CHILD POVERTY AND DEPRIVATION IN EAST AND SOUTHERN AFRICA€¦ · CHILD POVERTY AND DEPRIVATION IN...

CHILD POVERTY AND DEPRIVATION IN EAST AND SOUTHERN AFRICA: AN ANALYSIS OF SELECTED COUNTRIES

CHILD POVERTY AND DEPRIVATION IN EAST

AND SOUTHERN AFRICA:AN ANALYSIS OF SELECTED COUNTRIES

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Photos: Save the Children and UNDUGU Society

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All rights reserved – February 2017

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TABLE OF CONTENTS

Foreward iv

Acknowledgement v

Executive Summary vi

1. Introduction 1

2. Background 2

2.2 Methodology 32.2.1 Definitions of child poverty and deprivations 32.2.2 Research Methodologies 42.2.3 Desk reviews 4

3. Analysis of Childhood deprivations 5

3.1 Child nutritional status 53.2 Child health status 73.3 Education status 10

3.3.1 Gender and education deprivation 113.4 Access to water 13

4. Extent of multiple childhood deprivation among selected ESARO countries 14

4.1 Single deprivation Analysis 14 Household level dimensions 14 Individual level dimensions 15 Rural-urban disparities 174.2 Multidimensional deprivation 174.3 Multidimensional deprivation in rural areas 204.4 Overlapping deprivation 22

5. Conclusions and implications 27

References 30

Appendix 32

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List of BoxesBox 1: The classification of child poverty deprivations 4

Box 2: The nutrition challenge in Ethiopia 5

Box 3: Child deaths in Democratic Republic of Congo 8

List of TablesTable 1: East and Southern Africa scores in the end of childhood index ranking 3Table 2: Gender differences in education deprivations 12

Table A 2: Deprivation headcount rate by indicator and age-group 33

Table A 3: Deprivation distribution by location - children under five years old 33

Table A 4: Deprivation distribution by location - children 5-17 years 34

List of FiguresFigure 1: Prevalence of Stunting in ESARO countries (%) 6

Figure 2: Feeding related deprivations for children aged 0-23 months (%) 7

Figure 3: Deprivations in health among ESARO countries (%) 8

Figure 4: External Resource for Health as % of Total Expenditure on Health in 1995 and 2014 10

Figure 5: Education deprivation among ESARO countries (%) 11

Figure 6: Extent of water deprivation in selected ESARO countries (%) 13

Figure 7: Deprivation headcount rate by indicator (%) 14

Figure 8: Deprivation rates by indicator for children aged 0-4 years 16

Figure 9: Deprivation rates by indicator for children aged 5-17 years 16

Figure 10: Deprivation headcount rates by dimension and area 17

Figure 11: Headcount by number of dimension and residence (all 10 countries) 18

Figure 12: Number of deprivations children suffer from, by age-group 19

Figure 13: Deprivation distribution in rural areas by country - children under five years old 21

Figure 14: Deprivation overlap by dimension and country 23

Figure 15: Contribution of each dimension to the total adjusted multidimensional deprivation ratio: children experiencing 2-5 deprivations 26

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List of Acronyms

ACPF African Child Policy Forum

ACRWC African Charter on the Rights and Welfare of the Child

APSP Africa Platform for Social Protection

CRC Convention on the Rights of the Child

CSO Civil Society Organizations

CSSP Child Sensitive Social Protection

DHS Demographic and Health Survey

DRC Democratic Republic of Congo

DPT Diphtheria, Pertussis, Tetanus vaccine

ESARO East and Southern Africa Regional Office

HDR Human Development Report

IYCF Infant Young and Child Feeding

MDGs millennium development goals

MICS Multiple Indicator Cluster Survey

MODA Multiple Overlapping Deprivation Analysis

SDG Sustainable Development Goal

Sida Swedish International Development Cooperation Agency

SSA Sub Saharan Africa

UNDP United Nations Development Programme

UNICEF United Nations Children Fund

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FOREWARD

The Africa Platform for Social Protection (APSP) and Save the Children International, Regional Office for East and Southern Africa (ESARO) recognise the need for clear articulation of social protection policies and programmes that are child sensitive and child-friendly, within the East and Southern African region. Social protection is widely seen as a crucial component of poverty reduction strategies and efforts to reduce vulnerability to economic, social, natural and other shocks and stresses. Many social protection measures already benefit children without explicitly targeting them. However, ensuring greater consideration of children in the design, implementation and evaluation of social protection programmes can increase their impact in order to reach the most marginalised and deprived children

Child-sensitive social protection (CSSP), aims to maximize opportunities and developmental outcomes for children by considering different dimensions of children’s well-being. It focuses on addressing the inherent social disadvantages, risks and vulnerabilities children may be born into, as well as those acquired later in childhood due to external shocks.

Save the Children’s Global Strategy Ambition for Children 2030, situates “the most deprived children” as those who are not achieving or who are at high risk of not achieving Breakthroughs for their rights. These are children who are:

Not likely to survive to their 5th bir thdayNot enrolled in school and not achieving relevant learning outcomesNot adequately protected from all forms of violence.

This report on the status of child poverty in 10 countries in East and Southern Africa Region provides very useful information in understanding the status of child deprivation and multidimensional poverty in the region and persisting challenges towards provision of essential services for children. The report is both useful as it provides a framework for targeted child sensitive social protection programming for children and as an advocacy tool for influencing policy change on social protection.

It is our hope that the report will be a useful tool that informs government programming for children in social protection. Civil society organizations are also welcome to use this as an advocacy tool to generate demand for child sensitive social protection.

David Wright Dr. Tavengwa NhongoRegional Director Executive DirectorSave the Children International Africa Platform for Social Protection

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ACKNOWLEDGEMENT

APSP and Save the Children International would like to thank all those who diligently contributed to this process. We are sincerely grateful to our consultant Dr. Ibrahim Kasirye from the Makerere University, who supported the data analysis. Staff at the Regional and Multi-Country Office Programme Unit (RMCPU) of Save the Children International ESARO, including Yvonne Tagwireyi and Neesha Fakir as well as staff from the Africa Platform for Social protection (APSP) led by Dr. Tavengwa Nhongo, Samuel Obara and Helen Mudora. We are highly indebted to the Swedish International Development Agency (SIDA) for the financial support that made this process possible.

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EXECUTIVE SUMMARYThis report seeks to provide insight into the extent of child poverty and multiple deprivation in selected countries in the East and Southern Africa region. It seeks to investigate the drivers of child poverty as well as the challenges and opportunities for child sensitive social protection. The 2016 African Report on Child Well-being recognizes that sub Saharan Africa accounts for a disproportionate share of children who die during infancy and half the global population of children out of school (ACPF, 2016)1. Beyond income poverty, a much larger proportion of children are faced by multidimensional poverty, in other words, children are affected by more than one type of deprivation relating to education; health; shelter water and sanitation. Currently, there is limited information addressing the way children are affected multi-dimensionally and we hope that this study can shed light on some of ways in which children are multi-dimensionally deprived.

It is against this background that the Africa Platform for Social Protection (APSP) and Save the Children International, East and Southern Africa Regional Office (ESARO) commissioned a study to analyze the extent of child poverty and multiple deprivation in selected countries in the East and Southern Africa region, with the view to understanding how multi-levels of deprivation affect children in key countries. The methodological and data collection approach involved quantitative analysis of secondary data on the extent of child poverty deprivation, including recent Demographic Health Surveys2 and Multiple Indicator Cluster Surveys for 10 countries in the East and Southern Africa region. The 10 countries included in this study are: Angola, Malawi, Rwanda, Tanzania, Zimbabwe, Democratic Republic of Congo, Ethiopia, Zambia, South Sudan and Somalia.

The overall objective of this study is to generate evidence to support Civil Society Organization’s (CSO)’s to advocate for governments and duty bearers to mainstream child sensitivity into existing and new social protection policies and programs.

This study outlines key recommendations for the addressing child poverty and promotion of child sensitive social protection. These include:

Formation and adoption of supportive laws, policies and strategies for realising child sensitive social protection.

Design of integrated social protection programmes that focus on the multiple deprivations that children experience.

Adoption of social protection floors which are country and context specific.Adoption of a rights -based approach to social protection infused with principles of equality and non-

discrimination.Investment of more financial resources for social protection of children to create a positive impact

beyond childhood.Strengthen income security of children and their families and access to quality basic services.Institutional coordination of social protection programmes and social services and adoption of a multi-

sectoral approach between social protection programmes and key line ministries providing social services.

Advocacy for child- sensitive social protection by CSOs.Promoting child participation in the design and monitoring of social protection programmes. Collection of comparable data across countries and establishing national child poverty levels. Monitoring and evaluation process that includes indicators that respond to the needs of children.Considering the specific conflict related deprivations that children face in humanitarian and disaster

contexts.

1 The African Child Policy Forum. 2016. The African Report on Child-Wellbeing 2016. Ethiopia: ACPF, page 2 This includes surveys done in 2013 or later.

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1. IntroductionChild poverty is one of the defining challenges facing human kind in the 21st century. More than 385 million children were living in extreme poverty in 2012, and children account for 50.2% of the global extreme poor.3 More recent estimates show that in 2017, at least 700 million children were affected by various dimensions of child poverty such as a lack of education, engagement in harmful work, poor nutrition, early childhood marriages, displacement and death during infancy.4 Such levels of deprivation are unacceptably high especially after implementing 15 years of millennium development goals (MDGs) and now the Sustainable Development Goals (SDG’s). As such, development organizations including Save the Children International have taken a keen interest in understanding the drivers and effects of child poverty and the associated multiple deprivations. This is based on the realisation that the survival, development and protection of the child will affect the pace of attaining sustainable development goals (SDGs).5

In addition, a large population of children is affected by multidimensional poverty.6 According to the Global Child Poverty report, at least 750 million children across the globe are deprived in either education, health or nutrition.7 Furthermore, multidimensional poverty is more pronounced for children than adults. The Oxford Poverty and Human Development Initiative, estimates that nearly two out of every five children – 37 percent – are multi-dimensionally poor compared to only 21 percent for of adults.8 Additionally, more than eight out of ten of the 689 million poor children are growing up in South Asia and in Sub-Saharan Africa —specifically two-thirds of Sub-Saharan children are multi-dimensionally poor.9 Furthermore, for some countries in SSA e.g. Ethiopia, Niger and South Sudan over 90 percent of children are MPI poor.10

3 World Bank. (2016.) Poverty and Shared Prosperity 2016: Taking on Inequality. Washington, DC: World Bank.

4 Save the Children (2017) Stolen Childhoods- End of Childhood Report

5 The SDG1 intends to end poverty in all its forms everywhere by 2030. The key targets of SDG1 include: by 2030, eradicate extreme poverty for all people everywhere, currently measured as people living on less than $1.25 a day and by 2030, reduce at least by half the proportion of men, women and children of all ages living in poverty in all its dimensions according to national definitions.

