EXAMINING INEQUALITY

We believe that’s wrong. Every person should have an equal opportunity to lead a healthy, productive life.

For the past 20 years, we’ve invested in health and development in low-income countries, because the worst inequality we’ve ever seen is children dying from easily preventable causes. In the United States, we’ve invested primarily in education, because a good school is a key to success, but you’re less likely to have access to one if you’re low-income, a student of color, or both.

Goalkeepers is our annual report card on the world’s progress toward the Sustainable Development Goals (SDGs), 17 ambitious goals the member states of the United Nations committed to reaching by 2030. As we write, billions of people are projected to miss the targets that we all agreed represent a decent life. If we hope to accelerate progress, we must address the inequality that separates the lucky from the unlucky.

let’s take a closer look at the layers of inequality

Each time we zoom, we see yet another layer of disadvantage. These disadvantages don’t need to pile up on top of one another to make life hard—but when they do, as for the marginalized girl in Chad, the effect is brutal.

What is her life like? The data says she has probably been close to starving to death several times. The odds are that she never got the nutrients her body and brain needed to develop fully. It is likely that she can’t read or write, and that she will get pregnant well before she turns 20, although her body won’t be ready for the rigors of childbirth.

And when the time comes, there is a good chance she will give birth alone.

She deserves a better life. And we believe she can have one, as long as the world understands the many challenges she faces and gets to work on addressing them.

The series of charts that follow tell you a lot about geography and inequality.

We plotted health and education because they are the key components of what economists call human capital, which we highlighted in last year’s Goalkeepers Report as “the best way for a country to unlock productivity and innovation, cut poverty, create opportunities, and generate prosperity.”

Investments in human capital today help people increase their incomes tomorrow. But without human capital—that is, for those who are unhealthy and uneducated—it is virtually impossible to escape poverty.

health and education are improving everywhere in the world

Gender inequality cuts across every single country on Earth. No matter where you are born, your life will be harder if you are born a girl. If you are born in a poor country or district, it will be even harder.

Adolescence is when girls’ and boys’ futures really start to diverge. Boys’ worlds expand. They rely less on their parents, venture farther and farther from home, and enroll in high school or college or get a job, which puts them in contact with wider society.

At the same time, girls’ worlds contract. They transition, sometimes at a very young age, from being subservient to their parents to being subservient to their husbands. Although they enjoyed some measure of freedom while attending primary school, they are expected to return to the confines of the home, to devote themselves to cooking, cleaning, and raising children.

The proportion of girls who do at least two hours per day of unpaid domestic work almost doubles after they reach the age of 15; by the time she is an adult, the average woman spends more than four hours every day doing unpaid work. Men, by comparison, average just over one hour per day.

These obligations inside the home are just one example of social norms that conspire to limit girls’ opportunities as they approach adulthood. Across sub-Saharan Africa, for instance, girls average two fewer years of education than boys. And even when girls are well educated, they are much less likely to translate their years of schooling into a job in the formal work force. Globally, there is a 24 percentage-point gap between men’s and women’s labor force participation.

This lack of access to education and jobs is destructive for everyone. It keeps women disempowered, limits their children’s life chances, and slows down economic growth.

The large and lingering gaps between countries, between districts, and between boys and girls prove that although the world’s investments in development are working, the lives of the lucky and unlucky aren’t converging fast enough. We believe the development community needs to start doing business differently.

In last year’s Goalkeepers Report, we argued that human capital is critical to economic growth in poor countries. This year, we argue that human capital investments should be designed to reach girls and prioritize those countries and districts that have to make up the most ground.

That’s not an easy thing to do. Inequality, as we have said, is exceedingly complex. There is no silver bullet that will make geography, gender, and other random factors stop mattering. But guaranteeing that every single child has access to good health and education systems is a very good start in that direction. This is not just a moral aspiration; we believe it to be an achievable goal.

