More than 200 million children under the age of five in the developing world are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities (Lancet 2007). In addition, 165 million children (one in four) are stunted, with 90 percent of those children living in Africa and Asia (UNICEF et al, 2012). And while some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs. Child death is a tragedy. At 6 million deaths a year, far too many children perish before reaching the age of five, but the near certainty that 200 million children today will fall far below their development potential is no less a tragedy.
There is now an expanding body of literature on the determining influence of early development on the chances of success later in life. The first 1,000 days from conception to age two are increasingly being recognized as critical to the development of neural pathways that lead to linguistic, cognitive and socio-emotional capacities that are also predictors of labor market outcomes later in life. Poverty, malnutrition, and lack of proper interaction in early childhood can exact large costs on individuals, their communities and society more generally. The effects are cumulative and the absence of appropriate childcare and education in the three to five age range can exacerbate further the poor outcomes expected for children who suffer from inadequate nurturing during the critical first 1,000 days.
Research shows that there are large gains to be had from investing in early childhood development. For example, estimates place the gains from the elimination of malnutrition at 1 to 2 percentage points of gross domestic product (GDP) annually (World Bank, 2006). Analysis of results from OECD’s 2009 Program of International Student Assessment (PISA) reveals that school systems that have a 10 percentage-point advantage in the proportion of students who have attended preprimary school score an average of 12 points higher in the PISA reading assessment (OECD and Statistics Canada, 2011). Also, a simulation model of the potential long-term economic effects of increasing preschool enrollment to 25 percent or 50 percent in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 6.4 to 17.6, depending on the preschool enrollment rate and the discount rate used (Lancet, 2011).
Indeed, poor and neglected children benefit disproportionately from early childhood development programs, making these interventions among the more compelling policy tools for fighting poverty and reducing inequality. ECD programs are comprised of a range of interventions that aim for: a healthy pregnancy; proper nutrition with exclusive breast feeding through six months of age and adequate micronutrient content in diet; regular growth monitoring and immunization; frequent and structured interactions with a caring adult; and improving the parenting skills of caregivers.
Yet despite all the evidence on the benefits of ECD, no country in the developing world can boast of comprehensive programs that reach all children, and unfortunately many fall far short. Programs catering to the very young are typically operated at small scale and usually through external donors or NGOs, but these too remain limited. For example, a recent study found that the World Bank made only $2.1 billion of investments in ECD in the last 10 years, equivalent to just a little over 3 percent of the overall portfolio of the human development network, which totals some $60 billion (Sayre et al, 2013).
The following are important inputs into the development of healthy and productive children and adults, but unfortunately these issues are often not addressed effectively:
Maternal Health. Maternal undernutrition affects 10 to 19 percent of women in most developing countries (Lancet, 2011) and 16 percent of births are low birth weight (27 percent in South Asia). Malnutrition during pregnancy is linked to low birth weight and impaired physical development in children, with possible links also to the development of their social and cognitive skills. Pre-natal care is critical for a healthy pregnancy and birth. Yet data from 49 low-income countries show that only 40 percent of pregnant women have access to four or more antenatal care visits (Taskforce on Innovative International Financing for Health Systems, 2009). Maternal depression also affects the quality of caregiving and compromises early child development.
Child Care and Parenting Practices. The home environment, including parent-child interactions and exposure to stressful experiences, influences the cognitive and socio-emotional development of children. For instance, only 39 percent of infants aged zero to six months in low and middle-income countries are exclusively breast-fed, despite strong evidence on its benefits (Lancet, 2011). Also, in half of the 38 countries for which UNICEF collects data, mothers engage in activities that promote learning with less that 40 percent of children under the age of six. Societal violence and conflict are also detrimental to a child’s development, a fact well known to around 300 million children under the age of four that live in conflict-affected states.
Child Health and Nutrition. Healthy and well-nourished children are more likely to develop to their full physical, cognitive and socio-emotional potential than children who are frequently ill, suffer from vitamin or other deficiencies and are stunted or underweight. Yet, for instance, an estimated 30 percent of households in the developing world do not consume iodized salt, putting 41 million infants at risk for developing iodine deficiency which is the primary cause of preventable mental retardation and brain damage, and also increases the chance of infant mortality, miscarriage and stillbirth. An estimated 40 to 50 percent of young children in developing countries are also iron deficient with similarly negative consequences (UNICEF 2008). Diarrhea, malaria and HIV infection are other dangers with a deficit of treatment in early childhood that lead to various poor outcomes later in life.
