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  • 1. Early Childhood Development : A Powerful Equalizer Early Child Development : A Powerful Equalizer Final Report Glob a l Prepared by K no fo wlr E a rly C h i edge D Dr. Lori G. Irwin ld eve lop me nt Dr. Arjumand Siddiqi Dr. Clyde Hertzman
  • 2. Early Child Development : A Powerful Equalizer Final Report for the World Health Organization’s Commission on the Social Determinants of Health Prepared by Dr. Lori G. Irwin Dr. Arjumand Siddiqi Dr. Clyde Hertzman March 2007 Glob a l K HELP is a research institute within the For more information please contact: no fo College for Interdisciplinary Studies at the Lori G. Irwin wlr E a rly C h i edge University of British Columbia. Human Early Learning Partnership (HELP) D ld eve lop me nt 440 - 2206 East Mall Director: Dr. Clyde Hertzman Vancouver, BC V6T 1Z3 Voice: 604.827.5395 Fax: 604.822.0640 Email: lori.irwin@ubc.ca Website: www.earlylearning.ubc.ca/WHO Mapping Portal: ecdportal.help.ubc.ca
  • 3. acknowledgements 1 This summary report is based on a larger To our Commissioners, the Hon. Monique document titled the Total Environment Begin, Stephen Lewis, Dr. William Foege, Dr. Assessment Model of Early Child Alireza Marandi, and Dr. Denny Vågerö, we Development (team-ecd) written by Dr. thank you for championing the recognition Arjumand Siddiqi, Dr. Lori G. Irwin and of the importance of the social determinants Dr. Clyde Hertzman for the Commission of health and for committing to moving this on Social Determinants of Health. This work from knowledge to action. summary represents the efforts and com- We would like to acknowledge the input mitment of many people that contributed to we received from experts such as Dr. Alan the team-ecd document. We would like Kikuchi-White, Dr. Alan Pence, and Dr. Ilgi to gratefully acknowledge: the members Ertem. of the Knowledge Network for Early Child We are also grateful to our colleagues Development, Dr. S. Anandalakshmy, Dr. at the Human Early Learning Partnership Marion Flett, Ms. Mary Gordon, Ms. Abeba (help) for their contributions to earlier Habtom, Ms. Sarah Klaus, Dr. Ilona Koupil, versions of the team-ecd document Dr. Iraj Dr. Cassie Landers, Dr. Beatriz Londoño Poureslami, Ms. Emily Hertzman, Ms. Robin Soto, Dr. Helia Molina Milman, Dr. Bame Anderson and Dr. Stefania Maggi and to those Nsamenang, Dr. Frank Oberklaid, Dr. Alaa colleagues whose unending support made Ibrahim Shukrallah, Dr. Nurper Ulkuer, Dr. this work would possible: Ms. Jacqueline Camer Vellani, Dr. Annah Wamae, and Dr. Smit-Alex, Ms. Leslie Fernandez, and Ms. Mary Eming Young. Sophia Cosmadakis. We would like to extend a special thanks Finally, we want to extend a special thank to Dr. Meena Cabral de Mello, Senior Scientist, you to Ms. Karyn Huenemann for her edito- World Health Organization Department of rial expertise and to Ms. Shannon Harvey for Child and Adolescent Health and Technical her creative design. Officer for Early Child Development, for her input, review of previous drafts, and 1 This work was made possible through funding provided by the commitment to this work. We would also Public Health Agency of Canada and undertaken as work for the Early Child Development Knowledge Network established like to thank the University College London as part of the who Commission on the Social Determinants Secretariat Members, Dr. Ruth Bell, Ms. of Health. The views presented in this report are those of the Tanja Houweling, and the Geneva Secretariat authors and do not necessarily represent the decisions, policy or views of who or Commissioners. Glob a l K Knowledge Network Coordinator, Ms. Sarah no fo Simpson, whose patience and expertise has wlr E a rly C h edge ensured that our work integrates with the broader goals of the Commission. i ld De v e lop me ntNote: An updated version of this reportwill be produced subsequent to an externalreview process.design: www.shhdesign.ca
  • 4. Table of ContentsAbstract 3Political Briefing 5Executive Summary 7Introduction 15 figure 1: team-ecd schematic  17 Methods 18Results: team-ecd 19Spheres of Influence The Individual Child 19 The Family 21 Residential and Relational 26 Community ecd Programmes and Services 28 Regional and National 33 figure 2 : edi vulnerability map  33 Global 37Discussion and Recommendations 41Conclusions 45References 46Appendix A: 53Critical Appraisal of the Underlying EvidenceAppendix B: 55Examples of ecd Programmes and ServicesAppendix C: 61Population-based Measurement of EarlyChild Development from a National PerspectiveAppendix D: 63Children and Families in Global Perspective:Discussion of and excerpts from Heymann’sForgotten Families
  • 5. Early Child Development : A Powerful EqualizerAbstractThis document synthesizes knowledge about ways in which government and civil societyopportunities to improve the state of early actors, from local to international, can workchild development (ecd) on a global scale. In in concert with families to provide equitable Abstractkeeping with international policy standards, access to strong nurturant environments forwe define early childhood as the period from all children globally.prenatal development to eight years of age.What children experience during the early Key Words: early child development; equity;years sets a critical foundation for their entire social determinants of health; lifecourse;lifecourse. This is because ecd—including rights of the childhealth, physical, social/emotional andlanguage/cognitive domains—stronglyinfluences basic learning, school success,economic participation, social citizenry, andhealth. Within the work of the Commission,ecd has strong links to other socialdeterminants of health, particularly UrbanSettings, Gender, Globalization, and HealthSystems. Areas of common concern withthese determinants are discussed throughoutthis document. Research confirms a strongassociation between child survival and childdevelopment, such that the child survivaland health agendas are indivisible from ecd.Our developmental approach to the earlyyears includes the factors that affect childhealth and survival, but goes beyond theseto consider how the early years can be usedto create thriving global citizens. Here, weprovide a framework for understanding theenvironments (and their characteristics)that play a significant role in influencingearly development. The evidence and itsinterpretation is derived primarily from threesources: 1) peer-reviewed scientific literature,2) reports from governments, internationalagencies, and civil society groups, and 3) aKnowledge Network of experts in ecd thatis representative in both international andinter-sectoral terms. The principal strategicinsight of this document is that the nurturantqualities of the environments where childrengrow up, live and learn—parents, caregivers,family and community—will have the mostsignificant impact on their development. Inmost situations, parents and caregivers cannotprovide strong nurturant environmentswithout help from local, regional, national,and international agencies. We propose
  • 6. Early Child Development : A Powerful EqualizerPolitical BriefingEarly Child Development: protection policies that guarantee adequate income for all, and allow parents and caregiv-Investment in a Country’s Future ers to effectively balance their time spent at The early years of life are crucial in influ- home and work. Despite this knowledge, it is Politicalencing a range of health and social outcomes estimated that at least 200 million children in Briefingacross the lifecourse. Research now shows developing countries alone are not reachingthat many challenges in adult society—mental their full potential.health problems, obesity/stunting, heart Political leaders can play an important roledisease, criminality, competence in literacy in guaranteeing universal access to a range ofand numeracy—have their roots in early early child development services: parentingchildhood. Economists now argue on the basis and caregiver support, quality childcare,of the available evidence that investment in primary healthcare, nutrition, education,early childhood is the most powerful invest- and social protection. In the early years, thement a country can make, with returns over health care system has a pivotal role to play, asthe lifecourse many times the amount of the it is the point of first contact and can serve asoriginal investment. Governments can make a gateway to other early childhood services.major and sustained improvements in society To be effective, services at all levels need toby implementing policies that take note of this be better coordinated and to converge at thepowerful body of research while, at the same family and local community in a way that putstime, fulfilling their obligations under the un the child at the centre.Convention on the Rights of the Child. These kinds of family-friendly policies and Research now shows that children’s early practices clearly benefit children and families,environment has a vital impact on the way but they also result in economic benefits totheir brains develop. A baby is born with the larger society. Globally, those societiesbillions of brain cells that represent lifelong that invest in children and families in the earlypotential, but, to develop, these brain cells years—rich or poor—have the most literateneed to connect with each other. The more and numerate populations. These are thestimulating the early environment, the more societies that have the best health status andpositive connections are formed in the brain lowest levels of health inequality in the world.and the better the child thrives in all aspects Success in promoting early child develop-of his or her life, in terms of physical develop- ment does not depend upon a society beingment, emotional and social development, and wealthy. Because early child developmentthe ability to express themselves and acquire programs rely primarily on the skills ofknowledge. caregivers, the cost of effective programs We know what kinds of environments varies with the wage structure of a society.promote early child health and development. Regardless of their level of wealth, societiesWhile nutrition and physical growth are can make progress on early child developmentbasic, young children also need to spend their by allocating as little as $1.00 in this area fortime in caring, responsive environments that every $10.00 spent on health and education.protect them from inappropriate disapproval Child Survival and Child Health agendasand punishment. They need opportunities to are indivisible from Early Child Development.explore their world, to play, and to learn how That is, taking a developmental perspectiveto speak and listen to others. Parents and other on the early years provides an overarchingcaregivers want to provide these opportunities framework of understanding that subsumesfor their children, but they need support from issues of survival and health. A healthy start incommunity and government at all levels. For life gives each child an equal chance to thriveexample, children benefit when national and grow into an adult who makes a positivegovernments adopt “family-friendly” social contribution to the community—economically and socially.
  • 7. Early Child Development : A Powerful EqualizerExecutive SummaryThe early child period is considered to be cies, and civil society. These environmentsthe most important developmental phase and their characteristics are the determinantsthroughout the lifespan. Healthy early child of ecd; in turn, ecd is a determinant of Executivedevelopment (ecd)—which includes the health, well-being, and learning skills across Summaryphysical, social/emotional, and language/ the balance of the lifecourse.cognitive domains of development, each The seeds of adult gender inequity areequally important—strongly influences sewn in early childhood. In the early years,well-being, obesity/stunting, mental gender equity issues—in particular, genderhealth, heart disease, competence in literacy socialization, feeding practices, and access toand numeracy, criminality, and economic schooling—are determinants of ecd. Earlyparticipation throughout life. What happens gender inequity, when reinforced by powerto the child in the early years is critical for relations, biased norms and day-to-daythe child’s developmental trajectory and experiences in the family, school, com-lifecourse. munity, and broader society, go on to have a The principal strategic insight of this profound impact on adult gender inequity.document is that the nurturant qualities of Gender equity from early childhood onwardsthe environments where children grow up, influences human agency and empowermentlive and learn matter the most for their devel- in adulthood.opment, yet parents cannot provide strong Economists now argue on the basis of thenurturant environments without help from available evidence that investment in earlylocal, regional, national, and international childhood is the most powerful investmentagencies. Therefore, this report’s principal a country can make, with returns over thecontribution is to propose ways in which gov- lifecourse many times the size of the originalernment and civil society actors, from local investment.to international, can work in concert with The scope of the present report is fourfold:families to provide equitable access to strong 1. To demonstrate which environments matternurturant environments for all children glob- most for children. This includes environmentsally. Recognizing the strong impact of ecd on from the most intimate (family) to the mostadult life, it is imperative that governments remote (global).recognize that disparities in the nuturant 2 . To review which environmental configurationsenvironments required for healthy child are optimal for ecd, including aspects ofdevelopment will impact differentially on the environments that are economic, social, and physical in nature.outcome of different nations and societies.In some societies, inequities in ecd translate 3. To determine the “contingency relationships” that connect the broader socioeconomicinto vastly different life chances for children; context of society to the quality of nurturingin others, however, disparities in ecd reach a in intimate environments such as families andcritical point, where they become a threat to communities.peace and sustainable development. 4 . To highlight opportunities to foster nurturant The early years are marked by the most conditions for children at multiple levels ofrapid development, especially of the central society (from family-level action to nationalnervous system. The environmental condi- and global governmental action) and bytions to which children are exposed in the multiple means (i.e. through programmaticearliest years literally “sculpt” the developing implementation, to “child-centered” social andbrain. The environments that are respon- economic policy development).sible for fostering nurturant conditions for In keeping with international policy stan-children range from the intimate realm of the dards, early childhood is defined as the periodfamily to the broader socioeconomic context from prenatal development to eight yearsshaped by governments, international agen- of age. The evidentiary base, as well as
  • 8. Early Child Development : A Powerful Equalizer interpretation of the body of evidence, is disadvantaged children are developmentally by parents and caregivers and the physical derived from three primary sources: stronger than disadvantaged children in other conditions of the child’s surroundings), but 1) peer-reviewed scientific literature, nations, whereas, in all nations, children at also more distal factors that in various ways 2) reports from governments, international the higher ends of the socioeconomic spec- influence the child’s access to nurturant agencies, and civil society groups, and trum tend to demonstrate relatively strong conditions (e.g., whether government policies 3) international experts in the field of ecd outcomes. provide families and communities with (including the Commission on Social In this report we provide a framework sufficient income and employment, health Executive Determinants of Health, Knowledge Network for understanding the environments (and care resources, early childhood education, Summary for ecd) that is representative in both interna- their characteristics) that play a significant safe neighborhoods, decent housing, etc.). tional and inter-sectoral terms. role in providing nurturant conditions to While genetic predispositions and bio- This evidence-based multiple-sourced all children in an equitable manner. The physical characteristics partially explain how approach ensures that the conclusions and framework acts as a guide to understanding environment and experience shape ecd, the recommendations of this report are borne the relationships between these environ- best evidence leads us to consider the child as out of the perspectives of a diverse array ments, putting the child at the center of her a social actor who shapes and is in turn shaped of stakeholders and broadly applicable to or his surroundings. The environments are by his or her environment. This is known as societies throughout the world. not strictly hierarchical, but rather are truly the “transactional model,” which emphasizes One guiding principle is an “equity-based interconnected. At the most intimate level is that the principal driving force of child approach” to providing nurturant environ- the family environment. At a broader level are development is relationships. Because strong ments for children everywhere. Multiple residential communities (such as neighbour- nurturant relationships can make for healthy perspectives—from the provisions of human hoods), relational communities (such as those ecd, socioeconomic circumstances, despite and child rights declarations to the realities based on religious or other social bonds), their importance, are not fate. reflected by research evidence—make clear and the ecd service environment. Each of The family environment is the primary the importance of equity. Programs and these environments (where the child actually source of experience for a child, both because policies must create marked improvements in grows up, lives, and learns) is situated in a family members (or other primary caregivers) the circumstances of societies’ most disad- broad socioeconomic context that is shaped provide the largest share of human contact vantaged children, not just in absolute terms, by factors at the regional, national, and global with children and because families mediate aEconomists now argue on the but in comparison to the most advantaged level. child’s contact with the broader environment. children as well.basis of the available evidence What is now known is that, in every The framework affirms the importance of Perhaps the most salient features of the family a lifecourse perspective in decision-making environment are its social and economicthat investment in early society, inequities in socioeconomic regarding ecd. Actions taken at any of these resources. Family social resources include resources result in inequities in ecd. Thechildhood is the most powerful relationship is much more insidious than environmental levels will affect children parenting skills and education, cultural prac- not only in present day, but also throughout tices and approaches, intra-familial relations,investment a country can make, solely differentiating the rich from the their lives. The framework also suggests that and the health status of family members. poor; rather, any additional gain in socialwith returns over the lifecourse and economic resources to a given family historical time is critically influential for Economic resources include wealth, occu- children; large institutional and structural pational status, and dwelling conditions.many times the size of the results in commensurate gains in the devel- aspects of societies (e.g. government policy- The gradient effect of family resources on opmental outcomes of the children in thatoriginal investment. family. This step-wise relationship between clusters, programs, and the like) matter for ecd is the most powerful explanation for ecd, and these are “built” or “dismantled” differences in children’s well-being across socioeconomic conditions and ecd is called a over long periods of time. societies. Young children need to spend their “gradient effect.” However, some societies are Socioeconomic inequities in developmen- time in warm responsive environments that more successful than others at “dulling” the tal outcomes result from inequities in the protect them from inappropriate disapproval gradient effect, thus fostering greater equity. degree to which the experiences and environ- and punishment. They need opportunities to Societies accomplish this by providing a range mental conditions for children are nurturant. explore their world, to play, and to learn how of important resources to children as a right of Thus, all recommendations for action stem to speak and listen to others. Families want to citizenship, rather than allowing them to be from one overarching goal: to improve the provide these opportunities for their chil- a luxury for those families and communities nurturant qualities of the experiences children dren, but they need support from community with sufficient purchasing power. have in the environments where they grow up, and government at all levels. Importantly, an equity-based approach live, and learn. A broad array of experiences Children and their families are also is also the successful path to creating high and environmental conditions matter. These shaped by the residential community (where average ecd outcomes for a nation. Societies include those that are intimately connected the child and family live) and the relational that demonstrate higher overall average to the child, and therefore readily identifiable communities (family social ties to those with outcomes for children are those in which (e.g. the quality of time and care provided a common identity) in which they are embed-
