An independent assessment of Save the Children’s Commitments to the UN Strategy ‘Every Woman, Every Child’ February 2012

Forward This independent assessment of Save the Children’s Commitments to the UN Strategy ‘Every Woman, Every Child’ was commissioned by Save the Children International and performed by Pesh Framjee, Naziar Hashemi and Tom Davies of Crowe Clark Whitehill LLP. We would like to express our thanks to all at Save the Children who participated in this assessment.

Crowe Clark Whitehill LLP

Crowe Clark Whitehill LLP St Bride's House 10 Salisbury Square London EC4Y 8EH, UK February 2012

www.croweclarkwhitehill.co.uk

Contents Page

Executive Summary ................................................................................................................ 1

Commitment 1 - A significant investor in MNCH programming ........................................... 8

Commitment 2 - A global leader on newborn health .......................................................... 15

Commitment 3 - A direct participant in supporting health workers to save lives ............. 18

Commitment 4 - An innovator in community mobilisation for behaviour change and advocacy .................................................................................................... 21

Commitment 5 - A pioneer of innovative and effective partnerships ................................ 25

Commitment 6 - A vocal advocate for children’s rights and equity .................................. 30

Appendix 1 – Summary of key recommendations .............................................................. 33

Appendix 2 – Methodology ................................................................................................... 35

Appendix 3 – Acronyms ....................................................................................................... 37

1

Executive Summary

In 2010 Save the Children’s Chief Executive Officer wrote to the UN Secretary General, publically committing the organisation to the United Nation’s ‘Every Woman, Every Child’ Campaign and making six commitments in the following areas:

1) A significant investor in MNCH programming 2) A global leader on newborn health 3) A direct participant in supporting health workers to save lives 4) An innovator in community mobilisation for behaviour change and advocacy 5) A pioneer of innovative and effective partnerships 6) A vocal advocate for children’s rights and equity

More detail on the specifics of each commitment is provided in the body of this report. Delivering on these six commitments is of the highest priority to Save the Children International and the other members of the Save the Children family (hereafter ‘Save the Children’).The organisation has stated that it wishes to lead by example and demonstrate to others that it is prepared to hold itself to account and to present its progress against its targets. To support this Crowe Clark Whitehill LLP was appointed by Save the Children to perform an independent assessment of Save the Children’s progress towards meeting these commitments in the period to date. The summary of our findings for each Commitment are presented in the tables on the following pages. Further information is provided in the more detailed narrative. In the body of the report we have cited material and evidence from different sources to provide tangible examples of how Save the Children is meeting its commitments. It is important to recognise that until very recently the members of the Save the Children Fund family operated as autonomous independent organisations with little central coordination or structured reporting to one location. As a consequence the information gathering and sharing systems are still under development and the reporting to date of all the actions worldwide to support the commitments is likely to be incomplete in all its facets. We believe that this is being addressed with improved global knowledge management and information sharing and enhanced monitoring and evaluation. .

2

Commitment 1: “We will more than double our investment in maternal, newborn and child health and nutrition to reach $500 million per annum by 2015, including $150 million contributed by private individuals. In our country programmes and at the global level, we will promote policy changes that accelerate progress towards MDG 4, including through a greater focus on equity, real action to remove barriers to access, support for stronger health systems, and promotion of food and nutrition security and social protection.”

Achieved to date: 2010 expenditure on MNCH totalled $342

million; 2009 totalled $223 million.

38,997,422 children and adults reached indirectly and directly by MNCH programmes run by Save the Children.

Case studies from India, Nigeria and Sierra Leone demonstrate Save the Children’s implementation of this Commitment at a programmatic level.

To do: A reforecast of income and expenditure

by members should be compiled.

Annual projected expenditure on MNCH programming needs to increase significantly to meet the annual target of $500 million.

Continued implementation of the Country Plans for the twenty countries selected for the EVERY ONE campaign.

Collection and dissemination of

programmatic output data (due in early 2012) to demonstrate global outputs and impact and assess progress to date.

Conclusion and recommendations: Whilst there was a significant increase in expenditure on MNCH programmes between 2009 and 2010, current projections from Save the Children members suggest that the annual target of $500 million will not be met by 2015. However as indicated by ad hoc additional information these current projections are not necessarily a reliable indicator as they exclude significant new funding streams. We recommend that a separate reforecasting of income and expenditure committed to MNCH programming by the Members is performed to enable Save the Children to accurately ascertain how and whether the $500 million per annum investment can be reached by 2015. This should be kept up to date and monitored regularly. We recommend that these forecasts exclude income and expenditure related to potential future emergencies. At the time of making the commitment, the organisation did not prepare detailed and agreed projections so as to determine the reasonableness of the Commitment. We would recommend that in the future such projections be prepared and agreed prior to the making of such commitments. At present there is limited global data from the organisation’s country programmes on key areas such as the number of life saving interventions made. This naturally limits the ability of the organisation to demonstrate its global outputs and impact, or to review where its activities have fallen behind expectation. We understand that this will be addressed in early 2012 as the results are compiled from the overseas countries and we recommend that this be done as a matter of priority.

3

Commitment 2: “Working with others, we are leading a global effort to develop and promote newborn health policies and programmes that will dramatically reduce newborn deaths from preventable causes. We will expand and intensify our efforts to integrate proven, evidence-based technologies and approaches into national policies and large-scale systems in 12 priority countries.”

Achieved to date: Save the Children’s Saving Newborn

Lives program recognised as a leader in newborn health by key donors such as USAID and Bill & Melinda Gates Foundation.

Over 33 medical research articles financed and/or performed by Save the Children since 2009. This includes recent series on newborn heath published by the Lancet.

Establishment of the Healthy Newborn

Network as a global resource in the area of newborn health.

Case studies demonstrate Save the

Children’s efforts with regards to this Commitment in Ethiopia, India, Pakistan and Sierra Leone.

To do: Twenty countries have approved

Country Plans which include an expansion of Save the Children’s work in this area.1

The implementation of these country

programmes to continue with regular monitoring by Save the Children.

Conclusion and recommendations:

The original Commitment referred to Save the Children focussing on integrating proven, evidence-based technologies and approaches into national policies and large-scale systems in 12 countries. The organisation has since increased its target to 20 countries and each have approved Country Plans which are currently being implemented but which are naturally at an early stage of implementation. Other than the quantitative target of 12 countries, this Commitment does not specify any quantitative indicators by which we can conclude on Save the Children’s success or otherwise in meeting this Commitment. However, from the work performed in our assessment, we believe that it is reasonable to conclude that the organisation’s global operations are contributing significantly to the Commitment and its objective. Much of the information collated was as a result of our request and we recommend that the organisation seeks to collect such information as a matter of practice to enable it to better demonstrate its impact in this area. The organisation should also consider expanding the range of data collected in relation to the Healthy Newborn Network website to better assess the impact of the website and the resources downloaded. This could include, for example, the use of user surveys.

1 Afghanistan, China, Ethiopia, India, Nigeria, Pakistan, Sierra Leone, Bangladesh, Burkina Faso, Democratic

Republic of Congo, Indonesia, Kenya, Malawi, Mali, Mozambique, Nepal, Niger, Tanzania, Uganda and Zambia.

4

Commitment 3: “We will participate in the training and support of 400,000 health workers in developing countries to ensure better availability of life-saving services. This includes supporting the expansion and capacity-building of community health workers delivering services inside and outside of health centres.”

Achieved to date:

In 2010, Save the Children’s country programmes contributed to the training of 84,906 health workers. This includes 54,245 at the ‘intervention level’ and 30,661 at the ‘national level’.

To do:

In 2012-2015 Save the Children will continue to work towards meeting the cumulative target of 400,000 health workers trained.

Conclusion and recommendations:

Save the Children’s target is that it will participate in the training and support of 400,000 health workers up to 2015. Whilst an extrapolation of the results from the first year (84,906) suggests that it will reach the target during the four year period of 2011 to 2015 the organisation does not at present have a breakdown of how this figure is going to be reached by the country programmes.

We recommend that the organisation reviews the individual country training projections to ascertain how the target of 400,000 will be reached. This will enable the Commitment to be monitored effectively and for any possible programmatic shortfalls to be addressed in a timely manner. We also recommend that Save the Children gives consideration to introducing additional reporting requirements from the countries in relation to the number of health worker training days delivered so as to more effectively present the scale of training received by the health workers. Consideration should also be given to carrying out a more qualitative analysis of the type and usefulness of the training.

5

Commitment 4: “We will help mobilize communities in the countries with the highest child mortality, to hold governments to account, claim their right to quality health care, and take control of their lives in order to reduce maternal and child mortality.”

Achieved to date:

2010 saw 5,832,982 ‘hand-raising’ actions generated by the country programmes through which Save the Children operates.

Case studies from a number of countries in the Global South have been presented in the assessment as examples of this work.

In the Global North, significant advocacy work has also been performed in 2010 and 2011, including the work around the successful GAVI pledging Summit in 2011.

Save the Children’s role in this Summit specifically commended by UK’s Secretary of State for the Department for International Development.

To do:

The organisation has set itself a target of cumulative ‘hand-raising’ actions across the globe of 60 million up to 2015. The organisation should continue to monitor this meeting of the target.

In the Global North, advocacy by the Member agencies to continue especially in relation to the EVERY ONE Campaign.