6 A person is identified as multidimensionally poor (or ‘MPI poor’) if he or she lives in a household deprived in at least one third of the weighted MPI indicators.

7 Harland-Scott, Charlotte & Istratil, Romina 2016 Child Poverty: What drives it & what it means to children across the world: A report for Save the Children (London: Save the Children UK).

8 Alkire, S, Jindra, C, Robles, G and Vaz, A (2017).” Children’s Multidimensional Poverty: Disaggregating the global MPI,” Briefing 46, May 2017, University of Oxford.

9 Ibid10 Ibid

There exists large disparities in East and Southern Africa region between the poorest and richest children, with children from poor, marginalized and deprived households having high incidence of malnutrition, underweight, trapped in an early and forced marriage, forced into harmful work and less likely to attend primary school than the richest children.11 The overall objective of this study is to generate evidence to support civil society organizations (CSO)’s to advocate for governments and duty bearers to mainstream CSSP into existing and new social protection policies and programs. The specific objectives are:1. To generate information on the incidence,

types and levels of child deprivation and vulnerability in selected countries in the East and Southern Africa region.

2. To examine the level of deprivation in the countries of focus and what this means in terms of addressing child poverty.

3. To support CSO’s to demand for CSSP as well as provide recommendations that will inform the mainstreaming of CSSP into national policies and programs.

The choice of the 10 countries was guided by a number of research and methodological factors including: (i) the availability of a recent Demographic and Health Survey (DHS) data that was conducted in 2013 or after, or the presence of a Multiple Indicator Cluster Survey (MICS); (ii) sub regional location (i.e. East, Central or Southern Africa); (iii) implementation of a large scale social protection programme (e.g. Rwanda and Ethiopia); (iv) conflict, humanitarian and emergency context (Angola, Somalia and South Sudan); and (v) the country status/ranking on the Human Development Index. Table A1 in the appendix provides the details justifying the selection of the 10 countries. The remainder of the study is organized as follows. Section 2 provides the background to child poverty in SSA and ESARO. Section 3 describes the research methods and datasets sources used in the analysis. Estimates of the extent of child poverty deprivations are presented in section 4 as well as the extent of multiple deprivations among the selected 10 countries. Section 5 provides the conclusions and implications of the study on CSSP programming in Sub-Saharan Africa. 11 World Bank (2016) Health Nutrition and Population Statistics by

Wealth Quintile

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2. BackgroundAlthough the first Millennium Development Goals (MDGs) target of halving extreme poverty during 1990-2015 was achieved globally, this achievement was mostly attributable to the tremendous progress made in improving the welfare status of citizens in China and South Asia. China reduced extreme poverty to more than 90 percent during 1990-2015 while Southern Asia reduced extreme poverty rates by two thirds during the same period.12 On the other hand, extreme poverty rates stagnated in SSA at 60 percent during 1990-2002 and the progress registered in reducing extreme poverty during the implementation of the MDGs was only achieved during 2002-2015.13 More than four out even ten individuals in the sub region were experiencing extreme poverty in 2015.14 Furthermore, despite the efforts made in Sub-Saharan Africa to reduce mass deprivation, poverty still remains high. According to the 2015 African Development Report, a large proportion of Africans live below the $1.25 a day poverty line estimated in 2015 at 42.7 percent (equivalent to 403 million persons).15 In addition, the proportion within the second poverty line i.e. $1.25-$2 a day is also large at 28.6 percent, in 2015, while 28.8 percent have managed to overcome the international poverty line (above $2 per day).16 Beyond income poverty, a much larger proportion of children face multidimensional poverty, i.e., affected by more than one type of deprivation relating to

12 United Nations (2015). The Millennium Development Goals Report. 13 Ibid 14 Ibid15 African Development Bank (2016) African Development Report

2015: Growth Poverty and Inequality Nexus: Overcoming Barriers to sustainable development.

16 Ibid

education, health, shelter, water and sanitation. The 2014 Human Development Report (HDR) notes that globally, at least 1.5 billion people experience multidimensional poverty and at least half of these—750 million—are children (UNDP, 2014).17 Consequently, reducing child poverty is critical for attaining the global SDG goal of ending extreme poverty by 2030.

Some of the worst childhood indicators recorded in Sub-Saharan Africa, are found among the 22 countries in the East and Southern Africa.18 According to the 2017 Save the Children Stolen Childhoods report (2017) and the accompanying End of Childhood Index (2017) countries in the East and Southern Africa region have some of the largest population of disadvantaged children.19

Table 1 shows the global ranking of all the 22 countries in the region based on 8 dimensions which Save the Children defines as “childhood enders” (Save the Children, 2017, p.1). Within the region, 66 children per 1000 live births die during infancy, 36% of children are malnourished, 27% of children are out of school and 21% of girls (aged 15-19 years) are currently married (Save the Children, 2017). Overall, the region ranks poorly on what Save the Children terms “childhood enders” as majority of the countries in the region are ranked 130 places and above. It is only Botswana, South Africa, Namibia and Swaziland that are ranked better in terms of having lower threats to children.20 At least 3 countries, namely South Sudan, Somalia and Angola are ranked among the bottom 10 countries globally having the worst child indicators. Some of the factors that end childhood are also key drivers of child poverty e.g. lack of education, malnutrition, infant deaths, and early marriages. As such, countries in the region with the highest proportion of children facing stolen childhoods also face high rates of child poverty.

17 UNDP (2014) Human Development Report 2014: Sustaining Human Progress and Reducing Vulnerabilities and Building Resilience (New York: UNDP).

18 Save the Children (2017) Stolen Childhoods: End of Childhood Report 2017.The indicators consists of composite analysis on where the most and fewest children are missing out on childhood. The major considerations taken into account in the indicators include poor health, conflict extreme violence, child marriage, early pregnancy, malnutrition, exclusion from education and child labor. When taken together, these factors have created a global childhood crisis of massive proportions.

19 Ibid20 However, these Southern Africa countries still face very high rates

in Under 5 Mortality rates—in some instances higher than rates in poorer countries e.g. Rwanda.

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Table 1: East and Southern Africa scores in the end of childhood index ranking

Child DiesMalnourished Out of school

Child begins work life

Marriage Pregnancy Displaced Homicide

Indicator

Under-5mortality rate

(deaths per1,000 live

births)

Childstunting

(% childrenaged 0-59months)

Out-of-schoolchildren of

primary andsecondaryschool age

(%)

Childrenengaged inchild labor

(% ages

Adolescentscurrently

married orin union

(% girls aged15-19)

Adolescentbirth rate(births per1,000 girls

aged 15-19)

Populationforcibly

displaced byconflict

(% of total)

Homicide rate(deaths per

100,000populationaged 0-19)

1 Botswana 44 31 9 31 0 2.1 796 100

2 South Africa 40.5 23.9 14.4 3.3 44.4 0 9 788 103

3 Namibia 45 23 15 5.4 76 0.1 3.7 777 105

4 Swaziland 60.7 25.5 19.7 7.3 4.3 67.2 0 4.1 777 105

5 Rwanda 41 38 16 28.5 3.1 25.6 2.6 1.6 757 112

6 Kenya 49 26 13.2 11.9 90.2 0 2.4 750 119

7 Comoros 73 32 26.9 22 16.4 67 0.1 2.2 688 129

8 Uganda 54.6 34.2 20.3 16.3 28.8 108.9 0.5 4.3 681 132

9 Zimbabwe 70.7 26.8 24 19.6 108.9 0.4 3 664 138

10 Ethiopia 59 38 35 27 19 57 0.2 3 657 139

11 Burundi 82 57.5 25.4 36 8.6 28 4.9 2.3 650 141

12 Tanzania 48.7 34.4 30.2 28.8 23 117.7 0 2.6 635 145

13 Zambia 64 40 21 40.6 16.9 87.8 0 2.5 633 146

14 Malawi 64 37 15 39 24 135 0 0.4 619 149

15 Lesotho 90 33 24 18 93 0 8.8 611 150

16 Eritrea 46 50 63 53 9.2 2.2 608 151

17 Madagascar 50 49 29 23 34 115 0 5.5 587 157

18 Mozambique 78 43 27 22 37 137 0 0.9 578 160

19 DRC 98 43 18 38 21 122 3 6.6 558 162

20 South Sudan 92.6 31.1 67.5 40.1 63.4 22.2 1.7 488 166

21 Somalia 136.8 25.9 48.8 49 24.6 102.6 20.8 2.5 470 168

22 Angola 157 38 31 162 0.2 4.2 393 171

Eastern and Southern Africa 66.5 35.7 27 26.2 20.7 113.8 1.4 3.4 631

Sub Saharan Africa 83.1 35.2 29 27.5 24 122 1.8 4.2 596Source: Save the Children (2017)

Score Country rank

out of 172

countries

Childhood Ender

2.2 Methodology The methods used in the study include a desk review of drivers of child poverty deprivation within the East and Southern Africa region and secondary data analysis of the extent of child poverty.

2.2.1Definitions of child poverty anddeprivations

Children experience poverty in different ways to adults, which ultimately affect their development. To capture the different facets through which children experience poverty and vulnerability, for the purposes of this study, we adopted the UNICEF’s Multiple Overlapping Deprivation Analysis (MODA) approach (De Neubourg, et al. 2012).21 The MODA approach builds on existing initiatives such the Bristol indicators approach (UNICEF, 2007; Gordon et al, 2003) to measure child poverty.

These approaches consider children’s needs at different stages of their life cycle (i.e. at early

21 De Neubourg, C., J. Chai, M. de Milliano, I. Plavgo, Z. Wei (2012). ‘Cross-country MODA Study: Multiple Overlapping Deprivation Analysis (MODA) - Technical note’, Working Paper 2012-05.

childhood, primary childhood, and adolescence).

Whereas the Bristol approach only considers 7 types of deprivations relating to: nutrition, health, water, sanitation, housing, education and information, the MODA approach considers an additional dimension relating to a protection from violence overall, the MODA approach is guided by both the Convention on the Rights of the Child (CRC) and the African Charter on the Rights and Welfare of the Child (ACRWC). In Box 1 below, the indicators measuring the different types of deprivations are described.

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Box 1: The classification of child poverty deprivations

Category of deprivation Indicator

Nutrition/food deprivation (CRC Article 24 and ACRWC Article 14)

Children whose nutritional status (e.g., heights and weights for their age) are either more than 2 standard deviations below the median of the international reference population, i.e., anthropometric failure (deprived) and (ii) infant and young child feeding i.e. either children aged 0-5 months not breastfed or children aged 6-59 months living in a household with insufficient meal frequency.

Water Deprivation (CRC Article 24 and ACRWC Article 14)

Children who only have access to unimproved water sources (e.g., open wells/springs or surface water) for drinking or who live in households where the nearest source of water is more than 30 minutes away (indicators for deprivation of water quality or quantity).

Deprivation of Sanitation Facilities (CRC Article 24 and ACRWC Article 14)

Children who use unimproved sanitation facilities (e.g., have no access to a toilet of any kind near their dwelling, including communal toilets or latrines; use pour flush latrines, open pit latrines and buckets, etc.).

