Beyond the immediate loss of life and injuries, conflicts and humanitarian crises pose many challenges to children: they make finding work harder for parents, disrupt education, increase costs and poverty, all of which weakens the protections that should be in place to keep children safe from violence. In turn, these factors increase girls' risk of child marriage. As previous evidence shows, child marriage is often seen as a way to reduce financial pressures on families or to protect girls from other forms of gender-based violence. 

The [Child Atlas illustrates this relationship](https://www.childatlas.org/atlas?indicator1=PT_F_20_24_MRD_U18&topic1=CP.VG&indicator2=CONFLICT_AFFECTED&topic2=CI.CM), showing that many countries with high rates of child marriage are also places where a high share of children are affected by conflict (for instance Mali or Central African Republic). But this relationship is not consistent throughout: there are many conflict situations where child marriage is not as high as in more peaceful settings, and vice versa. And while the correlation shown in the Child Atlas can be indicative of a causal relationship – conflict increasing child marriage – we need more elaborate analytical tools to study this in detail. 

![child marriage_conflict.png](https://res.cloudinary.com/dmhlewc3v/image/upload/v1720712579/child_marriage_conflict_4a2c6b394f.png)

This was exactly what we did for the [Global Girlhood Report 2022]( https://resourcecentre.savethechildren.net/document/global-girlhood-report-2022-girls-on-the-frontline/) Most studies analysing the impact of conflict on child marriage focus on one particular area and use qualitative techniques, providing invaluable insights into the drivers of child marriage in humanitarian contexts. However, we were interested in quantifying this relationship across a large number of countries to understand how much child marriage might increase as a result of conflict. After almost two years, our analysis has just been published in the [academic journal SN Social Sciences](https://link.springer.com/article/10.1007/s43545-024-00940-7).

In this analysis, we first combined data across 56 countries, covering 3.5 million women and 2.1 million marriages. We then linked the household locations of these women to a geographically granular dataset covering conflict events over the last 30 years that shows whether any armed conflicts had taken place during that time and how many people had been killed. Bringing these two sets of information together, to see if child marriages were more prevalent during times of conflict.  

Our results showed that girls were 20% more likely to get married if a conflict took place in their area in previous five years. However, this finding hides a lot of variation, with the impacts varying between world regions and countries. You can read the whole study [here](https://rdcu.be/dNayG). 

Conflicts and humanitarian crises significantly heighten the risk of child marriage. Our research shows that girls in conflict zones are 20% more likely to marry, though the impact varies by region and country.

Girls on the Frontline: Are girls more likely to marry in conflict? 

Health insurance can play a crucial role to protect from high out-of-pocket costs that families and children often face when they need to access health services in many low-and middle-income countries. But does insurance actually help to improve outcomes for children? As part of my internship at Save the Children through [UCL’s Social Data Institute](https://www.ucl.ac.uk/social-historical-sciences/social-data) Internship Scheme, I analysed [Multiple Indicator Cluster Survey (MICS)](https://mics.unicef.org/) data from 2017-2023, covering approximately 340,000 children under five across 38 low- and middle-income countries. This blog post, summarises some key insights about the association between insurance and child health outcomes. 

The findings reveal a consistent pattern: **insured children show better health outcomes than uninsured children** across most countries. But before celebrating this as evidence for insurance expansion, we need to understand what these associations actually tell us—and more importantly, what they don’t.

# What was Measured
I examined three health indicators: Stunting reflects [chronic malnutrition](https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(19)30244-5/abstract) during critical early years. DPT3 vaccination measures [routine preventive healthcare access](https://www.ghspjournal.org/content/11/3/e220055). Care-seeking for diarrhoea reveals [how families respond to acute illness](https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-025-22047-1). Together, these indicators capture [distinct dimensions of child health and healthcare access](https://link.springer.com/article/10.1007/s12187-024-10178-7).

# Focusing on Robust Comparisons: The Statistics Explained
Our analysis covered 38 countries, but for this blog, I focused on those with large enough sample sizes to yield reliable results—specifically, where we observed sufficient numbers of insured and uninsured children. I then calculated odds ratios for these countries. An odds ratio indicates how much more or less likely insured children are to experience a certain outcome: if the odds ratio is above 1, it means insured children are more likely to be vaccinated or seek treatment; if it's below 1, they're less likely; and if it's exactly 1, there’s no significant difference between the two groups.

