Home | Main Page Title :Operationalisation of Mid-Decade Goals Document Type :Executive Directives (CF/EXD/...) Country :GlobalDocument Symbol/Series: CF/EXD/1993-008 Year Published : 1993 PDF Link : Detailed information (click on the twistee to see more) Executive Summary: Document Text: To: Regional Directors Representatives Assistant Representatives Executive Staff Advisory Clusters, HQ From: James P. Grant Executive Director Operationalisation of Mid-Decade Goals I write in connection with what will be UNICEF's top priority from now until the end of 1995 - the operationalisation and achievement of the Mid-Decade Goals. The purpose of this Executive Directive is to assist and guide your implementation of the consensus reached during the three regional consultations held in Nairobi, Bangkok and Bogota earlier this year; the decisions of the 1993 Executive Board and the review during the Post-Board meeting in May 1993. It also draws on the experience of some countries which already have commenced operationalisation of the mid-decade goals. These mid-decade goals form part of the overall objectives of the World Summit for Children. As many are already aware, the Declaration and Plan of Action of the World Summit for Children has now been signed by 148 Heads of State and/or Government, and already 85 countries have finalised their National Programmes of Action, with another 60 countries in the process of doing so. Many countries have also devolved their NPAs to provincial, municipal and sectoral levels. Since 1990, several regional meetings of the Heads of State and/or Government, have endorsed the Summit Goals and agreed upon a set of mid-decade goals to be achieved by 1995. While the list of mid-decade goals varies from region to region, a core set of ten goals has now emerged as achievable by almost all countries. These Mid-Decade Goals have since been endorsed by the WHO/UNICEF Joint Committee on Health Policy in February 1993 and further endorsed by the Executive Boards of UNICEF and WHO in May 1993. (See Annexes A & B). 1995 is a unique year as a mid-decade World Summit for Children review will be undertaken as agreed in the Summit. The World Summit for Social Development will also take place in March 1995 in Copenhagen. The goals as outlined in the attached annex will form an integral part of the Social Summit which will provide an opportunity for the attending Heads of State and/or Government to report on their achievements for children and development and their plans and commitments for the remaining years of the decade. The achievement of these doable mid-decade goals will give countries the necessary confidence to attempt to reach a more elaborate set of goals by the Year 2000. It will also create a momentum for the latter part of the decade. The attached Priority Action Plan for Achieving the Mid-Decade Goals between now and 1995, includes the following sections: 1. Goals and Targets 2. Strategic Elements of Programme Action 3. Elements of Operationalisation of Programme 4. Programme and Operational Implications for UNICEF 5. Funding Strategies 6. Prime Attention 7. Time Schedule The list of actions given provide the general framework for activities to operationalise the mid-decade goals. However, in view of the different stages of development and the different socio-cultural environment, countries are encouraged to develop action plans unique to the situation and problems of each country. Actions listed in the Priorities Action Plan are intended to serve as a guide and check list against which countries can compare their own planned activities to achieve the goals. While the principal responsibility is with governments and national institutions to implement the NPAs, UNICEF will naturally continue all support to enable countries to implement their NPAs and achieve tangible progress by mid-decade. This Priority Action Plan is to help focus action. UNICEF country offices should feel free to call on support from headquarters and regional offices. To this end, I have designated my Special Adviser, Dr. Nyi Nyi, to be in charge of the overall coordination of UNICEF efforts to support achievement of the Mid-Decade Goals. He will be responsible for ensuring that all UNICEF support systems are in place and also to coordinate headquarters and regional support as and when required. He will establish and head an Inter-Divisional Task Force which will meet frequently in headquarters with field inputs to monitor progress and report to me and the Deputies monthly or more frequently if the need arises, in order to provide more rapid and effective response to support the field. Country offices are requested to send a hard copy (with diskette) of their "Strategy and Workplans for Achieving the Mid-Decade Goals" in their countries, to the Chief of their respective Geographical Section and their Regional Director before the end of July 1993. The Workplans, the basic elements of which should already exist in most UNICEF offices, should describe the national plans and strategies to achieve the Mid-Decade Goals and the anticipated support required from UNICEF and other partners. The Workplans should include the following sections: 1. Basic situation analysis and challenges. 2. Strategies developed to achieve the goals. 3. Implementation plans including mobilisation of institutions and partnerships. 4. Monitoring arrangements. 5. Costs and financing mechanisms. 6. Support required from Regional Offices and Headquarters. The Country Workplans should be brief, include an executive summary and not exceed 40 pages. Regional Offices shall also prepare their support workplans and send a hard copy (with diskette) to the Chiefs of the respective Geographical Section. Headquarters divisions shall also submit their support workplans to their respective Deputy Executive Director with copies to Dr. Nyi Nyi. Both support workplans should be sent before the end of July 1993. I am fully aware of the enormity of the challenges ahead. But achieving these mid-decade goals is vital if we are to be able to live up to the promises made at the World Summit in September 1990. Without success on this front, we cannot expect to reach the goals set for the Year 2000. Only 30 months remain between now and the end of 1995. Fast, dedicated and concentrated action will be required from everybody if we are to succeed. I trust you will call on Dr. Nyi Nyi, Regional Directors, other colleagues in headquarters and regional offices and on me whenever you need assistance or advice. The stakes are high and I am counting on you. ANNEX A: 1993/12 Follow-up to the World Summit for Children On the recommendation of the Programme Committee, The Executive Board, Taking note of the "Progress report on the follow-up to the World Summit for Children" (E/ICEF/1993/12), Recalling General Assembly resolution 47/199 of 22 December 1992, Taking note of the "Consensus of Dakar" adopted at the International Conference on Assistance to African Children held in November 1992 and sponsored by the Organization of African Unity; the regional plan of action endorsed by the South Asian Association for Regional Cooperation Conference on Children in South Asia in Colombo, Sri Lanka, in September 1992; the Pan-Arab Plan adopted at the meeting of the League of Arab States held in Tunis, Tunisia, in November 1992; and the outcome of the meetings of the ministers and other representatives of Latin American Governments in Mexico City in October 1992 and of the First Ladies of Latin America and the Caribbean States in Colombia in September 1992, Takino note of the resolution on Child Care and Protection in the Islamic World adopted in April 1993 by the twenty-first Conference of Islamic Foreign Ministers, 1. Urges that the personal involvement of heads of State or Government in the commitments of the World Summit for Children be maintained and strengthened; 2. Encourages countries to examine their national programmes of action (NPAs) so as to identify feasible targets for achievement by mid-decade, develop annual action plans enabling NPA activities to bo incorporated into the regular national budgetary process and develop plans and programmes to make national programmes operational at provincial, municipal and district levels; 3. Requests that collaborations with international and regional financial institutions be strengthened further to assure that NPAs are taken into account at relevant moments of the poverty reduction, lending and adjustment processes; 4. Invites UNICEF, donor countries, non-governmental organizations and other partners, in consultation with the host Government, to consider ways and means to strengthen the delivery of social services, capacity-building and empowerment in the implementation of NPAs and country programmes supported by UNICEF 5. Requests the Executive Director to ensure that those follow-up activities of the World Summit for Children within the mandate of UNICEF be coordinated with the work of the relevant organizations and bodies of the United Nations, and that NPAs be integrated into action for sustainable development, also by taking them into account in the preparation, by interested Governments, of the country strategy note; 6. Invites donor countries and international and regional financial institutions in a position to do so to increase the share of official development assistance commitment to social priority sectors, and national Governments in a position to do so to increase the share of national budgetary allocation for the same sectors, so as to increase the proportion of resources devoted to basic education, primary health care, low-cost water supply and sanitation systems, responsible parenthood and family planning and nutrition programmes. ANNEX B: 1993/16. UNICEF/WHO Joint Committee on Health Policy On the recommendation of the Programme Committee, The Executive Board, 1 Welcomes the report of