In the case of education, not that long ago, conventional wisdom held that poor children didn’t really need to be educated. That idea has been discredited in every region in the world in the past 50 years, and most countries in the world are approaching universal primary school enrollment. The priority now is to make sure that all schools provide a high-quality education. There are proven approaches to teaching literacy and numeracy in a single classroom, but there is not yet consensus about what it will take to improve basic skills at the massive scale of every single child in every single school in every single country. Last year, this report highlighted promising innovations being tried in Côte d’Ivoire, India, and Zambia, as well as Vietnam’s nationwide success. All the human capital in the world, though, won’t lead to equality and prosperity if healthy, well-educated girls are subject to social norms that disempower them.

Harmful norms can be hard even to see, much less change, but countries are taking steps to help women confront them.

A big part of the solution is policies that help women and girls carve out new paths for themselves. For example, in places like Peru, where women have the right to own land and other assets and have ready access to contraceptives so they can plan their families, women’s labor force participation goes up. Later in the report, Arshi Aadil, an expert on digital financial inclusion, writes about policy reforms in India that are not only improving government services for the poor but also chipping away at the foundations of male supremacy.

Goalkeepers addresses just a few ways to create a better, more equal world. Thankfully, so many advocates are thinking creatively right now about inequality and its solutions. No one has gotten to the bottom of it yet, but we are all getting closer.

In the meantime, we know one thing for sure. No one’s life should be a roll of the dice. Were you born, as we were, with the odds in your favor? Or are you one of the billions of people born with the odds against you? Our goal is to even the odds for everyone.

When that happens, the future won’t be predicted by random factors like where you’re born or how many X chromosomes you have. In fact, it won’t be predicted at all. It will be made—by people’s dreams and hard work.

See Examining Inequality data resources.

The big idea is that health should not be a luxury—that all people should receive the care they need without suffering financial hardship. This is called Universal Health Coverage (UHC). The UN General Assembly adopted a resolution in 2012 calling on member states to prioritize UHC, and the idea has been gaining momentum ever since then.

The small number is 51. That’s my own personal back-of-the-envelope calculation of how many dollars the average sub-Saharan African country would have available to spend on health care per person under ideal circumstances. (My definition of “ideal circumstances” is a country collecting 20 percent of its GDP in taxes and spending 15 percent of its budget on health; the reality in most African countries is far from ideal.)

To be clear, I am not saying most countries currently spend $51 per person (they don’t) or that, if they did, it would be enough (it wouldn’t). I am merely demonstrating that compared to richer countries that can spend thousands of dollars per capita on health, sub-Saharan African countries have to figure out how to get by with very little.

So, how do countries buy UHC when they have less than $51 to spend? The answer is: by investing in primary health care—that is, basic services near where people live and work. A good primary health system is just and equitable, is easily accessible to everybody, doesn’t make the poor pay anything out of pocket, and addresses the vast majority of people’s lifetime health needs. Its goal is to keep people healthy, because sickness is expensive for the individual, the family, the community, and the state!

When I think about primary health care, I remember walking hand in hand with my mum to our local dispensary in rural Kenya, which was about one kilometer away. That’s where I got vaccinated. It’s where my mum got prenatal care when she was pregnant with our last-born sister. And it’s where everybody we knew went when they were sick and seeking advice or treatment.

Since the turn of the millennium, several African countries have invested in building far-reaching, high-quality primary health systems. Ethiopia and Rwanda, for example, have recruited tens of thousands of community health workers, women who are chosen by their neighbors and trained by the government to take care of people’s health.

Community health workers go to the people, instead of the other way around. And they don’t interact with people only when they are sick. They also promote healthy behavior (like proper diet and hygiene) and provide or promote preventive care (like immunizations) to keep people from getting sick in the first place. And then, of course, they are trained to treat common illnesses (like diarrhea and malaria), provide basic family planning services, and refer patients to health facilities if they need more sophisticated care.

As a result of these investments, Ethiopia and Rwanda are among the leaders in the region in reducing maternal and child mortality. And by the way, the GDP per capita in both countries is well below the regional average.