Health Deprivation (CRC Article 24 and ACRWC Article 14)

Children aged 1-4 years who have not received all DPT vaccinations, or (ii) skilled bir th attendance: if no or an unskilled bir th attendant assisted with the bir th of the last child.

Shelter Deprivation (CRC Article 27)

Children living in dwellings with more than four people per room (overcrowding) or (ii) material for construction i.e. children living in dwellings where both roof and floor are made of natural materials, which are not considered permanent.

Education Deprivation (CRC Article 28 and ACRWC Article 11)

Children of compulsory school age but not attending school or beyond primary school age with no or incomplete primary education.

Information Deprivation (CRC Article 13 and 17) –

Children who live in households with either no radio, television, phone, mobile phone, or computer.

Protection (CRC Art. 19, 37) Protection from violence: children aged 2-14 years resident in a household where a woman states to have experienced domestic violence

Source: Adapted from De Neubourg, et al. (2012) and Batana et al., (2014).22

2.2.2 ResearchMethodologiesThe MODA approach constitutes 3 measures i.e. (a) deprivation count; (b) deprivation overlap; (c) multidimensional child deprivation headcount. The analysis was performed at the; (a) combined level for the 10 countries; (b) individual country level and (c) based on the area of residence i.e. rural/urban location. The analysis was performed based on two demographic categories i.e. children aged less than 5 years and children of school going age (5-17 years). This choice of demographic disaggregation is guided by the fact that some indicators are age-group specific, such as nutrition and health are only available for children aged less than 5 years, while education and information are only available for children aged 5-17 years.

22 Batana, Y., John Cockburn, I. Kasirye et al., (2014) Situation Analysis of Child Poverty and Deprivations in Uganda” PEP Working Paper.

The rest of targeted countries (Ethiopia, South Sudan and Somalia) are either missing the “protection from violence” dimension (i.e. Ethiopia and South Sudan) or the nutrition dimension (i.e. Somalia). Consequently, for comparison across countries, we mainly use only 5 dimensions where all the countries have data.

2.2.3DeskreviewsSome important measures of child deprivation are not captured by the DHS surveys e.g. disability and harmful work for children.23 As such, we complement the secondary data deprivation analysis with desk review of documents. For example, we use the recently launched Stolen Childhood report to explain our multiple deprivation analysis results.

23 Save the Children 2013.

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3. Analysis of Childhood deprivations

3.1 ChildnutritionalstatusMalnutrition remains a major challenge within the East and Southern Africa region. For the 10 selected countries, on average 36 percent of children under five years of age in the East and Southern Africa region are affected by stunting. This means that they are too short for their age. Stunting is a measure of long term nutritional deprivation and it accounts for a child’s health before and after child birth. As indicated in Figure 1, only 2 out of the 10 countries considered in this study have stunting rates below 30%—namely, Somalia (26 %)24 and Zimbabwe (27%).25

24 More recent estimates suggest that stunting rates have reduced to 10% in Somalia by 2016 (Food Security and Nutrition Analysis Unit – Somalia, 2016). However, no explanation is offered for this dramatic reduction in stunting rates.

25 Before the land crisis in Zimbabwe, stunting rates were relatively low. In particular, stunting rates were 29 percent in 1994 and increased to 35 percent by 2005/6 before reducing to 27 percent by 2015 (Zimbabwe National Statistics Agency and ICF International, 2016). Overall, during the past 10 years, stunting rates in Zimbabwe have gradually reduced to the pre-land crisis levels.

The top four countries with the highest rates of stunting are: DRC (43%), Zambia (40%), Ethiopia (38%) and Angola (38%), Furthermore, at least three of the selected countries (i.e. Ethiopia, DRC and Tanzania) are among the top 24 countries globally with the largest population of malnourished children.26 In addition, among the 10 countries considered, wasting rates are highest in South Sudan (23%), Ethiopia (10%) and DRC (8%). This suggests that children in these countries are affected with frequent illnesses (malaria, diarrhoea, intestinal worms) and inadequate child care practices. Box 2 describes some of the nutritional challenges faced by Ethiopian children.

26 UNICEF (2009). Tracking Progress on Child and Maternal Nutrition: A Survival and Development Priority. New York: UNICEF.

Box 2: The nutrition challenge in Ethiopia

Ethiopia is among the few countries that have registered tremendous gains in reducing stunting rates during the past 10 years. Specifically, stunting rates in Ethiopia have reduced to 38% in 2016—from 54% in 2006 and most of the gains have been made by households in the middle of the welfare distribution.1 However, underweight rates have remained high at 23.6 % in 2016.2 The difference between stunting and underweight rates indicates nutrition challenges experienced during first 1000 days of life—including during pregnancy (growth faltering). The above statistics suggests that nutritional challenges during the first 1000 days have not changed in Ethiopia; what has changed is a reduction in share of children experience hunger.

Limited dietary diversity and insufficient micronutrient-dense food consumption as well as challenges with child feeding practices contribute to the high rates of child under nutrition in Ethiopia.3 About 58 percent of children aged less than five years are exclusively breastfed and introduced complementary foods at the appropriate age compared to 85% for Rwanda, 72% for Malawi and 62% for Zambia4; and only 7 percent of young children were receiving a minimal acceptable diet in 2016, up from 4% in 2011.5

Furthermore, poor nutrition indicators are also linked with poor utilization of health services (e.g. use of antennal services). For example, Ethiopia has very low levels of utilization of health services; only 28% of the births take place at health facility and 36% of children aged at least one year have received the basic immunizations.6 Furthermore, there are large gaps in utilization of health services—the richest households in Ethiopia are more than five times more likely to give birth in health facility compared to their poor counterparts. Low health utilization is linked to high out of pocket spending as well as low education attainment. Only 16% of women without education give birth in health facility compared to 39% for those with primary education and 77% for those who have attained secondary education.

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Malnutrition in DRC is not driven by inadequate incomes or lack of access to food—at least 23% of children in the richest quintile were stunted in 2013/14.27 As such, poor nutrition status among children in DRC appears to be a result of inadequate child care practices and a high disease burden. With regard to infant and child feeding practices, in 2013/14, only 55% of children in DRC were exclusively breastfed within the first hour of life while 11% of infants had receive other complementary foods before initiation of breastfeeding.28 Overall, only 48% of infants in the DRC are exclusively breastfed within the first six months of birth.29 Children in DRC also face a high burden of disease with about 40% of infant deaths due to diarrhoea and pneumonia and poor nutritional status increases the severity of disease.30 Among the selected countries in the East and Southern Africa region, Zambia has the second highest rate of stunting (40%). For Zambia, in addition to poor child care practices, high rates of household food insecurity coupled with inadequate access to water

27 MSP and ICF International (2014). Democratic Republic of Congo Demographic and Health Survey 2013-14.

28 ibid29 ibid. 30 World Bank (2010) Nutrition at a Glance; The Democratic

Republic of Congo

and sanitation influence children’s nutritional status in the country (Save the Children, 2016b).31 32

The other nutritional indicators considered are exclusive breastfeeding for infant less than 6 months and frequency of infant and young child feeding (for children aged 6-23 months).33 The latter indicator of insufficient minimum meal frequency depends on child’s age in months and whether the child is breastfed or not.34 Figure 2 shows that a higher proportion of children aged 6-23 months is affected by infant and young child feeding—ranging from 54% in Rwanda to a very high of 90.1% in South Sudan. Inadequate meal frequency partly captures the extent of food insecurity faced by children. Furthermore, Figure 2 also shows that deprivation in exclusive breastfeeding is generally low—the only exceptions are Angola and Malawi where more than 10% of children aged less than 6 months are not exclusively breastfed. 31 Save the Children (2016) Malnutrition in Zambia: Harnessing

social protection for the most vulnerable. 32 UNICEF (2016) The State of the World’s Children 2016: A fair Chance

for Every Child (New York, UNICEF).33 Based on the World Health Organization (2002) recommendation,

infants should be exclusively breastfed for the first 6 months of life and thereafter receive complementary foods with continued breastfeeding up to the age of 2 years.

34 Children are deprived due to meal frequency if the following conditions are met: (a) children aged 6-8 months and breastfed but receives less than 2 feedings in the last 24 hours; (b) children aged 9-23 months and breastfed but receive less than 3 feedings in the last 24 hours; and (c) children aged 6-23 months not breastfed and receive less than 4 feedings of which one should be milk.

Figure 1: Prevalence of Stunting in ESARO countries (%)

Sources: Save the Children (2017); Angola DHS 2017 UNICEF, 201632

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Figure 2: Feeding related deprivations for children aged 0-23 months (%)

2.3

5.6

3.9

1.2

3.4

4.1

10.8

10.2

2.1

54

59

60.9

61.6

65.7

67.7

68.9

75.2

90.1

Rwanda

Ethiopia

Tanzania

Zambia

Zimbabwe

DRC

Malawi

Angola

South Sudan

Deprived in minimum accepatble diet: ICYF (6-23 months) Deprived of exclusive breastfeeding (0-5 months)

Source: Authors calculations from the DHS and MICS surveys.

3.2 ChildhealthstatusFigure 3 presents the profile of health deprivation among the 10 countries based on three indicators—DPT vaccination, child bir th assistance and infant deaths. It indicates that countries with highest rates of infant deaths or also have rates of un-assisted child bir th. Specifically, young children in Somalia are more likely to die during infancy—137 deaths per 1000 live bir th while 56 percent of child births in the country are unattended. The very high rate of infant death in Somalia may be explained by armed conflict experienced since 1991—that fragmented and led to widespread internal displacement especially in Southern Somalia. Partly as a result of the prolonged conflict associated vulnerabilities, there are considerable inequity of access to public and private sector health providers in Somalia—with services readily available to rich urban dwellers35 and almost absent for poor rural

35 Urban dwellers account for 40 percent of the Somalia population.

populations36, internally displaced people and nomads (communities who make the majority of the Somali population).37 36 Federal Government of Somalia (2013), Health Sector Strategic Plan

2013-201637 Lynch, C. (2005) Report on knowledge attitude and practices for

malaria in Somalia

8


Figure 3: Deprivations in health among ESARO countries (%)

1

5

7

31

40

9

10

36

34

65

6

9

37

63

53

18

34

54

15

56

50

64

67

67

68

69

75

93

104

137

Rwanda

Malawi

Tanzania

Ethiopia

Angola

Zimbabwe

Zambia

South Sudan

Democratic Republic of Congo

Somalia

Under 5 Mortality Rate (deaths per1,000 live births)

No birth attendance or an unskilledbirth attendant (%)

Has not received all 3 DPT vaccinations(%)

Source: Authors calculations from the DHS and MICS surveys and Save the Children (2017) for Under 5 mortality rates for Somalia and South Sudan.