Conclusion and recommendations: There is a significant amount of advocacy and community mobilisation being performed across the globe by Save the Children and we therefore conclude that the organisation is continuing to address this Commitment. We recommend that Save the Children give greater consideration to as to how best information surrounding its global advocacy and campaigning activities can be presented not only on the individual Member websites, but also via the global campaign website and how the presentation of this information can be co-ordinated. This will most likely require additional investment in the communications resources within Save the Children International to ensure effective global co-ordination.

6

Commitment 5:

“We will engage with partners from the corporate sector, governments, media, academics, sport, entertainment, and civil society, at a national and international level, to help deliver life-saving programming and engage hundreds of millions in the movement to end needless deaths of mothers and children. In the United States, for example, our partnership with the Ad Council will result in $75 million of donated advertising space for public service announcements to engage the US public on MDGs 4 and 5.”

Achieved to date:

Development and implementation of a range of partnerships. These include: Academia – such as with the award

winning Helping Babies Breathe Partnership in the US.

Campaigning – with other NGOs in

the Health Workers Count campaign.

Media – this includes the $43.8m “See where the Good Goes” partnership with the US Ad Council.

Corporate partners – including Save the Children’s first global partnership – a three year $19 million agreement with Unilever.

To do:

Further development of the range and number of partners from all of these sectors.

Conclusion and recommendations: Whilst Save the Children did not set itself specific targets for the number of partnerships it sought to develop under this Commitment, our findings are that it has demonstrated that it has developed and implemented a range of effective partnerships across the globe and is therefore actively and successfully working to address this Commitment.

7

Commitment 6: “We believe in sustainable country-owned solutions to improve child and maternal survival. As a global proponent for children’s rights, we will promote human rights instruments, especially the UN Convention on the Rights of the Child, to ensure that states deliver their agreed obligations. We will call for equity in all health and nutrition programmes to ensure that disproportionate levels of mortality in poor and marginalised groups are no longer tolerated, and launch a global policy report with this message, “A Fair Chance at Life”.

Achieved to date:

Significant contribution to the formulation of the General Comment on Child health and children’s rights by the UN Committee on the Rights of the Child.

Regular contributions to the Universal Periodic Review process with the Office of the UN High Commission for Human Rights.

Equity and children’s rights issues highlighted by Save the Children’s policy publications, including the 2010 report “A Fair Chance At Life: Why equity matters for child mortality”.

To do:

Continuation of organisation’s contributions to the UN human rights bodies, especially that on the Rights of the Child.

Conclusion and recommendations:

Whilst our report details much evidence that Save the Children is actively pursuing this Commitment through its promotion of and use of existing human rights instruments, we have raised a recommendation that Save the Children should give further consideration to seeking to assess and demonstrate how this work is having an impact at a local level in improving children’s rights.

The pages that follow provide additional information on the six commitments

8

Commitment 1 - A significant investor in MNCH programming

“We will more than double our investment in maternal, newborn and child health and nutrition to reach $500 million per annum by 2015, including $150 million contributed by private individuals. In our country programmes and at the global level, we will promote policy changes that accelerate progress towards MDG 4, including through a greater focus on equity, real action to remove barriers to access, support for stronger health systems, and promotion of food and nutrition security and social protection.”

1.1 Save the Children has set itself a target of reaching total annual expenditure of $500

million in the area of maternal, newborn and child health and nutrition by 2015. The most recent results (for 2010) show annual expenditure in that year of $342 million, a significant increase (53%) on the 2009 total of $223 million as is presented in the table below.

Actual Expenditure by Save the Children Members January 2009 to December 2010

US $m*

Actual expenditure: 2009

Actual expenditure: 2010

Total Actual expenditure: 2009 and 2010

Australia 3,156,820 5,781,578 8,938,398

Canada 2,639,627 6,311,101 8,950,728

India 795,289 1,417,864 2,213,153

Italy 5,850,319 7,426,610 13,276,929

Netherlands 2,916,328 4,777,471 7,693,799

Norway - 2,897,779 2,897,779

South Korea 3,526,265 2,724,337 6,250,602

UK* 125,091,454 199,978,358 325,069,812

US 74,567,673 98,876,392 173,444,065

Others** 4,357,836 11,468,520 15,826,356

MNCH Expenditure from members

222,901,611 341,660,010

564,561,621

*The reported UK figures for actual expenditure in 2009 and 2010 are inclusive of livelihoods spend of $4.5m for 2009 and $10.5m for 2010. The UK will exclude livelihoods spend in future years to align its reporting with other members **Others: Brazil, Denmark, Dominican Republic, Fiji, Finland, Germany, Guatemala, Honduras, Iceland, Japan, Jordan, Mexico, New Zealand, Romania, Spain, Sweden, Switzerland

1.2 In seeking to assess Save the Children’s ability to reach its annual target of $500 million

by 2015 we ascertained that at the time of making the Commitment the organisation did not prepare projections which detailed the breakdown, by Save the Children member, of where the $500m was to be sourced by 2015. We would recommend that in future, prior to making such a commitment, that the organisation prepares detailed projections which are approved by the other members so as to ascertain the reasonableness of the commitment.

1.3 Save the Children members have, however, recently provided projections relating to

future income associated with the EVERY ONE campaign and their work on maternal, newborn and child health and nutrition. These are presented in the table below.

9

Income Projections (as of November 2010)

US $m 2011

2012

2013

2014

Australia 4 4 4 4

Canada 6 5 5 0

India 1 5 8 10

Italy 9 11 13 14

Netherlands 1 2 2 3

Norway 5 5 6 6

S.Korea 2 2 3 3

UK 130 131 113 133

US 96 102 108 113

Others 3 3 3 4

Projected Total from members

257 270 265 290

1.4 These projections show annual results significantly below the $500 million level (the

highest is $290 million in 2014) and all are below the total expenditure seen by Save the Children in 2010 of $342 million. Furthermore, the members have not been able to provide a breakdown of what element of the income relates to private individuals. Consequently, the organisation is not able to assess whether the annual commitment relating specifically to private individual contributions ($150 million) will be met.

1.5 We question the accuracy of these projections as based on the 2010 results of actual spend, these income projections appear to be too prudent. We understand that figures have not been updated from initial projections made in 2010. Early expenditure figures for 2011, from Save the Children UK and US, already demonstrate that the combined relevant expenditure from these two members is in the region of $267m whereas the projected income in the table above amounts to $226m.

1.6 In addition, Save the Children US has doubled its anticipated “new raise” target for 2011 of $96 million by raising $220m of multi-year “new raise” through the third quarter of 2011 for health and nutrition programming.

1.7 Furthermore, full statistics for expenditure and new raise for 2011 from all members are not yet available so Save the Children expects that the total of $257 million for 2011 shown in the table above will increase. Predictions for future expenditure will also be updated in February 2012

1.8 A re-forecasting in 2012 will be critical to determine whether Save the Children is on track for increasing actual health and nutrition programme expenditure to $500 million by 2015. We understand that the intention is that if the new projections continue to indicate a shortfall in committed expenditure the organisation will take measures to enhance the individual member commitment.

10

1.9 The projections above also do not include some significant programme contracts recently awarded to Save the Children. These include the new contract signed with Unilever at $19 million for three years, $14 million of further funding from the Gates Foundation and the $12.7 million programme recently awarded to Save the Children by the Swedish Government for the promotion of children’s rights for survival in India, Yemen and Zambia.

1.10 The compiled projections indicate that Save the Children will not meet its annual

commitment of $500 million by 2015. However as discussed above ad hoc additional information appears to show that the stated projected income figures are not necessarily a reliable indicator. It is vital that a reforecasting of income and expenditure committed to the programme is performed. Members need to prepare updated and accurate projections to enable Save the Children to ascertain how the $500 million per annum investment is likely to be reached by 2015. A detailed analysis at this stage, three years before the target year of 2015, will provide Save the Children with a greater chance of addressing any possible shortfalls.

1.11 The second element of this first Commitment, was Save the Children’s pledge that “In our

country programmes and at the global level, we will promote policy changes that accelerate progress towards MDG 4, including through a greater focus on equity, real action to remove barriers to access, support for stronger health systems, and promotion of food and nutrition security and social protection.”

1.12 This Commitment is enshrined within Save the Children’s vision of “a world in which every

child attains the right to survival, protection, development and participation.” In addition it is also a key aspect of the global “EVERY ONE Campaign”, launched in October 2009 and to which all members of Save the Children have committed.

1.13 As described on its website (www.everyone.org), the Campaign seeks to “save millions of

children’s lives” through engaging with politicians, the public, other aid agencies and the private sector in not only seeking policy changes but also delivering effective programmes to not only help meet MDG 4 but also MDG 5 - reducing by two thirds the under-five mortality rate and by three quarters the maternal mortality ratio. Specific targets set by the EVERY ONE campaign include some of the Commitments made to the UN including helping to train 400,000 health workers (see Commitment 3).

1.14 Since its launch in 2009, the organisation has demonstrably sought to fully integrate the

campaign within its corporate strategy and operations. There is a Global Campaign Management Team incorporating senior Save the Children staff from across the globe. The Global Campaign Director reports directly to Save the Children’s CEO. Furthermore, within many of the country programmes there is a specifically appointed EVERY ONE Campaign Director responsible, under the Country Directors, for ensuring that the objectives of the Campaign are embedded within the country programmes.

