Transcript Health care performance and public spending per capita average

Children lost ground during the crisis years of
transition; they are now at risk of losing out in
the recovery… WHY?
Gordon Alexander,
Senior Economic and Social Policy Advisor CEE/CIS Region
Global Child Poverty Study Meeting, Tashkent April 2-4 2008
Main Message: A new generation of
evidence-based policy for children
• data from people – and children
• from ‘inputs’ to ‘outcomes’
• focus on ‘performance gaps’
• being clear on Hypothesis : what are the policy
changes that you need evidence to support?
UNICEF
For first time in more than a decade,
resources are available
• A ‘window of opportunity’ over the next 5-8 years
• A 3rd wave of reforms is underway
• but there are risks
–
–
–
–
UNICEF
Spending will be on infrastructure
Policies remain sectoral
Political support for reform falters
External conditions change
4 Parts to Presentation
• Some Building Blocks
• Where are we now ?
• Big Issues (added value of study?)
• What is driving policy?
UNICEF
Building Blocks 1
Child Well-being is multi-dimensional – and
inter-connected
 Children’s life chances – powerfully influenced by
access to and quality of services
 Some periods/transitions esp critical (early years of
life, from school to job…)
 Children’s experiences at home, with friends and in
neighbourhood
 Importance of children’s perspectives
UNICEF
Building Blocks 2
Systems themselves are often the source
of failures for children
• Systems that had their logic in past - no longer respond to
current or emerging challenges
–
–
–
•
Certain groups of children always excluded
‘Intention’ may well be good but outcomes for children poor
Often unable to monitor effect of their policies
Reform can produce exclusion
–
–
–
–
UNICEF
‘gaps’ from withdrawal of state
models imported from outside, not fully contextualised
incomplete reform
old models restored
4 Principles from CRC to shape and guide
response

‘the best interests of the child’