  • 9. Early Child Development : A Powerful Equalizer ded. Residential and relational communities services that are readily transferable between offer families multiple forms of support, places; however, many programme features from tangible goods and services that assist require tailoring to the social, economic, and with child rearing, to emotional connections cultural contexts in which they are found. with others that are instrumental in the ecd services may be targeted to specific well-being of children and their caregivers. At characteristics of children or families (e.g., the residential/locality level, both govern- low birth-weight babies or low-income Executive ments and grass-roots organizations also families), may occur only in some communi- Summary play a highly influential role. Many resources ties and locales and not others, or may be more available to children and families are provided comprehensively provided. Each of these is on a community level through local recogni- also accompanied by their respective benefits tion of deficits in resources, problem-solving, and drawbacks; however, the overarching and ingenuity. There are, however, inequities goal of the global community should be to find in ecd that are apparent between residential means of providing universal access to effective communities, which must be addressed in a ecd programmes and services. Health care systematic way. systems (hcss) are key to providing many “Relational community” refers to the important ecd services. The hcs is in a people, adults and children, who help form unique position to contribute to ecd, since a child’s social identity: tribal, ethnic, hcss provide facilities and services that are religious, and language/cultural. Often, this more widely accessible in many societies than is not a geographically clustered community. any other form of human service, are already Relational communities provide a source concerned with the health of individuals and of social networks and collective efficacy, communities, employ trained professionals, including instrumental, informational, and are a primary point of contact for child- and emotional forms of support. However, bearing mothers. discrimination, social exclusion, and other The influence of the regional and national forms of subjugation are often directed at environments is fundamental in determining groups defined by relational communities. the quality and accessibility of services and The consequences of these forms of discrimi- resources to families and communities. They nation (e.g., fewer economic resources) can are also salient for understanding the levels result in discernable inequities. Moreover, of social organization at which inequalities in relational communities can be sources of opportunity and outcome may be manifest, gender socialization, both equitable and and the levels of organization at which action non-equitable. Relational communities are can be taken to ameliorate inequities. also embedded in the larger socio-political There are many interrelated aspects of contexts of society; as such, reciprocal regional environments that may be significant engagement with other relational groups, for ecd: physical (e.g., the degree of urbaniza- civil society organizations, and governmental tion, the health status of the population), bodies is a means of addressing the interests social, political, and economic. These aspects and resource needs of their members. of the regional environment affect ecd The availability of ecd programmes and through their influence on the family and services to support children’s development neighbourhood, and on ecd services. In during the early years is a crucial component contrast to more intimate environments, such of an overall strategy for success in childhood. as the family, the significance of large envi- ecd services may address one or more of the ronments, such as the region, is that regions key developmental domains (i.e. language/ have an effect on large numbers of children. cognitive, social/emotional, and physical Thus, changing the environment at this level development). The quality and appropriate- can influence the lives of many children. ness of services is a central consideration Much more research and accumulation of in determining whether existing ecd knowledge is required regarding how regional programmes improve outcomes for children. characteristics can be modified to positively There are principles of ecd programmes and influence ecd.0
  • 10. Early Child Development : A Powerful Equalizer The most salient feature of the national Rights in Early Childhood provisions of the environment is its capacity to affect Convention on the Rights of the Child, as pre- multiple determinants of ecd through conditions for international developmental wealth creation, public spending, child- and assistance, are two mechanisms that can be family-friendly policies, social protection, used. Analogous mechanisms have been used and protection of basic rights. The chances effectively in other areas of international that children will face extreme poverty, child development in the past. Executive AbstractSummary labour, warfare, hiv/aids, being left in the Civil society groups are conceptualized as care of a sibling, and so on, is determined, first being organized at, and acting on, all levels and foremost, by the countries in which they of social organization, from local residential are born. through global. The ability of civil society At the level of the national environment, to act on behalf of children is a function of comprehensive, inter-sectoral approaches the extent of “social capital” or connected- to policy and decision-making work best for ness of citizens, and the support of political ecd. Although ecd outcomes tend to be institutions in promoting expressions of civil more favourable in wealthy countries than organization. When civil society is enabled, poor ones, this is not always the case. It is clear there are many avenues through which they that a commitment of 1.5–2.0% of gdp to can engage on behalf of children. Civil society an effective mix of policies and programmes groups can initiate government, non-govern- in the public sector can effectively support ment organization, and community action children’s early development. Those nations on social determinants of ecd. They can with less economic and political power are advocate on behalf of children to assure that less free to determine their internal policy governments and international agencies adopt agendas, and are more influenced by the policies that positively benefit children’s interests of the international community, well-being. Finally, civil society groups are including other nations and multilateral instrumental in organizing strategies at the organizations. Notwithstanding this, most of local level to provide families and children the recommendations in this report are within with effective delivery of ecd services, to the capabilities of any national government improve the safety, cohesion, and efficacy of that meets the international criteria for a residential environments, and to increase the “competent authority.” capacity of local and relational communities The global environment can influence ecd to better the lives of children. Although through its effects on the policies of nations research on the direct effect of civil society on as well as through the direct actions of a range ecd is limited, the strong statistical associa- of relevant actors, including multilateral eco- tion between the strength of civil society and nomic organizations, industry, multilateral human development in societies around the development agencies, non-governmental globe leaves little doubt about its importance development agencies, and civil society to ecd. groups. A major feature of the global environ- ment in relation to children’s well-being is the element of power in economic, social, and political terms. Power differentials between types of actors, particularly between nations, have many consequences, including the ability of some nations (mainly resource-rich ones) to influence the policies of other nations (mainly resource-poor ones) to suit their own interests. Although power differentials may have invidious effects on ecd, they can be exploited for the benefit of children, too. Requiring a minimum level of government spending on ecd and compliance with the
  • 11. Early Child Development : A Powerful EqualizerIntroductionThe early child period is considered to be Lancet series on ecd estimates that there arethe most important developmental phase 559 million children under 5 in developingthroughout an individual’s lifespan. Healthy countries—including  million who are 155 Introductionearly child development (ecd)—physical, stunted and 62 million who are not stuntedsocial–emotional, and language–cogni- but are living in poverty—for a total of overtive—is fundamental to success and happiness 200  million children under five years of agenot only for the duration of childhood, butthroughout the lifecourse. ecd strongly influ-ences well-being, obesity/stunting, mental The agenda to improve childhealth, heart disease, literacy and numeracy survival and health is indivisibleskills, criminality, and economic participa-tion throughout life—all issues that have from the agenda to improve earlyprofound implications for economic burden child development.on countries. If the window of opportunitypresented by the early years is missed, it who are at extreme risk of impaired cognitivebecomes increasingly difficult, in terms of and social–emotional development. Mostboth time and resources, to create a successful of these children—89 million—live in tenlifecourse. Governments must recognize countries (India, Nigeria, China, Bangladesh,that effective investments in the early years Ethiopia, Indonesia, Pakistan, Democraticare a cornerstone of human development Republic of Congo, Uganda, and Tanzania)and central to the successfulness of societies. that account for 1 45 million (66%) of theIndeed, our planet provides no examples of 219 million disadvantaged children in thehighly successful societies among those who developing world. Many are likely to do poorlyhave ignored development in the early years. It in school and subsequently as adults will likelyis therefore critical for governments, interna- have low incomes, high fertility, and providetional agencies, and civil society partners to poor health care, nutrition, and stimulation tomove from knowledge to action in ecd. their own children, thus contributing to the intergenerational transmission of disadvantage (Grantham-McGregor et. al., 2007). The loss ofGovernments must recognize human potential that the above statistics repre-that effective investments in sent is associated with more than “a 20% deficit in adult income and will have implications forthe early years are a corner- national development” (Grantham-McGregorstone of human development et. al., 2007, p. 67). The overarching message of this report toand central to the governments, international agencies, and civilsuccessfulness of societies. society partners is this: the agenda to improve child survival and health is indivisible from ecd is important in all countries, the agenda to improve ecd. That is, taking aresource-rich and -poor alike, but special developmental perspective on the early yearsattention needs be paid to the potential provides a comprehensive framework of under-benefits to the resource-poor, where a child standing that subsumes issues of survivalhas a four in ten chance of living in extreme and health. A healthy start in life gives eachpoverty and 10.5 million children die before child an equal chance to thrive and grow intoage 5 from preventable diseases. Such children an adult who makes a positive contribution toare likely to suffer from poor nutrition and the community—economically and socially.poor health. They are also at high risk of never Accordingly, governments should adopt aattending school (unesco 2007). The recent strategy of investing in ecd in order to meet
  • 12. Early Child Development : A Powerful Equalizer the Millennium Development Goals (mdgs) Child Rights agendas are indivisible from ecd. to shape children’s outcomes (Siddiqi, Irwin health, it becomes crucial here to address the for poverty reduction, education, and health. Again, taking a developmental perspective on Hertzman, 2007). The team-ecd model factors influencing ecd itself. By expanding the early years provides a framework of under- builds on a diverse literature, including the notion of environmental spheres of standing that incorporates issues of survival previously described frameworks that have influence, adding a temporal component, and Governments should adopt and health as well as education and rights. addressed ecd from a social environmental placing children’s well-being at its centre, a strategy of investing in early perspective. These sources include Urie team-ecd offers the strongest means of scope of work Bronfenbrenner’s Bioecological Model (1986); understanding (and therefore acting upon)Introduction child development in order to developmental psychology perspectives on social determinants of ecd. Introduction meet the Millennium Develop- This work includes evidence related to infants ecd (Brooks-Gunn, Duncan Maritato, and children, from prenatal development 1997); notions of “biological embedding” spheres of influence on early child  ment Goals for poverty reduc- through to eight years of age, specifically (Hertzman 1999); frameworks of under- development tion, education, and health. considering how social determinants influence standing regarding social epidemiology and health across the lifecourse. It is of relevance social determinants of health (Dahlgren In this schematic (see figure 1), a variety Economists now argue on the basis of the to children on a global scale. We discuss the Whitehead, 1991; Emmons, 2003); research of interacting and interdependent spheres of available evidence that investment in early limitations to the application of these ideas regarding social relations in human society influence are instrumental for development childhood is the most powerful investment where appropriate. (Putnam, 2000; Weber, 1946); a vast in early childhood. They include the indi- a country can make, with returns over the literature in the political economy domain vidual, family, and dwelling; residential and life course many times the amount of the purpose (for a review of this literature, see Siddiqi, relational communities; ecd programmes original investment. Globally, societies—rich Irwin Hertzman, 2007); and the World and services; and regional, national and global or poor—that invest in children and families The purpose of this document is to Health Organization (who) Framework environments. In each sphere of influence, in the early years have the most literate and synthesize knowledge to inform the csdh on Social Determinants of Health (Solari social, economic, cultural and gender factors numerate populations. These are also the about opportunities to improve action on a Irwin, 2005). Because the who Equity Team affect its nurturant qualities. societies that have the best health status and global scale in the area of ecd. The evidence framework considers ecd as a determinant of lowest levels of health inequality in the world. assembled here focuses on priority associations Societies with the most successful policies and between social determinants of health and figure 1: team-ecd  programmes for ecd spend approximately health inequities across different country schematic 1.5%–2.0% of gdp per year on it (oecd, 2006). contexts. It comments on the extent to One study has estimated that every dollar which the social determinants of ecd can be spent to help a child reach school age while acted upon; is intended to stimulate societal thriving can generate up to $17 in benefits to debate on the opportunities for acting on society over the following four decades (even social determinants of health and to inform after controlling for inflation) (Schweinhart, the application and evaluation of policy Barnes Weikart, 1993; Schweinhart, 2004). proposals and programmes in the area of While the academic and grey literature ecd—nationally, across regions and globally. provides compelling evidence about the The areas of focus for each of the Commission’s importance of the early years, in practice, ecd Knowledge Networks—Globalization, Social is not at the centre of international, national Exclusion, Health Systems, Gender, Urban or local policies, programming and practice. Settings, Employment Conditions, Priority Despite the strength of the evidence, adequate Public Health Conditions and Evidence investments in ecd have been slow, particu- Measurement—are critical to understanding larly, in resource-poor countries where the the social determination of ecd, and as such greatest number of vulnerable children would are integral to this review. benefit the most. Within the work of the Commission on conceptual framework Social Determinants of Health (csdh), ecd has strong links to other social determinants The Total Environment Assessment Model of health, particularly Urban Settings, Gender, of Early Child Development (team-ecd) Globalization and Health Systems. Areas of has been developed for the csdh as a means common concern with these determinants of framing the types of environments (and are made clear, though implicit, throughout therefore experiences) that are integral this document. Moreover, we argue that Child to healthy ecd, and linking these to the Survival, Child Health, Education for All, and biological processes with which they interact 6