1.15 As further evidence of the organisation’s commitment to the EVERY ONE campaign and

its objectives, it should be noted that in a document issued by the CEOs of all Save the Children members under the title “Steer for 2012 Plans/Budgets” the EVERY ONE campaign is listed as one of the 4 goals for the 2012 period. The document states that Save the Children will “Invest in all 4 pillars of our [EVERY ONE] campaign (programs, fundraising, advocacy and pop-mob), with the main aim of ensuring a health worker within reach of every mother and child, plus follow-through focus on vaccines and new work on nutrition.”

11

1.16 Whilst all programmatic country offices have been invited to join the Campaign, 20 countries (see footnote 1 on page 3) have been selected as the priority countries – representing those countries in which almost 70% of under 5 deaths occur each year. Each of these countries has been required to submit a Country Plan detailing how the country intends to contribute to meeting the EVERY ONE campaign objectives. These have subsequently been approved by the Director of the EVERY ONE campaign and the Global Campaign Management Team. For each country, the relevant Country Plan details specific objectives with relevant indicators.

1.17 The EVERY ONE campaign team has devised a standard reporting template for the

countries to submit relevant data on an annual basis. The template requests information under 15 key categories including the number of health workers trained and the number of life saving interventions made (for example, anti-malarial treatments given).

1.18 2011 will represent the first year in which all countries are required to submit information

in relation to these key indicators. Therefore, at present it is not possible to ascertain what the overall scale of Save the Children’s global programme outputs has been in areas such as number of life saving interventions delivered through the organisation’s newborn and child survival programmes.

1.19 Two Save the Children Members, Save the Children US and UK do collect data on the

number of children and adults reached through their programmes. As the two largest members, information from these two countries does help to provide a sense of the scale of Save the Children’s global programme outputs in the area of MNCH.

1.20 For 2010 the data provided by Save the Children US shows the number of children and

adults reached indirectly and directly in MNCH programmes as 31,115,325, as per Save the Children’s published definitions of ‘Reach’2. For the UK, the corresponding figure was 7,882,097, giving a total for both members of 38,997,422.

1.21 Additionally, from those countries participating in the EVERY ONE campaign, information

has been obtained relating to the number of health workers trained in 2010 and the number of hand raiser actions (discussed in more detail under Commitments 3 and 4 below).

1.22 We believe that it is important to recognise that until very recently the members of the

Save the Children family operated as autonomous independent organisation with little central coordination or structured reporting. As a consequence the information gathering and sharing systems are still under development and the reporting to date of all the actions worldwide to support this commitment is likely to be incomplete in all its facets.

2 Definitions of Reach

Directly reached - A person is reached directly when one of the following conditions is met:

s/he has received one or more project/program inputs from a Save the Children member or its implementing partner;

s/he has participated in activities of a Save the Children member or its implementing partner; s/he has accessed services provided by Save the Children or one of its implementing partners; s/he has received inputs, activities or services from individuals/institutions to whom Save the Children or its

partners have provided sustained support. Indirectly reached - A person is reached indirectly through one or more of the following:

communications, IEC and/or awareness raising efforts or events conducted or supported by a Save the Children member or one of its implementing partners;

a family or community member whose well-being is expected to be enhanced by a person reached directly by Save the Children or one of its implementing partners.

12

1.23 As part of our assessment we have therefore also sought to include specific examples of Save the Children’s Maternal, Newborn and Child Health programming as recent demonstrations of the organisation’s work in this area.

1.24 In Nigeria, for example, Save the Children has been working with partners since 2001.

One programme of particular note is the “Partnership for the Revival of Routine Immunisation in Northern Nigeria - Maternal, Newborn and Child Health programme.”

1.25 This £8.96m programme is being implemented in the northern states of Yobe, Katsina,

Jigawa and Zamfara, with a total population of 17m. Baseline health indicators for children in Nigeria are very poor with the 2008 Department of Health Survey estimating 1.1m under 5 deaths annually and these are systematically higher in the North. Furthermore, an additional baseline survey carried out for the programme showed that only 3 % of children in the north were fully immunised.

1.26 Amongst other activities, the programme has sought to:

Strengthen federal, state and local capacity and governance of primary health care systems; improve human resource policies and practices and carry out operations research, including the testing of new approaches to service delivery and the formulation of evidence-based policies.

Upgrade health infrastructure and equipment and improve the delivery of MNCH services including routine immunisation & skilled birth attendance.

Mobilise communities in the 4 states, to help promote healthy behaviour and to demand better services.

1.27 Programme monitoring and evaluation reports have shown that Save the Children’s work

has achieved significant success, including:

By the end of 2010, the programme had supported the immunisation of over half a million children. For instance, the number of 1 year old children immunised against measles increased from 126,439 to 539,521.

The number of deliveries per year supported by skilled birth attendants increased from 8,172 to 22,190.

1.28 As a result of the programme’s success, in 2010 the UK and Norwegian governments agreed to extend the programme for an additional 2 years until the end of 2013.

1.29 Another programmatic example reviewed as part of our assessment is Save the

Children’s work in Sierra Leone where, in April 2010, the government abolished healthcare fees, previously a significant barrier to access for individuals.

1.30 Save the Children played a leading role in mobilising other civil society organisations

within Sierra Leone to push for the abolishing of these fees and the organisation’s role was acknowledged by the Sierra Leone Government. Following the passing of the bill a government representative said “We’d like to applaud Save the Children for their commitment and for being a true partner, not doing it for the glory, but for giving Sierra Leone something we can use for our children.”

13

1.31 Save the Children’s efforts and expertise in relation to the area of maternal, newborn and child health has been further acknowledged in the appointment of representatives of the organisation as co-chair of the Communications Committee and the Finance Committee - two of the six committees established by Government designed to monitor the implementation of the law.

1.32 The abolishing of healthcare fees in Sierra Leone is expected to have a very significant

impact on the health of mothers, newborns and infants in the country. In a recent speech made by the President of Sierra Leone to Parliament, it was reported that: “Between April 2010 and March 2011, the initiative (the dropping of healthcare fees) led to almost two million additional under five consultations, 39,100 more women delivered their babies in a health facility and 12,000 maternity complications were managed in health facilities with a 60% drop in the fatality rate in these cases. As a result we have reduced the infant mortality rate from 170 per 1,000 live births to 89 per 1,000 live births; the under-five mortality rate has been reduced from 286 per 1,000 live births to 140 per 1,000 live births. The maternal mortality ratio is also down from 1,300 per 100,000 live births to 857 per 100,000 live births. With the huge 250% increase in access to health services by children under five years of age, and the recorded high increase of nearly 70% in institutional delivery, it is convincing to believe that the free health care initiative has provided strong impetus for reaching the Millennium Development Goals 4 and 5 against 2015”.

1.33 Another example of Save the Children’s work in promoting policy changes which seek to

accelerate progress towards MDG 4 is in India – a country where there are nearly 2 million under 5 deaths every year – the highest number in any country.

1.34 Save the Children is playing a leading role in highlighting the issue of maternal, newborn

and child health during the country’s development of the Government’s 12th Five Year Plan (which will include 2015, the target year for the MDGs). Amongst other activities Save the Children co-ordinated and facilitated the “Newborn Child Survival Technical Advisory Group Consultation” in November 2010 which involved the participation of 125 organisations and individuals.

1.35 Dr Syeda Hameed, Member of the Health and Family Welfare Division of the Planning

Commission for the Five Year Plan, said of Save the Children at the time of the meeting that “By getting people here in such a large group I will have no choice but to say I am being pressured so much that I have to fulfil the expectations of my colleagues from around the country and some from outside. This is all very good pressure that you are building.”

1.36 The findings of this Group were presented to the Planning Commission in their meeting of

4th March 2011. Amongst the recommendations made by the Advisory Group was that there be an increased budgetary allocation of about 3% to 5% of the GDP for Health, of which 25% should be focussed on maternal and child health.

1.37 The Senior Health advisor to the Commission, Dr NK Sethi is minuted at the meeting as

stating that the “role of Civil Society Organisations has been crucial in providing inputs for the 12th Plan approach paper…and that she was of the view that the recommendations of the consultation would facilitate Planning Commission, Ministry of Health and Family Welfare and Ministry of Women and Child Development to identify the core strategies for addressing mother and child health issues during the 12th Plan.”

14

1.38 Although the Five Year Plan is still being finalised, the Prime Minister of India has subsequently announced that the 12th Plan will be focussed on health and has proposed that spending on this area will be increased from 1% to 2.5% of GDP.

1.39 Whilst the above information and the case studies demonstrate that Save the Children’s

MNCH programming has delivered significant outputs, the absence at present of detailed data from the organisation’s global operations on key areas such as the number of life saving interventions limits the ability of the organisation to fully demonstrate its global outputs and impact, or to review where its activities have fallen behind expectation. We understand that this will be addressed in early 2012 as the results are compiled from the overseas countries and we recommend that this be done as a matter of priority.

15

Commitment 2 - A global leader on newborn health

“Working with others, we are leading a global effort to develop and promote newborn health policies and programmes that will dramatically reduce newborn deaths from preventable causes. We will expand and intensify our efforts to integrate proven, evidence-based technologies and approaches into national policies and large-scale systems in 12 priority countries.”