the UNICEF/World Health organization (WHO) Joint Committee on Health Policy (JCHP) meeting in Geneva on 1-3 February 1993, 2. Endorses the following r-commendations contained tn paragraphs 26, 34-35, 45, 50, 54, 79, 87, 94 and 97 and annex 4 of document E/ICEF/1993/L.11: I. REVIEW OF WHO HEALTH POLICIES AND UNICEF DECISIONS 1. The Executive Boards of UNICEF and WHO should reinforce complementary action to strengthen primary health care (PHC) programmes, to intensify research, to support training, capacity-building, intersectoral cooperation and integrated approaches, to focus on those most in need, and to mobilize resources to augment national efforts in those areas. Every effort should be made to follow up the goals of the World Summit for Children, giving special attention also to human immunodeficiency virus/acquired immune deficiency syndrome in children 2. It is important that the governing body of each organization should be made aware of resolutions and decisions adopted by the other, so that priorities can be established and action taken to fulfil broad policy goals 3. Resource constraints should be acknowledged and priorities set accordingly, and optimum use should be made of available resources II. WORLD SUMMIT FOR CHILDREN Follow-up action 4. The Committee welcomed and saw the need for intermediate goals in order to achieve the longer-term targets of the Summit It noted, however, that individual regions and countries would have to set their own priorities and timetables within those parameters Country priorities would be most accurately reflected in the national programmes of action, already completed or currently in the process of completion in some 140 countries All countries that had not yet embarked on such programmes should be encouraged to do so, and to complete them as soon as possible. 5. The Committee endorsed intermediate goals (as contained in annex 4 reproduced below] It noted the importance of investment in capacity-building within countries, together with the motivation and training that would permit the implementation of programmes on an integrated basis - particularly within the framework of PHC - and their monitoring. Progress made Maternal health and newborn care 6. Noting that, in general, sophisticated technology was not required for maternal health and newborn care, but that adequate training and basic support in the form of equipment were called for, JCHP recommends; (a) Strengthening the collaboration between UNICEF and WHO, together with the United Nations Development Programme and the United Nations Population Fund, in order to accelerate research and development and to provide more effective support to national programmes; (b) Updating and revising the joint UNICEF/WHO statement on maternal and newborn care in collaboration with other organisations of the United Nations system and professional groups; (c) Fostering reliance on, and increased support to, WHO's established research and development processes for the identification and evaluation of technologies, the definition of procedures and the establishment of norms, drawing upon country experiences of UNICEF, national programmes and other organizations; (d) Jointly initiating the upgrading of midwifery as the critical link between safe motherhood and newborn care and a factor in the elimination of neonatal tetanus. 7. Recognizing the importance of maternal health and newborn care, its links with other concerns, notably safe motherhood, and its impact on the elimination of neonatal tetanus, JCHP endorses the broad outline of the basic package for maternal and newborn care, taking into consideration suggestions and concerns expressed during the general discussion. It recommends that UNICEF and WHO should explore ways of improving delivery at an affordable cost, recognizing the considerable work already being done by UNICEF, WHO, the World Bank and other organizations active in the area. Vaccine needs 8. JCHP endorses the action proposed to overcome constraints, namely (a) Support to countries that have the capacity to produce vaccines so that they become self-sufficient; (b) Through the Vaccine Independence Initiative, procurement of vaccines on behalf of Governments with either convertible or local currencies; (c) Continued negotiation with vaccine suppliers so that they maintain provision of vaccines at affordable prices; (d) Approaches to the donor community so that it contributes greater resources for the procurement of vaccines for the expanded programme on immunization This action should be given priority 9. Stressing the importance of the Children's Vaccine Initiative and regretting that its progress has been somewhat slower than initially hoped, JCHP recommends that UNICEF and WHO should give greater attention to publicizing the programme and seeking increased external support for its efforts Research on the development of new vaccines should also be stimulated. Control of diarrhoeal diseases including cholera and acute respiratory infections 10. Noting with concern the large number of deaths still attributable to diarrhoeal diseases and acute respiratory diseases, JCHP recommends that the Executive Boards of UNICEF and WHO should urge Governments to mobilize financial, technical, political and communication resources to provide the technically available means for reducing that mortality 11. JCHP commends the active cooperation between UNICEF and WHO and among WHO programmes in combating diarrhoeal diseases and acute respiratory infections and urges that it should continue 12. JCHP recommends that UNICEF and WHO should make every effort to define with countries the mechanisms for achieving their national targets, and to ensure that resources will be made available and a greater effort undertaken to implement national programmes UNICEF and WHO should continue to work closely at country level in the planning and evaluation of control activities, and to coordinate their technical and financial inputs This collaboration should also be coordinated with bilateral agencies and non-governmental organizations (NGOs). III IMPLEMENTATION OF THE "BABY-FRIENDLY" HOSPITAL INITIATIVES 13. JCHP recommends that UNICEF and WHO should urge full compliance, by June 1993, with government action prohibiting distribution of free or low-cost supplies of infant formula, and that the target date of June 1994 should be set for ending distribution of free or low-cost supplies of infant formula in both developing and industrialized countries 14. JCHP reiterates the importance of achieving the 1995 operational target of the Innocenti Declaration, namely that all maternity wards and hospitals would be "baby-friendly", in accordance with criteria based on the joint WHO/UNICEF-statement on breast-feeding and the special role of maternity services It further reiterates the importance of government action in achieving all targets of the Innocenti Declaration 15 JCHP reaffirms the importance of UNICEF and WHO support for: (a) Preparation of action strategies for protecting, promoting and supporting breast-feeding, including global monitoring and evaluation strategies; (b) Analysis and survey of national situations and design of national goals and targets for action; (c) Planning, implementation, monitoring and evaluation of national breast-feeding policies; (d) Specialized training and/or services IV. PROGRESS REPORTS ON COLLABORATIVE ACTIVITIES Healthy lifestyles for youth 16. Praising the work done, JCHP recommends that UNICEF and WHO continue to work together on the following actions: (a) Elaboration and dissemination of knowledge to support global, regional and national investments in the health and capabilities of young people, as an essential contribution to the economic and social development of countries and communities; (b) Design and adaptation of key interventions which contribute to the health and development of young people, including strategies for their implementation and methodologies for monitoring and evaluation, making use of the existing education system and involving Governments; (c) Identification and coordination of technical and other resources which would strengthen and develop national-level activities with existing partners, including health and social welfare, education, and youth-serving NGOs; (d) Mobilization of new partners, such as the media, the world of entertainment, industry (manufacturing, agricultural and the informal sectors), the criminal justice system and NGOs, in order to increase their contribution to improving the health and development of young people. 