Preprimary Schooling. Participation in good quality preprimary programs has been shown to have beneficial effects on the cognitive development of children and their longevity in the school system. Yet despite gains, enrollment remains woefully inadequate in Sub-Saharan Africa and the Middle East and North Africa. Moreover, national averages usually hide significant inequalities across socio-economic groups in access and almost certainly in quality. In all regions, except South Asia, there is a strong income gradient for the proportion of 3 and 4 year olds attending preschool.
IMPEDIMENTS TO SCALING UP
So what are the impediments to scaling up these known interventions and reaping the benefits of improved learning, higher productivity, lower poverty and lower inequality for societies as a whole? There are a range of impediments that include knowledge gaps (especially in designing cost-effective and scalable interventions of acceptable quality), fiscal constraints and coordination failures triggered by institutional organization and political economy.
Knowledge Gaps. Despite recent advances in the area, there is still insufficient awareness of the importance of brain development in the early years of life on future well-being and of the benefits of ECD interventions. Those who work in this area take the science and the evaluation evidence for granted. Yet awareness among crucial actors in developing countries—policymakers, parents and teachers—cannot be taken for granted.
At the same time much of the evaluation evidence from small programs attests to the efficacy of interventions, we do not yet know whether large scale programs are as effective. The early evidence came primarily from small pilots (involving about 10 to 120 children) from developed countries. [1];While there is now considerable evidence from developing countries as well, such programs still tend to be boutique operations and therefore questions regarding their scalability and cost-effectiveness.
There are also significant gaps in our knowledge as to what specific intervention design works in which context in terms of both the demand for and the provision of the services. These knowledge gaps include the need for more evidence on: i) the best delivery mode – center, family or community based, ii) the delivery agents – community health workers, mothers selected by the community, teachers, iii) whether or not the programs should be universal or targeted, national or local, iv) the frequency and duration of interventions, of training for the delivery agents and of supervision, v) the relative value of nutritional versus stimulative interventions and the benefits from the delivery of an integrated package of services versus sector specific services that are coordinated at the point of delivery, vi) the most effective curricula and material to be used, vii) the relative effectiveness of methods for stimulating demand – information via individual contact, group sessions, media, conditional cash transfers etc. In all these design questions, cost-effectiveness is a concern and leads to the need to explore the possibility of building on an existing infrastructure. There is also a need for more evidence on the kinds of standards, training and supervision that are conducive to Safeguarding the quality of the intervention at scale.
Fiscal Constraints. Fiscal concerns at the aggregate level are also an issue and force inter-sectoral trade-offs that are difficult to make. Is it reasonable to expect countries to put money into ECD when problems persist in terms of both access and poor learning outcomes in primary schools and beyond? Even though school readiness and teacher quality may be the most important determinants of learning outcomes in primary schools, resource allocation shifts are not easy to make for policymakers. In addition, as discussed above, we do not yet have good answers to the questions around the cost implications of high quality design at scale.
Institutional Coordination and Political Context. Successful interventions are multi-sectoral in nature (whether they are integrated from the outset or coordinated at the point of delivery) and neither governments nor donor institutions are structured to address well issues that require cross-sectoral cooperation. When programs are housed in the education ministry, they tend to focus on preprimary concerns. When housed in the health ministry, programs ignore early stimulation. We do not know well what institutional structure works best in different contexts, including how decentralization may affect choices about institutional set ups.
There are also deeper questions about the nature of the social contract in any country that shapes views about the role of government and the distribution of benefits across the different segments of the population. Some countries consider that the responsibilities of the public sector start when children reach school age and view the issues around the development of children at a younger age to be the purview of families. And in many countries, policies that benefit children get short shrift because children do not have political voice and their parents are imperfect agents for their children’s needs. Inadequate political support then means that the legislative framework for early year interventions is lacking and that there is limited public spending on programs that benefit the young. For example, public spending on social pensions in Brazil is about 1.2 percent of GDP whereas transfers for Bolsa Familia which targets poor children are only 0.4 percent of GDP (Levy and Schady 2013). In Turkey, only 6.5 percent of central government funds are directed to children ages zero to 6, while the population above 44 receives a per capita transfer of at least 2.5 times as large as children today (World Bank, 2010). Finally, the long gestation period needed to achieve tangible results compounds the limited appeal of ECD investments given the short planning horizon of many political actors.
THE FUTURE: AN AGENDA FOR SCALING UP ECD
Addressing the constraints to scaling up ECD requires action across a range of areas, including more research and access to know how, global and country level advocacy, leveraging the private sector, and regular monitoring of progress.