  • 13. Early Child Development : A Powerful Equalizer Methods Results: team-ecd  Spheres of Influence The process of synthesizing the available personal experiences drawn from a wide evidence raised the question of what counts variety of sources. While we have used the as evidence. We paid attention to the quality highest quality research evidence available,Methods influencing health and development over the Spheres of of the source, the context of the research, we are also aware that not all high-quality The Individual Child long-term is known as biological embedding Influence: the nuances of particular programmes and research is of practical significance or equally The Individual The earliest years of life are characterized by (Hertzman, 1999). populations served, and the ecological factors applicable in all global contexts. This multi- Child associated with the studies. Accordingly, source, multi-method approach helped to the most important development that occurs nutrition our evidentiary base is derived from three ensure that the conclusions and recommenda- in a human lifespan. There are several bases primary sources: tions of this report are consistent with the for the bold and unequivocal nature of this Children’s optimal growth and development 1) peer-reviewed scientific literature, perspectives of a diverse array of stakeholders, statement. The early years are marked by the requires adequate nutrition, and receiving and are broadly applicable to societies most rapid development, particularly of the adequate nutrition is a fundamental right 2) reports from governments, international agencies, and civil society groups and throughout the world. central nervous system. The “critical periods” of children (see General Comment #7 on We acknowledge both the limitations for the development of the brain almost the Convention on the Rights of the Child 3) international experts in ecd (including the csdh Knowledge Network for ecd that is posed by many of these studies being focused exclusively occur during this time. During [crc] [United Nations Office of the High representative in both international and inter- in resource-rich nations, and the many these early years, the experiences (e.g., good Commission for Human Rights (crc), sectoral terms). challenges that limit the extent to which quality nutrition) and the environmental 1990]) and begins in utero with adequately This Final Report is a summary of a broader experiences, programmes and research find- exposures (e.g., attachment to a caregiver) nourished mothers. During the first months comprehensive evidence document entitled, ings from one global context 2 can be applied that a child receives will be instrumental in of life, breastfeeding plays an important role like the model, team-ecd (Siddqi, Irwin to others. the successful development of early brain in providing children with the necessary Hertzman, 2007), so when in-depth informa- function. Not only will the child be shaped nutrients. In fact, exclusive breastfeeding tion is at issue, we to refer back to team-ecd. 2 Efforts aimed at universalization of knowledge and practices by these experiences physiologically, but is thought to reduce the chances of early Although there is a wealth of literature related have been based on dominant Anglo-American values, goals and the child will also shape these experiences. post-natal stunting (Smith et al., 2003). to ecd, only a limited number of studies norms (Nsamenang, 2005). Our best example of this is breast- The development that occurs in the early Breastfeeding carries with it the dual role feeding. For many years in the past, European and American focus upon ecd in resource-poor countries. organizations and corporate entities advocated for formula years provides the essential building blocks of adequate nutrition and healthy infant In addition, although we believe that qualita- feeding (Gussow, 1980). They have now introduced a global for a lifetime of success in many domains of development through stimulation and attach- tive research findings contribute a unique call for mothers to commit to “exclusive” breastfeeding for six life, including economic, social and physical ment as part of the breastfeeding process. months (who, 2003). In this case, the value of breastfeeding and important source of information to a in nations of Africa and Asia was already known through years well-being. Despite what the evidence—both scientific review such as this, the availability of studies of tradition and experience, but was trumped by “wisdoms” and traditional—tells us about adequate employing qualitative methods was limited. biological embedding nutrition for infants and children, there are There is also a heavy weighting of evidence in approximately 150 million children under the the literature for “at risk” or special popula- The interaction that occurs between individ- age of five years in the developing world alone tions, but these studies are also concentrated ual characteristics (genetic and physiologic) who suffer from malnourishment. Children in resource-rich nations. and experiences and exposures drawn from who are malnourished are more likely to We took a broad view of what literature the environment are basic to the development was relevant to ecd (see Appendix A), of the child. The human brain, in particular, 150 million children under the age investigating databases from multiple is the “master organ” of development. Early disciplines, including medicine, developmen- in life, genetically programmed sensitive of five years in the developing world tal psychology, sociology, nursing, population periods occur in the brain, during which time alone suffer from malnourishment. health, economics and anthropology. For the developing child is disproportionately each, evidence that pertained to any aspect of sensitive to the influences of the external suffer the consequences of poor physical and children’s well-being was included. In addi- environment (Barker, 1992; Bronfenbrenner, mental development; have poorer school tion, papers addressing the interconnectivity 1986; Wadsworth, 1997). The interplay of performance (Pelto, Dickin Engle, 1999; of family, residential, relational and broader the developing brain with the environment is Powell et al., 1998; Winicki Jemison, societal contexts were reviewed, even when the driving force of development; its legacy 2003); be susceptible to the effects of infec- these papers did not make direct reference is a unique configuration of synapses in the tion; have more severe diarrhoeal episodes; to effects on children. Whenever possible we brain that influences cognitive, social and have a higher risk of pneumonia; have lower used “causal evidence” in the scientific sense emotional functions thereafter. The process functioning immune systems; and often and complemented it with practical and of early experience becoming solidified and have low levels of iodine, iron, protein and
  • 14. Early Child Development : A Powerful Equalizer evolves over time; it requires, at a minimum, a thus energy, which can contribute to chronic and support for malnourished children and The Family illness (unicef, 2006). As women remain their families—especially the most vulnerable safe environment and developmentally appro- the primary caregivers for children, when children. priate resources. Stimulation (e.g., mothers The family is the primary influence on they have greater influence in household and children playing with homemade toys) a child’s development (unicef, 2007) decisions, women can significantly improve relationships has an independent effect on perceptual (“Family” is defined here as any group of their children’s nutritional status (Smith et al, motor development outcomes among stunted people who dwell together, eat together, 2003). Educating women has also been shown Although adequate nutrition is essential for children, over and above nutritional supple- and participate in other daily home-based Spheres of mentation (Grantham-McGregor et al., 1997). Spheres of Influence: not only to improve their children’s nutri- development, the quality of relationships activities together). The new crc General Influence:The Individual tional status, but it also results in multiple is equally important for children’s develop- McArdle suggests that “play is marginal to the Comment #7 on Early Childhood restates the The Family Child benefits for children by improving children’s ment. Existing literature leads us to consider plans of governments and local authorities” crc’s position on family as, survival rates and school attendance (Smith et children as social actors (Boyden Levison, (2003, p. 512) and not viewed as a “serious” the “fundamental group” and the “natural al, 2003). 2000; Irwin, 2006; Irwin et al., 2007; Irwin activity. Potentially, one of the most efficient environment” for growth and well-being but Johnson, 2005; Mayall, 1996), who are strategies for improving ecd is to find ways to recognises that the concept of family extends Nutritional deficiencies at all not only shaped by their environment but, convince parents and caregivers of the impor- well beyond the “nuclear” model. Parents and in turn, shape it as well. A child’s individual tance of play and the ways they can promote it. caregivers are identified as principal actors in stages of growth have long- development is transactional, reciprocal the construction of identity and the develop- term damaging effects on the and mutually constituted. Young children ment of skills, knowledge and behaviours, develop best in warm, responsive environ- and as duty-bearers in the realisation of the intellectual and psychological ments that protect them from inappropriate key messages: the individual child young child’s rights. (gc7 para.15). (White, development of children. disapproval and punishment, environments 2006, p. 2) in which there are opportunities to explore 1. Health, nutrition, and well-being of Family members provide most environmental Malnutrition is also implicated in more their world, to play, and to learn how to speak the mother is significant for the child’s stimuli for children, and families largely than half of all child deaths worldwide. and listen to others (Ramey Ramey, 1998). development. control a child’s contact with the distal Although this is a worrisome figure, it is Notwithstanding the complexity of ecd, 2 Three broad domains of develop- environment (Richter, 2004). The most also essential to recognize that nutritional the many factors that influence ecd come ment—physical, social–emotional and salient features of the family environment deficiencies at all stages of growth have down to these simple attributes of the child’s language–cognitive— are interconnected are its social and economic resources. Social long-term damaging effects on the intel- and equally important. day-to-day experience. Improving the quality resources include parenting skills and lectual and psychological development of children’s day-to-day experience through 3. Children shape their environments as well education, cultural practices and approaches, of children: unacceptable loss of human as being shaped by them. relationships needs to be a primary goal of all intra-familial relations, and the health status potential (Grantham-McGregor et al., 2007). initiatives regarding of parenting, childcare, 4 . Social determinants shape brain and of family members. Economic resources Malnutrition is therefore one of the most biological development through their and monitoring rights in early childhood under include wealth, occupational status and influence on the qualities of stimulation, important factors in poor development and the crc. dwelling conditions. Social and economic support, and nurturance available to the loss of development potential for children. We resources for children are highly intertwined, child. know that stunting as a result of chronic mal- the science of play yet imply different strategies for intervention 5. Play is critical for a child’s overall nutrition is shaped by a complex combination development. of environmental, social and economic factors, The central role of play in children’s develop- relationships  which begin in utero and affect both physical ment is not always appreciated. Play processes growth and mental development. Here is a influence synaptic formation and are linked A strong body of research demonstrates the prime example of where child survival, food to secure attachment with caregivers and significance of primary caregivers (and by security, ecd, education and gender equity relationships with other children. Play extension, families) on children’s long-term agendas converge. It is essential to reduce provides an important socializing function, development (Shonkoff Phillips, 2000). malnutrition globally, especially in 0 to 3 year beyond the merits of being physically active, Those factors that facilitate healthy social olds, but this requires systematic action at in which children learn about and negotiate bonds and the character of caregiving the local level in the areas of maternal health identity and the social subtleties of relation- practices that matter most for children are (including adequate nutrition) and health care; ships (James, 1993). Play may vary according now well understood. A key requisite for food security, with adequate micronutrient to individual children’s temperaments, healthy ecd is secure attachment to a trusted intake; safe water; access to education for all; gender, culture or their families’ parenting caregiver with consistent caring, support and protection from illness such as provided and caregiving practices, but the impact of and affection early in life (Bowlby, 1969). by immunization programmes. While play on developmental processes is universal Securely attached infants and toddlers use attention to these factors is important, it is across cultures (Bornstein et al., 1999). Play their emotional and physical security as a base equally important to ensure the presence of can be structured or unstructured; it can be from which to explore their environment. a systematic, community-based follow-up done alone, with a caregiver or in a group; it Successful attempts at exploration increase 0
  • 15. Early Child Development : A Powerful Equalizer the child’s self-confidence and encourage that are adverse for development (e.g., for their parents and siblings. Many children more exploration. Thus, the child begins to crowded or slum living conditions, unsafe have experienced orphanhood or become the learn about and master his or her environment neighborhoods) (Dipietro, 2000). ses can heads of their households due to the death of and to gain in both competence and self- also influence children through its effects on their parents. In particular, this may influence confidence. All families need some support to parental stress. Lower-income parents have girls’ development to a greater extent, since learn how to develop and apply sensitivity and been found to be at increased risk for a variety they are more likely to bear the responsibility responsiveness in their childcare practices. of forms of psychological distress, includ- of household matters, and may therefore Spheres of There are, however, both biological and ing negative feelings about self-worth and forego schooling (Richter, 2006). Here, we Influence: environmental factors that can negatively depressive symptomatology. It is thought that call for recognition that programmes sup- The Family impact on attachment. These include low birth this arises through a combination of greater porting the health of the caregivers of young weight, malnutrition and infections, poverty exposure to negative life events and having children are also investments in ecd, and and its associations, conflict and domestic fewer resources with which to cope with should be evaluated as such. violence, and mental health problems such adverse life experiences (Shonkoff Phillips, as maternal depression. In these instances, 2000). fathers external support for families is particularly There is a demonstrated link between important. socioeconomic circumstances and language The role of fathers as part of the family-level and cognitive outcomes in young children, sphere should not be underestimated, and is socioeconomic status based largely on the richness of the language often regrettably marginalized. The United environment available to the child (Hart Nations Commission on the Status of Women So consistent is the association between Risley, 1995). Family ses is also associated “[encourages] men to participate fully in all socioeconomic status (ses) and a variety of with ability to provide other resources, such actions towards gender equality and [urges] development and health outcomes throughout as health care and high-quality childcare, that the establishment of the principle of shared the lifecourse, that it has been termed a exert a profound influence on developmental power and responsibility between women “gradient effect.” The gradient effect of health (Hertzman Wiens, 1996). and men at home, in the community, in the family resources on ecd is the most powerful workplace, and in the wider national andThe gradient effect of family explanation for differences in children’s family health international communities” (United Nations well-being within societies, and these Office of the High Commission for Humanresources on ecd is the most resources profoundly affect all other aspects Family health conditions have a particularly Rights (uncsw), 2004, p.1). Certainly, thispowerful explanation for of the family environment (Siddiqi et al., in strong impact on ecd. Any chronic problem, includes the role of fathers in nurturing their press). A recent study by Houweling, Casper, either physical or mental (especially of children (unicef, 1997). In fact, engaging anddifferences in children’s well- et al. (2005) found a striking association the mother or primary caregiver), such as working effectively with fathers and otherbeing within societies, and these between socioeconomic status of families and intimate-partner violence (Anda et al., 2006; men who affect the well-being of children and under-5 mortality in a population of children Fettelli et al., 1998), maternal depression families is now firmly emphasized in policyresources profoundly affect all from 43 resource-poor countries. This same (Shonkoff Phillips, 2000), and chronic , frameworks as a strategic requirement for allother aspects of the family study suggested that, among these nations, illness, can have a deleterious effect on child children’s services (Fathers Direct, 2006). socioeconomic inequality in child mortality development. In situations involving mater-environment. was increasing (the gap was widening) as the nal depression, extreme poverty, or high gender overall economies were growing. Family ses levels of family stress, important parent-child has an impact on outcomes as diverse as low interactions may be impaired, resulting in Inequities within families may be significant birth-weight, risk of dental carries, poorer fewer opportunities for learning experiences from the standpoint of the social determi- cognitive test scores, difficulties with behav- in the home (Willms, 2003). The severity and nants of health, especially with respect to iour and socialization, and increased odds of chronicity of maternal depression are predic- gender: “Women’s access to power at the disengagement from school (Brooks-Gunn, tive of disturbances in child development household level has the most direct impact Duncan Maritato, 1997). (nichd, 2002). on families and children … [through lack of Social and economic resources influence A major health issue globally is the control over] allocation of resources for food, ecd through several mechanisms. For prevalence of Human Immunodeficiency health care, schooling and other family neces- instance, low levels of education and literacy Virus (hiv) among the adult population. sities” (unicef, 2007, p. 2 2). As a result, affect the knowledge and skill-base of chil- The effect on children has been widespread, female children are more likely to receive dren’s caregivers; feeding and breastfeeding from contracting the infection themselves less food, and to be denied essential health practices also vary according to ses. Children (through transmission from mother to child), services and education. Household chores and born into poor families are more likely to be to the phenomenon of children taking up caregiving keep adult women out of the paid exposed to—and affected by—conditions adult roles within the family, such as caring labour force and girls out of school. Moreover,