These odds ratios are shown on the vertical axes in the graphs below. The horizontal axes show the insurance coverage: moving further to the right means more children have insurance.  Each dot corresponds to a country, with larger dots indicating bigger sample sizes and, therefore, stronger data reliability. Red dots highlight associations that are statistically significant (meaning we can be confident the results aren’t just due to random chance), whereas blue dots indicate associations that didn’t reach statistical significance.

# DPT3 Vaccination: Predominantly Positive Associations
For vaccination, most countries show positive associations—insured children are more likely to be fully vaccinated. In low-coverage countries (under 15%) like Nigeria (2.9%), DRC (3.1%), and Laos (13.7%), insured children are roughly twice as likely to be vaccinated. At moderate coverage (40-60%), Algeria, Dominican Republic, and Ghana show more modest positive associations. The high-coverage picture (above 80%) is mixed: Costa Rica and Vietnam show strong associations, while Thailand (97.8%) shows essentially none despite large sample sizes—suggesting the relationship between coverage expansion and vaccination isn’t straightforward. Country-specific factors like who remains uninsured and how health systems function matter as much as coverage level.
![insurance_dpt3.jpg](https://res.cloudinary.com/dll8uzwex/image/upload/v1763571796/insurance_dpt3_c9f0937eff.jpg)

# Care-Seeking for Diarrhoea: Weaker Patterns
Diarrhoea care-seeking data are limited to children who had diarrhoea in the two weeks before the survey, resulting in a smaller sample. Only Laos and Ghana show a clear positive link, with insured families being twice as likely to seek care. Most countries show little association, indicating the effect is weaker than for vaccination. This may be because acute illness prompts care regardless of insurance, whereas insurance has more influence on routine services like vaccination.
![insurance_diarcare.jpg](https://res.cloudinary.com/dll8uzwex/image/upload/v1763571796/insurance_diarcare_7b5fcbe7cb.jpg)

# Stunting: Increased coverage reduces insurance’s positive impact
For stunting, the majority of countries demonstrate protective associations, indicating that insured children have a reduced risk of chronic malnutrition. The pattern across different levels of insurance coverage is striking: at low coverage (under 10%), insured children in DRC, Laos, and Nepal are half as likely to be stunted. At moderate coverage (20-60%), these associations weaken. At high coverage (above 70%), insurance has minimal impact.
![insurance_stunting.jpg](https://res.cloudinary.com/dll8uzwex/image/upload/v1763571796/insurance_stunting_d4887af848.jpg)

Unlike the other outcomes, stunting shows a [statistically significant relationship](https://www.ncbi.nlm.nih.gov/books/NBK459346/) between coverage level and association strength; as coverage increases, the protective association weakens. This likely reflects stunting’s cumulative nature:  This pattern likely reflects the cumulative nature of stunting: it develops over extended periods due to ongoing nutritional deprivation, inadequate sanitation, and recurrent infections. In countries with low insurance coverage, those with insurance are typically from socioeconomically advantaged backgrounds with superior nutrition and living conditions, independent of their insurance status. The large differences we observe may reflect who has insurance as much as what insurance does. This suggests we need to be cautious when interpreting these associations as evidence of causality.

A [research report with the complete analysis is available here](https://res.cloudinary.com/dll8uzwex/image/upload/v1763565608/Sacha_Bechara_Health_Insurance_Child_Health_Outcomes_decb60be3e.pdf)  – and you can also [interact with the data in this visualisation](https://sachabechara.neocities.org/interactive_forest_plot).

# A country perspective
Ghana’s National Health Insurance Scheme (NHIS), established in 2003, provides a compelling example of how insurance can improve child health outcomes. As I showed above, insured children in Ghana are more likely to receive routine vaccinations, seek care for diarrhoea, and have lower stunting rates. There are several factors that help explain why Ghana stands out compared with other countries: first, NHIS coverage is relatively high and the scheme is well-integrated with public health services, ensuring children can access care more consistently. Second, the scheme benefits from a stronger health system and better infrastructure compared to other low-income countries. Third, Ghana’s system effectively links enrolled families – particularly in urban and moderately advantaged households - to preventive and curative services. As a result, Ghana – despite ongoing equity issues - achieves far greater benefits from insurance than many other countries, where low coverage, widespread inequities, and an under-resourced health system mean children often cannot reliably access quality care even if they are insured.