17 Noting that the area where UNICEF and WHO could make the greatest contribution over the next 10 years would be in changing attitudes, JCHP recommends that the two organizations should discuss further the best means of bringing about change The aim should be to increase their effectiveness in the four areas listed above by modifying their ways of thinking and by involving other partners Health education Hygiene education with specific reference to community water supply and sanitation 18. Appreciating the progress already made jointly in promoting health education in schools, JCHP recommends that UNICEF and WHO should pursue action in that area, for example by (a) Cooperating with countries to implement comprehensive school health education, taking into account the needs expressed by education and health officials in countries and at the regional consultations on comprehensive school education; (b) Identifying countries that have potential for implementing and strengthening comprehensive school health education with which they would collaborate, together with other international organizations; (c) Identifying operational issues on which they might collaborate, on a meaningful scale, in order to develop or strengthen comprehensive school health education policies and to determine the means to plan and implement collaborative and complementary actions for building up capability in school health education at country level 19. JCHP further recommends that UNICEF and WHO should intensify their efforts in health information, education and communication through all possible sources, and seek innovative approaches and partnerships with, among others, the media; political, community and religious leaders; the entertainment industry; youth organizations and other NGOs; and existing health and information systems It emphasizes the importance of well-integrated age-appropriate health education for young and school-age children, adolescents, parents and the community at large. Malaria control 20. Welcoming the partnership between UNICEF and WHO in malaria control and endorsing the main points of the global strategy as set out in the background paper JCHP recommends that the two organizations prepare detailed strategies based on their "comparative advantages". V. DATE OF THZ THIRTIETH SESSION 21. It was agreed that the thirtieth session of the UNICEF/WHO JCHP should take place in Geneva immediately after the ninety-fifth session of the WHO Executive Board in January 1995. Consultations would be held between the two secretariats on the possibility of holding a special session in January 1994 Priority Actions for Achieving the Mid-Decade Goals (1993-1995) A check List MID-DECADE GOALS ACHIEVABLE GLOBALLY BY 1995 Additional goals/higher targets may be set on a country/regional basis. Many countries with infrastructures and drug availability have included a goal on ARI mortality reduction. 1. Elevation of immunization coverage of six antigens of the Expanded Programme on Immunization to 80 per cent or more in all countries; 2. Elimination of neonatal tetanus; 3. Reduction of measles mortality by 95 per cent and measles morbidity by 90 per cent compared to pre-immunization levels; 4. Elimination of poliomyelitis in selected countries and regions (as a contribution towards global eradication of poliomyelitis by the year 2000); 5. Virtual elimination of Vitamin A deficiency; 6. Universal iodisation of salt; 7. Achievement of 80 per cent usage of oral rehydration therapy as part of the programme to control diarrhoeal diseases; In countries with infrastructures and drug availability, this goal may be extended to include 50% of correct case management by health providers. 8. Making all hospitals and maternities "baby-friendly" by ending free and low-cost supplies of infant formula and breastmilk substitutes and following the Ten Steps recommended by UNICEF and WHO; 9. Eradication of guinea worm disease (dracunculiasis); 10. Ratification of the Convention on the Rights of the Child by all countries. PARTIAL TARGETS OF SELECTED GOALS BY 1995 1. Reduction of 1990 levels of severe and moderate malnutrition by one-fifth (20%) or more; 2. Strengthen basic education so as to achieve reduction by one-third of the gap between the current primary school enrolment/retention rate and the year 2000 goal of reaching universal access to basic education and achievement of primary education by at least 80 per cent of school-age children and reduction of the gender gap in primary education in 1990 by one-third; 3. Increase water supply and sanitation so as to narrow the gap between 1990 levels and universal access by the year 2000 of water supply by one-fourth and of sanitation by one-tenth. * New ** Special attention I. Immunisation Review situation since 1990 using the following as a check list: 1. Sustain coverage of 1990 level. 2. Raise coverage (at least) up to 80 per cent in all six antigens. 3. Build systems of centres and outreach, minimise mobile approach. * 4. Build surveillance systems. * 5. Introduction of non-monetary system of recognition for outstanding performance. 6. Accountability at national and sub-national levels. 7. Measures to increase efficiency. ** a. Reduce drop out rate to less than 10%. b. Introduce tracking of all infants. c. Organise regular routine immunisation sessions and mobilisation of all infants. d. Prolong the life of equipments, cold chain and vehicles - and facilitate maintenance. 8. Vaccines a. Encouragement and support for local production, wherever feasible. * b. Assurance of vaccine availability in all countries through self-reliance means within 5 years by using Vaccine Independence Initiative or local production. c. Continued support of CVI for research and development of improved and new vaccines. Elimination of Neo-Natal Tetanus 1. Immunisation of over 85% of pregnant women with tetanus toxoid. * 2. Institution of the system of providing life-long protection of tetanus.3. Clean delivery (will be useful for later work on Safe Motherhood). Reduction of Measles Mortality and Morbidity * 1. Raising measles immunisation to 90% or above coverage level and its retention. * 2. A single campaign of measles immunisation for all children up to age 15 (in late 1994 or early 1995) in all countries which have reached high levels of coverage (80% and above), followed by maintenance of high level coverage at 85% and above. * 3. Increased coverage in areas of outbreaks. 4. Looking into global manufacturing capacity in order to accommodate these campaigns. Elimination of Poliomyelitis in Selected Countries 1. Retention of polio-free status in countries and areas through high coverage and NIDs. 2. Extension of polio-free zones. * 3. Institution of outbreak control systems. 4. Break transmission of wild virus through "mop up" rounds. 5. Working closely with Rotary International and National Rotary Clubs. 6. Going full-scale where supplementary funds can be raised. 7. National policy on NIDs for under-3s or Under-5s. II. Virtual Elimination of Vitamin A (Using EPI Structures: EPI plus) * 1. Mapping Vitamin A deficient areas. * 2. Adoption of national policy on elimination of Vitamin A a. Capsule supplementation where deficiency exists. b. Fortification of food. c. Production/procurement and consumption of appropriate food. * 3. First Vitamin A capsules at measles immunisation (about 9 months old). * 4. Using EPI structures to deliver future doses at 18 and 24 months, (and later 6 monthly intervals in accordance with national policy). * 5. Educational and promotional campaign for diet diversification (especially consumption of green leafy vegetables). * 6. Involve Lions Clubs for fund-raising. III. Universal Iodisation of Salt 1. Salt Iodisation * a. Setting policies of universal consumption of iodised salt throughout the country. * b. Setting global standards of iodisation and development of methods and modes of testing. * c. Streamlining production, import policy, logistics and marketing. * d. Global convention on consumption, export and import (and local legislation) and establishment of means of surveillance. * e. Support for local production of iodised salt. * f. Global prior ordering of salt iodisation plants g. Setting up monitoring mechanisms at production, distribution and consumer levels. h. Home, school, community and market level testing (qualitative "one drop" test for iodine). 2. Elimination of IDD (Where universal salt iodisation has been undertaken) a. Identification and mapping of endemicity. b. Control of IDD through use of capsules. c. Surveillance systems. 3. Involvement of Kiwanis and bilateral agencies. IV. Raising ORT Use Rate Diarrhoea Management: 80% ORT Use Rate and Continued Feeding * 1. Identification of culturally acceptable home fluids. * 2. Campaigns to promote culturally acceptable and available home fluids (with continued feeding). * 3. Adoption of standard spoons and standard messages in countries where SSS is part of policy. * 4. Standardisation of ORS packet size and a standard measure/container in each country. * 5. Adequate local ORS production to meet national needs, where feasible. * 6. Making ORS available in the community through: a. Effective marketing of ORS in the commercial sector. b. Free/subsidised distribution through health centres. c. Bamako Initiative. * 7. Establish community-based ORT or ORS units (village healers/grocers/women leaders, community health workers, etc.) in every village/urban slum. * 8. Establish monitoring system for ORT/ORS (ORT use in all cases, ORS use for all cases seeking treatment outside the home). * 9. Where ORT use rate is high and relevant antibiotics (e.g. cotrimoxozole) are available, full case management may be introduced with due caution taken to minimise drug resistance. (INDICATOR/OBJECTIVE: 50% of health facilities providing standard case management of diarrhoea (and pneumonia) and drugs). * 10. Convention for standardisation, production and marketing of ORS. * 11. Involve Jaycees and other bilateral agencies for fund-raising and action Diarrhoea Prevention: [INDICATOR: 80% use/practice/for each intervention] * a. Hand-washing (after defecation, before eating and handling of food). * b. Disposal of child faeces. * c. Household water protection. d. Measles immunisation e. Vitamin A supplementation in endemic areas f. Breastfeeding g. Water supply, sanitation and latrines (to set partial targets nationally and sub nationally). V. Baby-Friendly Hospital Initiative 1. Three objectives a. Compliance of governments' actions to end free and low-cost supply of infant formula and breastmilk substitutes to hospitals and maternities in all developing countries by June 1993. b. Cessation of free and low-cost supply of infant formula and breastmilk substitutes in all hospitals and maternities in the industrialised countries by June 1994. c. All maternity hospitals and maternities to become baby-friendly by December 1995. 