Many other African countries have yet to make the necessary investments. My own country, Kenya, is much richer than Ethiopia and Rwanda, but the primary care system is weaker (though there is finally high-level political commitment to strengthening it). What matters are the choices that politicians make.

here are three choices they can make to achieve better health results with limited budgets:

spend a little more

In 2001, all 54 member states of the African Union committed to spend 15 percent of their state budgets on health. A precious few have ever met that commitment, and those who meet it year after year can be counted on one hand. Governments must balance countless priorities, so finding more money for health is not easy. But when you are making do with such small budgets, every extra dollar counts. Kenya currently spends $36 per person per year, or 7 percent of its budget, on health. If that went up to, say, $51, the universe of the possible would expand significantly. At $86, according to an analysis based on WHO data, governments of low-income countries could fully fund primary health care.

spend on right priorities

Many countries spend more on what is known as secondary and tertiary care than on primary care. That makes sense in one respect, because MRIs, X-rays, and many other features of secondary and tertiary care are expensive. But African governments can’t afford to spend most of their money to meet some of some people’s needs. In Thailand, which has one of the best primary care systems in the world, the government temporarily reallocated all its health infrastructure spending to rural areas because the health gap between rural and urban areas was so big. Now there is at least one health center in every single Thai village. African governments need to say, “Until we are sure primary health care has the investment it needs, we’ll make do with what we have for secondary and tertiary care.” It’s a difficult position to take, but it’s what countries that care about UHC have to do when there is so little money available.

spend more efficiently

Primary care systems can do a lot to stretch the dollars they spend. For example, they can invest in digital health, especially electronic medical records. Or they can focus on managerial innovation, like new ways for a continent with many countries and a large geographical area to pool purchasing and improve supply chains. This would ensure that the right products are available at the right prices and delivered to the right places at the right times.

Finally, it is crucial to use data to answer two key questions about UHC: What and who?

When you know you can’t provide every service, choices about what to provide make a big difference. For African countries, I boldly prescribe prioritizing sexual and reproductive health and rights. But you still have to decide where to put your resources, based not on generic global calculations but on actual conditions on the ground. For example, vasectomies may look cost-effective on paper, and they are good and encouraged, but the return will be less in a country where few providers can perform them, men are resistant, or the biggest challenge is a burgeoning adolescent population.

Next, the who. To make sure no one suffers financial hardship, you need to subsidize the most marginalized and vulnerable, including women, children, and girls, as well as the indigent. However, in countries where most people work in the informal economy and data is unreliable, it’s hard to know precisely who the indigent are. Kenya, with 80 percent of its population employed informally, is working on developing rigorous methodologies to target services more effectively. Ideally, as primary health systems begin to get the same results for less money, they’ll invest what’s left over in getting even better results.

Few countries have been as innovative and thoughtful about using digital technology to make people’s lives better as India. The government understood early on that technology made it possible to connect directly with citizens instead of working through layers and layers of bureaucracy. Then it started creating smart policies built around digital technology that improved both the quality and reach of government services. This essay, which describes the reform of cooking gas subsidies, demonstrates how aligning technology and policy can create a surprising domino effect.

But it’s about cooking gas only in the narrowest sense. In a wider sense, it’s about how digital technology helped the government of India design a series of innovative policies that have empowered 75 million marginalized women. In the very widest sense, it’s about how governments can serve citizens better.

For decades, Indian households bought the liquid petroleum gas they cooked with at a fixed, low price guaranteed by the government. This subsidy was poorly targeted, because everybody, including the rich, could receive it. (According to the IMF, the wealthiest 10 percent of Indian households received seven times more of the subsidy than the poorest 10 percent.) It was inefficient, because a lot of subsidized gas was sold in the black market to hotels, restaurants, and other businesses that should have paid market price. Finally, it was expensive; various gas subsidies could cost the government almost $10 billion per year, depending on the global price of gas.