# A crucial caveat – and what this means
This analysis provides us with some important insights, particularly regarding the relationship between health insurance coverage and health outcomes. Nevertheless, it is important to note that these patterns should not be interpreted as causal evidence that insurance improves health outcomes.  The primary issue is selection bias, wherein children with insurance often differ systematically from those without. Both insurance coverage and health outcomes are closely associated with factors such as wealth, education, and urban residence. Thus, when insured children appear to experience better outcomes, this reflects not only the potential effects of insurance but also the characteristics of those who obtain it. This challenge is most pronounced in settings where insurance coverage is limited and primarily accessed by more advantaged groups.

# So what does this mean? 
The evidence suggests that both genuine insurance effects and selection bias are present. The statistically significant association between coverage level and stunting, but not with vaccination or diarrhoea, indicates that different health outcomes may respond differently to insurance coverage. Long-term nutritional outcomes, in particular, appear especially susceptible to confounding factors. To generate robust causal evidence, researchers should employ more sophisticated methodologies, such as leveraging natural experiments or conducting randomised evaluations.

That said, these findings shouldn’t discourage expansion of coverage. Financial protection matters regardless of its immediate health effects, and the positive associations align with hypotheses that [reducing financial barriers improves health outcomes, especially for preventive services](https://pmc.ncbi.nlm.nih.gov/articles/PMC9073389/). But we also find that context matters enormously. Policymakers should expand coverage and rigorously evaluate whether insurance actually improves health in their specific context.

_About this analysis: This research was conducted during an internship at Save the Children UK through UCL’s Social Data Institute, analysing MICS data from 2017-2023 covering 38 countries. I am grateful to my supervisor Olivier Fiala, the Save the Children UK team, and the UCL Social Data Institute for their support and guidance. For questions, please reach out to sacha.bechara.23@ucl.ac.uk_

_Views expressed are the author’s own and don’t reflect positions of Save the Children or UCL._

This blog explores insights from 38 countries on how health insurance shapes child health—revealing benefits, caveats, and why context matters.

Does Insurance Benefit Child Health? Lessons from 38 Countries

In 2015, world leaders agreed on 17 Sustainable Development Goals (SDGs) to end poverty, tackle inequality and climate change, and create a better future for everyone. [A new analysis by Save the Children](https://res.cloudinary.com/gwlvoices/image/upload/v1762164634/Gaps_in_SDG_progress_for_children_633570b95a.pdf), using a machine learning model to better understand the link between public policies and outcomes, paints a sobering picture. **Despite progress in some areas, significant gaps remain for children worldwide – and many are unlikely to be met within the lifetime of today’s children, or even the next generation.** The UN World Social Summit this week in Doha offers a pivotal opportunity for global leaders to recommit to sustainable development, eradicating poverty, and creating equitable opportunities for all.

# Progress and persistent challenges in reaching the SDGs for children
Our analysis covers 90 child-relevant indicators across all 17 SDGs (many of which are available in the [Child Atlas](https://www.childatlas.org/)), and takes into account the important interlinkages between different policy areas. Some of the largest gaps globally appear in hunger and nutrition (SDG 2), education (SDG 4), affordable and clean energy (SDG 7), industry, innovation and infrastructure (SDG 9), and life on land (SDG 15). These gaps, however, vary significantly between income groups and regions. The widest gaps are found in Sub-Saharan Africa, followed by South Asia and the Middle East and North Africa – but the SDGs remain unfulfilled everywhere, including in high-income countries.

![Circular chart showing large 2030 SDG gaps, biggest in hunger, energy, infrastructure, and life on land.](https://res.cloudinary.com/gwlvoices/image/upload/v1762258952/circle_sdg_logos_56a7c069c9.png)

Beneath these gaps lie the real lives and prosperity of children worldwide. **Under current policy priorities – and without substantial additional investments in children and families – around 750 million children are projected to still be living in multidimensional child poverty across low- and middle-income countries in 2030.** 3.4 million children under 5 are expected to die before their fifth birthday and as many as 224 million children might be out-of-school by the end of the decade – despite the SDGs’ promises to end preventable child deaths and ensure that all girls and boys complete free, equitable and quality primary and secondary education.