  • 16. Early Child Development : A Powerful Equalizer It is clear that women’s roles (decision-making resilience Resilience can be enhanced through the power) within the family, as well as their relationships that families, caregivers, and educational levels, play an important part in Many families that face daily challenges children establish with others in their locality promoting ecd. Women’s education not only because of their socioeconomic disadvantages or relational communities (e.g., religion-based contributes to lower mortality rates but also are nevertheless able to create the essential communities), as well as through ecd, health, long-term education for girls. Gender equity nurturant environments for their children. nutrition, and other services that are provided at the family level contributes to reducing the Resilience refers to the capacity of a child to by governmental and non-governmental Spheres of intergenerational transmission of poverty thrive, despite growing up facing adversity. organizations (ngos), and through larger Influence: through improved development, access to Bartley’s review of research on this issue policies that facilitate educational attainment, The Family education, and proper feeding (unicef, 2007). points to “the importance of social relation- income transfers, health care, and access to ships, of ties to the community, and social safe housing. Institutional features of society family dwelling interactive ‘relationship’ skills as key sources that strengthen the “connectedness” of of protection” (2006, p. 5). The family citizens in positive ways will enhance resil- The family dwelling also contributes to (or provides the most important social relation- ience in children and families (e.g., Positive detracts from) nurture for children. Physical ships for enhancing children’s resilience Deviance [unicef, 2005]). Accordingly, and mental health are linked to housing (Grotberg, 1995). Children all over the governments, international agencies, and conditions such as overcrowding, indoor air world face situations such as witnessing and civil society groups should use the criterion of pollution, and dampness and cold (Dunn experiencing violence in their families and “connecting children with adult mentors” to Hayes, 2000). Conditions in slums and the broader community, bullying, disability, judge programme and policy proposals. shanty-towns can present further risks for divorce, and witnessing or experiencing the children. Studies of homeless families and effects of alcohol and substance abuse in their children find much higher rates of physical families, while others confront catastrophic key messages: the family and mental illness and worse developmental events or day-to-day atrocities such as war, outcomes among this population (Dunn poverty, disease, famine, floods, hiv/aids, 1. The family is a key nurturant environment Hayes, 2000). These conditions exacerbate and forced labour. How a child emerges from for children, and caregiving is a strong the other socioeconomic challenges that many these situations depends upon multiple determinant of children’s outcomes. TheGender equity at the family families face on a daily basis. factors at the individual, family, community, family acts to modulate the impact of thelevel contributes to reducing the and broader societal levels (Bartley, 2006; broader social environment on the child. It is centrally important, as it is the primary family support Grotberg, 1995). Studies of the experiencesintergenerational transmission of children exposed to war and children source of stimulation, attachment, social bonds, and support for the child, andof poverty through improved Families need to be able to access the resources of battered women demonstrate that the children learn in and through relationships. that enable them to make choices and deci- family can provide a buffer against extremedevelopment, access to education, sions in the best interests of their children, circumstances (Berman, 1996). Berman’s 2 . The notion of gradients is most salient at the family level, because the association betweenand proper feeding. including services such as parenting and and other studies point to the importance of socioeconomic status (ses) and children’s caregiver support (Richter, 2004), quality enhancing the family’s capacity to support developmental outcomes is globally childcare (Goelman, 2003; Lamb, 1998; young children in times of stress and atrocity consistent. when mothers do work, female children are nichd, 1996, 2002; Vandell, White, (Pinheiro, 2006). Families require proper 3. Families require access to a range of services, more likely to be kept home from school to 2000), and primary health care and education. such as parenting and caregiver support, care for other siblings, especially when there Globally, one particular area where families Families require proper safety quality childcare, primary health care, and is no option for substitute caregivers such as childcare. Also according to the recent require social protection is in resolving the nets, such as social protection basic education. The family requires social protection in areas related to work- and demands of work and home life. Heymann’s unicef report, (2006) research on children and families in policies, access to appropriate home-life balance. 4 . There are inequities within families that are Nearly 1 of every 5 girls who enrols in primary school in developing countries does not resource-poor countries demonstrates the services, and sufficient income, significant from the standpoint of the social importance of access to quality childcare for complete a primary education. Missing out families the world over (see Appendix D). to enhance their ability to bolster determinants of health, especially with on a primary education deprives a girl of the respect to gender. For instance, gender biases opportunity to develop to her full potential. Her research demonstrates that millions of children’s resilience. in feeding practices will influence the growth children worldwide are being left home alone, Research has shown that educated women and nutrition of girls, and a gender bias in left in informal childcare (often in the care of safety nets, such as social protection policies, attitudes to social roles will lead to boys and are less likely to die in childbirth; … are more likely to send their children to school; … other children), or being brought to work and access to appropriate services, and sufficient girls having differential access to education. [and] that the under five mortality rate falls by exposed to unsafe working conditions. Public income, to enhance their ability to bolster An increase in maternal decision-making about half for mothers with primary school provision of quality, affordable childcare is children’s resilience regardless of the daily power relative to males can positively education. (unicef, 2007, p. 4) part of the solution to this problem. challenges the family faces. influence children’s long-term outcomes. 4
  • 17. Early Child Development : A Powerful Equalizer Residential and Relational the opportunities and the constraints for outcomes in these contexts have not been Traditions regarding child rearing are passed play-based learning and exploration, which explored in a systematic way. The extent to down through generations, not only within Community are critical for motor, social/emotional, and which government policies support legal families but also throughout broader socially The child and family environment is shaped cognitive development (Irwin, 2006; James, legitimacy, basic housing, nutrition, schooling, bonded groups. both by the residential community (where the 1993). Similarly, the availability of high health, and other basic public services is crucial, child and family live) and the relational com- quality services will vary according to the particularly with the rapid rate of urbanization munity (based on social ties among networks socioeconomic circumstances of communi- occurring around the world. There are orga- key messages: residential and   Spheres of Spheres of Influence: of people with a shared identity). ties, including institutions and facilities for nizational models for mitigating the adverse relational community Influence:Residential and learning and recreation, childcare, medical effects of slum and shanty-town conditions Residential and Relational residential communities facilities, access to transportation, food (Dayal, 2001). 1. The physical spaces accessible to children Relational markets, and opportunities for employment create both the opportunities and the The core features of residential communities (Leventhal Brooks-Gunn, 2000). In both constraints for play-based learning that have been identified as being important resource-rich and resource-poor countries, In both resource-rich and and exploration, which are critical for for ecd include the socioeconomic, physi- local access to these essential services for resource-poor countries, local motor, social/emotional and cognitive development. cal, and service environments (Kawachi children should be used as a criterion for Berkman, 2003). The socioeconomic urban development. access to essential services for 2 . Children’s long term developmental environment of residential communities can children should be used as a outcomes are affected by children’s feelings of safety, the level of cohesion experienced be defined according to average or median slums and shanty-towns income level, the percentage of residents with criterion for urban development. by those living in proximity, the ses mix, access to services, the resources a high school diploma, or the percentage of Globally, an increasing number of children available, the integration or segregation employed or unemployed individuals in the are growing up in slums or shanty-towns, but relational communities of their relational community, as well as community (Leventhal Brooks-Gunn, children’s cognitive and socio-behavioural political and institutional participation or 2000). High levels of socioeconomic status The relational community is a primary influ- discrimination. are generally associated with better school ence on how children identify themselves and 3. The relational community is a primary readiness and school achievement in younger an example from a kenyan   others, and how outsiders identify children; influence on how children identify children (including verbal and reading community’s lived experience  therefore, it is a primary source of social inclu- themselves and others and how outsiders skills). Although socioeconomic inequalities sion and exclusion, sense of self and self-worth, identify children. Therefore, it is a primary between residential communities are often In one of the largest shanty-towns self-esteem, and gender socialization. The source of social inclusion and exclusion; sense of self and self-worth; self-esteem associated with inequalities in children’s surrounding Nairobi, Kenya, there was extent to which adults and children in com- and gender socialization. development, there are important caveats. a crisis. Teenage boys from each of two munities are linked to one another, whether 4 . Because gender norms and role expecta- Children from low ses families living in rival ethnic groups were regularly raping there is reciprocated exchange (of information, tions differ more between relational economically mixed neighbourhoods gener- girls from the other group. This activity in-kind services, and other forms of support), communities than any other determinant, ally do better in their development than low not was not only ruining the lives of the and whether there is informal social control gender equity issues need to be tackled ses children living in poor neighbourhoods girls affected, it was creating a climate of and mutual support, are determined at this most urgently at the level of the relational (Kohen et al., 2002). Adopting policies to distrust and fear that made it impossible level. These characteristics, known variously community. create economically mixed residential neigh- to create a sense of collective efficacy as social capital or collective efficacy, have bourhoods does not cost government any for the people living there—young been shown to be nurturant for children and more than allowing neighbourhood economic and old alike. A few years ago, the boys their families, both in the context of urban ghettoization, and can have developmental called a truce and started to patrol the neighbourhoods in resource-rich nations benefits for young children. area to prevent violence, not cause it. (Samspon, Morenoff Earls, 1999) and in the This shift in the norm between these village context in resource-poor nations (Carter physical and service characteristics two relational communities has led to a Maluccio, 2003). Essentially, child outcomes shift in the life chances of the children relate to the social ties between community There is a clear inverse association between living in the residential community. residents that facilitate the collective monitor- the socioeconomic status of a community Now, this is a community where 600 ing of children related to shared community and the extent to which its residents will hiv/aids orphans are being looked norms and practices, as well as positive role be exposed to toxic or otherwise hazardous after collectively, where the teenagers modelling (Bourdieu, 1984; Coleman, 1988, exposures such as wastes, air pollutants, poor have established their own radio station 1990; Jencks Mayer, 1990; Putnam, 2000). water quality, excessive noise, residential and newspaper, and where the primary Relational communities are often a main crowding, poor housing quality, and the like school is one of the top-functioning in the mechanism through which information (Evans Katrowitz, 2002). The physical country. regarding child-rearing practices, and child spaces accessible to children create both health and development are transmitted. 6
  • 18. Early Child Development : A Powerful Equalizer ecd Programmes and Services economic arguments  Engle et al. remind us “to achieve the $23,000 (Hertzman Siddiqi, 2000; Siddiqi Millennium Development Goals of reducing Hertzman, 2001). Thus, the scale of potential Quality ecd programmes and services are Economists now argue on the basis of the poverty and ensuring primary school comple- economic gain for resource-poor societies in those that nurture all aspects of children’s available evidence that investment in early tion for girls and boys, governments and adopting child development as a cornerstone to development—physical, social, emotional, childhood is the most powerful investment civil society should consider expanding high their development strategies can be measured language, and cognitive. Governments a country can make, with returns over the quality, cost-effective ecd programmes” not just in cost-benefit terms at the micro level, need to integrate quality ecd programmes lifecourse many times the size of the original (2007, p. 2 29). Early interventions can alter but in multiples of economic scale (Schady, Spheres of Influence: and services into social protection policies 3 investment. ecd programmes foster and the lifetime trajectories of children who are 2005; Behrman, Cheng Todd, 2004).Programmes to ameliorate the effects of growing up in promote the quality of human capital: that born poor or are deprived of the opportunitiesand Services poverty for millions of children worldwide is, individuals’ competencies and skills for for growth and development available to and to meet the Millennium Development participating in society and the work force those more fortunate. ecd programmes and The scale of potential economic Goals. The evidence is disturbing: 40% of (Knudsen, et al., 2006). The competencies services (e.g., childcare for working parents, gain for resource-poor societies in children in resource-poor nations live in preschool, access to primary school) have extreme poverty; 10.5 million children die high rates of return, and are an effective route adopting child development as a In every country, it is children from preventable diseases before they are to reduce poverty, to foster health, productiv- cornerstone to their development 5 years old; many children never attend from the poorest communities who ity, and well-being. school; 20-25% of children in resource-poor If governments in both resource-rich and strategies can be measured not just in countries suffer from malnutrition and poor are least likely to have access to resource-poor societies were to act while cost-benefit terms at the micro level, health (Grantham-McGregor et al, 2007). ecd programmes —“those most “those children were young, by implementing quality Evidence shows that conditions in resource- ecd programmes and services as part of but in multiples of economic scale.. poor countries that foster poverty, illness, exposed to malnutrition and their broader social protection policies, they lack of access to schooling, and malnutrition preventable diseases”—yet who yet would each have a reasonable expectation that lead to an intergenerational transmission of these investments would pay for themselves poverty affecting the productivity of future would also benefit the most.. many times over (Schweinhart, et al., 1993; adults and putting an increased burden of (unesco, 2007) Schweinhart, 2004). In resource-rich coun- cost on the economic resources of a country. tries where the issue has been studied directly, In resource-rich countries, the conditions and skills fostered through ecd programmes savings come from reduced remedial educa- are not as dramatic and the implications are not limited to cognitive gains, but also tion and criminal justice costs (Schweinhart, for human development are not as dire, include physical, social, and emotional gains, et al., 1993; Schweinhart, 2004). Economic but the differences are really just a matter all of which are determinants of health over gains come from improved access of mothers of degree. Across the resource-rich world, the lifecourse (Carneiro Heckman, 2003). to the labour force (Cleveland Krushinsky, developmental vulnerability rises as one goes Much of the burden of disease worldwide 1998) and increased economic activity in down the socioeconomic spectrum, such (e.g., cardiovascular disease, obesity, hiv/ adulthood among those whose developmental that, in most oecd countries, 25% or more of aids, depression) begins in early childhood trajectories were improved through interven- children reach adulthood without the basic (Marmot Wadsworth, 1997). Accordingly, tion (Schweinhart, 2004 – follow-up to age literacy and numeracy skills required to cope ecd programmes—which incorporate and 27). The economic benefits of ecd interven- in the modern world (Willms, 2003). Thus, link health-promoting measures (e.g., good tion over the long term have not been directly ecd is an issue for all societies, not just the nutrition, immunization) with nurtur- studied in resource-poor countries; however, resource-poor. ance, participation, care, stimulation, and it is widely understood that the transforma- Kamerman and Gabel’s global overview protection—offer the prospect of sustained tion of the “Tiger Economies” of Southeast of social protection policies found that in improvements in physical, social, emotional, Asia from resource-poor, low life expectancy oecd countries, policies that had a positive language, and cognitive development, while to resource-rich, high life expectancy societies influence on outcomes for children included simultaneously reducing the immediate and was accomplished primarily through invest- “increasing children’s access to reasonable future burden of disease, especially for those ment in children, from conception to school quality early childhood care and education” who are most vulnerable and disadvantaged. leaving. During this period, conditions for (2006, p. 11). They also found that in coun- According to the recent unesco Global young children markedly improved, with 3 Governments have an obligation to provide social protection tries where resources were limited (and policy Monitoring Report, in every country, it is infant mortality dropping from approximately affecting children which includes: 1) social assistance/economic support: conditional/unconditional cash transfers, child care data is also sparse) priorities must be set such children from the poorest communities 1 40/1000 in 1946 to less than 5/1000 in grants, social pensions, tax benefits, subsidized food, and fee that the most vulnerable are targeted, while who are least likely to have access to ecd 2000 (Hertzman Siddiqi, 2000; Siddiqi waivers; and 2) social services for children and their families universal coverage should remain the longer programmes—“those most exposed to “those Hertzman, 2001). From 1975 to 2002, the including protective (and preventive) services such as foster care, adoption, residential treatment, family and community term goal. malnutrition and preventable diseases” yet average gdp per capita in the Tiger Economies support services for children with special needs, as well as early who would also benefit the most (2007, p. 19). increased from approximately $4,000 to childhood care (Kamerman Gabel, 200 6).
