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Inequality Among Children in Reaching Their Developmental Potential
While child mortality has been decreasing around the world, children are not always able to thrive. This can be attributed in part to growing inequalities among children in different socioeconomic, geographic, and demographic groups. Speakers discussed inequalities among children, along with potential opportunities to improve conditions for children worldwide, including a greater emphasis on empowering women.
INEQUALITIES AND TWO GENERATION APPROACHES1
Mickey Chopra described the remarkable progress made around the world in reducing child mortality: child mortality levels have dropped from 12 million in 1990 to 6.6 million in 2012 (UNICEF, 2013a). This decline has occurred in all regions of the world, to a lesser or greater extent, including in unpromising settings. West and Central Africa saw a 40 percent decline, which was slightly less than average but still represented significant progress (UNICEF, 2013a). He cautioned, however, that this progress can mask certain inequalities. Because sub-Saharan African birth rates are soaring; the absolute number of children dying is the same or even greater now than it was in 1990 in more than 30 countries (UNICEF, 2013a), even with reduced mortality rates. Birth spacing also remains suboptimal, particularly in sub-Saharan Africa, indicating an unmet need for family planning in critical countries. Chopra encouraged
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1 This section summarizes information presented by Mickey Chopra, UNICEF.
an increased focus on the empowerment of women and the availability of family planning to improve child survival and development.
Countries have made significant progress in combating childhood illnesses such as malaria and diarrhea, but Chopra pointed out that there has been less progress on neonatal conditions, which in 2013 accounted for 44 percent of deaths in children under age 5 (WHO, 2012). He emphasized that critical developmental milestones occur in the earliest time periods, and more focus is needed in this area.
Gaps between the rich and poor are widening, with poorer populations less likely to have access to critical interventions and services (Barros et al., 2012). This is particularly true for newborn and maternal services. Chopra indicated that the largest inequalities are in accessing services such as having a skilled birth attendant and access to antenatal care visits. Even universal interventions, such as iodized salt consumption, show important economic disparities where the rich have far greater access.
Schooling is another area of inequality in access. Chopra highlighted data from Nigeria to explain the inequalities that exist. In Nigeria, children receive an average of 6.7 years of schooling (UNICEF, 2012a). However, there are sharp socioeconomic differences among different populations that vary by income, gender, geographic location, or ethnicity. Within each category, the richest children have more years of schooling than the poorest; boys have more schooling than girls; and those with the least access are poor, rural girls from the Hausa tribe who have essentially no education at all (UNICEF, 2012b).
To begin to address some of these inequities among children, Chopra described the Care for Child Development package created by the World Health Organization (WHO) and UNICEF (United Nations, 2013). The program is designed to teach caregivers better caregiver–child interactions. He showed results from the Pakistan Early Development Scale-Up trial (Yousafzki et al., 2012), which led to key improvements for children, including
- Higher-quality mother–child interaction
- Increased support for maternal psychosocial well-being
- Better quality of the home environment for child rearing
- Increased knowledge and practices pertaining to care for health, feeding, and development
- Better cognitive, language, and motor development outcomes for children
Chopra suggested that community-based interventions could have a significant impact in populations with limited access to interventions. These interventions could be quite simple and involve community work-
ers, and yet they could significantly improve areas of child development and stimulation. He provided an example of a social mobilization network in northern Nigeria, where UNICEF alone employs around 9,000 community health workers to combat polio. There are now more than 14,000 community health workers from UNICEF in the most deprived regions. Chopra indicated that these workers could be employed to provide services that support other areas of child development and support their caregivers. The cost-effectiveness of building off community platforms can be quite significant.
CHILD HEALTH AND NUTRITION AND THE LOSS OF HUMAN POTENTIAL IN INDIA2
Ramanan Laxminarayan stated that India lags behind other nations in early child development, despite impressive improvements in economic growth and child survival rates. He explained that 27 million children are born each year in India, and one-third of them are disadvantaged. Infant mortality in India was 4.7 percent in 2010 (World Bank, 2012), and 48 percent of children at age 5 are stunted (International Institute for Population Sciences and Macro International, 2007), with large variation across different Indian states (UNICEF India, 2011). While this number represents a significant improvement, Laxminarayan stated that this improvement still falls below the United Nations’ Millennium Development Goals.