Now comes the turning point of this story: India’s pioneering of what is known as “the JAM trinity.” The J stands for Jan Dhan Yojana, an Indian government program to help poor people open bank accounts. The A stands for Aadhaar, a program to provide every Indian resident with a unique ID linked to biometric authentication like fingerprints. And the M stands for mobile phones, which are quickly becoming ubiquitous in India. Together, accounts, ID, and phones make it possible for the government to deposit money directly into people’s bank accounts and verify the recipients’ identity. This in turn enables the government to be much more precise and ambitious about policymaking.

Starting in 2012 and continuing through 2015, the government used the JAM trinity to shift gradually from subsidizing the price of gas to transferring cash directly into people’s bank accounts after they had bought the gas at market price. The fully redesigned subsidy, launched nationwide under the name PAHAL in 2015, is the world’s largest cash transfer program.

PAHAL has addressed all three major problems with the old subsidy. Using Aadhaar, the government was able to remove 36 million duplicate or ghost recipients from the rolls, decreasing diversion to the black market and increasing overall efficiency. After a government campaign encouraging better-off people to stop claiming the subsidy, another 10 million Indians removed themselves from the rolls, improving targeting. As a result, PAHAL reduced the financial burden on the government: Although estimates vary, the government puts the savings at almost $9 billion since the PAHAL launch.

But the government hasn’t just pocketed the savings. It’s used them to create a brand new, third-generation cooking gas program, also powered by the JAM trinity, called Ujjwala. This program has been carefully designed to help poor women transform their lives in profound ways.

Most poor families, especially in rural areas, don’t cook with gas; even if it’s subsidized, it’s still more expensive than building fires with wood or animal dung. However, wood and dung fires fill kitchens with hazardous smoke (household air pollution is responsible for nearly 500,000 deaths per year in India). To address this crisis, Ujjwala provides qualifying rural households with a 50 percent subsidy to purchase a gas connection and stove. (The other 50 percent can be paid in installments.) So far, approximately 75 million women have benefitted from Ujjwala. The government is now considering additional reforms to encourage Ujjwala recipients to refill their gas canisters, which are not necessarily affordable enough or easy enough to get.

For example, the average Indian woman spends more than 40 hours per week doing domestic work, leaving precious little time for anything else. Using cooking gas saves women several hours per day they had been spending gathering firewood, building and managing fires that made them sick, and then cleaning up the ashes and dust.

Moreover, the government made an important decision about how the benefits would be disbursed that is disrupting traditional power dynamics in the home. Unlike with traditional benefits programs in India, it is women—and not their husbands— who are eligible for Ujjwala. To receive the gas subsidy, women need to sign up for a bank account.

Merely having and using a bank account changes women’s lives, by giving them decision-making power over the family’s finances. A randomized control trial of a different Indian social benefit program, a work guarantee program, found that when women received payments directly into their own accounts (instead of accounts in their husband’s names) and received training on how to use the accounts, they worked more and earned more. Their husbands also said they were more comfortable with their wives working outside the home. In other words, helping women gain control over financial resources ends up changing everyone’s sense of who they are and what they are capable of.

There is yet another way that policies designed around the JAM trinity are empowering the poor—by making government more accountable. For example, with the new cooking gas subsidy, government officials in 640 Indian districts receive daily progress reports on PAHAL, including enrollment, cash transfer, and error rates, so they can identify and address problems as soon as they arise.

Various states are also experimenting with ways to proactively solicit citizens’ input whenever they interact with government. In one state, for example, beneficiaries receive an automated call soliciting feedback on the quality of the service: Was the customer treated courteously? Did she receive the benefits she expected? Did she receive them without having to pay a bribe? Negative responses roll over into a human system to generate formal complaints.

On its own, the JAM trinity doesn’t do much. It needs to be paired with smart, pro-poor policies and services built around digital technology. Even then, digitally powered policies and services by themselves won’t end poverty and gender inequality. They need to be accompanied by analog reforms like changing discriminatory laws and policies. When all these pieces come together, though, the status quo can change fast.

See Digital Inclusion data resources.