  • 19. Early Child Development : A Powerful Equalizer Rather than provide a “laundry list” of services, they become a highly effective way tion from inappropriate discipline; and the childcare, and are strengthened by the specific ecd programmes that have evidence of promoting ecd. language environment is rich and responsive co-ordinating support of several spheres of of effectiveness, the following paragraphs The quality and appropriateness of (Ramey Ramey, 1998). Nurturant environ- influence (unesco, 2007; Irwin, 2004). present generic characteristics as well as programmes and services is a central ments should also include equity in treatment ecd services may be targeted to specific strategic and organizational principles of consideration in determining whether such of boys and girls: in opportunity, expecta- characteristics of children or families (e.g., quality, sustainable programmes that are programmes lead to good outcomes for tions, and aspirations (unicef, 2007). In low birth-weight babies or low-income transferable around the globe. children (Anderson et al., 2003; Hertzman addition to these fundamental aspects of families), may occur only in some com- Spheres of Spheres of Influence: ecd programmes and services address one Wiens, 1996; Magnuson, Ruhm quality, ecd programmes and services should munities and locales and not others, or may Influence:Programmes or more of the following key issues: breast- Waldfogel, 2007; nichd, 1996, 2002; Pelto, be based on consensus as to the nature of suc- be more or less comprehensively provided. Programmesand Services feeding, childcare, early childhood education, Dickin Engle, 1999; Wylie et al., 2006). cessful child development and a set of valid, Each of these is also accompanied by their and Services nutrition, and other forms of family support. There are three aspects of quality in ecd pro- reliable indicators of ecd (Kagan Britto, respective benefits and drawbacks; however, These include services directed to children, grammes and services: structure, process, and 2005; Janus Offord, 2000, 2007; unicef, the overarching goal of the governments should such as daycare, preschools, community- nurturance. Structure includes such things 2007) (see also Appendix B). be to find means of providing all children based child development centres, and other as appropriate staff training and expertise, Beyond the aspects of quality pro- with effective ecd programmes and services such programmes and services. There are staff to child ratios, group size, and physical grammes, a set of principles has been (Kamerman Gabel, 2006). also programmes and services that focus on characteristics of the service that ensure demonstrated to sustain ecd programmes children indirectly, through their support safety. Process aspects include staff stability and services worldwide. This includes Linking ecd programmes for parents and caregivers; these include and continuity, and relationships between cultural sensitivity and awareness; com- parenting programmes, home support or services providers, caregivers, and children munity ownership; a common purpose and and services with health care home visiting, and other family support (Goelman 2003; nichd, 1996, 2002). consensus about outcomes related to the systems will improve child programmes. In addition, health care services Nurturant environments include those where needs of the community; partnerships among are a very important point of contact for exploration is encouraged; mentoring in basic community, providers, parents, and caregiv- survival rates. young children and their families. When skills is provided; the child’s developmental ers; enhancing community capacity through ecd programmes and services are added advances are celebrated; development of new active involvement of families and other health care systems to the delivery of established health care skills is guided and extended; there is protec- stakeholders; and an appropriate management plan (which includes users) that facilitates the Health care systems (hcss) are in a unique country level policy development (see Chalaman- monitoring of quality and the assessment of position to contribute to ecd at a population the early childhood development  da); hiv/aids and single mothers’ programme programme effectiveness (Kagan Britto, level, given that hcss are already concerned virtual university  development (see Nyesigomwe and Matola); and 2005). With respect to ecd programmes with the health of individuals and communi-   innovative parent-support training (see Habtom). and services, a number of studies have shown ties, employ trained professionals, provide The Early Childhood Development Virtual Univer- These and other activity descriptions can be found these quality principles to enhance outcomes facilities and services, and are a primary sity (ecdvu) represents an innovative approach to at www.ecdvu.org (ecdvu, 2005), and in Pence for young children (e.g., Anderson et al, 2003; contact for child-bearing mothers. In many the leadership and capacity building requirements Marfo (2004). The ecdvu is one facet of a Consultative Group on Early Childhood instances, health care providers are the only of countries seeking to enhance their social and three-pronged capacity building effort—the other Development Bernard van Leer Foundation health professionals whom families come into economic development through addressing the hu- two being two-week ecd seminars and a major, Effectiveness Initiative Report, 1999; Engle contact with in the early years of the child’s man development needs of their youngest citizens, Africa-wide conference series (Pence, Habtom et al, 2007; Karoly, Kilburn, Cannon, 2005; life; they thus reach the majority of children and the families and communities which nurture Chalamanda, in press). The ecdvu program was them. The ecdvu is a key North-South institution unesco, 2007). Furthermore, the ecd in a community. When the hcs is used as a developed to work with communities, cultural currently working closely with academic institu- groups, and countries in ways that respect local programmes most associated with positive linkage point, health care professionals can be tions in Ghana, Malawi and Tanzania, and with knowledge but also provide interaction with other outcomes for children are those that build on highly effective in promoting ecd. academic, governmental and non-governmental sources of knowledge. The work of the ecdvu existing resources and networks and revolve The critical intersection of the ecd and groups in other parts of Sub-Saharan Africa (ssa) helps to advance major international development around the creation and maintenance of child survival agendas happens in hcss. and the Middle East and North Africa (mena). objectives, including the mdgs, Education for All, collaborative relationships between multiple While this report has included devastating The ecdvu was made possible through support and the crc, as well as regional and local objectives interest groups, such as families, communi- statistics about millions of children dying received from The World Bank, unicef, unesco, (e.g., prsps, swaps, national mdgobjectives). ties and services providers (for a recent review throughout the world—many from prevent- the Bernard van Leer Foundation (bvlf), cida, An external Impact Evaluation (see the World see Lancet Series Paper 3, Engle et al., 2007). able causes—here we suggest that linking a host of local organizations in a dozen ecdvu- Bank Evaluation [ecdvu, 2005]) conducted at the Programmes that build on existing resources ecd programmes and services with hcss will participating countries in ssa, and four countries conclusion of the 2001-2004 pilot delivery noted and networks often do so by encouraging improve child survival rates. The example in mena. International and local partner funds that, “By any measure ecdvu has been singularly have allowed the delivery of combination web- and the participation of parents, traditional of Kangaroo Care from Bogota, Columbia, is successful in meeting and exceeding all of its objec- face-to-face leadership courses designed to advance tives…, there is every reason to believe that future caregivers, and older siblings. These types of instructive here. Kangaroo Care is based on country-identified, inter-sectoral early childhood activities will achieve even greater results for programmes often include parent education, mothers, fathers and caregivers providing initiatives. These have included, for example: expanding and improving ecd” (ecdvu, 2005). parent support groups, home visiting, and skin-to-skin contact for low birth-weight community-based and community-run infants as part of early stimulation, which 0
  • 20. Early Child Development : A Powerful Equalizer has been shown to improve survival rates Development), bfhi (Baby Friendly Hospital Regional and National of the most vulnerable infants. Through Initiative) (unicef, 2007), and nutrition/ key messages:   skin-to-skin contact, infants gain the early growth monitoring and promotion that exist ecd  programmes and services The influence of the regional and national stimulation that matters for their survival; in most countries; they can then link children environments is fundamental in determining costs of this intervention are minimal, but and families to existing community-based 1. Programmes and services should be based the extent of services and resources that are benefits are immeasurable. ecd services. Examples of this process include on well-established quality frameworks available to communities and to families. Many health or community development pro- and include a strategy for monitoring the interrelated aspects of regional environments Spheres of quality of services. This also includes Spheres of Influence: grammes that have added an early stimulation may be significant for ecd, including the Influence: monitoring for equity in treatment of andProgrammes kangaroo care: beginnings in   and care component, and ecd programmes physical (e.g., degree of urbanization, the health Regional and opportunities for both girls and boys.and Services bogota, columbia  that have been coupled with other health status of the population), the social, the politi- National 2 . Governments have a central role to play to   services such as a women’s health programme cal, and the economic environments. These ensure that ecd programmes and services Each year about 20 million infants of low birth or a reproductive health programme. They are aspects of the regional environment affect ecd are fully integrated into social protection weight are born worldwide, which imposes a an important point of contact that can extend through their influence on the family, com- policies. heavy burden on healthcare and social systems ecd programming to children and families munity, and ecd services. in developing countries. (Ruiz-Pelaez, Charpak 3. The overall objective is to provide universal who would otherwise have no access, and can Most of the research performed thus far on Cuervo, 2004) access to inclusive, appropriate quality often do so for relatively small marginal costs. services and programmes that offer strong regional characteristics in relation to human A notable exception to using the hcs as a nurturant environments. To be sustainable, welfare concerns the impact of the socio-politi- Premature babies (under 2000 grams) born in point of contact is in the case of remote rural these services should build on existing cal environment. For instance, a rich literature poorly resourced settings may not have access to incubators and those that do are separated infrastructure (especially health care (primarily derived from the United States) from their mothers. Kangaroo Care was first Local, regional, and national systems) and mobilise national resources demonstrates an association between state-level (human, institutional and financial). income inequality (i.e., distribution of income) developed in 1978 to help premature babies with temperature regulation and bonding governments, with the support of 4 . There are multiple entry points for ecd and a variety of health outcomes. This research in Bogota. Mothers, fathers or caregivers international agencies and civil programmes and services, including health suggests that, above and beyond the wealth carry/sleep with newborn babies skin to skin care systems, community-based childcare, of a region (in this case, the state), the greater in upright positions 2 4 hours a day. Kangaroo society partners, must be the key and preschool education. the inequality in the distribution of income Care has been shown to be at least as effective players in developing, promoting, 5. Health care systems (hcs) are in a unique between households, the worse the health and as traditional care in incubatorsa at a fraction position to contribute to ecd at a popula- related outcomes of the population 4 , including of the costs. It is a practice with roots in local and funding a basket of quality ecd tion level, given that hcs are already adult mortality, infant mortality, low birth traditional child rearing that has been taken up in many industrialized nations (e.g., France, programmes and services. concerned with the health of individuals and communities, employ trained profes- weight, malignant neoplasms, coronary heart Sweden, usa, Canada and more). disease, expenditure on medical care, homicide, sionals, provide facilities and services, and Kangaroo Care has been shown to: areas or urban slums of resource-poor coun- are a primary contact for child-bearing and violent crime (Kaplan et al., 1996; Kennedy, • deliver ideal conditions for premature tries, where hcss cater to populations who are mothers. Kawachi Prothrow-Stith, 1996; Spencer, infants either too poor to access health services, or the 6. hcss ensure that development pro- 2004). The extent of income inequality, in turn, • reduce costs of caring for premature infants services are inaccessible or too weak. In these grammes combine health and nutrition is determined by decisions made partially at • improve breastfeeding rates situations, most community-based interven- services with early learning, rely on fami- the regional level regarding wage rates, income tions for women, children, and families are lies as partners, and have adequate quality, tax, transfers, social expenditures, and other • improves bonding delivered by ngos and voluntary organizations intensity, and duration in order to affect mechanisms of distribution and redistribution • in some settings reduce morbidity and (e.g., sewa, programmes delivered by Save, and children’s development cost effectively. (Zuberi, 2001). hospital stay the bvlf, Aga Khan, and Soros Foundations’ 7. hcss include effective interventions We know that in low- and middle-income community development projects). Further for the physical and mental health of countries, inequalities in child health out- While the case of Kangaroo Care is details can be found about Equal Access: mothers and children within the current comes—for example under-five mortality a unique hands-on early stimulation Using Communications to Reach Parents and maternal and child health strategies (e.g., rates—vary according to geography, such as programme, developed in hospitals and Communities on Early Child Development Making Pregnancy Safer Initiative and between rural and urban areas and between the Integrated Management of Childhood carried out within and beyond the walls in Nepal and Village-Based ecd Curriculum provinces. In regions where this is the case, the Illness), which should be widely imple- of institutions, health care providers can Development in Lao pdr in Appendix B. inequalities are often due to unequal allocation mented in resource-poor countries. facilitate ecd in various other ways as well. Local, regional, and national governments, of resources (Houweling, Kunst, et al., 2005). hcs can serve as a platform for information with the support of international agencies and Regional inequalities in ecd can also be seen in and support to parents around ecd; they civil society partners, must be the key players in resource-rich countries, as is the case for the can integrate ecd into existing programmes developing, promoting, and funding a basket of province of British Columbia, Canada (Kershaw, such as imci (Integrated Management of ecd programmes and services that conform to Irwin, Trafford Hertzman, 2006). The map in Childhood Illness) / Care for Development, the principles articulated here. 4 The relationship between income inequality and health is acsd (Accelerated Child Survival and nonetheless complex and widely debated.