2. Supportive actions for BFHI a. Government actions, reinforced by legislative actions to end free and low cost supply of infant formula and breastmilk substitutes in all hospitals and maternities. b. Lactation training and advisory services in support of breastfeeding. c. Reorganisation of hospitals and maternities with rooming in, etc. arrangements. d. Education and promotion of the benefits of breastfeeding. * e. Supportive measures to promote and protect breastfeeding, with special emphasis on exclusive breastfeeding for the first 4-6 months: - Prolongation of maternity leave; - Establishment of facilities in work places to enable mothers to continue breastfeeding; - Solving the problems of working mothers. VI. Eradication of Dracunculiasis 1. Identification and mapping of cases. 2. Community surveillance (also to be used for neonatal tetanus). 3. Water supply and health education (use of filters, safe water access and use, etc.) 4. Case finding and extraction of worm prior to eruption. 5. Case containment measures. Note: The mapping techniques and community surveillance techniques will be useful later for tracing of cases of poliomyelitis and measles. VII. Universal Ratification of the Convention on the Rights of the Child Working closely with the Governments and their Permanent Missions to the United Nations on: 1. Promotion to ratify the Convention (citing the commitments made by their Head of State and/or Government during the Summit as well as the UNICEF Executive Board Resolution 1993/13 on Universal Ratification of the Convention on the Rights of the Child by 1995). 2. Encouraging Governments to deposit the Instruments of Ratification with the U.N. Legal Office. 3. Allaying the concern that there is no contradiction between Islamic Sharia and the CRC. PARTIAL TARGETS I. Reduction of 1990 levels of severe and moderate malnutrition by one-fifth (20%) or more 1. Using the Triple A approach of Assessment, Analysis and Action. 2. Programming nutritional status as the outcome of food intake, infections and care. * 3. All area-based development programmes to adopt "reduction of malnutrition" as an objective and a measurable outcome. a. Setting a clear time-bound objective of reduction of malnutrition; b. Based on local initiative and local solutions through adoption of the principle of positive deviance; c. Integration of synergistic actions e.g. preventive health measures like immunisation, curative knowledge of ORT, availability of drugs and curative advice and treatment, credit and income generation related to nutrition (e.g. parents have to undertake to share the profits of the undertaking for the well-being of the child), close monitoring through growth charts, community financing and management, etc. II. Basic Education: Strengthen Basic Education so as to achieve reduction by one-third of the gap between the current primary school enrolment/retention rate and the year 2000 goal of reaching universal access to basic education and achievement of primary education by at least 80 per cent of school-age children and reduction of the gender gap in primary education in 1990 by one-third. 1. Focus ** a. Increasing enrolment and completion rates in primary education. ** b. Reducing gender disparities in enrolment and completion of primary cycle. ** c. Expanding complementary non-formal and non-conventional programmes to those not reached by regular schools. ** d. Reducing the rate of drop-out and repetition. ** e. Increasing the proportion of enrollers achieving minimum levels of learning skills and life skills.9 2. Main Strategies a. Making primary schools work more effectively e.g. approaches like enhanced authority of parents and communities, support to head-teachers and their accountability to the community, provision of essential learning materials. b. Targeting those not served by the regular system through complementary non-formal and non-conventional approaches - Bailey Bridge approaches, including use of para-teachers with training, close supervision and support, flexible scheduling, etc. c. Improvement of performance of multi-grade schools. d. Improvement of curriculum and teaching to make best use of the available school hours. e. Introduction of simple methodology for assessment of learning. f. Establishment of local area-based planning, management and monitoring. g. Expanding knowledge and skills of parents regarding their role in early child development and child's learning. h. Redirecting and redesigning literacy programmes. i. Development of country-specific targets, sub-targets and strategies. j. Development and implementation of simple and specific management interventions to assure effective functioning of existing infrastructures. 3. Where countries have already reached or are reaching the Year 2000 goals, measures may be taken to improve efficiency, effectiveness and relevance of systems. III. Water Supply and Sanitation: Increase water supply and sanitation so as to narrow the gap between 1990 levels and universal access by the year 2000 of water supply by one-fourth and of sanitation by one-tenth ** 1. Focus on advocacy for policy formulation/strategy development with governments and dialogue with other donors and NGOs. 2. Improved monitoring through better information and databases. * 3. Enhance impact on health through improved quality of services, targetting for synergistic impact, etc. * 4. Working towards reduction of costs. * 5. Restructuring of external/internal finances and development/enhancement of innovative institutional models. 6. Improved installation of cost-effective water supply systems and their maintenance. 7. Improved efficiency of water supply operations. 8. More attention on sanitation (e.g. introduction of concepts like making provision of pumps contingent on installation of latrines). 9. Attention to the role of women in water supply and sanitation. NOTE: A companion volume with more detailed accounts of different strategies is being prepared and will be issued separately. ELEMENTS OF OPERATIONALISATION OF PROGRAMME I. Elements 1. Strategic and Local Planning a. Identification and mapping of problems b. Strategisation of goals c. Planning at national, sub-national and local levels. (Devolving NPAs to provincial, municipal and sectoral levels). d. Review and modification of existing plans (in light of the Mid-Decade Goals). Note: i. Where appropriate, higher or additional targets may be set. ii. Prioritisation based on needs and feasibility. 2. Political Commitment a. Political commitment at different levels - national, sub-national, sectoral and local levels. b. Political sustainability of NPA process. - NPAs must become politically sustainable, beyond the duration of individual governments. They must be adopted as broad national documents, legitimised by all sectors of society and endorsed officially, e.g. - by legislation - by national charter - by national convention - by establishment of organizations like Children's Defense Fund. c. Integration of NPAs into national and sectoral planning and budgetting process. d. Building a national consensus on socially unacceptable phenomena e.g. unacceptably high child deaths, uneducated girls, etc. e. Preparation of annual workplans. f. Monitoring - Periodical review of the progress of NPA implementation (semiannually). - Feedback of monitoring results. - Follow-up political and management actions by political leaders. 3. Advocacy and Social Mobilisation a. Advocacy targetting the support of national and sub-national leaders, leaders in different sectors and walks of life, general public opinion, etc. [May need to involve the interventions of the Executive Director, his senior staff and Regional Directors]. b. Advocacy aimed at endorsements by different international and regional fora. c. Using NPAs as an instrument for advocacy with governments, communities and donors. It will be especially useful to initiate a dialogue. d. Ensuring the active involvement of the whole spectrum of the society leading to the assumption of ownership and direct responsibility for the achievement of the goals. e. Efficient and effective use of mass communications - for awareness, conscientization and action. f. Involvement of corporate and private sector and NGOs in specific activities. g. Creation of network of people and organizations. h. Special attention to areas of dense habitation. 4. Resource Mobilisation a. Reallocation of existing resources according to priority needs. b. Increase of ODA for children c. Increased allocation to social sector in national budgets. d. Increased government funding for children's needs. e. Private sector fundraising. f. Innovative fundraising. g. Funding by IFIs. [Proposed Actions are further detailed under "Operational Implications"]. 5. Monitoring and Review a. HQ - An early consensus on a set of minimal indicators, in consultation with other concerned agencies, separating impact indicators requiring less frequency and more frequently used process indicators. - Development of management indicators for local management. - Early finalisation of procedures to monitor different indicators. [The aim should be as few indicato rs as possibl e and the simples t way to implem ent them]. b. Field - The principal responsibility of monitoring is in country offices, linked to workplanning processes with milestones, etc. - Country programmes should include support to strengthen national information systems at both central and local levels. - Information must be rapidly developed and systematically collected to show progress towards the Mid-Decade goals. - Each country should have an integrated monitoring and evaluation plan, beginning with a situation analysis. - High level government involvement in NPA monitoring a la Mexico should be used as a model. c. All monitoring systems should be management-oriented. d. Regular review systems. NOTE: A set of indicative impact and monitoring indicators is given in Appendix "A". A detailed PRO on monitoring guidelines will be sent separately. II. Early start with most doables All countries are encouraged to start with most doable goals in order to stimulate a sense of confidence that the goals are achievable. Such actions will also create a momentum towards achievement of other goals in each country. Experience indicates that such momentum always lead to a sense of healthy and constructive cooperation and competition. III. Beyond the Mid-Decade Goals 1. All preparations for accelerated goal achievement finalised e.g. testing out ideas, methods, etc. 2. Epidemiology - epidemiological pictures for all countries/provinces leading to development of appropriate response strategies. 