The Democratic Republic of Congo and South Sudan follow Somalia as the other countries with very high rates of infant deaths—about one out of every ten children die before their fifth bir thday in these two countries. The experience of conflict in both countries may explain the relatively high infant death. Violent conflicts are associated with poor access to health infrastructures and unavailability of health personnel. Furthermore, displacement associated with violent conflict affects access to clean water and increases the risk of diarrhoea—one of the major causes of child deaths. In addition to high infant deaths, South Sudan has one of the highest Maternal Mortality Rates (MMR) in the world, estimated at 789deaths per 100,000 live bir ths in 2015 (WHO, 2015 p. 75), down from 1,500 deaths per 100,000 live bir ths in 2000.38 This may be partly explained by the very low number of institutional childbir ths as illustrated in Figure 3. On the other hand, apart from conflict, Box 3 illustrates other major causes of child deaths in DRC.

38 (United Nations, 2013)

Box 3: Child deaths in Democratic Republic of Congo

Higher child death in DRC is accounted for by Malaria and acute respiratory infections—both health burden accounts for 16 percent each of infant deaths in 20127. Furthermore, only 56 percent of children under five years sleep under a mosquito net in 2013/14. In addition, shorter birth intervals also explains the high level of child deaths in DRC Congo—specifically, children born with a less than 2 year birth interval are more than twice more likely to die before their fifth birthday compared to children with a 4 year birth interval.8

Somalia is also the most deprived in the DPT vaccinations. Specifically, 65% young children have not received all the basic three DPT vaccinations. The other countries with large DPT3 deprivations are Angola (40%), South Sudan (36%), and DRC (34%) while Rwanda and Malawi have the best DPT coverage rates. When all the 8 basic

9


childhood vaccinations are considered39, deprivation rates increase substantially in some countries—notably to 70% in Zambia, 61% in Ethiopia and 46% in Zimbabwe (Kanamori and Pullum, 2013; Central Statistical Agency and ICF, 2016). Most children who have received all the basic immunizations are in rural areas—with the differences between urban and rural children being 25 percentage points in Ethiopia. Other factors advanced for Ethiopia’s large population of children with incomplete immunization include frequent vaccine stock outs and rural-rural migration of mothers (Negussie, et al, 2016).40

Also, Figure 3 shows that Ethiopia has the highest rates of unattended bir ths. Specifically, 63 percent of bir ths in the country are not attended by a qualified health care provider (i.e., doctor, nurse, midwife, clinical officer or nursing aid). The high rates of un-attended bir ths in Ethiopia are explained by the severe constraints women face in accessing health services in the country. At least 70% of women aged 15-49 years of age report having challenges accessing health services especially due to lack of funds for treatment or due to the long distance to health services (Central Statistical Agency and ICF, 2016). As such, the use of maternal health services is limited. For example, in 2016, only 32 percent of Ethiopian mothers made at least 4 antenatal visits during the last pregnancy while 26% gave bir th at a health facility—up from 10 percent in 2011.41 Other countries with high rates of un-attended bir ths include Somalia, South Sudan and Angola—in these specific countries more than five out of every 10 bir ths are unattended.On the other hand, Rwanda and Malawi have the least deprivations due to unattended bir ths. Rwanda has the least child health deprivation indicators and its stellar performance is partly attributed to the introduction of a community-

39 The 8 basic vaccinations recommended by the World Health Organizations are (i) the BCG vaccine—against tuberculosis (TB), (ii) the three polio vaccines, (iii), the three diphtheria, pertussis, tetanus vaccine (DPT), and (iv) the measles vaccine.

40 Negussie, A., W. Kassahun, S. Assegid et al., (2016) Factors associated with incomplete childhood immunization in Arbegona district, southern Ethiopia: a case – control study BMC Public Health (2016) 16:27.

41 Ibid

based health insurance scheme (Mutuelles de Santé). This program, which was initially piloted in 1999, was formally inaugurated in 2005. Access to a Mutuelles de Santé significantly increased access to both preventive and curative health services.42

At least 78% of all households in Rwanda had access to community/mutual health insurance in 2014/15.43

The proportion of women giving bir th at a health facility in Rwanda doubled from 45% in 2007/8 to 91% by 2014/15.44 Furthermore, Rwanda’s better performance can also be partially attributed to the substantial receipt of external resources for health. Between 1995 and 2014, Rwanda registered the largest increase in external resources as a share of total expenditure on health—an increase of nearly nine times as shown in Figure 4. The second placed country with respect to changes in external resources for health—DRC registered a six-fold increase i.e. from 6.1% in 1995 to 37.8% by 2014. As a result of accessing large external resources for health, Rwanda’s health expenditure as a share of GDP nearly doubled from 4.2% in 1995 to 7.6% by 2014.45

42 Binagwaho, A., C. Lu1, B. Chin (2012) “Towards Universal Health Coverage: An Evaluation of Rwanda Mutuelles in Its First Eight Years”. PLoS ONE Vol 7. No. 6

Dhillon, R, S., M.H. Bonds., M. Fraden et al (2012) “The impact of reducing financial barriers on utilization of a primary health care facility in Rwanda”. Global Public Health Vol 7. No.1L 71-86.

43 National Institute of Statistics of Rwanda Ministry of Health (MOH) [Rwanda], and ICF International.(2015) Rwanda Demographic and Health Survey 2014-15.

44 Ibid.45 World Health Organization (2017). Global Health Expenditure

Database 2017: (http://apps.who.int/nha/database/Select/Indicators/en, accessed August 7, 2017).

10


Figure 4: External Resource for Health as % of Total Expenditure on Health in 1995 and 2014

4.6

28.6

11.8

11.9

9.1

6.1

5.2

42.4

2.6

73.8

38.4

41.7

35.9

37.8

46.2

South Sudan

Angola

Malawi

Zambia

Ethiopia

Tanzania


Rwanda

2014

1995

Source: World Health Organization (2017).

3.3 EducationstatusDeprivation in education is determined by measuring compulsory school attendance and primary school attainment.46 Figure 5 shows the levels of education 46 Compulsory school age and end of primary school age country-

specific age country-specific. For 5 countries—notably Malawi, Ethiopia, Tanzania, South Sudan and Somalia, primary schooling takes 8 years; however, the age of entry differs. In Ethiopia and Tanzania, it is at age 7 while for the Malawi, South Sudan and Somalia it is at age 6. For Zambia and Zimbabwe, primary schooling lasts 7 years; however, Zimbabwean children start at age 6 while counterparts in Zambia start at age 7. Rwanda and DRC have a primary school cycle of only 6 years with children in DRC starting earlier at age 6 while counterparts in Rwanda start at age 7. Finally, primary schooling in Angola starts at age 7 and last for 4 years—the secondary school cycle in Angola is much longer lasting 8 years. The source for the exact schooling age by country is the UNESCO, Institute for Statistics database, Table 1. Education systems [UIS, http://stats.uis.unesco.org/unesco/TableViewer/tableView.aspx?ReportId=163].

deprivation for the 10 selected countries. South Sudan records the highest rate of children with no or incomplete primary education with more than eight out of every ten children aged above 13 years deprived in primary school attainment, followed by Somalia (65%). At the same time, the two countries also lead in have the highest proportion of children of compulsory school going age not attending primary school i.e. 52% and 37% for South Sudan and Somalia respectively.

The above ranking for out of school children is similar to that of the 2017 stolen childhood report. In particular, at 68 %, South Sudan has the highest

rate of out-of-school children of primary and secondary school age, followed by Somalia (49 percent).47 Zimbabwe has the lowest rates of both attainment and attendance deprivation—18% and 2% respectively. The difference between the two indicators is a measure of the dropout rate in primary school i.e., leaving school without completing primary schooling. Malawi has the highest difference (53%) followed by Rwanda (45%), and Ethiopia (38%). This suggests that that for children able to join primary school these particular countries are the worst performers in terms of primary school retention.

47 Save the Children (2017)

11


Figure 5: Education deprivation among ESARO countries (%)

2

8

11

18

10

3

17

3

37

52

18

29

28

42

42

48

55

56

65

82

Zimbabwe

Zambia

Tanzania

Angola

DemocraticRepublic of Congo

Rwanda

Ethiopia

Malawi

Somalia

South Sudan

Children beyond primaryschool age with no orincomplete primaryeducationChildren of compulsoryschool age but not attendingschool


3.3.1GenderandeducationdeprivationTable 2 shows the shares of children of compulsory school age not attending school as well as children beyond primary school age with no or incomplete

primary education by gender. For some countries—notably Somalia, South Sudan Tanzania, Rwanda, Zimbabwe and DRC, girls are significantly more deprived than boys. For Tanzania and Zambia, girls are more deprived compared to boys for both attendance and attainment deprivation. For Rwanda, Zimbabwe and Malawi, girls have lower rates of attainment and hence higher rates of deprivation than boys. In particular, the attainment deprivation rates are 43% vs 54% for Rwanda, 14% vs. 22% for Zimbabwe and 51% vs 59% percent for Malawi, for girls versus boys respectively. The statistics in the chart should be interpreted with caution—especially for countries like Somalia and South Sudan who are currently experiencing conflict. Recent statistics from UNICEF show a large population of out of school children and large gender gaps in primary school enrolment in South Sudan. In 2015, in South Sudan, the rate of out-of-school children aged 6-12 years was 59% while there were two girls for every three boys enrolled in primary school.48

48 UNICEF (2015) The State of the World’s Children 2015

12


Table 2: Gender differences in education deprivations

All Male Female All Male Female

All 10 selected countries 12.2 12.3 12.1 48.3 48.7 47.8

Angola 11.9 11.8 12.1 55.2 53.9 56.4

Rwanda 2.9 3.4 2.3 48.1 53.7 42.5

Zimbabwe 1.8 2.1 1.3 18.3 22.4 14.1

Ethiopia 17 17.2 16.8 54.8 54.6 54.9

Tanzania 11.3 12.4 10.2 27.9 33.6 21.6

Zambia 8.1 8.8 7.3 28.7 29.8 27.6

Malawi 2.8 3.2 2.4 55.6 59.2 51.4

DRC 10 9.3 10.8 41.8 38.7 45

South Sudan 51.6 50 53.2 81.8 78.2 85.4

Somalia 37.2 34.9 39.7 64.7 58.6 70.6

Source: Authors calculations from the DHS and MICS surveys

Share of children of compulsory

school age not attending school

Share of children beyond

primary school age with no

or incomplete primary

education

Universal primary education (UPE) programmes in countries such as Ethiopia and Malawi have partly addressed the historical disadvantage faced by young girls. Specifically, gender disparities in primary schooling have been significantly

reduced as result of free education programmes. However, although UPE programmes addressed schooling issues for young girls, there has not been corresponding programmes targeting adolescent girls.

13


3.4 AccesstowaterFigure 6 shows the extent of water deprivation—based on either use of an unimproved water source49 or if the distance to the water source takes more than 30 min to search for water. DRC Congo leads in having the largest proportion of children who reside in a household with an unimproved water source (58%) followed by Angola (47%) and Zambia (41%). On the other hand, children are most distant from water sources in South Sudan (39%) followed by DRC (35%) and Ethiopia (34%).