  • 21. Early Child Development : A Powerful Equalizer Figure 2 demonstrates a three-fold difference statement comes in part from direct evidence in rates of vulnerability (1 4 .0-45.9%) for on national-level factors and in part from an figure 2: early development instrument (edi)   children reaching school age (5 years) accord- inescapable logical extension of the profound vulnerability map ing to the Early Development Instrument (see impact of socioeconomic factors at the family Appendix C). The pie charts layered on top of and neighborhood levels on children’s well- the regional areas describe the social and being. In other words, if socioeconomic economic characteristics of the given region. conditions matter, then so too do the societal Spheres of Influence: Figure 2 shows the scale of social and eco- factors that create the conditions themselvesRegional and nomic inequality across regions and the (Siddiqi Hertzman, in press). These condi- National associated inequalities in child outcomes. In tions are largely a function of the institutional many regions, however, ses does not seem to and structural aspects of the nation. The most predict vulnerabilities in ecd. The research to salient feature of the national environment is understand how some low ses communities its capacity to affect multiple environments “buck the trend” and produce good ecd (and thus determinants) of children’s well- outcomes is, itself, in its infancy. We are being through policies and laws. Cross-national confident that when the characteristics of studies have found an association between the these “resilient communities” are better dispersion of income at the national level and a understood, they will provide useful lessons variety of population health indicators, for communities around the globe. Figure 2 including life expectancy and infant mortality also demonstrates what a powerful tool the (Rogers, 1979; Flegg, 1982). In fact, the effect of mapping of ecd by locality and geographic income inequality on infant mortality with- region can be for the purposes of public stands the effects of other powerful predictors discussion and policy-making. of mortality during the first year of life, At the sub-national level, regional and including doctors per capita, nurses per capita, relational communities can intersect in ways urbanization, female literacy, and reproductive that create conditions for families and chil- rates (Waldman, 1992). dren that are systematically different from the rest of the country. For example, in southern Socioeconomic conditions matter, India, a large body of research has found that the norms of this region, in contrast to the as do the societal factors that create norms of northern India, “provide women the conditions themselves. more exposure to the outside world, more voice in family life, and more freedom of To date, the most comprehensive review of movement than do the social systems of the social policies in relation to inequities in child north” (Jejeebhoy Sathar, 2001). In fact, welfare across countries examines the impact recent research findings refute the notion that of policy on child (i.e., family) poverty among differences in women’s autonomy in South the oecd nations (Kamerman et al., 2003). Asia can be ascribed to religious differences Kamerman’s review identified five primary (with the main suggestion that Hindu women policy domains of significance: are more autonomous than Muslim women); 1) income transfers (cash and tax benefits), these findings show that the north-south 2) employment policies, regional differences are much more salient 3) parental leave and other policies to support (Jejeebhoy Sathar, 2001). Women’s maternal employment, autonomy itself is determined largely by 4) early childhood education and care services, and women’s education, which is much more 5) prevention and other interventions related to accessible in southern regions of India, such teen pregnancy and births. as the state of Tamil Nadu (Jejeebhoy, 1995; Data from the Luxembourg Income Study has Jejeebhoy Sathar, 2001), we know that demonstrated that, based on market income women’s autonomy influences the opportuni- (i.e., prior to taxes and transfers), at 31%, ties for optimal ecd (unesco, 2007). poverty rates 5 in the United States are up to The national environment serves as a powerful influence on ecd. The basis for this 5 Poverty was measured using a relative standard of 40% of median income, and 50% of median income. 4
  • 22. Early Child Development : A Powerful Equalizer 5-6% lower than in several oecd nations, The Global Level nations. sap involved increasing privatization including France and Sweden, and on par with key messages:   and decreasing the role of the government in others such as Australia, Canada, Spain, and regional and national It is often difficult to characterize globaliza- many aspects of national economic and social Germany. However, after taxes and transfers, tion, let alone its influence on children. There endeavours, including reducing investments the United States has the highest poverty rate 1. Regional variation in children’s develop- are many types of stakeholders that shape in social welfare programmes, such as among the oecd nations, at 18%, between 6% mental outcomes is a good staring point for the global environment, including nation- education, health care, and other services and 11% higher than all other oecd nations trying to understand “where the differences states, multilateral economic organizations, that benefit ecd, as a means of increasing Spheres of Spheres of Influence: (with the exception of Australia, which has are that make a difference” in a given society industry, multilateral development agencies, “efficiency” and spurring economic growth in Influence:Regional and a post tax and transfer poverty rate of 16%) and, thus, for determining the prospects for non-governmental development agencies, the resource-poor nations. Ghana’s experi- Global National (Smeeding Ross, 1999). Prior to transfers, intervention and improvement. and civil society groups. The global environ- ence with structural adjustment is briefly poverty rates across oecd nations were 2 . Effective governance for ecd programs and ment can influence ecd through its effects described here. It is particularly compelling, consistently high, with a range of 32% in Italy services generally takes place at the regional on the policies of nations. A major feature since it is often viewed by international to 80% in the Netherlands. However, after level. This is the level at which accountabil- of the global environment in relation to agencies as perhaps the most successful case governments applied redistributive measures, ity and interpretations of policy should be children’s well-being is the element of power of structural adjustment in Africa. the rates for lone mothers are reduced to enacted. Also, the region is often the level at in economic, social, and political terms. Ghana’s sap commenced in 1983 and which programs and services that indirectly approximately 10% in many oecd nations, Power differentials between types of actors, involved reducing government expenditures influence ecd are delivered (e.g., housing, with a low of 4% in Germany. By contrast, the and particularly between nations, have by cutting social services, adjusting the employment). poverty rate for lone mothers in the United many consequences, including the ability of exchange rate through devaluation of the 3. National governments should be held States remained at 60% (Beaujot Liu, 2002). some nations (mainly resource-rich ones) national currency, abandonning price responsible for guaranteeing the rights A randomized controlled trial in Mexico to influence the policies of other nations controls, privatizing state-owned enterprises, to which they are obligated through their (Gertler, 2004) integrated access to cash signing of the crc and their commitment (mainly resource-poor ones). This in turn and increasing the export-based portion of transfers with improvements in children’s to the mdgs. In practice, this means may mean that the ability of resource-poor the economy. On a macro-level, the gdp of physical health and has shown much success. putting in place policies to alleviate nations to enact policies that are optimal Ghana has improved, inflation has dropped, progresa is a national programme designed disparities that have an impact on ecd. for ecd is compromised. Efforts to enable and foreign investment has increased, but the to mitigate the effects of extreme poverty 4 . Investing in ecd is a long-term economic nations to gain independence over their own social welfare of Ghana’s citizens has wors- and socioeconomic inequalities in child and social strategy that takes on great futures, and encouragement of multilaterals ened. Of particular interest to this report, well-being. The programme involves giving importance at the national level. Returns to favour policy directions that benefit access to basic services for many children and cash transfers to families, provided that on investment may be realized in as short children are major elements in promoting families was compromised. The devaluation children aged 0-60 months are immunized a term as 3-5 years, in terms of children’s ecd. Notwithstanding this, most of the of the currency has meant an increase in cost and attend well-baby visits where their improved readiness for school. In contrast, recommendations in this report are within of imported goods; poverty has decreased inequity in children’s development nutritional status is monitored. They are given the capabilities of any national government slightly, but socioeconomic inequalities have undermines societal progress. ecd should nutritional supplements, and their parents that meets the international criteria for a increased (Konadu-Agyemang, 2000). be positioned as a non-partisan public are given health education. Pregnant women “competent authority.” saps have influenced children (directly health issue. receive prenatal care, lactating women receive or indirectly) in the areas of survival, 5. “Child and family friendly” societal postpartum care, other family members immunization, prevalence of health atten- receive physical check-ups once per year investment strategies can be enacted Efforts to enable nations to gain dants, nutrition, and balanced urbanization regardless of the relative level of the per (where they also receive health education), and capita gross domestic product (gdp) of a independence over their own (Bradshaw et al., 1993). Although direct adult family members participate in regular evidence of policy effects on health requires meetings where health, hygiene, and nutri- society. futures, and encouragement of further specific study, the experience of 6. Reporting obligations under key tional issues are discussed. An evaluation of international conventions, such as the multilaterals to favour policy Ghana and other nations is instructive. this study found that children born during the The global environment is also character- two-year intervention period experienced 25% crc, International Labour Organization (ilo) Global Reports, and Convention directions that benefit children are ized by important declarations that affirm less illness in the first six months of life than on the Elimination of All Forms of major elements in promoting ecd. the rights of children (crc, 1990) and of the control children, and children aged 0-35 Discrimination against Women (cedaw), women (United Nations Division on the months during the intervention experienced can be used as levers for change at the One well-known set of policies that was Advancement of Women (cedaw), 2007), national level. 39.5% less illness than their counterparts in introduced to many resource-poor nations in which, by extension, influences the well- the control group. Children in the progresa 7. Child survival and ecd are inseparable. the 1980s and early 1990s was the Structural being of children. In particular, the new Nations focusing on child survival should programme were also one fourth as likely to Adjustment Programme (sap) of the World General Comment #7 on Implementing take responsibility for ensuring that their be anemic, and grew one centimeter more, Bank and International Monetary Fund. The Rights in Early Childhood of the crc (2005) social and economic policies pay equal on average. Finally, the results of this study purpose of sap was to increase the economic creates an opportunity to hold “state parties” importance to both survival and develop- suggest that the effects of the programme were ment of children. prosperity of low-income nations for the responsible for the physical, social/emo- cumulative, increasing the longer the children purpose of paying debts to high-income tional, and language/cognitive development stayed in the programme (Gertler, 2004). 6
  • 23. Early Child Development : A Powerful Equalizer of young children, as well as eradicating child to be protected from child labour, the importance of global   child labour. Other sections of the crc also particularly work that is harmful to her or his ecd indicators have varying degrees of relevance to ecd. development. For example, Article 6 explicitly decrees The international community needs to that state parties (which primarily refers to The world’s capacity to amelio- agree on valid ways to measure ecd that are nations) are responsible for ensuring “to the analogous to existing global measurements of maximum extent possible … the development rate child labour has increased, health and human development, such as Infant Spheres of of the child.” cedaw “was adopted in 1979 primarily owing to more avenues Mortality Rates (imrs), Under Five Mortality Influence: by the [United Nations] General Assembly, Rates (u5mrs), stunting, and the Human Global [and] is often described as an international for advocacy and institutional Development Index. This is essential to bill of rights for women” (United Nations support for the protection of child achieving national and international recogni- Division on the Advancement of Women, tion of the scale of the ecd challenges we cedaw 2007). Since the convention is aimed well-being, e.g. Article 32 of crc. face, and to establishing credible international at improving the circumstances of women, goals. We are currently able to measure imr it clearly has implications for the well-being the role of civil society  and u5mrs across whole societies in a valid, and development of children. In addition, the reliable, and credible fashion. As a result, Global Monitoring Report from unesco ties At the global level, the role of non-gov- individual states and the global community Education for All to ecd. ernmental international bodies and civil recognize the scale of the child survival One of the most alarming concerns for society is critical for creating the economic, problem and have set the mdgs to address it. today’s children is the issue of child labour. social, and political conditions that support Similarly, the level of early childhood nutri- Data from 2002 compiled by the ilo suggest ecd and children’s welfare more broadly. tion across populations is estimated through that approximately 2 46 million children Civil society makes a particularly strong rates of stunting. This act of measurement, are engaged in some form of child labour, contribution to ecd and population health. too, has led to national and international which is defined as most productive activity Civil society groups are conceptualized as recognition of the scale of the problem, and of children, but “excludes the activities of being organized at, and acting on, all levels an mdg has been set. The problem is that we children 12 years and older who are working of social organization, from local residential have no comparable indicator for ecd, and only a few hours a week in permitted light through global. The ability of civil society to therefore no measurement, no data; no data,The international community work and those of children 15 years and above act on behalf of children is a function of the no problem; no problem, no action. Creating a whose work is not classified as ‘hazardous’” extent of the social capital, or connectednessneeds to agree on valid ways to (2002). Of these, 171 million child labourers of citizens, and the support of politicalmeasure ecd that are analogous were working in hazardous situations or institutions in promoting expressions of civil The who Commission on theto existing global measurements conditions. The overwhelming number organization. When civil society is enabled, Social Determinants of Health of child labourers (over 127.3 million) is there are many avenues through which it canof health and human develop- concentrated in the Asia-Pacific region, engage on behalf of children. Civil society has a special role to play, sincement, such as imrs, u5mrs, followed by Sub-Saharan Africa (48 million) groups can initiate government, ngo, and its broad population health and Latin America and the Caribbean (17.4 community action on social determinants ofstunting, and the hdi. million). Among child labourers, boys slightly ecd. They can advocate on behalf of children perspective allows it to outnumber girls (132 million versus 113 to ensure that governments and international understand the importance of million), but even more disproportionately agencies adopt policies that positively benefit (95.7 million compared to 74 .8 million) bear children’s well-being. They can be instru- global monitoring of ecd. the burden of work that is characterized as mental in organizing strategies at the local hazardous (ilo, 2002). level to provide families and children with global measurement system to monitor ecd The use of children to perform labour in effective delivery of ecd services; to improve needs to be an essential component of every order to produce commodities to be sold on the safety, cohesion, and efficacy of residential nation’s ecd strategy. Now that signatory the market is certainly nothing new; however, environments; and to increase the capacity countries are required to report progress in the world’s capacity to ameliorate child labour of local and relational communities to better fulfilling General Comment #7 of the crc has increased (although we may not always the lives of children. Although research on the (Implementing Rights in Early Childhood), act on this capacity), primarily owing to direct effect of civil society on ecd is limited, there is an incentive for the international more avenues for advocacy and institutional the strong statistical association between the community to create a global ecd measure- support for the protection of child well-being. strength of civil society and human develop- ment system. The elements of such a system Article 32 of the crc makes it imperative ment in societies around the globe leaves little are described in Appendix C. The who that state parties recognize the right of the doubt about its importance to ecd. Commission on the Social Determinants of