3. Development of integrated packages and guidelines for action e.g. case management, safe motherhood, management of the sick child, etc. 4. Surveillance systems in place for all goals and targets where relevant. 5. Sector analyses done and strategies developed for all sectors. 6. Incorporation of cross-sectoral programming concerns on women, urban, environment, etc. IV. Programme Thrusts During 1993-1995, there will be three principal programme thrusts: 1. Pursuit of goals and targets (see above). 2. Systems development (including capacity building) 3. New Frontiers = Attention to emerging issues and challenges. Systems Development While systems development will involve improvement of the existing system and infrastructure in most parts of the world, special attention will need to be given to Africa and countries where systems are either non-functioning because of the severe recession of the 1980s or non-existent. Countries with better infrastructure may aim to broaden the scope of the work of the system while increasing its efficiency and effectiveness. [Note: 1. A model of health care system arising out of the Nairobi Consultation is given in Appendix "B". This model will be useful in countries where health systems are no longer functioning or especially functioning poorly. 2. Ways to assure functional effectiveness of existing systems to achieve the goals are given in Appendix "C". 3. A note on the organisation and mobilisation for primary education at the community level with a view to its sustainable expansion is given in Appendix "D"]. New Frontiers While major focus will be given to the pursuit of the Mid-Decade goals and targets, attention will also need to be given to emerging issues which are likely to become principal challenges in the next decade. For example, in the health sector, the new frontiers requiring attention would include HIV/AIDS, safe motherhood, women's health, substance abuse, diseases and maladies associated with lifestyles, etc. Although the magnitude of the problems is still relatively smaller, challenges associated with children in especially difficult circumstances would require attention in order to forestall the major upheaval in the next decade. PROGRAMME AND OPERATIONAL IMPLICATIONS FOR UNICEF In order to pursue the goals effectively, UNICEF's programme and operational systems would also need to be reviewed for their efficiency and effectiveness and necessary follow-up actions taken where required. The following sections list systems and activities which need to be reviewed by both headquarters and field offices in relation to their work, wherever relevant. Programme Implications 1. Streamlining of programming process a. Shorter time-frame: The country programme exercise should take no more than 9-12 months. b. Less documentation - HQ to coordinate requests to avoid duplication and unnecessary requests (creation of a focal point for all requests; see operational implications). - Negotiations for donor reporting may suggest shorter, focussed and less frequent reports. c. Less meetings - Less formal review meetings - Development of information systems to reduce need for meeting outside countries/regions. 2. Capacity building a. Need to be a component in all programmes where necessary. b. Comprises development and upgrading of: - Human resources - Institutions - Systems - Production capacity, where feasible 3. Degree and Scope of Empowerment a. Knowledge and skills b. Decision making 4. Sustainability a. Need to look at all five aspects of sustainability - Political - Financial - Technical - Managerial - Cultural b. Sustainability analysis c. Ten questions: (1) What institutions or infrastructure will have been built or strengthened during programme implementation? How? (2) What is likely to be the gender-specific impact of the programme? How can the programme be designed to help reduce gender or other disparities? (3) What impact will the programme have on existing institutions? (4) If external support stops, will the programme collapse? Operate at lower capacity? Operate at capacity higher than at the beginning of programme but lower than at peak period? (5) Are unit costs of the programme - after initial heavy investment - affordable for going to scale? (6) Does the programme encourage involvement of non-traditional partners? Community groups? NGOs? (7) How does the programme encourage self-reliance and help build local capacity? (8) How does the programme respond to people's other felt needs? Can links be established with programmes responding to those needs - e.g. employment opportunities, credit schemes, other extension services? (9) How will the programme impact on the environment, on sustainability of people's livelihood? (10) What synergistic impact will the programme have on other programmes, in reaching other goals? How can these synergisms be further multiplied? 5. Costs a. Better understanding and use of - Unit costs - Options appraisal - Knowledge of budgetary process. b. Costing of NPAs 6. Establishing a culture of evaluation a. Culture of analysis. b. Use of evaluation in programming and developing strategic options. c. Evaluation as a management process. d. Evaluation of programmes after each cycle. e. Impact/Output/Outcome-oriented evaluation . 7. Enhancing process of learning from one another. 8. Documenting experiences 9. Monitoring (See under "Elements of Operationalisation") 10. Working with other partners a. Importance of Country Strategy Note as a framework. b. Using WSC goals, NPA and monitoring as a framework of interagency co-operation - Need for heads of UN agencies to send letters to their country-level representatives regarding NPA goals. - Thematic collaboration (e.g. human development goals, poverty alleviation, child survival and development, etc.) - Role of NGOs and others as representatives of the civil society. c. Need to examine the opportunities provided by UN Restructuring exercise. d. Establishment of common monitoring systems. Operational Implications 1. Staff recruitment, staff placement and training a. Different staff profile - Must be adapted to new needs (e.g. knowledge of costing, high level advocacy, monitoring, etc.) - Increased professionalism - Develop new skills/new knowledge [Need to match government counterparts] - Sector analysis - Strategisation of an idea or a concept - Technical as well as social skills - Operationalisation of a concept and/or an objective. b. Staff recruitment - To reflect new staff profile, assessment needed at both HQ and regional levels to identify sources of qualified staff from: - existing pool - inter-agency pool - NGOs - national governments - support from external consultants - An up-to-date Consultant Roster with indicators of availability and expertise. c. Staff placement - All vacancies should be filled within four months. d. Skills development - Training of existing staff is particularly needed for: - Costing and budgeting - Monitoring/use and presentation of data - Management and leadership - Advocacy and fund raising - Training of Trainers - Special accounts - Emergency - Problem-solving sessions (like in UCI review). - Others. 2. Supply a. Appropriateness of supply - Types of vehicles - Assessment of actual needs, rather than the scheduled replacement, should guide the replacement of equipment, vehicles, etc. b. Cost-effectiveness of choice c. Local procurement - When appropriate, use of local procurement should be stressed for building local capacity - When large amounts of local currency are generated, local procurement roles should be adapted and made more flexible. d. Review of supply policies e.g. - Essential drugs vs. brand name drugs. 3. Implications of emergencies a. Supply delays to non-emergency countries b. Drain on human resources. 4. Financial and accounting systems More responsive and faster systems, reflecting current needs, are urgently needed, particularly for: a. Reducing discrepancies between HQ and country office programme budget records b. Accelerating processing of pledges, issuance of PBAs and financial accounts c. Allocating funds raised in developing countries within the country of origin, after deduction of costs d. Special accounts and funds-in-trusts e. Overhead policies and procedures f. Debt swaps, particularly ownership of financial instruments and income recognition g. Alternative fundraising from financial institutions, national social funds and the private sector. 5. Resource Mobilisation a. Promotion of the concept of 20/20 b. National Budget - Advocacy of 20/20, appropriately adapted - HQ to provide guidance and support as required - Intervention by the highest level, when required - Where social investment is close to or above 20%, focus on detailed allocation within the social sector [vulnerable sectors, etc.]