2.1 Save the Children recognises that “Among all children, newborns have the highest risk of

death. More than 40% of deaths in children occur in the first month of life.” Globally 3.3 million newborns are estimated to die each year and 2.6 million babies are still born. Accordingly, Save the Children sees being a global leader in the area of newborn health as integral to its mission.

2.2 Save the Children’s principal initiative in this area is its Saving Newborn Lives program.

Based within Save the Children’s operations in the US, the Saving Newborn Lives program seeks to “reduce global neonatal mortality by providing catalytic support to develop and scale-up packages of effective, evidence-based newborn care interventions.”

2.3 Amongst its principal funders, the Saving Newborn Lives program receives significant

support from the Bill & Melinda Gates Foundation. Indeed, speaking at the Economic Forum in Davos in January 2011, Melinda Gates said of the Saving Newborn Lives program:

“The initiative encourages women to give birth in a health clinic and then provides them with three home visits from healthcare workers, in the weeks following the birth. These visits help mothers learn about how to care for their children, including exclusively breast feeding.”

2.4 The expertise of the Saving Newborn Lives program in the area of newborn health is

further evidenced by donors such as the United States Agency for International Development (USAID). Save the Children is the lead partner in the area of newborn health and community interventions for USAID’s Maternal and Child Health Integrated Program (MCHIP). This is USAID Bureau for Global Health’s “flagship maternal, neonatal and child health programme, which focuses on reducing maternal, neonatal and child mortality and accelerating progress towards achieving MDGs 4 & 5.” (www.mchpi.net).

2.5 With a programme budget of $600m, this is USAID’s largest such programme and

provides assistance to governments and civil society organisations in over 30 countries. As the website says “MCHIP works with USAID missions, governments, nongovernmental organizations, local communities and partner agencies in developing countries to implement programs at scale for sustainable improvements in MNCH.”

2.6 In 2011, further recognition of Save the Children’s position as experts on newborn health

was achieved when Save the Children was appointed a technical partner in the $200m, 5 year USAID programme entitled SPRING - Strengthening Partnerships, Results and Innovation in Nutrition Globally.

2.7 The SPRING programme seeks to advance global and country-level nutrition-related

policies and programs to improve the nutritional status of vulnerable populations - especially women, infants, and young children. Amongst other activities, the programme seeks to build the capacity of countries to design, implement and evaluate nutrition programs and to promote the effective delivery of a core package of nutrition interventions.

16

2.8 Save the Children’s position as a leader in the area of newborn health is further supported by the research it has financed, performed and published. Since its establishment, the Saving Newborn Lives programme alone has published and disseminated over 225 peer-reviewed publications and over 150 technical and policy briefs, training manuals, guidelines, and books to increase awareness, build the knowledge base, and encourage action for improving newborn health.

2.9 Since 2009, 33 articles in which Save the Children staff were involved as authors have

been cited in Medical Journals internationally. The quality of these articles is evidenced by the fact that amongst other publications, 5 articles have appeared in the Lancet journal. (The Lancet was recognised in 2010 as the medical journal with the second greatest impact globally - 2010 Journal Citation Reports).

2.10 The articles in the Lancet include those in the recent series on Newborn Health published

in 2011 of which the most recent (May 2011) is “Stillbirths: How Can Health Systems Deliver for Mothers and Babies?”3 This last publication has to date been cited by three other medical journal articles subsequent to its publication.

2.11 In addition, Save the Children’s research work is regularly cited in publications by other

organisations, such as the World Health Organisation (eg: the Somali Nutrition Strategy Document – 2011-134) and UNICEF (eg: Taking Evidence to Impact: Making a difference for vulnerable children living in a World with HIV and AIDS5)

2.12 To further encourage the spread of evidence and experience in the area of newborn

health, Saving Newborn Lives also established the Healthy Newborn Network in 2009 - www.healthynewbornnetwork.org

2.13 The website has significant numbers of visitors and is a leading resource in the area of

newborn health. For example, in the six month period from July to November 2011 it had 24,355 visitors from 170 countries. Those countries in the top 10 number of visitors include (in descending order), US, India, UK, Canada, Australia, Philippines, South Africa, Nepal, Pakistan and Kenya.

2.14 Hosted on the website, this global community resource provides access to information,

research and various resources for practitioners, policy makers and other stakeholders in the area of newborn health. In the same six month period referred to above, resources were downloaded 376 times.

2.15 The Commitment specifically refers to Save the Children’s intention to focus on

integrating proven, evidence-based technologies and approaches into national policies and large-scale systems in 12 countries. The organisation has since increased its target, with all 20 countries which have submitted Country Plans for the EVERY ONE campaign required to ensure that their programmes “in all cases…promote and support evidence-based interventions” prior to the Country Plans being approved.

3

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673610623069.pdf?id=40bade4753939e7f:62ee2433:132f79daf5c:-65c91318415023738 4 http://www.emro.who.int/somalia/pdf/somali_nutrition_strategy_low_resolution.pdf

5 http://www.unicef.org/ukraine/TAKING_EVIDENCE_TO_IMPACT_FINAL.pdf

17

2.16 Whilst, as we have discussed above, only limited global data for the organisation’s work

in 2011 has been received, we have reviewed programme reports from countries including Ethiopia, India, Pakistan and Sierra Leone which demonstrate that Save the Children is actively seeking to integrate evidence-based approaches and technologies into national policies and or large-scale systems and some of these are referred to elsewhere in this report.

2.17 With a further three years of the EVERY ONE campaign to run many of these Country

Plans are in an early stage of their implementation. However, as this area represents one of the organisation’s specific Commitments, we would reiterate the importance of Save the Children continuing to ensure that the specific targets for these twenty countries are closely monitored to ensure that they are on target to meet this commitment.

2.18 Other than the quantitative target of 12 countries, this Commitment did not specify any

quantitative indicators by which we can conclude on Save the Children’s success or otherwise in meeting this Commitment. However, from the work detailed above, we believe that it is reasonable to conclude that the organisation’s global operations are contributing significantly to the Commitment and its objective

2.19 It should however be noted that much of the information included above (such as

numbers of research papers published in medical journals and their citations in other journals) was performed only following our request as a means of demonstrating the impact of Save the Children’s work in these areas. We would recommend that the organisation seeks to collect this information as a matter of practice to enable it to better demonstrate its impact in this area. The organisation should also consider expanding the range of data collected in relation to the Healthy Newborn Network website to better assess the impact of the website and the resources downloaded. This could include, for example, the use of user surveys.

18

Commitment 3 - A direct participant in supporting health workers to save lives

“We will participate in the training and support of 400,000 health workers in developing countries to ensure better availability of life-saving services. This includes supporting the expansion and capacity-building of community health workers delivering services inside and outside of health centres.”

3.1 In addition to Save the Children’s advocacy and research work, Save the Children

considers it vital to ‘practice what it preaches’ and to be actively involved in training and supporting health workers in the developing world. As the organisation’s “Build to Breakthrough” plan explains:

3.2 “To stop needless deaths of newborn babies and children and achieve the fourth

Millennium Development Goal, we need a health worker within reach of every vulnerable child, who is trained, equipped and supported to deal successfully with the principal threats to that child’s survival through the first five years of life.”

3.3 In 2010 Save the Children helped train 84,906 health workers in the countries as shown

in the world map above. This information has been taken from the management information returned by each country on an annual basis as part of the organisation’s EVERY ONE campaign as discussed in Commitment 1 above. At the time of writing this report the preliminary information for 2011 is not available.

3.4 It should be noted that the above information presents both health workers trained by

Save the Children itself (described as being at the ‘Intervention level’ and totalling 54,245) and those workers trained at what Save the Children describes as a ‘National level’ (30,661). The National Level indicator relates to those health workers trained where Save the Children has made a ‘significant contribution’ to the training of the health worker although the organisation has not itself delivered the training.

19

3.5 In order to determine whether it is relevant for a country programme to track National Level indicators, Save the Children has defined ‘significant contribution’ and guidance has been provided to each of the implementing countries. The guidance states that: “Significant contribution refers to situations where there is good evidence that Save the Children’s activities have contributed to increased access to services or increases in national coverage of interventions and is defined by the following criteria:

(a) situations where Save the Children has played a leadership role in national

partnerships that have informed and influenced policies, strategies and programmes including clinical guidelines and national training curricula and/or resulted in increased funding for health, nutrition or livelihoods programming which have led to increased coverage of specific interventions for MNCH

(b) AND/OR direct interventions for which Save the Children has provided significant

direct technical and financial support in multiple districts or states (covering >10% of the national population) such as support for training of facility and/or community workers, provision of essential supplies or commodities, community mobilization, behaviour change communications, quality improvement, and facility rehabilitation. Country Offices must be able to substantiate any claim to significant contribution through documentation of programme or advocacy work”

3.6 It is also necessary to consider what is the nature of the training being received by health

workers which is included in the 400,000 target. Again, Save the Children’s monitoring and evaluation guidance details what can be included. The guidance states:

“Countries will identify which key high impact training packages they are supporting through the EVERY ONE campaign and report the number of health workers completing training in those packages at national and sub-national levels.