non-discrimination

participation

resources ‘to the fullest extent possible’
UNICEF
A Story of Crisis and Economic Re-bound
GDP per capita CEE/CIS low point early-mid 90s, upward
trend since ’98-99. Similar pattern of recovery but
increasingly divergent paths…
Albania
150
GDP per capita index (1989 =100)
Armenia
Azerbaijan
Belarus
Bulgaria
100
Croatia
FYR Macedonia
Georgia
Kazakhstan
Kyrgyzstan
50
Moldova
Romania
Russia
Tajikistan
0
UNICEF
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
19
89
Turkmenistan
Ukraine
Uzbekistan
Where are we now?
Measuring vs 7 dimensions of child well-being
 Material situation
 Housing
 Health
 Education
 Peer relationships
 Family forms and care
 Risk and Safety
UNICEF
Progress at the top (laws, policies…)
but less at the bottom (implementation)
• Vulnerability still High
• Rise in disparities
• Erosion of social services
• New dimensions – migration, decentralisation, HIV/AIDS
UNICEF
Performance Gap 1
Poverty is coming down….
100%
90%
Non-Poor: Above
$ 4.30 a Day
80%
215.1
264.2
70%
329.2
60%
395.6
Vulnerable: Above
$ 2.15 and Below
$ 4.30 a Day
50%
40%
160.7
30%
153.3
20%
10%
0%
108.8
46.0
UNICEF
102.0
61.2
40.0
18.4
Around
1990
Poor: Below $ 2.15
a Day
Around
1998-99
Around
2002-3
By 2007
Source : World Bank 2005
But not all children are benefitting from
economic growth
GDP and public care of children:
1,200
GDP
Formal care
6,000
1,100
5,000
1,000
4,000
900
3,000
800
2,000
700
1,000
600
0
500
1999
2000
2001
2002
2003
2004
2005
UNICEF
Source: TransMonee. Analysis based on complete trend data from 16 countries.
Formal care (rate per 100,000)
Average GDP per capita (in current PPP
$)
7,000
75
Performance Gap 2: Life Expectancy (2004)
Slovenia
Albania
Croatia
Poland
Uzbekistan Armenia
Azerbaijan
70
Czech Republic
Slovakia
Bulgaria
Georgia
Hungary
Romania
Latvia
Lithuania
Estonia
65
Turkmenistan
Moldova
Kyrgyzstan
Belarus
Ukraine
60
Kazakhstan
Russia
0
UNICEF
5000
10000
15000
20000
GDP per capita PPP$
Fitted values
Source: TRANSMONEE
Performance Gap 3 : Under 5yr Mortality
30
Kyrgyzstan
25
Georgia
20
Uzbekistan
Romania
15
Kazakhstan
Moldova
Turkmenistan
Azerbaijan
FYR Macedonia
Bulgaria
Russia
Albania
Armenia
Ukraine
10
Latvia
Lithuania
Poland
Croatia
Slovakia
Estonia
5
Belarus
Bosnia-Herzegovina
Hungary
Czech R. Slo
0
5000
10000
15000
20000
GDP per capita PPP$, in 2004
UNICEF
Fitted values
Source: TRANSMONEE
New barriers for the poor
Informal Payments During Most Recent
Consultation
65
Georgia
56
Armenia
47
Republic of Moldova
42
Kyrgyzstan
40
Kazakhstan
28
Ukraine
19
Russian Federation
8
Belarus
0
UNICEF
10
20
40
30
50
60
70
%
Source: Balabanova 2004
Performance Gap 4 : Education
Upper Secondary Education enrolment 15-18yrs (%)
Poland
100
Hungary
Czech Republic
Bulgaria
Croatia
Slovakia
80
Russia
Belarus
Uzbekistan
Lithuania
Romania
FYR Macedonia
Latvia
Kazakhstan
60
Ukraine
Albania
Bosnia-Herzegovina
40
Georgia Armenia
Azerbaijan
Kyrgyzstan
Moldova
20
Tajikistan
Turkmenistan
UNICEF
0
5000
10000
Gdp per capita PPP, 2004
15000
20000
Source: TRANSMONEE
O
EC
rk
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Ru
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Bu ia
lg
ar
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Se
rb
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Ro
m
M
on ania
te
ne
gr
Az
o
er
b
Ky aija
n
rg
yz
st
an
D
ia
UK
ni
a
nd
ov
en
to
Tu
Sl
Es
nl
a
UNICEF
Fi
Quality of Education
PISA 2006 – Reading Scores
600
500
400
300
200
100
0
Performance Gap 5 : Pre-Primary enrolment
(2004)
Hungary
Czech Republic
80
Latvia
Slovenia
Bulgaria
Romania
Russia
Slovakia
60
Moldova
Ukraine
%
Lithuania