Operational Research and Learning Networks. Within the EDC research agenda, a priority should be the operational research that is needed to go to scale. This research includes questions around service delivery models, including in particular their cost effectiveness and sustainability. Beyond individual program design, there are broader institutional and policy questions that need systematic assessment. These questions center on issues including the inter-agency and intergovernmental coordination modalities which are best suited for an integrated delivery of the package of ECD services. They also cover the institutional set-ups for quality assurance, funding modalities, and the role of the private sector. Finally, research is also needed to examine the political economy of successful implementation of ECD programs at scale.
Also necessary are learning networks that can play a powerful role in disseminating research findings and in particular good practice across boundaries. Many of the issues regarding the impediments for scaling up are quite context specific and not amenable to generic or off-the-shelf solutions. A network of peer learning could be a powerful avenue for policymakers to have deeper and face-to-face interactions about successful approaches to scaling up. South-South exchanges were an enormously valuable tool in the propagation of conditional cash transfer schemes both within Latin America and globally. These types of exchanges could be equally powerful for ECD interventions
Advocacy. There is a need for a more visible global push for the agenda, complemented by advocacy at country or regional levels and a strong role for business leaders. It should be brought to the attention of policymakers that ECD is not a fringe issue and that it is a matter of economic stability to the entire world. It is also in the interest of business leaders to support the development of young children to ensure a productive work force in the future and a thriving economy. Currently, there is insufficient recognition of the scale of the issues and the effectiveness of known interventions. And while there are pockets of research excellence, there is a gap in the translation of this work into effective policies on the ground. The nutrition agenda has recently received a great deal of global attention through the 1000 days campaign and the Scaling up Nutrition Movement led by the United States and others. Other key ECD interventions and the integration and complementarities between the multi-sectoral interventions have received less attention however. The packaging of a minimum set of services that all countries should aspire to provide to its children aged zero to six would be an important step towards progress. The time is ripe as discussions around the post-2015 development framework are in full swing, to position ECD as a critical first step in the development of healthy children, capable of learning and becoming productive adults.
Leveraging the Private Sector. The non-state sector already plays a dominant role in providing early childhood care, education and healthcare services in many countries. This represents both a challenge and an opportunity. The challenge is that the public sector typically lacks the capacity to ensure quality in the provision of services and research evidence shows that poor quality child care and education services are not just ineffective; they can be detrimental (Lancet 2011). The challenge is all the greater given that going to scale will require large numbers of providers and we know that regulation works better and is less costly in markets with fewer actors. On the opportunity side of the ledger, there is scope for expanding the engagement of the organized private sector. The private sector can contribute by providing universal access for its own workforce, through for-profit investments, and in the context of corporate social responsibility activities. Public-private partnerships can span the range of activities, including providing educational material for home-based parenting programs; developing and delivering parent education content through media or through the distribution chains of some consumer goods or even financial products; training preprimary teachers; and providing microfinance for home or center-based childcare centers. Innovative financing mechanisms, such as those in the social impact investing arena, may provide necessary financing, important demonstration effects and quality assurance for struggling public systems. Such innovations are expanding in the United States, paving the way for middle and low-income countries to follow.
ECD Metrics. A key ingredient for scaling up is the ability to monitor progress. This is important both for galvanizing political support for the desired interventions and to provide a feedback loop for policymakers and practitioners. There are several metrics that are in use by researchers in specific projects but are not yet internationally accepted measures of early child development that can be used to report on outcomes globally. While we can report on the share of children that are under-weight or stunted, we cannot yet provide the fuller answer to this question which would require a gauge of their cognitive and socio-emotional development. There are some noteworthy recent initiatives which will help fill this gap. The UNICEF-administered Multiple Indicator Cluster Survey (MICS) 4 includes an ECD module and a similar initiative from the Inter-American Development Bank collects ECD outcome data in a handful of Latin American countries. The World Health Organization has launched work that will lead to a proposal on indicators of development for zero to 3 year old children while UNESCO is taking the lead on developing readiness to learn indicators (for children around age 6) as a follow up to the recommendations of the Learning Metrics Task Force (LMTF) which is co-convened by UNESCO and the Center for Universal Education at Brookings.
The LMTF aims to make recommendations for learning goals at the global level and has been a useful mechanism for coordination across agencies and other stakeholders. A related gap in measurement has to do with the quality of ECD services (e.g., quality of daycare). Overcoming this measurement gap is critical for establishing standards and for monitoring compliance and can be used to inform parental decisions about where to send their kids.
ECD programs have a powerful equalizing potential for societies and ensuring equitable investment in such programs is likely to be far more cost-effective than compensating for the difference in outcomes later in life. Expanding access to quality ECD services so that they include children from poor and disadvantaged families is an investment in the future of not only those children but also their communities and societies. Getting there will require concerted action to organize delivery systems that are financially sustainable, monitor the quality of programming and outcomes and reach the needy.
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