other Vulnerable Children in
Developing Countries Act of 2005
Requirements:
International assistance to highly vulnerable children is comprehensive, coordinated,
and effective, and built on evidence-based practices.
• Special Advisor (appointed or delegated by the Secretary of State)
• Interagency strategy to determine strategic priorities
• Whole-of-government M&E system
• Annual reports to Congress
• USAID is the lead agency (Senior Coordinator to the USAID Administrator)
• $2.85 billion per annum
3

4. From evidence to action
Results of the U.S. Government
Evidence Summit on Children Outside
of Family Care (December 2011):
• 150 experts participated
• 3,500 articles were reviewed
• Senior interagency leaders committed
to developing a strategy, published in
Lancet
• 60 authors contributed to 7 papers
published in Child Abuse and Neglect:
The International Journal
• One year later (December 2012), the
U.S. Government Action Plan on
Children in Adversity was launched at
the White House
4

5. U.S. Government Action Plan
The first-ever strategic guidance for U.S. government assistance to children overseas
5

6. Children in Adversity: who are they?
25%
live in
extreme
poverty
1.9 billion children
in LMIC
Adversity: Serious deprivation or danger
Poor health and nutrition
Low education
attainment
Outside of family care
Exposure to violence, exploitation, abuse
United Nations Population Division World Population Prospects 2010
UNICEF State of the World’s Children 2012
6

7. Critical Pathways and Investments
7
compromised

8. Action Plan Objective
Promote
Evidence-
Base
Integration
Strengthen
Systems
Put Family
Care First
Protect Children
from Violence,
Exploitation,
Abuse, and
Neglect
Build Strong
Beginnings
PRIORITY
SUPPORTING
8

9. White House Launch
December 19, 2012
"And every child — no matter where they live, no matter the
circumstances into which they are born — should have the
opportunity to survive and thrive… And so while we know that our
future prosperity and our security are intimately tied into the
results we deliver for children today, we also know that we have
within our power today to ensure that all children survive and get
healthy food, all children grow up in a family, and all children are
safe from the violence and terror that sometimes erupts in our
world.”
USAID Administrator Rajiv Shah, December 19, 2012
9

10. “It is easier to build strong children than to repair broken men.”
Frederick Douglass
10

11. U.S. Government Commitment
Goal:
The U.S. Government will help ensure that children under
five not only survive, but also thrive by supporting
comprehensive programs that promote sound development
of children through the integration of health, nutrition, and
family support.
Outcomes:
 Increase the percentage of children achieving age-
appropriate growth and developmental milestones.
 The number of USG-funded programs that integrate
health, nutrition, developmental protections, and
caregiving support is increased.
11

12. The global burden
• 6.9 million children under the age of 5 worldwide die each
year.
• More than 25 times that number -- over 200 million
children -- survive, but do not reach their developmental
potential.
• As a result, their countries have an estimated 20 percent
loss in adult productivity.
Grantham McGregor, S. et al., (2007). Developmental potential in the first 5 years for children in
developing countries. Lancet, 369:60-70
WHO and UNICEF. Care for Development.
12

13. 109
891
Expected to die
before their
5th birthday.
Expected to live
past their
5th birthday.
Approximately 1/3 are not
expected to reach their
developmental potential
Grantham-McGregor et al. Lancet. 2007
January 6; 369(9555): 60–70
In Sub-Saharan Africa,
for every 1000 children born in 2011…
13

14. The importance of early intervention
14

15. Adversity impairs development
15

16. The economics:
breaking the poverty cycle
Rates of return on investments made during the early childhood years average
between 7 and 10 percent, greater than investments made at any other time in
the life cycle. 16

17. What works?
Healthcare
Standard health screenings for pregnant women
Skilled attendants at delivery
Childhood immunizations
Well-child visits
Nutrition
Breastfeeding promotion
Salt iodization
Iron fortification
Early Learning
Parenting programs (during pregnancy, after delivery and throughout early childhood)
Childcare for working parents (of high quality)
Free preprimary school (preferably at least two years with developmentally appropriate curriculum and
classrooms, and quality assurance mechanisms)
Social Protection
Services for orphans and vulnerable children
Policies to protect rights of children with special needs and promote their participation and access to ECD
services
Financial transfer mechanisms or income supports to reach the most vulnerable families (could include cash
transfers, social welfare, etc.)
Child Protection
Mandated birth registration
Job protection and breastfeeding breaks for new mothers
Specific provisions in judicial system for young children
Guaranteed paid parental leave of least six months
Domestic violence laws and enforcement
Tracking of child abuse (especially for young children)
Training for law enforcement officers in regards to the particular needs of young children
17Source: World Bank. Strategic Evaluation Impact Fund.