. c. Government funding - Advocacy for increased government funding for their country programmes especially in countries where the economic situation is favourable d. Private Sector - Likely to become the fastest growing source of funding in several countries in the short term, and globally in the medium/long term - Activities at the country level will be directly coordinated by the country office, in consultation with/assistance from GCO when required - Funds raised from private sector will remain within the country of origin: country programmes will include reference to the possibility of obtaining Supplementary Funds from the private sector - Second order of priority for allocation after the country of origin will be the region where the country is located. e. Existing Resources (of country programmes) - Reallocation to priority areas, as required - May be supplemented by global funds where appropriate and available - Global funds to serve as conduits to receive supplementary funds for priority areas. f. ODA - Action HQ: UN mission and donor capitals FOs: Local embassy and missions - Visits to donor capitals will be coordinated by PFO - HQ to provide guidelines on the use of the 20/20 vision for advocacy with donors at the country level. g. IFIs - FOs are encouraged to explore the possibility and mobilisation of funding support from the World Bank, Regional Development Banks, etc. - Good quality NPAs may be circulated as a base source of information. h. Innovative Fundraising - When and where appropriate, the possibility of debt conversion, use of blocked currency funds, etc. should be pursued, initiated by Field Offices in consultation with PFO. - PFO to organise regional workshops on debt. i. Thematic Funding - Need to explore thematic funding support for different goals e.g. Rotary for Polio Kiwanis for IDD Jaycees for CDD Lions for Vitamin A Innerwheel for BFHI - Need to give full credit and publicity to donors, especially in the media j. Field Visits - FOs to arrange field visits especially by donors and prospective donors. 6. Information Systems a. Improvement of automised communications systems between offices and within offices. b. Computerisation of office operations, beyond GFSS/Programme Manager (e.g. standard mail registry and follow-up system). c. At HQ level, scanning of information before distribution to the field to assess relevance. d. Establishment of HQ focal points to streamline information requests. 7. Office Premises a. Review HQ mechanisms on rental of office premises, rental increases and modified leases. FUNDING NEEDS 1. Country programmes need to spend 20% of GR on immunisation, to be eligible for requests from global funds. 2. A minimum of 4% of country programmes (GR) should be allocated to ORT, if required. 3. Most urgent needs a. EPI - Vaccine needs $25 M - Potential sources - USAID - Support for VII - Continued mobilisation of Rotary - Five-year self-reliance/self-financing plan for vaccines b. ORT/CDD - Mobilisation of Jaycees and Private Sector - Potential sources - USAID b. IDD - Support from Kiwanis - Need for up-front money in 1993 - Support from Australia c. BFHI - Unspent balances of completed SF projects - NatComs and selected governments 3. Immediate urgent needs from global funds, where available. PRIME ATTENTION This section outlines activities which should receive prime attention from both headquarters divisions and field offices in the next few months. They have been mentioned earlier in the context of overall activities which need to be reviewed and undertaken. 1. Sustained political commitment at international, regional and national levels, e.g. a. International: Social Summit 1995 Women's Conference 1995 Population Conference 1994 Year of the Family 1994 b. Regional: Ibero-American Summit Meeting of First Ladies ASEAN OAU SAARC LAS, etc. c. National: Political sustainability Devolving into provinces and municipalities. 2. Operationalisation of NPAs. a. Finalisation of NPAs b. Political sustainability of NPAs c. Devolving into provinces, municipalities and sectors d. Costing of actual and extra needs e. Preparation and approval of Operational Plan for Mid-Decade Goals f. Commencement of operations g. Budgetary reallocation h. Domestic and external fundraising i. Monitoring of progress 3. Commencement of Operations a. Workplans for each goal - individually and also in the context of collective plan for the well-being of children. b. Multi-sectoral participation and endorsement by Government. c. Social mobilisation - including communication. d. Programme operations - especially advanced planning including prior placement of orders [Will need HQ allocation of extra funds for placement of orders but not to be spent within the year]. 4. Fundraising a. Domestic and regional fundraising - Regional coordination to avoid intra-regional rivalry b. Thematic fundraising c. Country-based fundraising d. More active involvement of National Committees and NGOs. e. International and regional financial institutions. 5. Immediate financial needs a. Upfront money for IDD. b. Extra need for vaccine support ($25 M for 1993). 6. Monitoring systems a. Adoption of indicators b. Operational instructions c. Review system 7. Systems requiring urgent attention a. Programme i. Programming process Reduction in length of time and paperwork - process not to last more than 9-12 months. b. Financial system i. Faster reconciliation/knowledge of status of programme expenditure ii. Faster issuance of PBAs iii. Income recognition iv. Allocation of funds raised in developing countries within the country of origin. c. Personnel i. Faster recruitment and placement of staff [STANDARD: No vacancy should be left unfilled for more then 4 months]. ii. Consultation on professional qualification and relevance of experience of recruitees - to fit in with the new staff profile. iii. Training plan. 8. Setting up support mechanisms in HQ and Regional Offices. Countries should be able to call on Regional Offices and Headquarters at moments of difficulties or impasse. TIME SCHEDULE A. FIELD (i) By Mid July 1993 (a) Preparation of Country and Regional Priorities Workplans for 1993-1995 (b) Support to finalisation of NPAs (c) Strategisation of NPA goals (d) Adaptation of country programmes (e) Preparation of Strategy and Workplans for Mid-Decade Goals. (ii) From July 1993 onwards (a) Approval of Strategy and Workplans for Mid-Decade Goals (by Governments) (b) Review of country programmes with governments (c) Preparation of provincial and municipal NPAs (d) Preparation for implementation (e) Implementation NOTE: A (ii) (a) and (b) could be done together, if necessary. B. HEADQUARTERS (i) By End July 1993 (a) Preparation of Priorities Workplan for 1993-1995 (b) Preparation of support plans (c) Review of structures and procedures to facilitate implementation (d) Setting targets for work assignments (e) Review of field plans developed (ii) From July 1993 onwards (a) Participation in Review of Strategy and Workplans for Mid-Decade Goals (b) Review of country programmes with governments (c) Global mobilisation plan (d) Support to field implementation (e) Monitoring of implementation (f) Implementation of HQ elements of Priorities Workplans. 24 June 1993 Annex 4: World Summit for Children: Intermediate goals for 1995 1. Eliminate neonatal tetanus through both immunization and clean delivery. 2. Reduce meas deaths by 95 per cent and cases by 90 per cent, through high coverage with immunization and reaching those not yet reached. 3. Achieve poliomyelitis-free status in countries in the American, European and Western Pacific regions of WHO, as well as selected countries in other regions, comprising at least 60 per cent of the world population. 4. Achieve at least 80 per cent oral rehydration therapy use and continued feeding in selected countries and 80 per cent of the following in all countries proper case management at home and health facility, or by a health provider; access to oral rehydration salts and case management; and improving mothers' knowledge 5. End distribution of free or low-cost breast-milk substitutes in all maternity centres and hospitals in the developing countries by the end of 1992, and in all countries by June 1994; The conformity date for lndustrialized countries has been set to coincide with the entry into effect of the European Community directive on infant formula scheduled for June 1994. and achieve "baby-friendly hospital" status by all hospitals in 1995 in accordance with the "baby-friendly" hospital initiative. 6. Achieve full implementation of universal salt iodization in most of the countries where iodine deficiency disorders (IDD) are a public health problem; where full salt iodization is not possible in areas where IDD are a severe public health problem, supplementation with oral or injected iodized oil will be recommended as a temporary measure 7. Achieve a significant increase in dietary intake of vitamin A in children from six months to six years of age, through food and/or fortified products, where diets are deficient in vitamin A where clinical vitamin A deficiency is a public health problem, vitamin A supplementation for pre-school children every four to six months will be urged, as a time-bound short-term measure, until dietary intakes reach basal requirements. 