49 The following water sources are considered as unimproved: unprotected well into yard, public unprotected well, surface water (i.e. river, dam, pond etc.), tanker truck, and any other unspecified water source category.

Figure 6: Extent of water deprivation in selected ESARO countries (%)

14

19

23

27

28

37

39

41

47

58

28

36

19

33

30

34

27

14

19

35

Malawi

South Sudan

Zimbabwe

Rwanda

Somalia

Ethiopia

Tanzania

Zambia

Angola


Children who live in households it takesmore than 30 min to search for water

Children in a household usingunimproved water source


14


4. Extent of multiple childhood deprivation among selected ESARO countries

4.1 Singledeprivationanalysis

Figure 7: Deprivation headcount rate by indicator (%)


HouseholdleveldimensionsFor all the 10 countries combined Figure 7 reveals that water and housing are the most common form of deprivation among children aged less than 18 years. On average, 51% of children in the selected countries are deprived of water.

With regard to the housing dimension Figure 7 shows that children are twice more likely to be

affected by overcrowding (41%) than having floors and roofs made of natural materials (21%).50 Furthermore, children in at least 2 countries, namely, South Sudan and DRC are deprived in housing at rates greater than 70% (See Figure 8 and 9). Water and housing deprivation are closely followed by sanitation deprivation (48%). Overall, the highest deprivation rates are household-level dimensions (i.e. water, housing, and sanitation).

50 A child is deprived if either if both roof and floor are made of natural material—which are not considered permanent. Natural materials for floor include earth and cow dung while those of the roof include grass thatch.

15


IndividualleveldimensionsFor individual-level dimensions, especially relating to nutrition, Figure 7 shows that deprivation in the Infant Young, and Child Feeding (IYCF) is the most dire indicator with 57% of children aged 0-4 years deprived in it. South Sudan (73%) and Malawi (58%) are the most deprived countries with respect to infant feeding (Table A2). Figure 7 also shows that about 48 percent of children less than 5 years are deprived of health. Furthermore, Figure 8 shows that the 3 countries with the highest proportion of young children deprived in health are Somalia (82%), Ethiopia (67%) and Angola (62%). The above table also shows that children in Rwanda (27%) and Zimbabwe (30%) are the least deprived in health. The relatively well functioning health system in Rwanda, explains partly, why the country experiences considerably very low health deprivations (See explanation in section 3.2). Within the health dimension, Table A2 shows that young children are more affected by unskilled birth attendance (39%) than failure to receive all 3 DPT immunizations (24.3%). Table A2 also shows that Ethiopia, Somalia, South Sudan and Angola lead in both having the highest proportion of unskilled birth attendance as well as the lowest DPT immunizations, while Rwanda and Malawi have both the least proportions of un-attended births and highest rate of DPT immunizations.

Deprivation in water is defined as a child either using an unimproved source or a source that is more than 30 minutes away (union of the two indicators). Water deprivation rates vary across countries and depending on demographic category. Children aged 0-4 years are

slightly more deprived of water compared to children aged 5-17 years (Figures 8 and 9). With respect to countries considered, Table A2 shows that DRC, Angola and Ethiopia have the highest rates of water deprivation—73%, 56%, 55% of children are deprived in the water dimension respectively. For the water dimension, the source is major cause of deprivation is use of an unimproved source for drinking water rather than the distance to the water source. However, the two indicators of water deprivation do not seem to intersect considerably as 34% of children have unimproved water source while 27% are in a household where it takes thirty or more minutes to fetch water (Table A2). This suggests that, for children deprived of water, only one of the indicators is met satisfactorily.

Although violence is one of dimension with the lowest proportion of child affected, for some countries it is a major source of deprivation. Children from Somalia are least protected from violence—Table A2 shows two out of every three children face some form of violence in the country. The impacts of conflicts have led to separation of children from their families and parents, leaving them exposed to abuse, violence and exploitation. Previous assessments note that children living on the streets of cities and towns in Somalia are suffering from substance abuse, violence, and increased vulnerability to recruitment, exploitation and physical and sexual violence.51

51 UNICEF, 2011, Inter-Agency Child Protection Rapid Assessment Summary Report.

16


Figure 8: Deprivation rates by indicator for children aged 0-4 years

0

30

60

90

Angola Zimbabwe Zambia Tanzania Rwanda Malawi DRC Ethiopia SouthSudan

Somalia

Nutrition Health Water Sanitation Housing Domestic violence


Figure 9: Deprivation rates by indicator for children aged 5-17 years

0

30

60

90 Education Information Water Sanitation Housing Domestic violence


17


Rural-urbandisparitiesAs indicated in Figure 10, regardless of demographic group, there are wide variations in the dimensions deprived depending on where a child resides. Specifically, children in rural areas are significantly more deprived than their urban counterparts, in almost all dimensions, with the notable exception of the nutrition and violence dimensions. For nutrition, the rural-urban differences are not significant whereas for violence, children in urban areas experience more violence than in rural areas. For both demographic groups, the difference in single dimension deprivation between rural and urban children is highest in the areas of housing and water, as children resident in rural areas have deprivation rates over 30 percentage points higher than urban children. For deprivation linked to housing, the source of the large divergence between rural and urban areas is having floors and roofs made of non-permanent natural materials—where rural children are more than three times more likely to be resident in households with natural materials than urban children (52 % vs. 15% respectively). This is explained primarily by the household status on the welfare distribution—rural households are poorer and as such less likely to afford permanent construction materials.For water, the divergence is explained by the distance to the water source—rural children are about twice more likely to be in a household where it takes thirty or more minutes to fetch water compared to urban children (32% vs 16% respectively). This is explained

by the limited availability of water infrastructure in rural areas than urban areas due to costs. Certain water infrastructure e.g. public stand-posts can only be provided to geographically concentrated population—a key characteristic of urban households—compared to geographically dispersed population in rural areas.

4.2 MultidimensionaldeprivationAs explained in this study, multiple deprivation considers the proportion of children that are deprived in more than one dimension. Figure 11 shows the numbers of deprivations per child for children aged 0-4 years and those aged 5-17 years by area of residence for all the 10 countries combined. It is indicated that majority of children in 3 or more dimensions simultaneously. Regardless of area of residence, the “all category” shows that the distribution is skewed to the right, indicating that showing a higher percentage of children deprived in more dimensions—especially in 3 to 4 dimensions. Furthermore, there are differences between rural and urban children, in other words, the distribution of deprivations for urban children are skewed to left indicating that majority are deprived in 1 to 2 dimensions while for children in rural areas, deprivations are skewed towards the right. Additionally, there are major differences between young and older children, as a substantial proportion of older children are not deprived in any dimension (16% for all children regardless of the area which they reside in) and this rate rises to 32% in urban

Figure 10: Deprivation headcount rates by dimension and area

39.8

55.5

60.965 64.5

26.7

36.9

32.130.1

33

26.830.4

Nutrition Health* Water* Sanitation* Housing* Violence

Children 0-4 years

Rural Urban

28.2

41.4

57.2

52.8

60.8

25.3

17.9

11.8

28.4 28.9 27.5 28.4

Education* Information* Water* Sanitation* Housing* Violence*

Children 5-17 years

Rural Urban


18


areas. Indeed, in urban areas, the rate of deprivation reduces significantly with the increase in number of dimensions considered. Among older children, the majority are deprived in 2-3 dimensions. Analysis by gender (not indicated in the chart) shows that there are no significant differences in head count deprivation for either young or older children.

Figure 11: Headcount by number of dimension and residence (all 10 countries)

8.2

15.5

22.5

25.3

20.1

8.5

Deprivedin 0

Deprivedin 1

Deprivedin 2

Deprivedin 3

Deprivedin 4

Deprived in5 or more

0-4 years All

Rural

Urban

16.1

21.222.6

21.2

13.7

5.3

Deprivedin 0

Deprivedin 1

Deprivedin 2

Deprivedin 3

Deprivedin 4

Deprivedin 5 or more

5-17 years All

Rural

Urban


Table A3 in the appendix show the percent of all children who are deprived, by numbers of deprivations per child for children aged less than 5 years. There is variation across countries regarding most frequent number of deprivation. In Angola (26.8%), Zimbabwe (26.9%) and Rwanda (40.8%), one deprivation per child is mostly prevalent. In Tanzania (25.2%), Malawi (31.9%), and Somalia (30.2%), two deprivations per child are most prevalent while in Zambia (24%), DRC (30%) and South Sudan (34.5%) it is three dimensions per child. It is only in Ethiopia (30.6%), where four deprivations per child are most common. The above distribution is similar for both children aged 0-4 years and children aged 5-17 years with the exception for Zimbabwe and Ethiopia for children aged 5-17 years. Table A4 shows that no deprivation at all is most prevalent in Zimbabwe whereas Ethiopia joins Zambia, DRC and South Sudan in having three deprivations per child as the most common among children aged 5-17 years.

Figure 12 graphically shows the number of dimensions deprived for children in Zimbabwe, Zambia, Tanzania, Malawi and Ethiopia.. In Zimbabwe, younger children

are more deprived compared to children aged 5-17 years. At least 36.5% of children aged 5-17 years do not experience any dimension in Zimbabwe compared to only 25.5% for children aged 0-4 years. In contrast, in Zambia, children aged 5-17 years’ experience more deprivations compared to younger children. In particular, 34.7% of children aged 5-17 years in Zambia experience none or one dimension compared to only 24.6% for children aged 0-4 years. On the other hand, a lower proportion of children aged 5-17 years in Zambia experiences 3 or more dimensions (43%) compared to children aged 0-4 years (56.1%).

For Tanzania, Figure 12 shows that children aged 5-17 years are twice more likely to experience none or one dimension (53.4%) compared to children aged 0-4 years (26.5%). Furthermore, younger children are more likely to be deprived in 3 or more dimensions (45.6%) than older children (24%). The distribution for Malawi is similar to that of Tanzania. Overall, Figure 12 shows that that multiple deprivations among infants and older occur frequently. Zimbabwe stands out as a country with the lowest rates of multiple deprivations.