18. Two birds, one stone
18

19. Sustained results
0%
1%
2%
3%
4%
5%
6%
7%
height weight
%increaseofmean
comparedtocontrolgroup
Supplementation
Maternal tutoring
Both
Source: Van der Gaag, J. School Performance and Physical Growth of Underprivileged Children: Results of the
Bogotá Project at Seven Years. (1983). World Bank, Washington D.C.
19

20. What does success look like?
• The percentage of children achieving age-appropriate
growth and developmental milestones is increased.
 National surveillance through DHS and MICS (data is
collected but as yet not analyzed)
 Project-level indicators (WHO, UNICEF, World Bank, and
NGOs have models. USAID has as yet not adopted any).
• The number of USAID-funded programs that integrate
health, nutrition, developmental protections, and caregiving
support is increased.
 Reported through annual reports to Congress required
by PL 109-95.
20

21. “Any proposed programs should respect the primacy of the family.”
James J. Heckman, Nobel Laureate in Economics
21

22. U.S. Government Commitment
Goal:
U.S. Government assistance will support and enable families to
care for their children, prevent unnecessary family-child
separation, and promote appropriate, protective and
permanent family care.
Outcomes:
 Increase the percentage of children living within
appropriate, permanent, and protective family care.
 Reduce the number of children living in institutions.
 The percentage of families providing adequate nutrition,
education opportunities, care, and protection for their
children is increased.
22

23. The global burden
The most vulnerable children in the world – children outside of
family care – have fallen off the statistical map.
Global estimates:
• 17.8 million children have lost
both parents
• 2-8 million children may be living
in institutional care
• 1.1 million children are trafficked
for forced labor
• 1.8 million children are victims of
sex trafficking or pornography
• 300,000 children are associated
with armed forces or groups
All children count, but not all children are counted.
23

24. Children are at high risk of
growing up without a biological
parent, usually their father
Percentage of children under 5 living with their
biological mother but w/o their biological father
Percentage of children under 5 living with their
biological father but without their biological
mother, and
Percentage of children under 5 living without both
biological parents (x-axis)
Source: UNICEF. Inequities in Early Childhood Development: What the data say - Evidence
from the Multiple Indicator Cluster Surveys. February 2012. Figure 5, Page 9.
Note: This analysis included 40 countries.
24

25. The importance of family
• Optimal support for child health, nutrition, and development
comes through protective and permanent caregiving in a
family environment.
 Children outside of family care often experience higher
prevalence of abuse, neglect, lack of stimulation, poor
health, and inadequate nutrition with negative long-
term outcomes.
• Most children (approx. 80%) are institutionalized as a result of
extreme poverty rather than parental death or abandonment.
25

26. The effects of caregiving
• Institutionalization can lead to serious developmental, cognitive,
emotional delays and challenges.
 Children placed in appropriate family care by age 2 recover
normative growth and development by age 8.
 Children removed from institutions after age 2 do not reach
normative ranges.
EEG level: Institutionalized children EEG level: Never-institutionalized children
• Placing children in protective family care results in better child
outcomes and is significantly less expensive than institutional care.
26

27. What works?
• Household economic strengthening plus support for
caregivers
 Employment, savings and loans programs, cash transfers
 Positive parenting: reducing harsh discipline, substance abuse
 HIV prevention and treatment
 Child care
• Genuinely free and equally accessible primary education
• Family tracing and reunification in emergencies
• Family reunification, foster- and kinship-care
27

28. What does success look like?
• The percentage of children living within appropriate, permanent,
and protective family care is increased.
 National surveillance through a new measurement tool
(currently under development, to be piloted in 2 countries)
• The percentage of children living in institutions is reduced.
 National surveillance focusing on 6 priority countries
• The percentage of families providing adequate nutrition, education
opportunities, care, and protection for their children is increased.
 Project-level indicators monitored within targeted sub-
populations.
28

29. “Safety and security don’t just happen;
they are the result of collective consensus and public investment. We owe our children, the most
vulnerable citizens in our society, a life free of violence and fear.”
Nelson Mandela
29