But sometimes—although it feels strange to say— there’s opportunity in crisis. Shortly after the famine, we established a disaster management policy and built up food reserves so that when droughts happened, we could at least save the lives of our people.

As the years passed, we invested heavily in the productivity and resilience of our agriculture sector. We had to, because more than 80 percent of our people live in rural areas. In 2003, the African Union met in Maputo, Mozambique, and governments committed to spend 10 percent of their budgets on agriculture; we spend more than that. In 2015, we suffered a drought just as severe as the one that led to the 1984 famine, but the world never heard about it because we had built better systems to help farmers cope.

Our thriving agriculture sector is part of why Ethiopia’s overall economic growth has been so impressive, and why we are on track to become a middle-income country by 2025. But there is one thing that could derail us: climate change. Climate change is caused by the actions of richer countries, but the most vulnerable people in poorer countries are feeling it first.

Fortunately, the work we’ve been doing for the past 20 years will help our farmers respond to the changing climate in the next 20. In 2005, we launched a very large program that pays people to work on agriculture-related public works projects. The impact is twofold: The poor have the means to purchase food and other necessities when emergencies strike, and they build community assets like bench terraces, bunds, check dams, deep trenches, and microbasins that conserve water, prevent soil erosion, and ultimately contribute to higher yields. Three years later, we launched another program to foster a mass movement around sustainable land management.

We have also hired one of the largest cadres of agricultural extension agents in the world. They are a source of timely information; for example, they provide early warnings about droughts and advice about how farmers might adjust. They also focus on longer-term education. Our network of extension agents is one reason why Ethiopian farmers are more likely to use fertilizer, improved seeds, or irrigation than farmers in many neighboring countries.

We have no illusions about what we are up against. Several years ago, we launched our Climate Resilient Green Economy strategy, which recognizes that our future prosperity is riding on proper stewardship of our environment.

We cannot stop the droughts. We can flourish in spite of them.

Twenty years ago, when I started farming this land, the weather was better. But it keeps getting hotter. July should be a cold month; this year it’s much hotter than usual. And the rains are not dependable. One year there are good rains, and the next year there's drought. It usually begins raining in late May or early June. This year, it’s already late July and it hasn’t rained yet. We’re still waiting. We try to sow at the best times, but we can’t control the rain. If it doesn’t start raining until July and stops before October, we won’t get anything from our fields. If things get bad, I have some sheep I can sell or trade. I am thinking about investing in beehives for honey.

Even though the weather is worse, our farming is much better now. When I was growing up on my parents’ farm, the land was destroyed. They didn’t get any kind of help from the government. When the famine came in 1984, moving the family to Sudan was the only option.

Now, we get information and education from agricultural experts who come to our community. Before, we didn’t use modern seeds. Now I use the best wheat seeds. I plant wheat that’s ready to harvest earlier, so it does better in a drought. Before, we didn’t use fertilizer, herbicides, or pesticides. Now I can use all three. I know about weeding. I know how to protect my field from drying out in the sun. My yields have almost doubled.

We try to adapt to the conditions here and overcome. I want my children to get an education. I didn’t get one when I was a child; I didn’t go to school a day in my life. But all three of my children are enrolled. I must make sure that they are fed. If I grow wheat early this year, I will switch to barley during the next growing season because I want barley for my kids to eat. My children can’t learn and study with empty bellies. Every decision I make is about what my family needs.

Based on an interview.

See Climate Adaptation data resources.

Featured Global Goals Indicators

Last year we picked three indicators out of the 18 to explore in more detail with additional data. This year we’ve selected maternal mortality, stunting, and neglected tropical diseases (NTDs) and focused on highlighting countries and programs which are showing success at fighting inequality.

Global Goals Indicators

In addition to our three featured deep dives, below you can explore the other 15 indicators which we track annually. For each, we show the available data charting global progress since 1990. For select indicators, we show projections to 2030 based upon current progress and two additional scenarios, produced by our partner, the Institute for Health Metrics and Evaluation. This year we also explored a dimension of inequality for each indicator masked by the global averages.