19



36.6

24.9

19.2

13.7

4.7

0.9 0.1

0 1 2 3 4 5 6% o

f ch

ild

ren

5-1

7 y

ea

rs

Number of deprivations experienced (5-17 years)

Zimbawe (DHS,2015)

25.526.9

20.4

15.2

9.1

2.50.4

0 1 2 3 4 5 6

% o

f ch

ild

ren

0-4

ye

ars


Zimbabwe (DHS 2015)

15.8

19.1

22.223.1

14.4

5.0

0.5

0 1 2 3 4 5 6Number of deprivations experienced

(5-17 years)

Zambia (DHS 2013)

9.0

15.6

19.4

24.0

21.4

8.8

1.9

0 1 2 3 4 5 6

% o

f ch

ild

ren

0-4

ye

ars


Zambia (DHS 2013)

24.9

28.5

22.6

14.5

7.1

2.2

0.2

0 1 2 3 4 5 6Number of dimensions experienced(5-17 years)

Tanzania (DHS 2015)

4.8

21.7

27.9

24.5

14.5

5.4

1.2

0 1 2 3 4 5 6

% o

f ch

ild

ren

0-4

ye

ars


Tanzania (DHS 2015)

Figure 12: Number of deprivations children suffer from, by age-group

20



21.2

27.6 26.8

17.6

6.0

1.00.0

0 1 2 3 4 5 6


Malawi (DHS 2015)

14.3

26.7

31.9

18.5

6.9

1.50.2

0 1 2 3 4 5 6

% o

f ch

ild

ren

0-4

ye

ars

Number of deprivations experienced(0-4 years)

Malawi (DHS 2015)

5.9

9.9

15.2

24.6

30.0

14.4

0 1 2 3 4 5Number of deprivations experienced

(5-17 years)

Ethiopia (DHS 2016)

3.96.6

14.0

29.1

33.7

12.8

0 1 2 3 4 5

% o

f ch

ild

ren

0-4

ye

ars

Number of deprivations experienced(0-4 years)

Ethiopia (DHS 2016)

4.3 Multidimensionaldeprivationinruralareas

There are large differences across and within countries regarding the distribution of deprivation. First, regarding area of residence, children in rural areas are worse off in every dimension, especially in housing and water. The only exception is the protection from violence dimension where urban children are more exposed to violence than their rural counterparts. Secondly, across countries, there are wide variation in extent of multiple deprivation. Figure 13 shows the deprivation distribution in rural areas by country for children under five years old. It is indicated, the largest proportion of children not deprived in any dimension in rural areas is in Rwanda (21%) followed by Zimbabwe (12%). In the other countries, it seems that children experience at least one dimension of deprivation. On the other side of

the distribution, Ethiopia (16.8%) and Zambia (13%) lead the countries in having children deprived in at least 5 dimensions simultaneously.

Furthermore, whereas seven in ten young children in rural areas in Rwanda experience only or two deprivations at the same time, in Ethiopia and DRC, more than eight out of every ten young children in rural areas experience at least three or four deprivations simultaneously. The above results may be explained by depth of deprivations across countries. For example, in Rwanda, the two leading dimensions of deprivations among young children are water (48.5%) and nutrition (27%). On the other hand, in Ethiopia, the leading dimensions of deprivation is sanitation (83%) followed closely by health (67%), and housing (61%). For DRC, the three leading dimensions are housing (75%), water (73%) and sanitation (63%).

21


Figure 13: Deprivation distribution in rural areas by country - children under five years old

0.6

3.6

13.6

29.1

36.3

15.4

1.4

0 1 2 3 4 5 6

Ethiopia (2016)

0.5

7.3

27.2

35.1

22.3

7.5

0 1 2 3 4 5

% o

f chi

ldre

n 0-

4 ye

ars

in r

ural

are

as

South Sudan (MICS 2010)

0.7

3.9

17.0

32.934.1

11.4

0 1 2 3 4 5

% o

f ch

ildre

n 0-

4 ye

ars

in r

ural

are

as

Democratic Republic of Congo (DHS 2013)

20.6

42.6

27.6

8.0

1.1 0.1

0 1 2 3 4 5

% o

f ch

ild

ren

0-4

ye

ars

in r

ura

l are

as

Rwanda (DHS 2015)

9.4

25.1

34.8

20.8

7.9

1.80.2

0 1 2 3 4 5 6

% o

f ch

ild

ren

0-4

ye

ars

in r

ura

l are

as

Malawi (DHS 2015)

3.4

17.2

26.9 27.0

17.3

6.7

1.6

0 1 2 3 4 5 6

% o

f Chi

ldre

n 0-

4 ye

ars

in r

ural

are

as

Tanzania (DHS 2015)

11.6

21.9

25.3

22.5

14.3

3.8

0.7

0 1 2 3 4 5 6

% o

f Chi

ldre

n 0-

4 ye

ars

in ru

ral a

reas

Zimbabwe (DHS 2015)

2.1

7.4

17.2

28.8 29.1

12.8

2.7

0 1 2 3 4 5 6

% o

f Chi

ldre

n ag

ed 0

-4 y

ears

in ru

ral a

raes

Zambia (DHS 2013)


22


4.4 OverlappingdeprivationIt is important to understand whether children predominantly experience a single dimension or multiple dimensions simultaneously, across countries. Figure 14 considers the extent of overlap of dimensions for nutrition, health and education for 10 countries by area of residence. The blue bar shows the proportion of children deprived in only the specified dimension while subsequent bars shows the proportion of children deprived in both the specified dimension and others and no other dimensions, while the other parts of each bar show how many children are deprived in the specified dimension and also other

dimensions concurrently. The larger the blue bar is, in comparison to the other bars, shows that the specified dimension is a unique issue. Apart from Zimbabwe, education deprivation is also a unique concern in among children in urban Malawi and Rwanda. Similarly, nutrition is a unique challenge among young children in urban Rwanda.

For Rwanda, while both rural and urban are equally deprived in nutrition, (the entire bar shows; 25% for both). Whereas 59% of urban children experience malnutrition as a unique problem, only 27% of rural children do the same in rural areas. At least 45% of malnourished children in rural Rwanda are deprived

in one other dimension compared to only 28% in urban areas.

For countries such as South Sudan, Zambia, DRC, Ethiopia and Somalia, about 66 percent of the children living in rural areas are either deprived in health, nutrition or education, are also deprived in three to five other dimensions. Of the 50% children deprived in health in Zambia, 13% are deprived in two other dimensions while 32% are deprived in three or more dimension in addition to health. Similarly, out of the 37% children deprived in nutrition in rural Zambia, 7.8% are deprived in two other dimensions while 25.2 are deprived in at least 3 dimensions in addition to nutrition.

The extent of multiple deprivations among children aged 5-17 years, deprived in education is less severe compared to either health or nutrition for children aged 0-4 years. The only exception is South Sudan, where the extent multiple deprivation with education outweighs that with health or education. It is worth noting that a high overlap between any two dimensions may not necessarily suggest a relationship between the two dimensions. These results point to need for integrated approaches to address the various aspects of childhood poverty.

1.4

13.9

25.6

29.0

21.9

8.3

0 1 2 3 4 5

% o

f chi

ldre

n 0-

4 ye

ars

in r

ural

are

as

Somalia (MICS 2011)


23


Figure 14: Deprivation overlap by dimension and country

0.0% 20.0% 40.0% 60.0% 80.0%

Urban

Rural

Urban

Rural

Urban

Rural

Educ

atio

n(5

-17)

Hea

lth(0

-4)

Nut

ritio

n(0

-4)

Tanzania (DHS 2015)

Deprived only in the specified dimension Deprived in 1 other dimension

Deprived in 2 other dimensions Deprived in 3-5 other dimensions

0.0% 7.0% 14.0% 21.0% 28.0% 35.0%

Urban

Rural

Urban

Rural

Urban

Rural

Educ

atio

n(5

-17)

Heal

th(0

-4)

Nut

ritio

n(0

-4)

Zimbabwe (DHS 2015)



0.0% 20.0% 40.0% 60.0%

Urban

Rural

Urban

Rural

Urban

Rural

Educ

atio

n(5

-17)

Hea

lth(0

-4)

Nut

ritio

n(0

-4)

Zambia (DHS 2013)



24


0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

Urban

Rural

Urban

Rural

Urban

Rural

Educ

atio

n(5

-17)

Hea

lth

(0-4

)N

utri

tion

(0-4

)

South Sudan (MICS 2010)



0.0% 7.0% 14.0% 21.0% 28.0% 35.0%

Urban

Rural

Urban

Rural

Urban

RuralEd

ucat

ion

(5-1

7)H

ealth

(0-4

)N

utrit

ion

(0-4

)

Malawi (DHS 2015)



0.0% 20.0% 40.0% 60.0%

Urban

Rural

Urban

Rural

Urban

Rural

Educ

atio

n

(5-

17)

Hea

lth

(0

-4)

Nut

riti

on

(0

-4)

DRC (DHS 2013)



25


0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Urban

Rural

Urban

Rural

Educ

atio

n

(5-1

7)He

alth

(

0-4)

Somalia (MICS 2011)



0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

Urban

Rural

Urban

Rural

Urban

RuralEd

ucat

ion

(5-1

7)He

alth

(0-4

)Nu

triti

on(0

-4)

Rwanda (DHS 2015



0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Urban

Rural

Urban

Rural

Urban

Rural

Educ

atio

n(5

-17)

Hea

lth(0

-4)

Nut

ritio

n(0

-4)

Ethiopia (DHS 2016)



26


Figure 15 shows the contribution of 5 dimensions to childhood deprivation for children aged less than 5 years.52 Sanitation contributes the largest share to total deprivation for the 9 countries considered.53 For all countries combined, sanitation is followed by housing, water, health and nutrition in that order. Overall, the two dimensions of sanitation and housing

52 The violence dimension is excluded since a number countries (Rwanda, DRC, and South Sudan) have missing information for this dimension.

53 Somalia is excluded due to lack of data for the nutrition dimension.

contribute about 50 percent of observed deprivation for most countries. The only exceptions are Angola, Rwanda and Tanzania. For Rwanda and Tanzania water contributes the highest share to deprivation, notably 36 and 27 percent respectively, while in Angola, health contributes the largest proportion of deprivations amongst children (27 percent).

Figure 15: Contribution of each dimension to the total adjusted multidimensional deprivation ratio: children experiencing 2-5 deprivations

0%

20%

40%

60%

80%

100%

Total Zimbabwe Zambia Tanzania Rwanda Malawi DRC Ethiopia SouthSudan

Angola

Cont

ribu

tion

to

the

adju

sted

dep

riva

tion

he

adco

unt

in %

Nutrition Health Water Sanitation Housing


27


5. Conclusions and implicationsThis study details why child deprivation remains an important issue in the East and Southern Africa region. Despite the efforts made by countries in Sub- Saharan Africa, to reduce mass deprivation, poverty remains high. Furthermore, a large population of children continue to face multiple deprivation. A number of issues underpin multiple child poverty deprivation in the East and Southern Africa region, ranging from lack of basic health services to distant water infrastructure and exposure to conflict and crises situation. This implies that the gains from reductions in the proportion of persons affected by monetary poverty are outweighed by large population of children facing destitute conditions. Based on the findings of the report, we make the following recommendations to policy makers, governments and civil society:Adoption of supportive laws, policies and strategies for realization of child sensitive social protection: Social protection has emerged as a tool that addresses poverty, inequality and exclusion. Strengthening social protection requires a strong legal framework for its advancement. Save the Children International and APSP advocate for a specific legal framework on social protection which should be guided by child sensitive provisions as well as a social protection policy that guides the administration of social protection programmes. Beyond implementing interventions within sectors, countries in the East and Southern Africa region need to develop supportive policies, laws and national strategies that address multiple deprivations. Similar to the overarching

national development plans (NDPs) currently under implementation in a number of countries, there is need to create and implement specific national action plans to reduce child poverty with consideration of multiple deprivations The ultimate goal of such plans would be to emphasize programmes and interventions that are child sensitive in nature and that consider the holistic needs of children. Given, the very high levels of deprivations in most of the countries considered, there is need to tailor social protection interventions to country contexts. Design of integrated social protection programmes: Social protection programmes should be designed to address both the economic and social vulnerabilities of children whilst supporting children as active participants of social change in their lives, including in their communities, societies. There is need to scale up both unconditional cash transfer programmes to target more children from marginalised, deprived and vulnerable families, and those in emergencies or in countries experiencing conflict. Furthermore, in order to create impact a child sensitive social protection, there is need for each country to define a minimum package for child sensitive social protection. This package includes access to education, health, food and nutrition, shelter, child friendly WASH facilities and protection from abuse. The social protection packages should be comprehensive to include the needs of children within a specific context. In addition, to providing community health services, some countries notably DRC, Zambia, Ethiopia, and Angola requires

28


interventions to boost child nutritional status. For the latter case, the focus should be on ensuring exclusive breast feeding during the first 6 months after birth. In addition, the delivery of social protection programmes should be timely and predictable. For example, if the cash transfer contributes to school levies, this should be timely, to avoid non- attendance of school. Social protection programmes should be designed while taking into consideration age and gender specific needs.