Poland
40
Croatia
Albania
Armenia
Georgia
20
Azerbaijan
Uzbekistan Turkmenistan
Kazakhstan
Bosnia-Herzegovina
0
Kyrgyzstan
Tajikistan
FYR Macedonia
UNICEF
0
5000
10000
GDP per capita PPP
15000
20000
Source: TRANSMONEE
Access to Pre-School - by Income Quintile
100
90
80
70
60
50
40
30
20
10
0
Top quintile
Be
la
ru
s
M
on
te
ne
gr
o
&
Uk
ra
in
e
Al
ba
ni
a
eo
rg
ia
G
FY
R
a
gy
st
an
M
ac
ed
on
i
Se
rb
ia
UNICEF
Ky
r
sta
n
Bottom quintile
Ta
ji k
i
%
Figure 3.11: Attendance rate, 3-4 year olds, by household consumption
level, selected countries, 2005
Source: UNICEF 2007
Performance Gap 6: Stunting Children <
5yrs by household assets
35.0
30.0
Poorest w ealth index
Richest w ealth index
25.0
20.0
15.0
10.0
5.0
Be
la
M
ru
on
s
te
ne
gr
o
Se
rb
Bo
sn ia
ia
&
H
.
M
ol
do
M
va
ac
ed
on
ia
G
eo
rg
Ar ia
m
en
Ka
ia
za
kh
Ky stan
rg
y
Tu z st
an
rk
m
en
ist
U
an
zb
ek
is
ta
Az
n
er
ba
ij a
n
Al
ba
n
Ta i a
ji k
is
ta
n
0.0
UNICEF
Source: MICS 2006
UNICEF
M
la
on rus
te
ne
R gro
om
Bo an
sn ia
ia
&
M H.
o
M ldo
ac
v
ed a
on
G ia
eo
rg
ia
Tu
rk
Ar ey
Ka me
za nia
kh
Ky sta
n
Tu rgy
rk zs
t
m
en an
U ista
zb
n
ek
i
Az sta
er n
ba
ija
Al n
ba
Ta nia
jik
is
ta
n
Be
%
Stunting by maternal education
Low maternal education
High maternal education
30
25
20
15
10
5
0
Source: MICS 2006
Performance Gap 7 : Young People
120
Mortality Rates 15-19yrs
Russia
100
Kazakhstan
80
Turkmenistan
Lithuania
Ukraine
Belarus
Estonia
Latvia
60
Moldova
Kyrgyzstan
Uzbekistan
Romania
40
Albania
Azerbaijan
Georgia
Bulgaria
Croatia
Poland
FYR Macedonia
Hungary
Bosnia-Herzegovina
20
Armenia
Slovakia
Slovenia
Czech Republic
0
UNICEF
5000
Fitted values
10000
GDP Per Capita $ PPP
15000
20000
Source: TRANSMONEE
An epidemic with its roots in poverty
Incidence of HIV infections
Source: EuroHIV 2007
UNICEF
Why did children lose out in the first
phase of transition?
• Pre-occupation economic and political stabilisation
• Fiscal squeeze
• Lack of institutional structures that protected their
interests
• Reform of areas that mattered was politically painful
• Past practices …
UNICEF
Long period of underinvestment in Health
Government Expenditure on Health as % GDP CIS Countries 1996-2006
7.00
Kazakhstan
Kyrgyzstan
6.00
% GDP
Tajikistan
5.00
Turkmenistan
4.00
Uzbekistan
3.00
Armenia
2.00
Azerbaijan
1.00
Georgia
Ukraine
0.00
1996
UNICEF
1998
2000
2002
2004
Russian Federation
Republic of M oldova
Source: WHO
database 2008
Belarus
A more mixed picture on Education
6
Government Expenditures on Education/GDP (%) 2004
Ukraine
Belarus
Hungary
Poland
5
Moldova
Czech Republic
4
Bulgaria
Kyrgyzstan
Azerbaijan
3
Albania
Georgia
Tajikistan
FYR Macedonia
Kazakhstan
2
Armenia
0
UNICEF
5000
10000
15000
20000
GDP per capita PPP$, 2004
Fitted values
Source: TRANSMONEE
Yet these are the areas of public demand for
investment
EBRD Life in Transition survey 2006
HEALTH
PENSIONS
HOUSING
EDUCATION
Health care
Pensions
UNICEF
Other
Education
Housing
Environment
Public infrastructure
What are the big issues?
• Extent to which economic growth becomes pro-poor ?
• What are ‘family-friendly’ social protection & labour
market policies?
• A package of interventions & services all children have
access to?
• Increased budgets not just going into buildings and
roads?
• Are Social Services responding to most vulnerable?
• How is Decentralization best approached?
UNICEF
Lastly, Child well-being and GDP are not
correlated: Policy Matters!
UNICEF
What does this mean for the study?
• That need for a clear hypothesis
• The link to policy - right from the start
• How can the analysis support (and inform)reform?
• Lead to a change in paradigm
UNICEF