To be included, trainings must follow a standardized curriculum that is nationally endorsed and/or in line with international training packages (i.e. WHO, UNICEF, etc). In addition, trainings must include clear objectives and the minimum duration should be at least one full day. Orientation sessions or isolated sessions should not be included in this indicator. Countries will identify and describe the available training packages and work with partners to track numbers completing training each year.

Trainings that may be reported will fall under the following general areas:

Management of acute malnutrition

Promotion of recommended infant and young child feeding practices

Case management of childhood illness

Antenatal Care

Basic/Comprehensive Emergency Obstetric Care

Essential Newborn Care (ENC)/Postnatal Care (PNC)

Prevention of Mother-to-Child Transmission of HIV (PMTCT)

Family Planning

Health systems management topics

Basic training (pre-service)” 3.7 There remains a subjective element to the inclusion of health workers trained, especially

for those categorised within the ‘National level’ statistics and these items are not specifically covered by any form of external audit or assurance albeit we appreciate that the costs of performing such an assignment would most likely outweigh any resulting benefit.

20

3.8 Furthermore, it is quite possible for the same individual to be a recipient of more than one

training course and for them to therefore be included twice. Again, not only would the costs of monitoring the recipients of the training and comparing attendees in each course be prohibitive, but we would argue that it is quite reasonable to record the number of attendees on individual training events so as to provide an accurate representation of the scale of Save the Children’s training programmes at both the Intervention and National level.

3.9 The issue of subjectivity of those included within the ‘National Level’ should not

discourage Save the Children from recording this information, not least of all because it is at that intervention level that arguably the more sustainable impact is made.

3.10 As Save the Children themselves say, “In order to enhance the likelihood of sustainability,

wherever possible Save the Children works to strengthen health workers within the host country’s health system. By supporting the strategy and plans of the host government, we can strengthen training content and methods, improve supervision, and improve management information and logistics systems. We avoid creating new cadres of workers paid by Save the Children, but work instead within the existing health system.”

Looking forward - meeting the commitment: 3.11 Save the Children’s target is that it will participate in the training and support of 400,000

health workers up to 2015. Whilst an extrapolation of the results from the first year (84,906) suggests that it will reach the target during the four year period of 2011 to 2015 the organisation does not at present have a breakdown of how this figure is going to be reached by the country programmes.

3.12 We recommend that the organisation reviews the individual country training projections to ascertain how the target of 400,000 will be reached. This will enable the Commitment to be monitored effectively and for any possible programmatic shortfalls to be addressed in a timely manner.

3.13 In relation to the information recorded under the number of health workers trained,

something which Save the Children should consider is how best to present the scale of training received by the health workers. For the purpose of reporting achievement of the training commitment someone receiving a day of training carries equal weight to someone who attends a week long course.

3.14 However, the duration of training varies from country-to-country and by type of health

worker. In some settings, for example, frontline health workers posted to first-level facilities may receive as much as two years of training, whereas community health workers often receive a few weeks or months of training, depending on their educational background, and the role they are expected to play.

3.15 We therefore recommend that Save the Children gives consideration to introducing

additional reporting requirements from the countries in relation to the number of health worker training days delivered so as to more effectively present the scale of training received by the health workers. We also recommend that a more qualitative analysis of the type and usefulness of the training is carried out.

21

Commitment 4 - An innovator in community mobilisation for behaviour change and advocacy

“We will help mobilize communities in the countries with the highest child mortality, to hold governments to account, claim their right to quality health care, and take control of their lives in order to reduce maternal and child mortality.”

4.1 Integral to Save the Children’s work across the globe is assisting the individuals and

communities with whom the organisation works to better help them through the provision of information relating to health care and assisting in community mobilisation to help them access the health care to which they are entitled.

4.2 Whilst Save the Children did not seek to set a specific target within this Commitment of

the number of people mobilised locally, the results for 2010 have been quantified. In the countries in which Save the Children operates programmes, a total of 5,832,982 ‘hand-raising’ action have been reported. A hand-raising action is considered one where an individual performs a single activity (eg: signing a postcard, or attending a rally) in support of Maternal, Newborn and Child Health activities.

4.3 To best demonstrate Save the Children’s role as a community mobiliser we have sought

to find and cite some examples from the organisation’s global portfolio of projects. 4.4 In Sierra Leone, following the dropping of health care user access fees discussed under

Commitment 1 above, it was vital that communities and individuals were made aware of their new rights and the impact of this legal change so as to improve take up of the healthcare services now available to them.

4.5 Save the Children took a leading role in addressing this issue. As part of the

organisation’s mobilising activities Save the Children organised what is believed to be the largest ever SMS campaign seen to date in Sierra Leone. Involving 2 or the country’s 3 mobile phone networks, the campaign will see phone users on these networks receive 17 messages on issues relating to the access to healthcare. The first message was sent in October 2011 and reached an estimated 2.2m people.

4.6 In addition, the organisation has organised a series of radio dramas again highlighting

key issues of access to healthcare services. These are being broadcasted across 27 radio stations whose audience are estimated at just under 5m.

4.7 In Ethiopia, to help raise the issue of Maternal, Newborn and Child Health care, Save the

Children has entered into a three year contract with the organisers of the Great Ethiopian Run to publicise these issues. At the second such run in 2011, 4,000 took part in the run and there were over 7,000 spectators. Haile Gebreselassie, the former Olympic Champion and the official ambassador of Save the Children’s EVERY ONE Campaign in Ethiopia, was present at the start of the mass race and spoke at the Pre-race media press conference and the VIP reception where he stated he lost his mother to child birth and how much this campaign resonates with him.

4.8 A number of events were held over the weekend, including a technical roundtable hosted

by the Maternal Health Advisor from the Federal Ministry of Health. Other high profile attendants of the events included President of the Southern Nations and Nationalities Region Ato Shi feraw Shigute, Head of Public Relations from the Federal Ministry of Health, The Mayor of Hawassa.

22

4.9 The Ethiopia programme has also sought to further raise the issue of Maternal, Newborn and Child Health issues by launching its first media competition. As its guidance states, “the aim of the competition is to produce the most relevant, far reaching, and well composed media pieces on maternal and child health that are likely to have the biggest impact on their targeted audience.” To date over 30 journalists have entered the competition in three categories: Print, Electronic and Social Media.

4.10 In India, Save the Children used the nation’s hosting of the 2010 Commonwealth Games

to successfully raise the issue of maternal and child mortality. The organisation used the event to publish its report “Common Wealth or Common Hunger,” which reported, amongst other headlines, that 64 per cent of the world’s underweight children live in Commonwealth countries and that India, the hosts of the Commonwealth Games, had both the highest number and the highest proportion of underweight children.

4.11 The publication of the report received sufficient attention to result in parliamentary interest

that a member of parliament, Shri T.M Selvaganapathi asked the following question of the Minister of Women and Child Development in parliament:

Will the Minister be pleased to state: “whether it is a fact that the country ranks first among the Commonwealth countries as far as malnourished children are concerned; whether it is also a fact that the malnourished children are more in the country as compared to other developing nations; and if so, the steps being taken by Government to improve the health of children in the country?”

4.12 Save the Children’s advocacy and campaigning is not limited to the Global South. The

organisation seeks to mobilise a global community of individuals determined to improve maternal, newborn and child health. Indeed it seeks to achieve a total of 60 million hand raising actions across the globe by 2015.

4.13 As Robert Orr, United Nations Assistant Secretary-General commented, “Save the

Children’s work to put these issues on the global agenda and to line up citizen and voter support in a number of countries has been critical. Without this proactive effort it would not have been possible to bring together such a diverse range of partners behind women’s and children’s health.”

4.14 Examples of Save the Children’s advocacy and mobilisation efforts in the Global North

include the activities in Italy where a huge campaign under the banner of ‘Don’t let them go’ saw 792,937 hand raisers participating in the 4 week campaign in October 2010 (of which 721,281 related to those sending SMSs). The corresponding national TV and SMS campaign and raised nearly €2.9 million for Save the Children’s work.

4.15 In addition, members of the Fiorentina football team posed with the balloons and branded

their shirts with the Save the Children logo to show their support. “Today we decided that our support for this international organisation , for an important project like EVERY ONE, should grow to a higher level , and we decided to offer … the most visible plat form … we have available – our shirts.” Mario Cognigni, Fiorentina’s Vice-President, Fiorentine Football Club

4.16 In the UK, Save the Children launched a mass media campaign in January 2011 for its

“No Child Born to Die” campaign, part of Save the Children’s global EVERY ONE campaign. To date, over 188,000 people have watched its campaign video.6

6 http://www.youtube.com/savethechildrenuk#p/c/1A341F2018293B39/0/Jn9oMA1GQ5Q

23

4.17 The UK in 2011 was also the host country for the GAVI Summit and the organisation sought to capitalise on this to increase the profile of the “No Child Born to Die” campaign including amongst parliamentarians. The organisation succeeded in having an early day motion in the Houses of Parliament in January 2011. Proposed by Malcolm Bruce MP, the Chair of the International Development Committee in the UK, and supported by 125 Members of Parliament, the early day motion stated:

“That this House notes with concern the analysis in Save the Children's No Child Born to Die campaign that eight million children a year die before their fifth birthday, mainly in the poorest countries and largely due to easily preventable causes such as pneumonia, malaria, diarrhoea and complications after birth which rarely lead to child mortality in rich countries; believes that every child should receive healthcare, irrespective of the conditions into which they are born, and that this requires a focus on extending immunisation and the training of healthworkers; and calls on the Government as a leader on global health, a commendable supporter of the Global Alliance for Vaccines and Immunisations (GAVI), and host of June's 2011 GAVI summit, to galvanise other donor countries to put immunisation in poor countries on a sustainable financial footing, and ensure that life-saving vaccinations reach the world's poorest and most vulnerable children as part of a global effort to save 15 million children's lives by 2015.”