To support efficient child sensitive social protection programmes, Save the Children advocates that CSSP programmes must be linked to programmes that strengthen their impact (Save the Children, 2017 p. 3). Save the Children believes that cash transfers must be accompanied by “complimentary actions and interventions (otherwise termed Cash Plus). These interventions can include behavioural change outcomes, supporting income strengthening activities for parents, supporting families to strengthen child care practices and an increase in investments in children at household level (Save the Children, 2017 p. 3). Save the Children believes that CSSP must be accompanied by interventions that are rooted in “strengthening the care and agency of children” (Save the Children, 2017, p. 5)

Adoption of Social Protection Floors: As defined by the ILO, social protection is floors are basic social security guarantees which include the following: a) access to services and goods in the areas of

health, nutrition and education, which must be defined by national governments.

b) Basic income security for children including, health, nutrition and education as well as income security for persons unable to secure adequate income &

c) Basic income security for older persons54

In addition to social protection programmes there is a dire need for countries in the East and Southern Africa region to define their Social Protection Floors which act as the first level of a comprehensive national social protection system that helps realize human rights for all through guaranteeing universal access to essential services including health, education, housing, water and sanitation, and other services as nationally defined. This is in addition to the provision of social transfers, in cash or in

54 International Labour Organisation, 2012, R202 - Social Protection Floors Recommendation, 2012 (No. 202)

Recommendation concerning National Floors of Social Protection, Geneva: ILO, available from http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:R202

kind, to guarantee income security, food security, adequate nutrition and access to essential services. Such social protection floors should be country and context specific, depending on the multiple deprivations experienced by children.

Promote a rights based approach to social protection: countries need to adopt a rights based approach to social protection, and move away from treating social protection as charity. Social protection programmes should embody with human rights principles of equality and non-discrimination. Specifically, social protection should incorporate the principles of accessibility, adaptability, adequacy, transparency, participation and accountability. Additionally, social protection programmes should be cognisant of discrimination that may emerge even among the vulnerable dues to factors such as gender, age or disability.

Investment of more financial resources for social protection of children: Investment in children results in a positive impact on a child’s development beyond childhood. Although the national budgets in countries in East and Southern Africa, continue to expand, resources are not sufficiently are allocated to meet the needs of marginalised and deprived children and their families. As budgets expand, there is need to allocate budgets for introducing or expanding cash transfer schemes. As demonstrated by Rwanda, community health insurances—which covers maternal and child health services, can go a long way in improving health outcomes for children. In Rwanda, the government contribute to part of insurance premiums based on poverty status. Countries with substantial natural resources such as Angola can go a step further implement child support grants to vulnerable families.

Strengthen income security of children and their families and access to quality basic services: In order to enhance child wellbeing, there is need to strengthen income security of parents and caregivers as an essential strategy in reducing child poverty and breaking intergenerational transmission of poverty. Apart from focusing on labour policies that promote the labour rights of working adults and caregivers, and sufficient cash income, income security also focuses on access to basic services for children and their families. There is need for investment of more financial resources for children to promote access to basic services including education, health, water, housing and sanitation. This study shows that children in the East and Southern Africa region are deprived especially in water, housing and education. This means that countries in ESARO must improve the

29


access to quality basic services in order to promote child wellbeing.

Institutional coordination of social protection programmes and social services: In addition to cash transfers, donors in East and Southern Africa region, need to support institutional coordination among relevant government Ministries to mainstream social protection, influencing budget allocation and spending. Such coordination can make the case for robust economic justice policies that address child poverty and multiple deprivation. An integrated social protection system is highly effective in addressing the multiple deprivations that are experienced by children. A multi-sector approach is also key in creating the linkages between social protection and other sectors that have an impact on child wellbeing, including education, health, nutrition, water and sanitation and violence among others.

Advocacy for CSSP by CSOs: Civil Society Organizations need to highlight the multiple deprivations children face, and to advocate for the use of integrated and child focused social protection options that address the multiple causes of child poverty in East and Southern Africa region. Such advocacy is based not only on the extent of child deprivation but also on the existence of legal and policy frameworks on social protection that provide an opportunity for analysis of child sensitive intervention by governments. Key areas of advocacy include provision of nutrition information, advocacy for exclusive breast feeding, and effective weaning practices, promotion of school feeding programmes as well as access to water and housing.

Promote child participation: The design of social protection programmes should be child sensitive, embracing the principles of child participation in the design and delivery of social protection programmes. Most social protection programmes in the region have been designed through a Top-down model, where many governments in the East and Southern Africa region, have designed programmes with minimal consultations with beneficiaries especially children. In line with the UNCRC principles that promote child participation55, it is essential that children’s views are represented in the design, delivery and monitoring of social protection

55 Article 12 of the Convention inculcates the view that of every child has the right to “freely express her or his views, in all matters affecting her or him, and the subsequent right for those views to be given due weight, according to the child’s age and maturity” (Committee on the Rights of the Child, GENERAL COMMENT No. 12 (2009) The right of the child to be heard, Geneva: UNCRC).

programmes. Such participation should be cognisant of the evolving capacities of children.

Collect comparable data across countries: This report shows that challenges remain within the East and Southern Africa region regarding the availability and usefulness of data required to understand as well as address childhood poverty. The availability of data should inform national child poverty plans of action as well as national poverty targets. There is a need for national statistical agencies to regularly collect information and publish national child poverty measurements to raise awareness of the challenge child poverty among policy audiences, civil society and national governments. Furthermore, child poverty measurements should be comparable across the East and Southern Africa sub region. National statistical departments can spear-head the collection of regional and national representative surveys, that could offer a more comprehensive outlook on the extent of extreme and multi deprivation in the region.

Monitoring and evaluation: As part of monitoring and evaluation, the measurement of child poverty should have tracking indicators that respond to the needs of the child. The indicators can be drawn from the minimum package for child sensitive social protection as determined by a country. In addition, indicators used in the measurement of child poverty should include provisions that allows children to give their views on policies and programmes related to addressing multiple deprivation.

Address conflicts: This study shows that most of the countries with the highest levels of deprivation, in the East and Southern Africa region are either experiencing conflicts or are post-conflict states (e.g. in Somalia, South Sudan and DRC). In such countries, Furthermore, substantial public resources are currently devoted to addressing regional conflicts—resources that could have been used to expand social safety nets within the countries. As such, here is an urgent need to address the drivers of conflicts within East and Southern Africa region.

Finally Save the Children and the Africa Platform for Social Protection believe that CSSP programmes should be designed to meet the needs of and address the root causes of poverty in childhood. The delivery mechanisms of CSSP programmes should not put children at risk, and should be sustainable and reasonable. The size, amount and frequency of the transfer should be adequate to meet the holistic needs of children at all times.

30


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Alkire, S, Jindra, C, Robles, G and A. Vaz (2017). “Children’s Multidimensional Poverty: Disaggregating the global MPI,” Briefing 46, May 2017, University of Oxford

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Binagwaho, A., C. Lu1, B. Chin (2012) “Towards Universal Health Coverage: An Evaluation of Rwanda Mutuelles in Its First Eight Years”. PLoS ONE Vol 7. No. 6

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Committee on the Rights of the Child (2009) “General Comment No. 12 (2009) The right of the child to be heard”, Geneva: UNCRC

De Neubourg, C., J. Chai, M. de Milliano, I. Plavgo, Z. Wei (2012). “Cross-country MODA Study: Multiple Overlapping Deprivation Analysis (MODA) - Technical note”, Working Paper 2012-05.

Dhillon, R, S., M.H. Bonds., M. Fraden et al (2012) “The impact of reducing financial barriers on utilization of a primary health care facility in Rwanda”. Global Public Health Vol 7. No.1L 71-86.

Federal Government of Somalia (2013), Health Sector Strategic Plan 2013-2016: Ministry of Development and Public Services – Directorate of Health, Mogadishu

Food Security and Nutrition Analysis Unit – Somalia (2016). Somalia Food Security and Nutrition Analysis: Post Gu 2016” Technical Series Report No VII. 69

Gordon, D., Nandy, S., Pantazis, C., Pemberton, S., and Townsend, P. (2003a). The Distribution of Child Poverty in the Developing World. Bristol, UK, Centre for International Poverty Research.

Gordon, D., Nandy, S., Pantazis, C., Pemberton, S., and Townsend, P. (2003b). Child Poverty in the Developing World. Bristol, UK, Centre for International Poverty Research.

Harland-Scott, Charlotte & Istratil, Romina 2016 Child Poverty: What drives it & what it means to children across the world: A report for Save the Children (London: Save the Children UK).

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Lynch, C. (2005) Report on knowledge attitude and practices for malaria in Somalia (Mogadishu: Malaria Consortium)

Kanamori, M.J and T. Pullum (2013) “Indicators of Child Deprivation in Sub-Saharan Africa: Levels and Trends from the Demographic and Health Surveys” DHS Comparative Reports No. 32.

Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF (2016).

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32


AppendixTable A 1: Selected ESARO countries

Country/sub region Remarks/Basis for selection

(A) EAST AFRICA

1 Tanzania (2015/16) Presence of a recent DHS survey and low human development indices (ranked 151 out of 188 countries in the 2016 HDI)

2 Rwanda (2014/15) Recent DHS survey, presence of large scale social protection programme and low human development indicators (ranked 159/188 in the 2016 HDI)

3 Ethiopia (2016) Recent DHS, presence of large scale social protection programme and very low human development outcomes (ranked 174 out of 188 countries in 2016).