  • 24. Early Child Development : A Powerful Equalizer Health has a special role to play here, since its broad population health perspective allows key messages: global Discussion and it to understand the importance of global monitoring of ecd, and its access to world 1. The current international climate is Recommendations leaders puts it in a position to effectively propitious for advancing ecd. Heightened advance this argument. awareness of the importance of ecd and convergence of initiatives at the interna- A child requires nurturant conditions parenting and caregiver support, qualitySpheres of tional level are creating a new momentum. to thrive. The process of development is childcare, nutrition, social protection, Discussion and Influence: influenced not only by a child’s nutritional primary healthcare, and basic education. Recommendations 2 . Alliances that are independent of state Global parties should be encouraged among those and health status but also by the kind of To be effective, these services need to be who are concerned with the well-being interactions—beginning in utero—infants coordinated at the regional level, and deliv- of young children. These can occur at the and children develop with caregivers in ered at the local level in a way that puts the level of the family (e.g., the grandmother to their environment. We know that early child at the centre. Children benefit most grandmother program) or at the level of the environments influence individual children’s when national governments adopt child-and local community (e.g., networks like those development independent of and in combina- family-friendly policies that guarantee developed by the bvlf, Aga Khan, and Soros tion with their biologic characteristics, and adequate income for all, and allow parents Foundations). there is a growing awareness of specific and caregivers to balance their time spent 3. Because of its global responsibility in periods in children’s brain development at home and work. Governments should take Recommendation 3 population health, the who should that affect health outcomes over a lifetime. up the challenge of creating a work-life/home- strengthen its commitment to ecd as a key social determinant of health. Enriched environments and the quality of life balance, by putting systems in place to stimulation, security, and support during ensure that quality community-based 4 . The international community has a role to play in creating consensus on how to sensitive periods of development are of childcare relevant to local culture and context monitor child development through indica- utmost importance from conception to eight is available for the children of working tors that can be analyzed at the national, years of age. The environments respon- mothers. regional, and community levels, and tracked sible for fostering nurturant conditions for In order to achieve a global consensus on over time. children range from the intimate realm of the the importance of ecd, there is a need to 5. The crc’s new General Comment #7 on family to the broader socioeconomic context foster a broader and more profound under- Implementing Rights in Early Childhood shaped by governments, international standing of what is involved in ecd, and to a creates an opportunity to hold States Parties agencies, and civil society. These environ- much wider audience than in the past. This responsible for physical, social/emotional, ments and their characteristics are the social would have to take shape as a social marketing Recommendation 4 and language/cognitive development of determinants of ecd. An essential precondi- campaign that expands to include audiences young children, as well as eradicating child tion for ecd is the child’s basic right to exist; not traditionally thought of as ecd stakehold- labour. Recommendation 1 thus, national governments have an essential ers: finance and planning departments of predisposing role to play by ensuring that government, the economic sector, the corporate all children are registered at birth, through world, and media. In addition, who, unicef, maintaining a functioning, comprehensive unesco, the World Bank, and key ngos birth registry. should form a consortium to ensure broad We now understand that the transactional dissemination of the science of ecd in nature of young children’s relationships are conjunction with the social marketing far more important for their growth and campaign. development than has traditionally been recognized. Children do not just grow up The csdh should model ways to according to internal laws of biology; they grow and develop through the interplay of promote an understanding that human relationships in the environments the mdgs will only be achieved if where they live. In order to provide nurturant environments for their children, all families ecd is addressed seriously. need support from community and govern- Recommendation 2 ment. The quality of support received by The csdh should model ways to promote Recommendation 5 families should be monitored by local ngos as an understanding that the mdgs will only be part of the reporting under the crc. The goal achieved if ecd is addressed seriously. is universal access to a range of ecd services: In order to do this, and because of its global 40 4
  • 25. Early Child Development : A Powerful Equalizer responsibility in population health, the who Governments need to develop strategies for Recommendation 12 to support in-country watchdog functions inRecommendation 6 should strengthen its commitment to ecd as “scaling up” effective programmes from the fulfillment of General Comment #7. Although a key social determinant of health, beyond the local to the national, without sacrificing the this is an ambitious goal, it need not be an csdh, by subsuming its child survival and characteristics of the programme that made expensive one. It is estimated that an endow- health programmes globally under the develop- it effective. Implementation integrity and ment that generates us $1-2 million revenue mental perspective articulated in this report. accountability at the local level must be per year would permit these functions to be Governments, by ratifying the crc, have sustained, even when programmes are scaled- fulfilled. Discussion and committed themselves to realizing rights up to the national level. unicef, with the concurrence of the ga- Recommendations in early childhood. This means that local, The social determinants of health ecd should develop a common formula forRecommendation 7 regional, and national governments should operate from the most intimate sphere of calculating national expenditures on ecd, as incorporate the “science of early child develop- influence for children—the family—to the well as per capita investment in children. An ment” into policy. Most countries require most distant—the global sphere. While Recommendation 15 economic analysis that indicates the “return on capacity building to meet this goal. Given the governments can do much to change the investment” that society can anticipate from overlap in underlying determinants, govern- circumstances of the world’s children and different types of ecd programmes and servicesRecommendation 8 ments should be building upon an established families, this review has also demonstrated should be created and disseminated. child survival and health programmes to make the need for global collaboration in the area Recommendation 13 ecd programmes accessible through existing of ecd. We propose an expanded global platforms. The health care system is often interagency collaboration (herein, the Global Local, regional, and national the most cost-effective platform and most Alliance for ecd, or ga-ecd), that will build governments should incorporate universal point of contact. upon existing informal networks of agenciesRecommendation 9 Governments should create an inter- currently working on ecd internationally, the “science of early child develop- ministerial policy framework for ecd that such as unicef, unesco, World Bank, b v lf, ment” into policy. clearly articulates the roles and responsibilities Soros Foundation, the Aga Khan Foundation of each sector and how they will collaborate. and the who. Governments should also integrate ecd A more formal partnership would facilitate policy elements into the agendas of each developing an interactive global knowledge sector to ensure that they are considered platform for communities and individuals to routinely in sectoral decision-making. share knowledge related to ecd; monitoring Governments will need to reallocate country work through facilities such as the resources to decrease inequities in access to crc; and providing advocacy for ecd and high-quality ecd programmes and services; advice to countries on the science of ecd. to facilitate this, ourreview has identified The ga-ecd could become an effective site evidence that can be used as a benchmark of advocacy for increased investment in for judging the quality of ecd programmes child- and family-friendly policies. It should and services. Community involvement is work towards linking ecd to the mdgs, an important component of successful ecd especially to mdgs on poverty reduction, programming; because of this, governments education, gender equality, and child survival.Recommendation 10 should involve local communities in developing The ga-ecd should take responsibility for and implementing ecd policies, programmes strengthening the ecd “watchdog” function and services. This does not absolve govern- that needs to be performed by independent ments from their responsibilities but ensures agencies within countries. In practice, this stronger relationships between government would require the ga-ecd to play a role in and the local communities where service aiding and ensuring that countries remain delivery occurs. accountable through the crc’s General ecd programmes should be monitored for Comment #7; including the voices of childrenRecommendation 11 quality and effectiveness. This should include in their country reports; and demonstrating an assessment of barriers to and opportuni- how they have considered the evolving ties for access, with a particular focus on capacities of children. decreasing inequity in ecd. Mechanisms need A global funding strategy needs to be put in Recommendation 14 to be developed and implemented to insure place to allow effective monitoring of General that communities and central agencies work Comment #7. In particular, a funding arrange- together to collect reliable data on outcomes. ment is required to sustain the ga-ecd and 4 4
  • 26. Early Child Development : A Powerful EqualizerConclusionsWhat a child experiences during the earlyyears sets a critical foundation for theentire lifecourse. ecd, including physical, Conclusionssocial/emotional and language/cognitivedomains, strongly influences basic learning,school success, economic participation, socialcitizenry, and health. The principal strategicinsight of this document is that the nurturantqualities of the environments where childrengrow up, live, and learn matter the mostfor their development, yet parents cannotprovide strong nurturant environmentswithout help from local, regional, national,and international agencies. Therefore, thisreport’s principal contribution is to proposeways in which government and civil societyactors, from local to international, can workin concert with families to provide equitableaccess to strong nurturant environments forall children globally. Recognizing the strongimpact of ecd on adult life, it is imperativethat governments recognize that disparitiesin the nuturant environments requiredfor healthy child development will impactdifferentially on the outcome of differentnations and societies. In some societies,inequities in ecd translate into vastlydifferent life chances for children; in others,disparities in ecd reach a critical point wherethey become a threat to peace and sustainabledevelopment. The result of our efforts suggesttwo primary directions for the future:1) continued research to provide a better understanding of the effects of environments on biological embedding and ecd, particularly that of broader environments, and2) the use of available information to inform action to further the goal of a “grass-roots to global” child-centered social investment strategy. 4
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  • 29. Early Child Development : A Powerful Equalizer Rogers, G. (1979) Income and inequality as Siddiqi, A., Kawachi, I., Berkman, L., Subramanian, UNESCO (United Nations Educational, Scientific Waldman, R.J. (1992) Income distribution determinants of mortality: an international S.V. Hertzman, C. (in press) Variation of and Cultural Organization) (2006). Strong foun- and infant mortality. Quarterly Journal of cross-section analysis. Population Studies, 33, socioeconomic gradients in children’s development dations: early childhood care and education. Economics, 107, pp.1283-1302 . pp.3 43-351. across advanced capitalist societies: analysis of 25 Paris, UNESCO, 3 November. [Internet]. Available Walker, S.P., Wachs, T.D., Gardner, J.M., Lozoff, OECD nations. International Journal of Health from http://portal.unesco.org/education/en/ Ruiz-Pelaez, J. G., Charpak, N., Cuervo, L.G. B., Wasserman, G.A., Pollitt, E. Carter, J.A. Services. ev.php-URL _ID=51 483URL _DO=DO_ (2004). 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  • 30. Early Child Development : A Powerful Equalizer generalizability of the work. Despite this Appendix A: scientific limitation, the moral and ethical value or obligation to consider the wishes/ Critical Appraisal of the perspectives/needs of children in this Underlying Evidence evidence was paramount. We therefore do not make broad claims that extend beyond the evidence; rather, we suggest that, from theReferences Appendix A Elsewhere, it has been convincingly argued body of literature regarding children’s that, for several reasons, the traditional perspectives, children deserve to be consid- hierarchy of evidence may not be suitable for ered social actors, and that it is our duty to “appraising the evidence for social or public consider their views in our work. The bio- health interventions.”6 One particular case in physiological responses to environmental which this is especially true is in the search stimuli that result in developmental out- for evidence concerning social determinants comes for young children have undergone of health. That traditional evidentiary numerous and rigorous investigations. This is hierarchies are incompatible (or, at least, not especially true compared to the body of completely compatible) with the available knowledge regarding biological–environmen- and desirable types of information in this tal interactions for adults. Our knowledge of area is supported by the prominence given “biological embedding” comes from well- to measurement and evidence issues by the controlled experimental conditions that have who’s csdh. been completed both in primates (including The evidence gathered by the Knowledge humans) and non-primates. In this way, Network for Early Child Development information at this level meets the traditional (kn-ecd) draws on several notions of what “gold standard” of evidence. constitutes valid and reliable “evidence.” The With the family as a sphere of influ- aim is to provide meaningful ways of weigh- ence, the evidence-base is virtually void of ing the available data and information in the experimental evidence. This is largely because field. The following provides an overview of it is neither feasible nor ethical to random- the manner in which evidence was weighed ize or control family conditions. There are for inclusion in this report. It is organized exceptions to this, such as experimental (or according to the “spheres of influence” quasi-experimental) evidence obtained from outlined in the team-ecd framework, since studies of siblings and orphans. Where pos- “types of evidence” cluster along these lines sible, these studies have been included. For as well. the most part, studies conducted about the At the level of the individual, much of effect of family characteristics/structure/par- the recent evidence that is available in the enting on children have been observational. literature has developed out of the broad Within observational research, both descrip- acceptance of the crc. With children tive studies (e.g., ecologic and cross-sectional recognized as fully human beings with studies) and analytic studies (e.g., cohort evolving capacities to contribute to their lives, studies) have been completed. Wherever researchers have also recognized the value of possible, results obtained from cohort including children’s perspectives in knowl- studies were favoured over those obtained edge generation. A major limitation in from descriptive studies. In comparison to interpreting this body of evidence (yet also its cross-sectional studies, cohort studies enable strength, in that it is methodologically the establishment of temporal order: that appropriate 7) is that the small sample sizes the cause arose before the outcome. At the and nature of qualitative research limits the family-level, there was also an explicit desire to demonstrate population-level patterns between socioeconomic conditions and child 6 Petticrew, M and Roberts, H. (2003.) Evidence, hierarchies, and typologies: Horses for courses. Journal of Epidemiology and development, and moreover, to demonstrate Community Health. 57: 5 27-5 29. variation in these patterns across populations 7 Ibid. or societies. Therefore, at this level, for this