# Falling behind: Most countries won’t reach the SDGs in time
Progress matters as much as the size of the gap. Even large gaps can close quickly if progress is rapid, while smaller ones may persist for decades if progress is slow or indicators are regressing. Our model – covering 170 country-specific analyses and up to 90 individual indicators – estimates how long it will take, based on current trends, to reach the SDG targets. The findings are stark: only 20% of country-indicator pairs are expected to reach their targets by 2030. **Globally, more than half are unlikely to reach the goals by 2050.** And 607 million children live in countries where most indicators are regressing or will not meet their targets until 2080 or later – half a century after the 2030 deadline. Progress is particularly slow for hunger and nutrition, gender equality, inequalities, sustainable cities, and many planet-related goals such as life on land and below water.

![Stacked bars show most SDG targets won’t be met by 2030; many lag until after 2100, especially on climate and inequality.](https://res.cloudinary.com/gwlvoices/image/upload/v1762259193/goalreached_global_65c0f39b31.png)

# A foundation to better understand public policies for children
Failing to deliver for children now undermines the global community’s vision for a sustainable, peaceful and prosperous future set out under the 2030 Agenda. This analysis offers new insights into the world’s far-too-slow progress towards the SDGs under current policy trajectories (and complements other more traditional efforts, like the ones by [UNICEF in 2023](https://data.unicef.org/resources/sdg-report-2023/) and those presented in the [Child Atlas’ SDG page](https://www.childatlas.org/sdg)). It also provides a foundation to better understand how public finance decisions affect children – and how to identify public policies that deliver the greatest impact for them.

_This is the first Save the Children analysis using the Policy Priority Inference (PPI) framework, developed at the Alan Turing Institute. The PPI is a computational model that integrates large amounts of empirical data with a robust theoretical framework, capturing the workings of complex systems and the realities of political economy. Check out the [briefing](https://res.cloudinary.com/gwlvoices/image/upload/v1762164634/Gaps_in_SDG_progress_for_children_633570b95a.pdf) (and [full methodological note](https://res.cloudinary.com/gwlvoices/image/upload/v1762164528/Methodology_PPI_Oct2025_e9b1431b1b.pdf)) for further information on the methodology._

A new Save the Children analysis reveals that most Sustainable Development Goals for children are far off track – with hundreds of millions still facing poverty, hunger and lost opportunities well beyond 2030.

A Generation Left Waiting: Gaps in SDG progress for children

Josephat*

We hope that we can build a world where life is good and where no child is left behind.

world-stc.geojson

Legal age of marriage and any exceptions to that legal age

Setting and enforcing a minimum legal age of marriage helps prevent child marriage, protect children from exploitation, and promote their rights. This measure identifies the legal minimum age at which individuals can marry under national laws.

Children living in household that received social transfers or benefits in the last 3 months (%)

Children living in household that received social transfers or benefits in the last 3 months (%). Social transfers covers various forms of financial assistance and support provided to vulnerable families and individuals.

CIVICUS rating of civic space (respect in policy and practice for the freedoms of peaceful assembly, association and expression which are underpinned by the state’s duty to protect civil society)

CIVICUS rating of civic space (respect in policy and practice for the freedoms of peaceful assembly, association and expression) underpinned by the state’s duty to protect civil society and evaluating the  environment for civil society organisations.

Children experiencing at least one extreme climate event per year (%)

Children experiencing at least one extreme climate event  per year (%), such as wildfires, crop failures, droughts, river floods, heatwaves, and tropical cyclones. Extreme climate events threaten children's safety, health, and well-being.

Children experiencing at least one crop failure per year (%)

Children experiencing at least one crop failure per year (%). Crop failures due to factors such as adverse weather conditions, pests, or diseases can lead to food insecurity, malnutrition, and poverty.

Children experiencing at least one tropical cyclone per year (%)

Children experiencing at least one tropical cyclone per year (%). Tropical cyclones bring extensive destruction such as strong winds, heavy rainfall, and flooding, endangering children's lives.

Children experiencing at least one drought per year (%)

Children experiencing at least one drought per year (%). Droughts can lead to food and water shortages, malnutrition, displacement, and adverse health outcomes.