4.18 The GAVI Summit was used as a key focus for Save the Children’s campaign, especially

in the UK. Amongst other activities, in advance of the meeting, Save the Children published its “Vaccines for All” report which included the fact that one-fifth of the world’s children – around 24 million – are still missing out on life saving immunisation. A fact reiterated in the video produced by Save the Children and released in advance of the Summit highlighting to world leaders that they had 4 hours to save 4 million lives when they met in June 2011.7

4.19 Save the Children’s leading advocacy role in the build up to the Summit was widely

recognised, including by donors such as the UK’s Department for International Development. One official from the Government Department stated that “Support and advocacy from NGOs such as Save the Children was integral to the overall success of the GAVI pledging conference. DFID was grateful for the support that Save the Children offered with advocacy up and down the country and overseas, as well as the great press coverage they helped to generate.”

4.20 The GAVI pledging summit surpassed its target of raising $3.7 billion which would provide

vaccines for 250 million of the world’s poorest children, with a total of $4.34 being pledged.

4.21 Save the Children’s role at the Summit was further acknowledged in a letter from the Rt

Hon Andrew Mitchell MP, Secretary of State for the Department for International Development, to Justin Forsyth, CEO of Save the Children UK in which he wrote: “I want to thank you personally for your contribution to the GAVI Alliance pledging event…The outcome we achieved together – is an extraordinary result and a significant step forward in the fight to protect the world’s children from needless death and suffering…I feel enormously privileged to have been part of the work and I want to thank you for everything you did to make it a success.”

7 http://www.gavialliance.org/library/audio-visual/videos/4-hours-to-save-4-million-lives---saving-lives-through-

vaccinations/

24

Bill Gates and Justin Forsyth at the GAVI pledging summit. The Bill and Melinda Gates Foundation pledged $1bn to the GAVI initiative at the summit.

4.22 It is evident from our assessment that there is a significant amount of advocacy and

community mobilisation being performed across the globe by Save the Children and we therefore conclude that the organisation is continuing to address this Commitment. However, in compiling this report we have noted that Save the Children is not currently projecting the scale of these activities to the wider audience and supporters.

4.23 For instance, whilst Save the Children members have their own websites which present

the latest news and information on the organisation’s advocacy and community mobilisation work, the fact that communication resources are predominantly based in the member organisations means that the news reported focusses on the work of the individual Save the Children member, not on Save the Children globally.

4.24 The one website which does seek to disseminate Save the Children’s global work is the

EVERY ONE website (www.everyone.org). However our review of this website, and in particular of the ‘other campaign news’ from countries across the world regularly shows news from September 2010 and not of more recent events.

4.25 Accordingly, we recommend that Save the Children give greater consideration to as to

how best information surrounding its global advocacy and campaigning activities can be presented not only on the individual member websites, but also via the global campaign website and how the presentation of this information can be co-ordinated. This will most likely require additional investment in the communications resources within Save the Children International to ensure effective global co-ordination.

25

Commitment 5 - A pioneer of innovative and effective partnerships

“We will engage with partners from the corporate sector, governments, media, academics, sport, entertainment, and civil society, at a national and international level, to help deliver life-saving programming and engage hundreds of millions in the movement to end needless deaths of mothers and children. In the United States, for example, our partnership with the Ad Council will result in $75 million of donated advertising space for public service announcements to engage the US public on MDGs 4 and 5.”

5.1 As Save the Children itself states, it “never set out to do it alone.” To address the global

issues relating to Maternal, Newborn and Child Health, the organisation believes that integral to its efforts is working in partnership with individuals, other civil society groups, governments, international bodies, corporates and academics.

5.2 The organisation has not set itself specific targets for the number of partnerships it has

sought to develop. Accordingly, for the purpose of this review, we have worked to present examples from the various partnerships the organisation has developed across the globe to demonstrate how the organisation is meeting this Commitment.

5.3 With academics and medical bodies, a leading example is the Helping Babies Breathe

partnership. In this initiative, Save the Children works in programme countries with Laerdal Medical, Johnson & Johnson, the American Academy of Paediatrics and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

5.4 In October 2011 the success of this partnership was recognised when it was awarded

with the USAID Partnership Award. As USAID’s press release itself reported:

“Helping Babies Breathe seeks to reduce neonatal mortality by increasing the availability of resuscitation to manage newborn asphyxia during birth. Since its launch in June 2010, this partnership has mobilized $13.3 million in cash and in-kind contributions from partners – leveraging $6 for every U.S. dollar invested. The partnership has introduced Helping Babies Breathe in 27 countries, convening stakeholder meetings and training over 18,000 health providers, and has reduced asphyxia-related neonatal mortality by over 50 percent among 7,000 newborns in a pilot study in Tanzania.”

5.5 Partnership in campaigning: Commitment 3 above presents Save the Children’s progress

to date in supporting the training of health workers across the globe. Central to the organisation’s work in this area is raising the awareness to the need for increased numbers of health workers and the associated funding. Save the Children has stated:

5.6 “As the UN Secretary General has noted, the world is suffering from a massive gap of

more than 3.5 million health workers. This includes a pressing need for at least 1 million community health workers and 350,000 midwives. Millions more existing workers lack the support, equipment and training they need.”

5.7 In this regard, Save the Children has taken a leading role in the Health Workers Count

campaign. This is a partnership of 309 international NGOs and civil society organisations which seeks to advocate and spread the word on the need for more health workers. Amongst other responsibilities, Save the Children operates the campaign’s website (www.healthworkerscount.org) and co-ordinates many of the campaigning activities.

26

5.8 The advocacy work of the Health Workers Count partnership focussed particularly on the UN summit held in September 2011, marking a year since the UN’s ‘Every Woman, Every Child’ strategy was launched. The campaign partnership sought to use the Summit as an opportunity to reiterate the importance of the role of health workers, in particular in meeting Millennium Development Goals 4, 5 and 6.

5.9 The combined strength of the campaign partnership enabled the organisations to receive

global media coverage including coverage in the Guardian Online8. Thousands of people signed up to online petitions and showed their support for the campaign by transforming themselves into health worker superheroes health workers on the campaign’s website, including Sarah Brown, the wife of former UK Prime Minister, Gordon Brown and USAID administrator, Raj Shah.

Health Workers Count campaigners in Time Square during the UN Summit.

5.10 At the UN summit itself Save the Children staff, working with the partnership, delivered a

speech at the UN and a number of celebrities, ministers and civil society leaders including Desmond Tutu, Beverley J. Oda (Canadian Minister of International Development), Dr. Raj Shah, Dr. Tedros Adhanom Ghebreyesus (Ethiopian Minister of Health), and 50 cent, signed the Health Workers Count icon, adding their support to the campaign’s pledge: “I pledge to do all can to make sure everyone, no matter where they live, is within reach of a health worker.”

8 http://www.guardian.co.uk/global-development/poverty-matters/2011/sep/23/health-workers-maternal-child-

money

27

5.11 At the Summit a number of commitments were made in relation to health workers. These

included:

Ethiopia pledging to increase the proportion of births attended by a skilled professional from 18% to 60%;

Bangladesh committing to double the percentage of births attended by a skilled health worker by 2015 and train 3,000 midwives;

Uzbekistan committing to improve the quality of care provided to mothers and children by training 25,000 health workers;

5.12 Save the Children has also built an active NGO coalition focused on frontline health

workers to address the challenge set out by the UN Secretary General’s Special Envoy on the Health MDGs to put one million frontline health workers on the ground by 2015. The Frontline Health Workers Coalition, a group of 16 NGOs and a growing group of corporate partners (including GSK, Merck, Johnson & Johnson, BD, Pfizer, Intel, Medtronic and Novo Nordisk) are advocating for the US Government to play a leadership role on addressing the shortage of frontline health workers and is funded by the Merck Foundation. This public-private sector – NGO alliance held planning meetings in 2011 to better coordinate and deliver on their commitments to advance the global health workforce agenda.

5.13 In seeking to engage a wider audience in the developed world, Save the Children has also sought to develop a range of partnerships with the media. For example in the UK, Save the Children UK partnered with the TV series, the X Factor in the ‘Born to Sing’ campaign.

28

5.14 At the 49 concerts held by the X Factor (with total audiences of approximately half a million), a campaign message featuring Simon Cowell, X Factor finalists and other celebrities was shown both at start of the shows and during the interval.9

5.15 In the US, Save the Children has partnered with the Ad Council to create a public service

advertising campaign. Called “See Where the Good Goes”™, the three year campaign seeks to raise awareness of what frontline health workers in developing countries are doing to address the preventable and treatable causes of childhood mortality. The pro bono creative agency for the campaign is BBDO and the Ad Council is able to gain donated media space.