8. Stop dracunculiasis (guinea worm disease) transmission in all affected villages APPENDIX "A" : MONITORING INDICATORS The enclosed table summarizes the impact and process indicators for use in plans to reach the Mid Decade Goals. To set them in the context of work already in progress they are aligned with those already in use for tracking progress towards the World Summit for Children goals for the year 2000. Considerable effort and discussion have now resulted in a consensus with WHO and other expert groups on the impact indicator by which to measure (evaluate) the global goals for 2000. These indicators measure the impact of programmes and generally require techniques, samples, and measurement that can only be reported periodically - perhaps at intervals of several years. These are shown in column two of the table for the Mid Decade Goals. The Mid Decade Goals are a subset of the goals for the year 2000 that have been endorsed by the WHO and UNICEF Executive Boards. They are shown in column three of the table. The Mid Decade Goals are l 995 targets that take into account the steps that are needed to reach the year 2000 goals. A standard minimum set of process indicators have been identified to measure progress towards these Mid-Decade Goals. These are found in column four of the table and will be incorporated in a standardized reporting form for submission to New York headquarters twice yearly to facilitate the tracking of progress. Most of the minimum indicators repeat those already familiar to country offices and are marked as "same" in the table. New ones are highlighted. Country offices will find other indicators useful to guide the management of programme progress. The choice of management indicators will necessarily reflect the precise strategy, implementation plan and execution of projects and activities designed to reach the goals and serve to guide local managers in the regular oversight and modifications required. For example, the programme to eliminate neonatal tetanus might use local programme management indicators, such as whether or not a strategy is in place in high risk areas, the number of new traditional birth attendants trained, the proportion of deliveries attended by trained personnel, etc. The actual management indicators used will depend upon each country programme. While headquarters would not expect to receive the results of these indicators, each country office will find it useful to identify the management indicators that will be monitored locally and describe them in its workplan for reaching the Mid Decade Goals. Headquarters and regional offices will concentrate their own periodic reviews on the Mid Decade Goals process indicators given in column four. Monitoring guidelines to assist country offices in preparing for these regular reviews will be issued by headquarters in August. June 25 1993 World Summit for Children and Mid-Decade: Goals and indicators Year 2000 goalYear 2000 goal IndicatorsMid-decade goal (MDG) 1995MDG process indicators for HQ, RO and CO use Maintenance of a high level of immunization coverage (at least 90 per cent of children under one year of age by the year 2000) against diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis and against tetanus for women of child-bearing ageProportion of one year old children immunized against diphtheria, pertussis and tetanus (DPT) Proportion of one year old children immunized against measles Proportion of one year old children immunized against poliomyelitis Proportion of one year old children immunized against tuberculosis Proportion of pregnant women immunized against tetanus Proportion of children protected against neonatal tetanus through immunization of their motherSame except coverage level to be at least 80% or more in all countriesAll indicators as in column 2 Elimination of neonatal tetanus by 1995Annual number of cases of neonatal tetanusSameSame Reduction by 95 per cent in measles death and reduction by 90 per cent of measles cases compared to pre-immunization levels by 1995, as a major step to the global eradication of measles in the longer run.Annual number of under-five deaths due to measles Annual number of cases of measles in children under five years of ageSame-- Same Global eradication of poliomyelitis by the year 2000Annual number of cases of polioElimination of polio in selected countries and regionsSame Virtual elimination of vitamin A deficiency, and its consequences, including blindnessProportion of children 2 to 6 years of age with night blindness Proportion of children 6 months to 6 years of age with serum vitamin A below 20 micrograms/100 ml Proportion of lactating women with breastmilk vitamin A below 30 micrograms/100ml (or less than 8 micrograms/gram of milk fat)Virtual elimination of vitamin A deficiencyDepending on strategy of national programme: - % of target age group receiving Vitamin A high dose supplement - % of target age group regularly consuming vitamin A fortified food; - relevant indicator on fortified foods being developed. Virtual elimination of iodine deficiency disordersProportion of population in iodine deficient areas consuming adequately iodized slat Proportion of children aged 6 to 11 years with any size of goitre (palpable and visible) Proportion of population (school age children or general population) with urinary iodin levels below 10 micrograms/100ml of urine Proportion of newborns with serum TSH levels above 5 mIU/LUniversal iodization of saltProportion of salt manufactured/imported which is adequately iodized Reduction by 50 per cent in the deaths due to diarrhoea in children under the age of five years and 25 per cent reduction in the diarrhoea incidence rateProportion of all cases of diarrhoea in under-fives treated with ORT (increased fluids and feeding) Annual number of under-five deaths due to diarrhoea Average annual number of episodes (cases) of diarrhoea per child under five years of ageAchievement of 80 per cent usage of ORT as part of the programme to control diarrhoeal diseasesSame Proportion of all cases of diarrhoea in under-fives WHO seek care outside home and are treated with ORS Empowerment of all women to breast-feed their children exclusively for four to six months and to continue breastfeeding, with complementary food, well into the second yearProportion of infants less than 4 months of age WHO are exclusively breastfed Proportion of children 20 to 23 months of age WHO are breastfeeding Proportion of infants 6 to 9 months of age WHO are receiving breastmilk and complementary food Proportion of all hospitals and maternity facilities which are baby-friendly according to global BFHI criteriaMaking all hospitals and maternities "baby-friendly" by ending free and low-cost supplies of infant formula and breastmilk substitutes and following the Ten Steps recommended by UNICEF and WHOSame Proportion of all target facilities which are certified baby-friendly Elimination of guinea-worm disease (dracunculiasis) by the year 2000Annual number of cases of dracunculiasis in the total population Number of villages which have any cases of dracunculiasisEradication of guinea-worm disease (dracunculiasis)Number of villages in endemic areas free of guinea-worm for past two years Ratification of the Convention of the Rights of the Child (CRC) by all countriesDepositing of the Instruments of Ratification with the United Nations Legal Office Between 1990 and the year 2000, reduction of severe and moderate malnutrition among under-five children by halfProportion of under-fives WHO fall below minus 2 standard deviations form median weight for age of NCHS/WHO reference population. Proportion of under-fives WHO fall below minus 3 standard deviations from median weight for age of NCHS/WHO reference population. Proportion of under-fives WHO fall below minus 2 standard deviations from median height for age of NCHS/WHO reference population Proportion of under-fives WHO fall below minus 2 standard deviations from median weight for height of NCHS/WHO reference population.Reduction of 1990 levels of severe and moderate malnutrition by one-fifth (1/5) or more.Same Universal access to basic education, and achievement of primary education by at least 80 per cent of primary school-age children through formal schooling or non-formal education of comparable learning standard, with emphasis on reducing the current disparities between boys and girlsProportion of children entering first grade of primary school WHO eventually reach grade 5 Number of children enrolled in primary school WHO belong in the relevant age group, expressed as a percentage of the total number in that age group Proportion of children of primary school entry age WHO enter school at that age Proportion of children aged 10 to 12 reaching a specific level of learning achievement in literacy, numeracy and life skillsStrengthen Basic Education so as to achieve reduction by one-third of the gap between the current primary school enrolment/retention rate and the year 2000 goal of reaching universal access to basic education and achievement of primary education by at least 80 per cent f school-age children and reduction of the gender gap in primary education in 1990 by one-thirdSame Same Same (All above indicators by gender) Universal access to safe drinking waterProportion of population with access to an adequate amount of safe drinking water located within a convenient distance from the user's dwellingIncrease water supply and sanitation so as to narrow the gap between the 1990 levels and universal access by the year 2000 of water supply by one-fourth and of sanitation by one-tenthSame Universal access to sanitary means of excreta disposal Proportion of population with access to a sanitary facility for human excreta disposal in the dwelling or located within a convenient distance from the user's dwellingSame APPENDIX "B": ACHIEVING THE GOALS THROUGH A SUSTAINABLE HEALTH STRATEGY (AN EXPANDED BAMAKO INITIATIVE APPROACH) This strategy is an expanded Bamako Initiative approach which will enable achievement of the Mid-Decade Goals while laying the foundations for Year 2000 goals and at the same time building a sustainable health system. It will be most effective where systems not yet or only partially exist. I. Through this strategy, we will 1. Achieve the Mid-Decade Goals in EPI, ORT, Vitamin A, IDD, Breastfeeding and Guinea Worm. 2. Lay the foundations and make considerable progress in achieving the goals for Year 2000 e.g. through case management for diarrhoea, pneumonia, malaria, STD, etc. 3. Build a sustainable system for health. 4. Empower households to appropriately manage their health. II. Principles and Approaches: Merging and Accelerating Child Survival and Bamako Initiative 1. Going beyond the health sector: empowering households/families with appropriate technology (ORT, Case management, Bed nets, Exclusive Breastfeeding). 2. A village-based recording and monitoring system: mapping, enumeration, surveillance. 3. Organising communities around the health centre. 4. EPI Plus essential drugs built on the back of outreach for EPI, ORT/Vitamin A and Treatment of Minor Ailments to the villages and facilitates community-based surveillance and problem-solving. 