Children experiencing at least one wildfire per year (%)

Children experiencing at least one wildfire per year (%). Wildfires can result in widespread destruction of ecosystems, property damage, air pollution, and affect health, posing risks to children's safety.

Children experiencing at least one river flood per year (%)

Children experiencing at least one river flood per year (%). River floods can result in displacement, damage, injuries, and loss of life, posing significant risks to children's safety, health, and well-being.

Children experiencing at least one heatwave per year (%)

Children experiencing at least one heatwave per year (%). Heatwaves can have serious health consequences, including heat-related illnesses and deaths, particularly among vulnerable populations.

Probability of a child dying before they reach their first birthday (per 1,000 live births)

Highlighting the effectiveness of healthcare systems and socio-economic conditions impact child welfare, infant mortality shows the likelihood of a child dying before their first birthday (expressed as the number of deaths per 1,000 live births)

Probability of a child dying before they reach their fifth birthday (per 1,000 live births)

Under-five mortality is an important indicator of the health and well-being of children and their families. It measures how many children die before they reach the age of five years (expressed as the number of deaths per 1,000 live births). 

Cost of the least expensive locally-available foods to meet requirements for food-based dietary guidelines (in current PPP dollar/person/day)

This indicator measures the cost of the least expensive locally-available foods required to meet the dietary recommendations (in current PPP dollar/person/day). This helps evaluate the economic barriers to achieving a healthy diet.

Population who cannot afford a healthy diet (%)

This indicator measures the percentage of the population who cannot afford to consume a healthy diet due to financial constraints (%). Monitoring the population unable to afford a healthy diet highlights disparities in food access and affordability.

National guidelines for competencies of health workers in adolescent health

National guidelines outlining the competencies of health workers in adolescent health ensure that healthcare providers are equipped with the necessary knowledge and skills to address the unique health needs and concerns of adolescents.

Children living in a conflict zone, defined as proximity of =50km around a violent conflict (%)

Children living in a conflict zone, defined as proximity of =50km around a violent conflict (%). Conflicts heightened children's safety, well-being, and development. This data helps identify populations at risk and inform humanitarian responses.

Prohibition of corporal punishment in alternative care settings, day care, schools, penal institutions and as sentence for a crime

Banning corporal punishment helps protect children from physical harm, psychological trauma, and violations of their rights. This measure assesses the existence and enforcement of legal prohibitions on corporal punishment in various settings.

Index of perceived levels of?public sector corruption from 0 (highly corrupt) to 100 (very clean)

The Corruption Perceptions Index ranks public sector corruption in 180 countries. Perceived levels helps identify corruption risks and challenges in governance and service delivery. The results are given from 0 (highly corrupt) to 100 (very clean).

Children or young people (aged 3-5 years above age for the last grade) who have completed primary education (%)

Children or young people (aged 3-5 years above age for the last grade) who have completed primary education (%). It helps to understand if children finish school, ensuring that more students achieve the qualifications necessary for future opportunities.

Children or young people (aged 3-5 years above age for the last grade) who have completed lower secondary education (%)

Children or young people (aged 3-5 years above age for the last grade) who have completed lower secondary education (%). It helps to understand if children finish school, ensuring that more students achieve the qualifications necessary for future opportunities.

Children or young people (aged 3-5 years above age for the last grade) who have completed upper secondary education (%)

Children or young people (aged 3-5 years above age for the last grade) who have completed upper secondary education (%). It helps to understand if children finish school, ensuring that more students achieve the qualifications necessary for future opportunities.

Interest paid on public debt (% government revenues)

Interest paid on public debt (% government revenues). High levels of interest payments relative to government revenues can strain fiscal resources and limit funding available for essential public services and development programs.

Assessment of debt distress by World Bank and IMF based on the Debt Sustainability Framework

The Debt Sustainability Framework analyses countries' debt burdens, repayment capacity, and vulnerability to debt-related risks. It  identifies countries facing unsustainable debt and potential financial crises, informing debt management.

Women (aged 15-49 years) who experienced physical or sexual violence (%)

Women who experienced physical or sexual violence (%). Addressing gender-based violence is crucial for protecting women's rights, safety and well-being. This data informs strategies for prevention and support services for survivors.