5.16 As at the end of July 2011, the total value of such donated media was $43,768,500. This

helped contribute to some very significant impressions within the US media market. In 2010 news reports of “See Where the Good Goes” advertising campaign and the publication of the Save the Children publication State of the World’s Mothers 2010 saw total traditional media coverage of 48.5 million impressions (TV – 26 million, radio 16 million and print 6.5 million). Social media coverage totalled more than 139 million views.

5.17 Partnerships have also been developed with the media to help publicise Save the

Children’s reports. For example, a partnership with public-interest broadcaster Link TV and its Gates-funded ViewChange.org project resulted in a 30-minute documentary based on Save the Children’s State of the World’s Mothers report.

5.18 “ViewChange: The Mothers Index” was aired on Link TV, which has 6.7 million regular

viewers via DIRECTV and the DISH Network. The special was also featured on the sites of major global health advocacy organizations, such as Gates Foundation and ONE. It resulted in almost 100,000 visitors viewing Save the Children’s online presentation, downloading 44,500 copies of the report.

5.19 Save the Children has also sought to develop partnerships with corporates and 2010 and

2011 have seen some significant developments in this area. Save the Children’s corporate donors include America Express, Bank of America, GSK, P&G and Reckitt Benckiser and recently Save the Children US has embarked on a five year partnership with the global healthcare company Merck (known as MSD in markets outside of the US and Canada). With financial support of $5 million through 2015, the partnership “will help train and support 10,000 more frontline health workers and create greater public awareness and call to action for more frontline health workers.”

9 http://www.youtube.com/watch?v=z3P9T5WyPgI

29

5.20 Other corporate supporters include Save the Children’s first global partnership - a $19 million three year agreement with Unilever as well as Mothercare and the Early Learning Centre (under the Born to Care partnership in the UK). Mothercare and Early Learning Centre are running the initiative and are aiming to raise £1.75 million over three years to support Save the Children’s work. Leann Atkinson, Head of Corporate Social Responsibility, said the company chose to partner Save the Children because it has a global presence and because its brand values fit well. “Our DNA is about care for parents, and nothing is more important for them than the protection of their children.”

5.21 In conclusion, whilst Save the Children did not set itself specific targets for the number of

partnerships it sought to develop under this Commitment, our report does demonstrate that it has developed and implemented a range of effective partnerships across the globe and is therefore actively and successfully working to address the Commitment.

30

Commitment 6 - A vocal advocate for children’s rights and equity

“We believe in sustainable country-owned solutions to improve child and maternal survival. As a global proponent for children’s rights, we will promote human rights instruments, especially the UN Convention on the Rights of the Child, to ensure that states deliver their agreed obligations. We will call for equity in all health and nutrition programmes to ensure that disproportionate levels of mortality in poor and marginalised groups are no longer tolerated, and (this month) launch a global policy report with this message, “A Fair Chance at Life” in New York.”

6.1 For Save the Children, the achievement of the Millennium Development Goals is not the

end point. Whilst the Goals may be met, millions of the poorest and most vulnerable children and mothers will still not have access to sufficient nutrition and health services. After 2015 the organisation is committed to continue to push the international community to focus on reaching the remaining marginalised children and mothers and work to ensure, for instance, that each is within reach of a health worker.

6.2 One of the most significant areas of focus in this regard is in relation to Save the

Children’s work with the UN Committee on the Rights of the Child. In particular, Save the Children has played a leading role in 2010 and 2011 in advocating for the need for a General Comment on child health and children’s rights. This legal instrument will require that countries prioritise policies that cut child mortality so as not to be in breach of their responsibilities under the Convention of the Rights of the Child.

6.3 On this issue, Save the Children has been working with other NGOs, including World

Vision, Unicef and the WHO and the significant role it has played has been recognised by both the Committee on the Rights of the Child and by other partner members, as the following quotes obtained for this report testify to:

6.4 “Save the Children’s excellent research and analysis on the health of children, including

its seminal study on the legislative and institutional developments in countries with the highest infant mortality, has been determinant for the decision of the Committee on the Rights of the Child to produce a General Comment on Health. Save, as we all know it, is persistent on its commitment to support the fulfilment of child rights and is a good partner to other international organizations in the field of health, nutrition and well-being as well as is committed in supporting the right of children to be heard.” - Marta Mauras, Vice-President of the Committee on the Rights of the Child relating to Save the Children’s work on the child’s right to health.

6.5 "Over the course of the past year, Save the Children's Geneva Office has been

instrumental in accelerating progress in relation to the fulfilment of children's right to health. In particular, we have valued the essential role Save the Children has played in our joint advocacy efforts and partnership in catalysing and supporting the process of preparation of a General Comment on the child's right to health by the Committee on the Rights of the Child. The impact of this work will be tremendous, as the General Comment will provide a vital tool in strengthening legal frameworks and providing guidance to States on how to implement the obligations in the Convention for which they are accountable." Nicolette Moodie, Human Rights and Gender Liaison Officer, Unicef

6.6 As a further example of Save the Children’s work in promoting human rights instruments,

Save the Children also makes regular submissions within the Universal Periodic review process with the Office of the United Nations High Commissioner for Human Rights. The submissions relate to primarily issues of child survival and health.

31

6.7 These submissions are edited together into one OHCHR Compilation which is fed into the process. Save the Children then actively lobbies with states to try to have these issues raised in Advance Questions to the state which is being examined and also in the HRC sessions themselves. It is only after this stage that final recommendations emerge. Accordingly, submission issues can be cut at any stage and so having an initial submission through to the final recommendations represents a significant achievement.

6.8 Save the Children has had increasing success in the last two years through its advocacy

and partnership efforts in Geneva and since 2010 has succeeded in having 10 of its initial submissions included in the final country reports. These have included two recommendations in relation to Swaziland (one on infant mortality and one on infant malnutrition) and in relation to Tanzania – where one recommendation was accepted on child mortality - “Implementing measures to increase women’s access to healthcare facilities and medical assistance by trained personnel, in particular in rural areas”.

6.9 Stefan Germann, World Vision International, Director : Partnerships & Learning, Global

Health & WASH team stated, "Save the Children's expertise and authority, working in Geneva alongside partners such as World Vision, has been important in driving forward action to strengthen international frameworks, to ensure that children's right to survival and health becomes a reality. Working together through international human rights mechanisms and with global bodies such as the WHO and UNICEF will ensure that more children live, and that they lead healthier lives. Save the Children is a well respected, collaborative and important Geneva-actor with whom World Vision is delighted to work."

6.10 Save the Children has sought to put equity and children’s rights at the heart of its

advocacy and policy work. Some examples of this are in relation to Save the Children’s policy publications.

6.11 These include the report “A Fair Chance At Life: Why equity matters for child mortality”

published in advance of the September 2010 UN Summit on the Millennium Development Goals. As Save the Children states in the report, “Taking an equitable approach to improving child survival matters in and of itself; the principles of equity and freedom from discrimination underpin all children’s rights, including the right to survival. But our analysis shows that addressing inequity can also accelerate overall progress towards MDG 4: the deaths of 4 million children could have been prevented (across 42 countries over a 10 year period) if countried had made more equitable reductions in child mortality.”

6.12 The importance of this issue is acknowledged by Lord Mark Malloch-Brown, the former

Administrator of the United Nations Development Programme (1999-2005). Writing in the forward to the report he states, “The report shows that an intensified effort to reduce child mortality can succeed only if equity is put front and centre. Ensuring that every child has a fair chance in life is a moral imperative. But there is also – as Save the Children’s research demonstrates – a compelling instrumental case for prioritising equitable progress in order to achieve MDG 4.”

6.13 Save the Children further reiterates the issue of children’s rights and equity in its 2011

publication “An Equal Start: Why Gender equality matters for child survival and maternal health.”

6.14 As the report states “Failing to tackle gender discrimination is resulting in lives lost

unnecessarily, wasting economic potential and slowing progress on MDGs 4 and 5. Research conducted by Save the Children suggests that although child mortality is on the decline, gender disparities are increasing. More girls than boys are dying during childhood, and in some regions gender disparities are increasing.”

32

6.15 In the foreword to the report, Baroness Kinnock of Holyhead, former UK Minister of State for Africa and the United Nations, commented, “This report demonstrates that gender inequality affects child survival through discriminatory practices like foeticide and infanticide. Gender inequality also perpetuates systematic discrimination against women and girls in a number of other ways that contribute to child and maternal mortality… An Equal Start challenges us to place women and girls at the centre of our work, and to break the cycle of discrimination.”

6.16 As part of its active engagement with the UN’s ‘Every Woman, Every Child’ initiative,

Save the Children has also sought to influence the Commission on Information and Accountability to have greater consideration to equity within its Global Strategy. In February 2011, Save the Children published its policy brief, “Closing the Equity Gap”. Descried as a “call to the UN Commission on Information and Accountability for Women’s and Children’s health to put equity at the heart of efforts to reduce maternal, newborn and child mortality.”

6.17 Subsequent to the publication of this report, the Commission published its 2011 report

“Keeping Promises, Measuring Results”. As its second recommendation, the Commission recognised the importance of equity in measuring results. It called for the following: “Health Indicators: By 2012, the same 11 indicators on reproduction, maternal and child health, disaggregated for gender and other equity considerations, are being used for the purpose of monitoring progress towards the goals of the Global Strategy”.