5. Outreach carrying EPI, ORT/ORS/Vitamin A. 6. Specific action in commercial/manufacturing sector related to iodisation and distribution/marketing of salt, ORS marketing, etc. 7. The Health Centre serves as the hub of the health system. 8. The system is managed and sustained through the Bamako Initiative. III. Minimal Care Package at Health Centre 1. Care of the sick child - including diarrhoea, pneumonia, malaria, measles, Vitamin A deficiency, severe malnutrition. 2. Preventive child care including immunisation, Vitamin A, promotion of exclusive and sustained breastfeeding. 3. Care of the sick adult including malaria, complicated deliveries and STD. IV. Community Management and Financing 1. Decentralised social mobilisation supported by mass media, FFL. 2. Micro-planning, work scheduling, monitoring, training and supervision. 3. Progressive community financing of drugs, petrol for outreach, of incentives and/or performance bonuses for achieving goals. 4. External funding of motor-bicycles, but maintenance paid by health staff (as contribution to hire-purchase scheme). APPENDIX "C": ACHIEVING MID-DECADE GOALS THROUGH EXISTING HEALTH SYSTEMS: ASSURING FUNCTIONAL EFFECTIVENESS TO ACHIEVE SPECIFIC OUTCOMES In several countries, the primary health care infrastructure is largely in place. The challenge is making the infrastructure functionally effective through systems development, and scaling up programmes for nationwide coverage. Through the achievement of the mid-decade goals, the most vulnerable - mother and child - will be covered with a minimum package of services. Where infrastructure exists, the following approaches and activities are suggested. - Defining and achieving mid-decade goals at progressively lower levels (national, sub national and regional levels) to assure equitable health services within the country. - Supporting decentralization and devolution - local governments to plan and provide minimum health services through: - political and legal/regulatory instruments; societal recognition of health needs of mothers and children (and allocation of resource). - introduction of simple and specific management techniques to assure standardization and availability of health care services. - Phasing implementation - phasing being an important aspect of large-scale activities. It makes the entire operation manageable and simultaneously develops managerial capacity, thus making expansion possible and effective. Phasing could apply to: - the level of technology used from the minimum to an expanded set. - the phasing-in of a larger set of interventions. - nationwide application (for example, programming for nation-wide application, followed by a focus on population groups that are difficult to reach). - phasing in geographic terms (districts); and - phasing financial support to ensure the viability of interventions and sustainability of services. - Establish effective management within a defined geographic area (district?) for the package of services. Both public and private sectors to be involved. The structure needs to deal with . - preventive programmes - treatment and case management at (a) household, (b) health centre, and (c) referral unit - organization, control and management of services and programmes - The components for management of district health services include: - selection of appropriate technical interventions, appropriate to (a) the household, (b) the health centre and (c) the referral unit. - mobilizing human resources from the community, the private sector, government and NGOs, and developing an adequate system of remuneration for services required. - organization and scheduling services at various levels. - promoting programmes for skill development; ways of involving and motivating people. - ensuring availability of supplies and logistics, especially affordable drugs and equipment, together with skilled managers. - going beyond the health sector; empowering households/families with appropriate technology and knowledge (ORT, Case Management, Bed nets, Exclusive Breastfeeding). - ensuring that monitoring, management and evaluation are an integral part of any programme, and that existing management information systems are carefully studied and used to generate the information needed. (A sense of achievement in progress made and measured is one of the most important factors for sustaining political and social interest.) - developing a financing plan which promotes community management and financing, using the principles of the Bamako Initiative, and which reflects a cost effective choice of technology and attracts contributions from the community, the private sector, government and donors. - design and launch a campaign to ensure sustained societal action against "preventable childhood" deaths. - Creating self-reliance and assuring sustainability - through building capacity for management and technical services - local production of supplies wherever feasible. - establishment of norms, regulations and procedures to ensure quality of services. APPENDIX "D": LAYING THE FOUNDATION FOR UNIVERSAL PRIMARY EDUCATION There is enough willingness on the part of families and communities to make sacrifices for their children's education and enough is known about what works and what does not for building foundation of sustainable universal primary education. The key strategy is a community-based planning, management and monitoring system for bringing and keeping all eligible children in a primary education programme - in a sense, application of the Bamako Initiative in primary education. The strategy will help: - Make significant rapid progress in expanding primary education; - Lay the foundation for further rapid progress in the latter half of the decade to reach the universalization goal; - Make systems move out of a rut and permit mobilization of new resources and the building of community capacities. Principles - A small catchment-area-based planning, management and monitoring (CAP-MM) mechanism - say, for a population of 50,000 with 8,000 primary age and 1,500 entry-age children - with substantial decision-making authority takes responsibility for universal primary education, giving this the first priority among basic education goals. - A partnership of government administration, education department, community representatives and NGOs forms the local planning management body for basic education. - A unified local system of regular primary schools and different complementary non-formal approaches offers all children a chance of primary education; the "best" need not stand against the "good" . - The local CAP-MM body targets all entry-age children, brings them into a programme, adding rapidly new non-formal programmes as necessary; ensures availability of essential inputs; tracks all enrolled children to ensure their continuation in programme; thus achieve universalization in five to seven years in the catchment area. - Primary education for all supports knowledge, skill and behaviour goals of health, nutrition and water and sanitation activities; maximizes their benefits; and makes them sustainable. - Primary education for all makes the goals of capacity building and empowerment of people real at the community level, enabling people to organize for self-help and to address such concerns as gender disparity and protecting the environment. - The CAP-MM body for basic education in a community may partially overlap or be linked with a similar body for health, nutrition and hygiene (a local Bamako Initiative body?) to promote synergy among key social services and enhance their total effectiveness. Methods known to work With a catchment-area planning, management and monitoring mechanism: - Regular primary schools infrastructure will perform better with accountability of headmasters and teachers to meet measurable performance criteria, each head of a school held responsible for a neighborhood, parents strongly present in the school management committees, flexibility to adapt school programme and learning content to local needs, and guarantee of essential learning inputs. - Non-formal primary education programmes - necessary conditions are small units, para-teachers from community with short initial training and strong continuous supervision, abridged curriculum with focus on learning skills and life-skills, minimal capital costs, strong parental and community involvement, NGO partnership, multi-grade and bi-lingual teaching where needed. - Management and technical support - the government education hierarchy need to re-orient itself to support CAP-MM, rather than run schools itself; all curriculum, teacher-training, planning and management activities and evaluation and monitoring need to be geared to improving capacity of and supporting the CAP-MM body and its tasks. Resources and Financing Within the framework of overall government and public responsibility for universal primary education: - A pragmatic combination of national government, local government, community, private sector, NGOs and beneficiary contribution need to be promoted for each catchment area. - Government budget allocations can be utilized more cost-effectively by local CAP-MM bodies if they and schools are given greater authority to manage budgets. - Government budgets need to be complemented by resources from communities, private sector, NGOs and external assistance in a total resource mobilization strategy for each catchment area. - Pragmatic "Bailey bridge" solutions have to be adopted to provide basic opportunities to all children, "cutting the coat according to the cloth" in each catchment area and progressively improving standards as resources and capacities improve. This approach has to be sold to the national leadership and UNICEF has to be closely involved in demonstrating its functioning in selected locations.