Children (aged 7-14) who demonstrate foundational numeracy skills (%)

Children (aged 7-14) who demonstrate foundational numeracy skills (%). This data can inform curriculum, teaching, and interventions to improve numeracy, ensuring all children have foundational numeracy skills.

Children (aged 7-14) who demonstrate foundational reading skills (%)

Children (aged 7-14) who demonstrate foundational reading skills (%) This data can inform literacy programmes, teaching, and policies to improve reading, ensuring all children acquire essential literacy skills.

Children and young people (age 5-24 years) currently attending primary education or higher, receiving support for school tuition or other school related support (%)

Children and young people (age 5-24 years) receiving support for school tuition or other school related support (%). Scholarships, grants, subsides or fee waivers can help ensure access to quality education and reduce financial barriers.

Number of attacks on students, personnel and institutions

The number of reported attacks covers various forms of violence, including physical assault, threats, and attacks on educational facilities. Tracking attacks is essential to safeguard the right to education and ensure a safe learning environment.

Young people (age 15-24 years) who can both read and write with understanding a short simple statement (%)

Young people (age 15-24 years) who can both read and write with understanding a short simple statement (%), a key skill for children and young people to thrive and harness future opportunities.

Children attend organised learning programmes one year before the official primary entry age (%) 

Early childhood education programmes have an important role in cognitive development. The percentage of children in organised learning programmes reflects early childhood education initiatives and readiness for formal schooling. 

Government expenditure on education as percentage of GDP (%)

Share of the GDP allocated to education-related expenditures by the government. It reflects the level of investment in education relative to the overall economy, and provides insights into the prioritisation of education within the national budget.

Expenditure on education as percentage of total government expenditure (%)

Proportion of a country's total expenditure allocated to education-related programs and initiatives. It reflects the government's commitment to investing in education, adequate funding is essential for expanding access to quality education.

Total expenditure on social protection (excluding health) as percentage of government expenditures (%)

Total expenditure on social protection as percentage of government expenditures (%). Social protection covers various policies and programs aimed at reducing poverty, vulnerability, and inequality. 

Expenditure on social protection systems for children as percentage of government expenditures (%)

Expenditure on social protection systems for children as percentage of government expenditures (%). Child-focused social protection can involves cash transfers or child allowances that benefit directly children and their families.

Expenditure on social protection systems for children as percentage of GDP (%)

Expenditure on social protection systems for children as percentage of GDP (%). Child-focused social protection can involves cash transfers or child allowances that benefit directly children and their families.

Total expenditure on social protection (excluding health) as percentage of GDP (%)

Total expenditure on social protection as percentage of GDP (%), measuring the level of investment in social safety nets. Social protection covers various policies and programs aimed at reducing poverty, vulnerability, and inequality. 

External health expenditures as percentage of total health expenditures (%)

The ratio of healthcare funding from external sources to total health expenditure (%). This measure informs decision-makers on external aid dependency and asses health financing mechanisms sustainability and resilience.

Population with poor or borderline food consumption according to the Food Consumption Score (%)

The Food Consumption Score evaluates dietary diversity and nutritional adequacy. This measure indicates the percentage of the population with poor/borderline food consumption, offering insights into food security and nutritional well-being.

Change of food prices compared to corresponding month of the previous year (%)

Change of food prices compared to corresponding month of the previous year (%). Such fluctuations can disrupt food affordability, access, and nutrition, affecting children's dietary intake and well-being.







Policy/legislation on free access to health services for adolescents

A policy or legislation that guarantee free access to healthcare services for adolescents ensures equitable access to essential health services, regardless of socioeconomic status or ability to pay.

Policy/legislation on free access to health services for children

A policy or legislation that guarantee free access to healthcare services for children ensures equitable access to essential health services, regardless of socioeconomic status or ability to pay.

Domestic general government health expenditure as percentage of GDP (%)

Percentage of a country's Gross Domestic Product (GDP) that is spent on healthcare by the government (%). This indicator reflects the level of investment in the healthcare sector relative to the country's overall economic input.

Domestic general government health expenditure as percentage of total government expenditure (%)

The proportion of a country's total government expenditure allocated to health-related programmes and services (%); understanding this statistics helps assess the government's commitment to prioritising healthcare within budget allocations.

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