4 Somalia (2011) Humanitarian challenges: a country with a history of civil war with a MICS survey conducted in 2011

(B) CENTRAL AFRICA

5 Democratic Republic of Congo (2013)

A DHS survey conducted in 2013, a country will re-occurring humanitarian challenges due to history of civil conflict and very low human development indicators (ranked 176 out of 188 countries).

6 South Sudan (2010) A country with a history of humanitarian challenges, very recent civil conflict as well as presence of a MICS survey conducted in 2010.

(C ) SOUTHERN AFRICA

7 Angola Presence of a recent DHS survey and humanitarian challenges: extended conflict experience (1975-2002)

8 Malawi (2015/16) Presence of a recent DHS survey and very low human development indicators (ranked 170 out of 188 countries in 2016)

9 Zimbabwe (2015) Presence of a recent DHS survey as well as a MICS survey which can serve comparison

10 Zambia (2013) Presence of a DHS survey conducted in 2013 and higher incidence of multidimensional poverty in comparison to other countries such as Swaziland.

33


Tabl

e A

2:

Dep

riva

tion

hea

dcou

nt r

ate

by in

dica

tor

and

age-

grou

p

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

0 to

4

year

s

5 to

17

year

s

Nut

riti

on39

43.3

29.8

35.3

36.5

26.6

32.2

41.3

36.2

54.7

-In

fant

and

you

ng c

hild

feed

ing

56.8

62.7

53.1

52.7

51.9

45.7

57.9

55.8

48.7

73.3

-

Was

ting

(wei

ght

for

heig

ht)

8.7

5.1

3.6

6.5

4.9

2.3

3.2

8.2

12.2

22.3

-

Hea

lth

4862

.521

.138

.441

.67.

311

.441

.967

.356

.882

.3D

PT im

mun

isat

ion

(1-4

yea

rs)

24.3

40.4

8.7

9.8

7.1

1.4

4.6

34.2

30.6

35.9

69.5

Skill

ed b

irth

att

enda

nce

3953

.217

.933

.639

.96.

29

15.4

63.4

53.9

55.7

Edu

cati

on21

.930

.57.

512

.814

.917

.515

.122

22.7

58.2

45.6

Com

puls

ory

scho

ol a

tten

danc

e12

.212

.21.

88.

111

.32.

92.

810

1751

.637

.2

Prim

ary

scho

ol a

ttai

nmen

t48

.355

.218

.328

.727

.948

.155

.641

.854

.881

.866

.7

Info

rmat

ion

3124

.87.

919

.713

.423

.632

.942

.135

.658

.558

.5-

21.4

Info

rmat

ion

devi

ces

3124

.87.

919

.713

.423

.632

.942

.135

.658

.558

.5-

21.4

Wat

er49

.255

.953

.231

.235

.948

.946

.752

.850

.348

.548

.536

.335

.973

.169

.655

.152

.546

.946

.940

.939

.6D

rink

ing

wat

er s

ourc

e34

.249

.546

.321

.223

.242

.139

.941

.138

.127

.127

.414

.713

.561

.757

.639

.236

.420

19.2

2927

.8

Dis

tanc

e to

wat

er s

ourc

e27

.420

.819

.116

.919

.714

13.8

26.9

26.7

33.4

32.7

27.5

2834

.634

.934

.933

.635

.936

.730

.330

.1

Sani

tati

on47

.738

.134

.537

.336

.763

.961

31.9

29.1

29.3

2819

.315

.963

.360

.482

.581

.786

.185

.932

30.3

Toi

let

type

47.7

38.1

34.5

37.3

36.7

63.9

6131

.929

.129

.328

19.3

15.9

63.3

60.4

82.5

81.7

86.1

85.9

3230

.3

Hou

sing

51.4

27.1

28.9

26.9

28.5

56.6

51.7

30.2

27.2

3.4

4.3

6051

.474

.870

.461

.163

.977

.378

.934

.141

.4Fl

oor

and

roof

mat

eria

l21

.217

.519

.57.

78.

915

.718

6.6

7.3

3.3

4.2

8.4

1214

.517

.243

.751

.736

.143

.230

.840

.1

Ove

rcro

wdi

ng40

.912

.812

.721

.822

.650

.244

.226

.522

.90.

10.

158

48.2

71.3

65.4

36.4

33.7

65.7

64.8

7.1

6.1

Pro

tect

ion

from

Vio

lenc

e26

.823

.620

.919

.215

.126

.222

.626

.622

.6-

17.3

24.7

21.4

-32

.516

.814

.6-

-65

.769

.8D

omes

tic v

iole

nce

26.8

23.6

20.9

19.2

15.1

26.2

22.6

26.6

22.6

-17

.324

.721

.4-

32.5

16.8

14.6

--

65.7

69.8

Sour

ce: A

utho

rs c

alcu

latio

ns fr

om t

he D

HS

and

MIC

S su

rvey

s

Ethi

opia

Sout

h Su

dan

Som

alia

Indi

cato

rD

imen

sion

All

sele

cted

co

untr

ies

Zim

babw

eZ

ambi

aT

anza

nia

Rw

anda

Mal

awi

DR

CA

ngol

a

Tabl

e A

3: D

epri

vati

on d

istr

ibut

ion

by lo

cati

on -

chi

ldre

n un

der

five

year

s ol

d

Num

ber

of d

epri

vati

ons

expe

rien

ced

01

23

45

60

12

34

56

01

23

45

6

Ang

ola

18.7

26.8

22.0

17.2

10.7

4.1

0.5

4.4

13.8

21.8

27.7

22.0

9.3

1.0

29.0

36.1

22.2

9.7

2.6

0.4

0.1

Zim

babw

e25

.526

.920

.415

.29.

12.

50.

411

.621

.925

.322

.514

.33.

80.

749

.335

.512

.12.

80.

30.

10.

0Z

ambi

a 9.

015

.619

.424

.021

.48.

81.

92.

17.

417

.228

.829

.112

.82.

721

.029

.823

.215

.57.

91.

90.

6

Tan

zani

a13

.221

.925

.220

.412

.65.

81.

07.

218

.425

.923

.815

.67.

21.

39.

536

.931

.416

.05.

21.

00.

0R

wan

da26

.740

.824

.37.

01.

00.

1-

20.6

42.6

27.6

8.0

1.1

0.1

-31

.733

.822

.68.

82.

30.

8-

Mal

awi

14.3

26.7

31.9

18.5

6.9

1.5

0.2

9.4

25.1

34.8

20.8

7.9

1.8

0.2

39.7

34.9

16.6

7.0

1.7

0.1

0.0

Dem

ocra

tic R

epub

lic o

f Con

go4.

29.

719

.630

.027

.68.

9-

0.7

3.9

17.0

32.9

34.1

11.4

-12

.723

.826

.222

.911

.72.

7-

Ethi

opia

5.9

8.8

15.0

26.0

30.6

12.7

1.1

0.6

3.6

13.6

29.1

36.3

15.4

1.4

28.8

31.1

20.8

12.6

5.8

0.9

-So

uth

Suda

n1.

28.

728

.034

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.96.

7-

0.5

7.3

27.2

35.1

22.3

7.5

-2.

912

.530

.132

.916

.94.

7-

Som

alia

4.2

19.2

30.2

23.8

16.1

6.5

-1.

413

.925

.629

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.98.

3-

5.4

28.3

38.2

19.2

7.6

1.3

-So

urce

: Aut

hors

cal

cula

tions

from

the

DH

S an

d M

ICS

surv

eys All

Rur

al a

reas

Urb

an a

reas

34


Tabl

e A

4: D

epri

vati

on d

istr

ibut

ion

by lo

cati

on -

chi

ldre

n 5-

17 y

ears

Num

ber

of d

epri

vati

ons

expe

rien

ced

01

23

45

60

12

34

56

01

23

45

6

Ang

ola

20.5

2721

.416

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.33.

90.

54.

914

.422

.227

.421

.28.

91.

137

.735

.920

.88.

62.

50.

30

Zim

babw

e36

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.213

.74.

70.

90.

120

.726

.325

.619

.36.

71.

20.

172

.921

.84.

50.

70.

20.

00.

0

Zam

bia

16.5

19.7

22.8

23.2

13.6

3.8

0.4

5.1

12.8

24.7

30.9

20.1

5.8

0.5

34.3

30.6

19.9

11.0

3.5

0.6

0.1

Tanz

ania

25.7

29.0

22.4

14.3

6.6

1.8

0.2

18.1

28.4

25.3

17.5

8.2

2.3

0.2

51.5

31.0

12.6

3.5

1.1

0.3

0.0

Rwan

da27

.235

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.62.

20.

20.

020

.836

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.412

.22.

50.

20.

053

.129

.612

.44.

00.

80.

10.

0

Mal

awi

22.7

27.7

26.6

16.9

5.4

0.7

0.0

16.1

27.8

29.7

19.4

6.2

0.9

0.0

57.4

27.5

10.6

3.4

1.0

0.1

0.0

Dem

ocra

tic R

epub

lic o

f Con

go7.

512

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.823

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10.

91.

25.

416

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.431

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.31.

220

.526

.124

.518

.38.

02.

30.

3

Ethi

opia

7.6

13.8

22.1

28.9

20.8

6.6

0.3

1.2

8.3

22.8

33.8

25.4

8.1

0.3

33.8

36.1

19.3

8.5

2.0

0.3

0.0

Sout

h Su

dan

1.5

6.2

15.9

28.8

31.5

16.1

-0.

63.

813

.628

.634

.419

.0-

4.0

12.7

22.3

29.5

23.4

8.0

-

Som

alia

6.7

21.6

25.4

20.6

14.4

8.4

3.0

2.2

10.6

23.0

24.2

21.8

13.3

4.9

10.3

31.9

30.5

17.2

7.0

2.8

0.4

Sour

ce: A

utho

rs c

alcu

latio

ns fr

om th

e D

HS

and

MIC

S su

rvey

s

All

Rur

al a

reas

Urb

an a

reas

(Foo

tnot

es)

1 C

entr

al S

tatis

tical

Age

ncy

and

ICF

(201

6). E

thio

pia

Dem

ogra

phic

and

Hea

lth S

urve

y 20

16: K

ey In

dica

tors

Rep

ort. A

ddis

Aba

ba, E

thio

pia,

and

Roc

kvill

e, M

aryl

and,

USA

. CSA

and

IC

F.2

Ibid

3 U

SAID

(201

4) E

thiop

ia Nu

trition

Pro

file4

UNI

CEF

(201

3)5

Ibid

6 Ib

id 7

Wor

ld H

ealth

Org

aniz

atio

n (2

014)

The

Hea

lth o

f the

Peo

ple:

Wha

t Wor

ks? T

he A

fric

an R

egio

nal H

ealth

Rep

ort

2014

.8

In D

RC

Con

go, a

t le

ast

27%

of c

hild

ren

have

a b

irth

inte

rval

of l

ess

than

2 y

ears

(M

inis

tère

de

la S

anté

Pub

lique

(M

SP)

and

ICF

Inte

rnat

iona

l. 20

14).

35


36


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