6.18 Whilst our report details much evidence that Save the Children is actively pursuing this

Commitment through its promotion of and use of existing human rights instruments, we would recommend that Save the Children give further consideration to seeking to assess and demonstrate how advocacy performed within these organisations is having an impact at a local level in improving children’s rights.

6.19 For instance, if Save the Children succeeds in have a submission included as a

recommendation within one of the OHCHR periodic reviews, is there a means by which the ultimate impact of this can be demonstrated within the relevant country? In this regard, we understand that the organisation is currently reviewing this with its ‘Local to Global’ initiative and we would recommend that this be pursued further as Save the Children is well placed with offices both at the locations of the international bodies (Brussels, New York, Geneva and Addis Ababa) as well as within the relevant countries to which the recommendations are made.

6.20 This review should also consider the means by which local country programmes can best

pursue the issues raised by Save the Children at an international level and ensure that to the fullest extent possible this can be included within the country’s programmatic and advocacy work. At present, such a link has not been formalised within the organisation.

33

Appendix 1 – Summary of key recommendations

1 At present the income projections show Save the Children failing to meet its annual commitment of $500 million by 2015. We recommend that a reforecasting of income and expenditure committed to MNCH programming is performed and that Members are asked to prepare updated and accurate projections to enable Save the Children to accurately ascertain how the $500 million per annum investment is likely to be reached by 2015. (1.10)

2 We recommend that in future, prior to making a quantitative commitment such as the $500 million expenditure target, that Save the Children prepares detailed projections which are approved by the other members so as to determine the reasonableness of the commitment and how it will be met (1.2)

3 At present there is limited global data from the organisation’s country programmes on key

areas such as the number of life saving interventions made. This naturally limits the ability of the organisation to demonstrate its global outputs and impact, or to review where its activities have fallen behind expectation. We understand that this will be addressed in early 2012 as the results are compiled from the overseas countries and we recommend that this be done as a matter of priority. (1.39)

4 Under Commitment 2, some of the information presented within this report (for example

numbers of research papers published in medical journals and their citations in other journals) was performed following our request as a means of demonstrating the impact of Save the Children’s work in these areas. We would recommend that the organisation seeks to collect this information as a matter of practice to enable it to better demonstrate its impact in this area. The organisation should also consider expanding the range of data collected in relation to the Healthy Newborn Network website to better assess the impact of the website and the resources downloaded. This could include, for example, the use of user surveys. (2.20)

5 Save the Children’s target is that it will participate in the training and support of 400,000

health workers up to 2015. The organisation does not at present have a breakdown of how this figure is going to be reached by the country programmes. We recommend that the organisation reviews the individual country training projections and ascertains how the target of 400,000 will be reached. This will enable the Commitment to be monitored effectively and for any possible programmatic shortfalls to be addressed in a timely manner. (3.13)

6 In addition to the current recording of health workers “trained” we recommend that Save

the Children gives consideration to introducing additional reporting requirements from the countries in relation to the number of health worker training days delivered so as to more effectively present the scale of training received by the health workers. We also recommend that a more qualitative analysis of the type and usefulness of the training is carried out. (3.15)

7 In relation to Save the Children’s advocacy work under Commitment 4, we recommend

that Save the Children give greater consideration to as to how best information surrounding its global advocacy and campaigning activities can be presented not only on the individual Member websites, but also via the global campaign website and how the presentation of this information can be co-ordinated. This will most likely require additional investment in the communications resources within Save the Children International to ensure effective global co-ordination. (4.25)

34

8 Under Commitment 6, our report details much evidence that Save the Children is actively

pursuing this Commitment through its promotion of and use of existing human rights instruments such as the OHCHR periodic reviews. However, we would recommend that Save the Children give further consideration to seeking how it can assess and demonstrate that advocacy performed within these organisations is having an impact at a local level in improving children’s rights. In this regard, we understand that the organisation is currently reviewing this with its ‘Local to Global’ initiative and we would recommend that this be pursued further as Save the Children is well placed with offices both at the locations of the international bodies (Brussels, New York, Geneva and Addis Ababa) as well as within the relevant countries to which the recommendations are made. This review should also consider the means by which local country programmes can best pursue the issues raised by Save the Children at an international level and ensure that to the fullest extent possible this can be included within the country’s programmatic and advocacy work. At present, such a link has not been formalised within the organisation. (6.18 - 6.20)

35

Appendix 2 – Methodology

The methodology behind this evaluation report was:

A start-up meeting with Save the Children staff in London – including with Ben Hewitt – Operations Director for the EVERY ONE Campaign and commissioner of this assessment and Nicola Chevis, Monitoring and Evaluation Manager, EVERY ONE Campaign.

Desk research - a review of a wide number of documents provided by Save the Children for the review. These included EVERY ONE operational plans, Save the Children Strategy documents, Country Plans, programme reports and evaluations, global monitoring and evaluation data and Save the Children policy publications and other reports.

Throughout the report, where we have quoted from a document we have clearly identified the document’s name and, where relevant, its source. In addition, we have also commented upon situations where evidence or analysis has not been prepared and have made recommendations for its preparation, where appropriate (such as expenditure projections under Commitment One). When reviewing the information provided to us by Save the Children, it should be noted that we have not necessarily sought to externally validate or audit the contents of such information but have relied upon Save the Children’s own internal policies and procedures for its validity.

Interviews (telephone and face to face) with a number of relevant Save the Children staff (see list at the end of this Appendix). It should be noted here that a number of the Commitments consider Save the Children’s advocacy work and its impact on, for example, governmental policy changes. As always with the assessment of advocacy work, there is the challenge of attribution – ie: to what extent any policy change can be directly linked to an organisation’s advocacy programme. In an attempt to address this issue we have sought wherever possible to obtain feedback and quotes from individuals working in those organisations towards which Save the Children’s advocacy was focussed. We are grateful to them in particular for their contribution to this report. For the purposes of this assessment it was agreed with Save the Children that interviews would be held only with employees of Save the Children and its Members. Future assessments could consider incorporating feedback directly from the organisation’s beneficiaries.

Interim follow up meeting with Ben Hewitt and Nicola Chevis.

Submission of a draft report to Save the Children staff in London for feedback prior to report finalisation. Feedback was provided by Ben Hewitt, Nicola Chevis and Patrick Watt, EVERY ONE Global Campaign Director.

Presentation of the final report to Save the Children.

36

We would recommend that in order to ensure that the findings of this assessment are effectively considered within Save the Children, that a proper dissemination strategy for this report be undertaken by senior members of the EVERY ONE Campaign to ensure feedback and validation from all relevant staff and relevant stakeholders.

The Save the Children staff interviewed as part of this assessment were: Ben Hewitt - Operations Director Global Campaign Team Nicola Chevis - Monitoring and Evaluation Manager, Global Campaign Team Louise Holly - Senior Health Advocacy Adviser, SC UK Ben Phillips – Mobilisation Director, Global Campaign Team Ali Readhead – EVERY ONE Campaign Manager, SC UK Sierra Leone Cicely McWilliam - Senior Advisor, Policy, Campaigns, Media, EVERY ONE SC Canada David Oot - Associate Vice President, Health and Nutrition, SC US Tanya Weinberg - Media and Communications Director, SC US Dr Meena Gandhi - Former Head of Health and HIV/AIDS SC UK, Ethiopia Hiwot Emishaw - EVERY ONE Community Mobilization and Communications Manager, SC UK, Ethiopia Michael French - UN Geneva Representative & Head of Office Dr Rajiv Tandon - Senior Advisor-Maternal, Newborn, Child Health and Nutrition, SC India Shireen Miller - Advocacy, Campaign and Communication Director EVERY ONE, SC India

37

Appendix 3 – Acronyms

CEO – Chief Executive Officer DFID – UK Department for International Development GAVI – Global Alliance for Vaccines and Immunisation GDP – Gross Domestic Product MCHIP - USAID’s Maternal and Child Health Integrated Program MDG – Millennium Development Goals MDG 4 – Reduce by two thirds, between 1990 and 2015, the under-five mortality rate MDG 5 – Reduce by three quarters the maternal mortality ratio; achieve universal access to reproductive health MNCH – Maternal, Newborn and Child Health MP – Member of Parliament NGO – Non Governmental Organisation OHCHR – Office of the High Commissioner for Human Rights SPRING – USAID’s Strengthening Partnerships, Results and Nutrition Globally Program UK – United Kingdom UN – United Nations UNICEF – United Nations Children’s Fund US – United States USAID – United States Agency for International Development WHO – World Health Organisation

© 2012 Crowe Clark Whitehill LLP

Find out more about us at

www.croweclarkwhitehill.co.uk Crowe Clark Whitehill LLP is a member of Crowe Horwath International, a Swiss verein (Crowe Horwath). Each member firm of Crowe Horwath is a separate and independent legal entity. Crowe Clark Whitehill LLP and its affiliates are not responsible or liable for any acts or omissions of Crowe Horwath or any other member of Crowe Horwath and specifically disclaim any and all responsibility or liability for acts or omissions of Crowe Horwath or any other Crowe Horwath member. Crowe Clark Whitehill LLP is registered to carry on audit work by the Institute of Chartered Accountants in England and Wales and is authorised and regulated by the Financial Services Authority.