30. U.S. Government Commitment
Goal:
The U.S. Government will facilitate the efforts of national
governments and partners to prevent, respond to, and
protect children from violence, exploitation, abuse, and
neglect.
Outcomes:
 Reduce the percentage of children who experience
violence, abuse, exploitation, and neglect.
 Increase the percentage of children who receive care and
protection.
30Obj 3 - Protect Children

31. The global burden
• Between 133 million and 275 million children are
estimated to witness domestic violence annually.
• 25-30% of children experience severe forms of
punishment.
• 150 million girls and 73 million boys under 18 experienced
forced sexual intercourse or other forms of sexual violence
in one year.
• 36 percent of girls and 29 percent of boys globally have
been sexually abused.
• 115 million children are engaged in hazardous work; 5.5
million are in forced labor.
• 1.8 million children are victims of sex trafficking or
pornography.
• An estimated 300,000 children are associated with armed
forces or groups. 31

32. The lasting effects of adversity
CDC. Adverse Childhood Experiences.
32

33. Health impacts:
violence against children
Health-risk behaviors
• Sexual promiscuity
• Sexual perpetration
• Alcohol abuse
• Illicit/injected drug use
• Smoking
Mental health and well-being
• Depression, post-traumatic
stress disorder (PTSD)
• Aggression
• Anxiety
• Somatic complaints
• Attempted suicide
• Social ostracism
• Anxiety
• Academic achievement
• Re-victimization
• Unwanted pregnancy
Disease and injury
• STDs, including HIV
• Gynecological problems
• Heart disease
• Diabetes
• Stroke
• Cancer
• Suicide
33

34. Association between childhood sexual
violence and selected health conditions,
females 13–24 years old, Swaziland, 2007
3.7
3.5
3.0 2.9
2.3 2.3
2.0 1.8
1.2
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Adjustedoddsratio*
*Adjusted for age, community setting, SES, and orphan status
Source: Jim Mercy, CDC
34

35. What works?
• Developing nurturing relationships between children and caregivers
• Strengthening the economic status of households
• Reducing access to and use of alcohol, illegal drugs, and weapons
• Promoting gender equality to prevent violence against girls and women
(addressing violence against women and children together)
• Changing cultural norms and social attitudes that promote violence;
integrating violence prevention into sector programs
• Support programs for survivors and initiatives to reverse under-
reporting of violence, exploitation, abuse, and neglect
35

36. What does success look like?
• The percentage of children who experience
violence, exploitation, abuse, and neglect is reduced.
 National surveillance through the Violence Against
Children Surveys.
• The percentage of children who receive appropriate care and
protection after experiencing violence, exploitation, abuse, or
neglect is increased.
 Project-level indicators monitored within targeted sub-
populations.
36

37. Outcome
Reduce % children not meeting
growth and developmental
milestones
Reduce % children living outside
of family care (COFC)
Reduce % children who
experience violence or
exploitation
Existing Data
Stunting and Poverty (DHS) [used
as ‘proxy’ indicators]
COFC living *in* HHs
(DHS, MICS)
CDC VACS
DOL/ILO Child Labor Surveys
Missing
Cognitive Delays, Developmental
Milestones
COFC living *outside* of HHs
USG Funding for VACS
Filling the Gap
Measurement Experts Group
Measurement Experts Group
Methods Development/Grand
Challenge
Promoting VACS and CLS in
Priority Countries
Measurement Challenges
3 outcomes
6 countries
5 years
37Results-based Approach

38. Build Strong Beginnings
Protect Children
Put Family Care First
Outcomes for Rwanda
38
40% reduction in the number of children under the age of five with cognitive delays
– Integrate cognitive & social stimulation into existing child health and nutrition programs
– Coordinate with faith-based actors in their application of caregiving programs
75% reduction in the number of children living outside of family care
– Prevent child-family separation through provision of nutrition, care, education and protect
– Close all orphanages in all provinces. De-institutionalize 3,400 child from orphanages to family care
– Strengthen national surveillance system for children living outside of family care
50% reduction in violence against children in target populations
– Incorporate anti-violence counseling for children into current projects reaching 60,000 children & families
– Support national childhood violence surveillance systems
Elimination of exploitive child labor from tea industry
– Remove 4,000 children from tea industry supply chain through transition into service work & schools
– Implement an integrated child labor monitoring system