Laxminarayan also showed data from a 2012 study (UNU-IHDP and UNEP, 2012) that examined inclusive wealth3 for different nations. He explained that the study showed that human capital dominates the inclusive wealth of such countries as Japan and the United States. Canada has a larger proportion of natural capital, though human capital still dominates its inclusive wealth. In India, by contrast, natural capital outweighs the human capital. Laxminarayan explained that human capital includes indicators and outcomes, such as population by age and gender, mortality probability by age and gender, employment, educational attainment, employment compensation, and labor force by age and gender. Human capital is a useful measure, as it can be otherwise difficult to measure how much a population is thriving. Laxminarayan argued that if early child development is enhanced, measures of human capital will improve.
Child malnutrition has been declining in India, but at a slow rate,
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2 This section summarizes information presented by Ramanan Laxminarayan, Center for Disease Dynamics, Economics, and Policy.
3 In 2012 the United Nations developed an inclusive wealth metric, which includes a full range of assets such as manufactured, human, and natural capital, to measure a nation’s wealth and the sustainability of its growth (UNU-IHDP and UNEP, 2012).
just under 1 percent per year. In contrast, Bangladesh has lowered its malnutrition rates an average of 3.5 percent per year (Gragnolati et al., 2005). Laxminarayan noted that one-fourth of children in the highest quintile of income are underweight (International Institute for Population Sciences and Macro International, 2007), indicating that food insecurity is not always a major factor. Crop yield has increased in the past 40 years,4 but calorie intake has simultaneously declined as data from the National Sample Survey indicates (Basu and Basole, 2012; Chandrasekhar and Ghosh, 2003; Deaton and Dreze, 2009); in other words, increasing food production is not the answer, either.
Laxminarayan stated that high rates of stunting and poor nutritional status represent a significant loss of child development potential. He showed results that indicate that height is correlated to improved cognitive scores, higher wages, greater educational attainment, and improved health (Vogl, 2014). In other words, height is a proxy for the early-life environment. In this context, Laxminarayan noted that cell phone usage in rural areas of India has increased dramatically recently (Mehta, 2013). He asked why the poor, when given an opportunity, choose to spend their additional income on luxury durables, such as cell phones, rather than on the nutrition of their children. He posited that they may be uninformed about the long-term economic benefits of child nutrition and growth, or perhaps assessments of the economic cost of undernutrition or of retarded child development in India are incorrect. In a later discussion period, a participant suggested that parents may not know how to spend to reduce malnutrition.
India spends significant resources on child development, efforts that pay off when implemented well, Laxminarayan explained. India’s budget includes $10 billion in direct food subsidies; $6 billion in health spending; $3.2 billion in integrated child development services; $2 billion in midday meal programs; and $500 million in drinking water and sanitation.5 Further, integrated child development services began in 1975 as a concerted government effort, harmonizing work in early education, nutrition, health, and immunization. It consists of centers all over the country, roughly 1 for every 800 people, with a penetration rate of 91.5 percent into India’s villages. He also noted that the quality of the integrated child development services programs can vary. While they are staffed reasonably well, many supervisory positions remain empty, and there may be situations in which positions are auctioned off. Laxminarayan posited
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4 See http://www.indiastat.com for more information and statistics (accessed May 5, 2014).
5 See http://www.accountabilityindia.in for more information and statistics (accessed May 5, 2014).
that multisectoral interventions, implemented well, are needed to achieve child development potential.
GROWING UP UNEQUAL: TRENDS IN GLOBAL INEQUALITY AMONG CHILDREN6
Parfait Eloundou-Enyegue stated that children are growing up increasingly global, but, at the same time, unequal. He stated there are many global influences on expected norms, particularly with the rise of mass international communication and the Internet. As a result, children experience more direct international contact, and aspirations and expectations around the world are converging.
