The UN High-Level Summit concluded yesterday. The main headline is the $40 billion in commitments over the next five years for the Global Strategy for Women and Child Health. The real test will be whether donors deliver on these commitments, and are flexible enough in their definition of improving “women and child health” to take into consideration significant broader determinants such as education.
A key strength of the MDGs has been their simplicity and scope. The flip side of the coin is a tendency towards a ‘silo model’ of interpretation. Each MDG has its own cluster of experts, advocates, and donors, and recent economic modelling exercises have attempted to order MDG priorities on a cost-benefit basis. The result is a tendency towards a fragmented interpretation of the MDG framework in public policy discourse.
This mindset has real consequences. What we see in global health are various initiatives competing for a limited pot of funds, drawing on links about how their cause will contribute to progress towards MDGs, most recently MDGs 4 and 5. The more important question is whether there is more money overall targeting the largest causes of morbidity and mortality and the social determinants of better health.
The strong links between women’s education and better health outcomes have been long recognized. It is strongly associated through productivity, income-generation and wider effects to nutritional status. Similarly, levels of education are positively associated with a wide-range of practices – late marriage, ante-natal care, skilled attendance during delivery, recourse to health treatment and so one – which are known sources of risk reduction.
A new Lancet study by Professor Emmanuela Gakidou and colleagues from IHME provides compelling longitudinal evidence of what this relationship looks like across the world. The study found that 4.2 million fewer children died in 2009 because women received more years of schooling. Between 1970 and 2009, mortality in children under age 5 dropped from 16 million to 7.8 million annually, and the study estimates that 51% of the reduction can be linked to increased education among women of reproductive age.
The evidence is clear. It is difficult to look at the evidence without reaching the conclusion that sustained and accelerated progress towards the MDGs on child and maternal health depends in large measure on progress in education. Just look at these graphs from IHME on regional and country-level trends.
Potential pathways of influence from education to improved child health outcomes are often difficult to extrapolate. Broadly, however, education equips people with knowledge about nutrition, illness prevention and treatment, and service provision, and it empowers people to demand their entitlements. Of course, education also does much more than this. Under the right conditions, it can facilitate the development of more secure and diversified livelihoods, strengthen equity, and enhance the voice of poor people in political processes.
To return to my initial argument, one of the strongest illustrations of the problem with the MDG ‘silo mentality’ is the interface between education and child nutrition. Specialised education agencies tend to focus on headcount indicators of progress, defined in terms of net intake or enrolment rates or school completion. Less attention has been directed towards the health and nutritional status of children entering school.
Undernutrition is close to my heart- perhaps this is why I bring it up so often. But what does it mean for progress towards education-for-all, when one-in-three of the children entering primary school have experienced malnutrition? There is compelling evidence that the damage resulting from under-nutrition and micronutrient deficiency in the first two years of life is irreversible.
Against this backdrop, improving child and maternal health has much to do with women’s education and malnutrition. What were the commitments at the UN summit to education? The World Bank committed to increase its support by $750 million for zero-interest and grant investment in basic education, and Dell committed $10 million towards education technology initiatives. These pale in comparison to the commitments for the Global Strategy for Women and Child Health which is why I really hope that a broader approach will be taken involving relevant sectors.
Devi Sridhar (I am greatly indebted to conversations with Dr. Kevin Watkins for the ideas in this post).