Inequalities are found at three concentric levels: between countries, within countries, and within families, and Eloundou-Engyegue attributes demographic shifts as key to the drivers such as dependency and caregiving. Also, family transformations contribute to the drivers. He first described between-country inequality. Eloundou-Enyegue said that inequality in education spending across countries is declining slightly, but the level of inequality remains higher than the inequalities in GDP per capita among countries. In other words, inequality among children is larger than it is for the general population (Eloundou-Enyegue and Rehman, 2009). There are enormous differences in resources available per child. For instance, Panama, which spends an average amount of education dollars for children, may spend $100 per child. Relative to Panama, the Democratic Republic of Congo spreads that hypothetical $100 in education spending across 55 children, and countries that spend higher amounts on education would spend that amount on one-fourth of a child (Eloundou-Enyegue and Rehman, 2009). Herein lies inequality across countries in the amount of education dollars spent per child.
In a decomposition analysis, Eloundou-Enyegue then showed that global convergence across the regions has been driven exclusively by Asia’s economic productivity, which overshadows factors such as population size and age structure. The lack of demographic convergence is a break from fostering convergence in the level of resources allocated per child, and according to Eloundou-Enyegue should be addressed. The expectation is that future demographic convergence will induce further convergence in the level of resources per child.
Shifting to examine inequality within a country, Eloundou-Enyegue noted that demographic changes have an influence. He examined four demographic forces:
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6 This section summarizes information presented by Parfait Eloundou-Enyegue, Cornell University.
- Family size—There are large differences in the birth rate between the top income quintile and the lowest. Declines in fertility rates have occurred only in the higher income brackets. In Liberia, for instance, the fertility rate ranges from three births per woman in the upper quintile to eight births per woman in the lowest quintile.7
- Family structure—Differences in the age at marriage, maternal employment, and single motherhood all fuel inequality for children (McLanahan, 2004). These factors are also related to level of income of women.
- Nucleation—Extended families and fostering children have historically provided a buffer against inequality (Isiugo-Abanihe, 1985). However, that buffer can erode if fewer children are being fostered, fosterage becomes more selective (Case et al., 2004), or the fosterage is less effective (Eloundou-Enyegue and Shapiro, 2005). The impact of this on inequality, Eloundou-Enyegue said, is not fully known.
- Assortation—Assortation is the tendency for people to marry based on income or education—the rich marry the rich and the educated marry the educated (Schwarz and Mare, 2005). Assortative marriages lead to greater inequality.
Within families, one factor of inequality is gender differences among children: girls are typically educated less than boys. Education data suggests that gender differences are converging worldwide, including in sub-Saharan Africa where these differences had often been the largest but were now converging at the primary and slightly at the secondary level (World Bank, 2014).
Eloundou-Enyegue explained that there are three opportunities for action to reduce inequality for children:
- Ambitious goals—The Millennium Development Goals Plus (MDG+) offer an opportunity to set even more ambitious goals for nations who meet the Millennium Development Goals standards. In schooling for instance, the minimum threshold could move from basic education to secondary school completion and greater attention could be paid to early education and quality education as well.
- Emergence—Many countries in Africa are hoping to move to emerging status. Eloundou-Enyegue noted that 2035 is the date
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7 Eloundou-Enyegue calculated these values from DHS data. See http://dhsprogram.com/data for that data (accessed May 2, 2014).
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commonly used to describe when African countries will emerge. He noted, however, that there is no particular importance associated with that date, and he argued that people should focus on children today.
- Demographic dividend—In the next few years, African countries will enter a period of transition with lowered fertility rates, allowing for an increased investment in social and economic development for children.
Eloundou-Enyegue concluded by emphasizing ways to take action. One is to invest in a life-course and child-centric perspective. He stated that childhood is not Las Vegas—what happens in childhood does not stay in childhood, it actually stays with you throughout life. Strategically, building alliances across horizons to crossbreed ideas can generate new ways to address issues in child development that can link to growth in low-income countries. Another way is to take advantage of capturing dividends and identify policy measures to capitalize on the shifts taking place. The rewards of lowering inequality for children are real—several African countries in particular have the opportunity to move forward, if they invest more resources in cultivating children and monitor trends within families and how they cultivate children.