  • 31. Early Child Development : A Powerful Equalizer task, cross-sectional, ecologic information was included. The trade-off here was in services section for creating nurturant environments for children. In some cases, the Appendix B: • developing support mechanisms within communities for preventing disease, for sacrificing temporal order to highlight an examples were chosen to support a particular Examples of ecd  helping families to care for sick children, important aspect of developmental distribu- point, such as with the Kangaroo Care; in and for getting children to clinics or tion that could not be captured without an other cases the inclusion was based upon the Programmes and Services hospitals when needed. ecologic perspective. Temporal order has been availability of information on the programme (Source: http://www.who.int/child-adoles- well established in the aforementioned cohort or service. We endeavoured to include the cent-health/integr.htm)Appendix A The folowing programmes and services are Appendix B studies, which were also included to provide highest quality programmes and services presented as examples of “good practice” an individual-level perspective on socioeco- where available. care for development towards creating nurturant environments in a nomic conditions and ecd. For the studies included in the regional, diversity of contexts. Evidence for the residential and relational national, and international spheres, scientific In partnership with unicef, the who communities, for similar reasons, arises rigour was much more difficult to ensure. has developed a special early childhood primarily from prospective cohort investiga- As mentioned in the broader team-ecd Linked to Health Care Systems development component, called the Care for tions. Studies chosen for review were those evidence document (Siddiqi, Irwin Development, intended to be incorporated which arose from the strongest research Hertzman, 2007), this is largely due to the integrated management of childhood  into existing imci programs. Care for designs; those which were the best controlled, lack of studies conducted at this level. The illness (imci) Development aims to enhance parents’ and and most free of other forms of bias, as judged literature review yielded very little experi- caregivers’ awareness of the importance by the journals in which they appeared and mental information, of which the primary The who’s imci program seeks to reduce of play and communication with children their known scientific reputation in the field. example is the progresa study. Beyond that, childhood mortality, illness, and disability by providing them with information and In order to maintain a social determinants most of the information gathered comes from as well as promote health and development instruction during children’s clinical of health perspective on the evidence we cross-sectional or other forms of descriptive among children aged 0-5 years. imci has both visits. Evidence has shown that Care for included in this report, in the ecd pro- observational studies. These studies, though preventive and curative aspects, which are Development is an effective method of grammes and services section, rather than they don’t provide definitive evidence, were designed to be implemented at the level of supporting parents’ and caregivers’ efforts to provide a “laundry list” of specific ecd included because they make strong sugges- the family, the community, and through the provide a stimulating environment for their programmes and services that have evidence tions about future areas to be investigated, hcs. imci prioritizes the proper identification children by building on their existing skills. of effectiveness, we chose to present generic and because there are strong plausible links and treatment of childhood illnesses within a Health care professionals are encouraged to characteristics as well as strategic and between micro-levels for which we have variety of settings, including homes and health view children’s visits for acute minor illnesses organizational principles of quality and data (such as the family) and macro-environ- facilities, but also provides counselling for as opportunities to spread the messages of sustainable programmes that are transferable ments such as the regional, the national, and parents and caregivers, and referral services for Care for Development, such as the importance around the globe. One rationale behind this international environments. In traditional severely ill children. The main implementation of active and responsive feeding to improve decision is that, despite the best evidence of a scientific terms, plausibility is often assessed involves the following steps: children’s nutrition and growth, and the programme or service’s effectiveness, we in biological terms. We contend here that • adopting an integrated approach to child importance of play and communication cannot support the practice of taking a what is apparent is a sociological plausibility. health and development in the national activities to help children move to the next successful program or service from one health policy stages in their development. context and expecting it to work as effectively (who pamphlet available at: http://www. (or at all) in another context. What we can • adapting the standard imci clinical who.int/child-adolescent-health/integr.htm) support is consideration of generic character- guidelines to the country’s needs, istics and principles that have crossed policies, available drugs, and to the local breastfeeding and infant stimulation  contexts, or characteristics of nurturant foods and language environments that we know have been • upgrading care in local clinics by train- A pilot project in southern Iran aims to reach proven to support children’s development. ing health workers in new methods the national development goals of safe To answer the question of criteria for inclu- to examine and treat children, and to pregnancies and deliveries, promote breast- sion of examples of programmes and services counsel parents effectively feeding and birth spacing, provide early in this report, we turn to many sources: psychological stimulation, as well as to help 1) to our ecd experts who have been on the • enabling upgraded care by ensuring parents avoid developmental delays among ground and experienced the effects of a sufficient supply the right low-cost young children. The project attempts to particular programmes—this includes the medicines and simple equipment support and promote breastfeeding practices, notion of “best practice”; 2) to the grey • strengthening care in hospitals for those both in the hospital and after discharge literature; 3) to the evidence of program and children too sick to be treated in outpa- (receiving a home health nurse visit and services effectiveness; and 4) to consideration tient clinics consultation), by offering lactation consul- of whether programs meet the criteria which tants, interaction with and support of new we articulate in the ecd programmes and mothers, and providing relevant training for 4
  • 32. Early Child Development : A Powerful Equalizer new mothers who require more information, the program involves local medical training to any parental concerns about development reach out and read (ror) which has shown significant impact on institutions, local administration, and and behaviour, many nurses provide anticipa- breastfeeding success. In the region, women’s community participation. Nurses visit tory guidance and suggest ways of promoting Reach Out and Read (ror) is a U.S. national literacy level is generally low, especially in newborn babies almost every week during the development. They run first-time mothers’ non-profit organization that promotes early rural areas. The program’s aim is to bridge the first month, and regularly afterwards. A groups, and provide parents with a range of literacy by giving new books to children gap between tribal and cultural patterns and Healthy Life Style Center is also involved in written materials about ecd. and advice to parents attending pediatric beliefs about breastfeeding; child nutrition, knowledge development, training, monitor- (Department of Health and Aged Care. (1998) examinations about the importance of readingAppendix B Appendix B health, and development; and the practice of ing, and evaluation. The Healthy Life Style A healthy start for 0-5 year olds. Department aloud. ror programs make early literacy a correct breastfeeding, by providing support Centre is a para-governmental training centre of Health and Aged Care Occasional Papers standard part of pediatric primary care and as for consistent, high-quality information on with strong academic links to medical and Series, No. 3. Commonwealth of Australia.) such are a point of contact with the hcs, one breastfeeding. This hcs point of contact social research institutions. This program has that has proven to support children’s early provides an opportunity for parents to access recently been evaluated and the report will be community development empowerment  development. Following the ror model, phy- lactation consultation and early childhood available soon. (cde) sicians and nurses advise parents that reading education classes. The mid-term evaluation of This program, and several similar initia- aloud is the most important thing they can the project, in the form of a kap (Knowledge/ tives supported by international ngos, The Community Development do to help their children love books and to Attitude/Practice) study revealed that the the World Bank, and others, can play an Empowerment (cde) Program in Malaysia start school ready to learn. Pediatricians and hcs’s involvement in the breastfeeding and important role in furthering Kazakhstan’s was established to address the needs of other clinicians are trained in the three-part nutritional education efforts in the region hcs reform. children and families in resource-poor ror model in an effort to promote pediatric significantly improved mothers’ knowledge, communities in an attempt to improve the literacy: which led to their health promoting behav- Turkey environment within which children are 1. At every well-child check-up, doctors iours in terms of their children’s health and raised. cde includes the following activities: and nurses encourage parents to read nutrition. Further evaluation is still required The Mother-Child Education Program • expanding preschool programs with aloud to their young children, and offer to provide evidence about the impact of the (mocep), started in 1993, provides children emphasis on stimulating cogni- age-appropriate tips and encourage- program on children’s developmental from disadvantaged communities with early tive, physical, and socioemotional ment. Parents who may have difficulty outcomes. enrichment programs and helps to strengthen development reading are encouraged to invent their (Froozani, M.D., Permehzadeh, K., Dorosty parenting skills. This approach supports own stories to go with picture books and Motlagh, A.R. Golestan, B. (1999) Effect and encourages parents and caregivers, who • health care workers conducting spend time naming objects with their of breastfeeding education on the feeding are recognized to be a child’s first teachers, meetings with community members children. pattern and health of infants in their first in providing children with the experiences to identify and map the existing formal 2. Providers give every child between the 4 months in the Islamic republic of Iran. they need to develop their competencies. and informal services that meet the ages of six months and five years new, Bulletin of the World Health Organization The program attempts to empower families particular needs of families developmentally appropriate children’s 7 7(5), pp.381-385.) to make and act on informed decisions about Once identified, the priorities for the commu- book to keep. their children by educating primary caregiv- nities are to establish a childcare program and 3. In literacy-rich waiting room environ- nurse home-visiting ers to better support children’s cognitive, immunization plan for young children, as well ments, often with volunteer readers, physical, and socioemotional development. It as income-generating activities for women parents and children learn about the Kazakhstan combines home visiting by registered nurses and single mothers. Parents participated in pleasures and techniques of looking at with parent education. Home visits allow the development and coordination of the books together. Through its existing nurse home-visiting the nurses to observe mothers in interaction interventions, such as pediatric assessment, Research findings evaluating the impact system, Kazakhstan has introduced an ecd with their children. The program works with educational services, intervention services, of ror’s efforts have been remarkably education module to increase parents’ mothers in relation to their various needs and childcare coordination. A major feature consistent. Compared to families that have understanding of their children’s psycho- while addressing child development informa- of the program is to strengthen the links not participated in ror, parents who have social and cognitive developmental tion and parenting. between parental values, the community’s received the ror intervention are signifi- needs—without additional costs. The Care for (Source: http://www.acev.org/english/ social structure, and the hcs. This program cantly more likely to read to their children and Development Module of the imci Training training/ect.html) builds on existing community resources and have more children’s books in the home. Most Package, jointly developed by who and has been shown to be cost effective. cde importantly, studies examining language unicef, were used as the basic training Australia addresses children’s particular ecd needs in in young children found an association package. The project is supported jointly by combination with health care services and between the ror intervention and statisti- who and unicef, and is carried out under the Maternal and child health/community nurses programs, and supports mothers to engage in cally significant improvements in preschool leadership of the Kazakhstani Ministry of visit young children regularly over the first 5 income-producing activities. language scores, a good predictor of later Health. It builds on the country’s existing years of life in Australia, 8 and one of the goals literacy success. hcs, and aims at improving the capacity of of this activity is to promote ecd. In addition 8 Home visiting programs like this Australian model can be found There are currently ror program sites service providers. During implementation, to monitoring development and responding in many countries; the scope and age range of the visits may vary. located in all 50 states, the District of 6
  • 33. Early Child Development : A Powerful Equalizer Columbia, Puerto Rico, the U.S. Virgin immunization  interventions, should not be underestimated. Chaturvedi, E., B. C. Srivastava, J. V. Islands, and Guam. ror programs are housed   Immunization programs are often reliant Singh, and M. Prasad. 1987. “Impact of at hospitals, health centers, and private Expanded Programme on Immunization upon a combination of public, private, Six Years’ Exposure to the ICDS Scheme pediatric practices. (Source: http://www. (epi) national, and international funding sources, on Psychosocial Development.” Indian reachoutandread.org/index.html) and as such these programs often compete Pediatrics24:153–64. The who’s Expanded Programme on with other programs and priorities of national http://www.unicef.org/india/media_2640. integrated family-based ecd (ifbecd)  Immunization (epi) was originally launched health agendas. While the 30-year history of htm andAppendix B Appendix B in 1976, at a time when less than 5% of the epi has yielded worldwide success, variations http://www.unicef.org/india/nutri- In Thailand, several local and International world’s children received immunization and fluctuations in immunization coverage tion_188.htm) organizations, for example, unicef, against the six most easily preventable at the national level indicate the difficulty Christian Children’s Foundation, and Save the diseases: diphtheria, tetanus, pertussis involved in maintaining the universality of In Absence of Health Care Systems Children, in collaboration with Department (whooping cough), polio, measles, and tuber- immunization programs. of Health in the Ministry of Public Health and culosis. Over the past 30 years, the epi has (www.afro.who.int; www.unicef.org/ local universities, have supported the devel- increased its coverage to the point where there health/files/UNICEFTechnicalNote1Malaria equal access radio in nepal opment of the Integrated Family-Based ecd are now an estimated 500 million immuniza- ImplementationApproach(1).doc (ifbecd) project, which has been in effect tion contacts with children around the world R Kim-Farley, R. (1992) Global The Equal Access Initiative uses appropriate since 1990. The project operates out of child on an annual basis. Disease prevention is a Immunization. Annual Review of Public and low cost technology (satellite broadcast- health centres and involves collaboration major component of reducing child mortality, Health, Vol. 13, pp.2 23-237.) ing, am/fm broadcasts) and community between experienced mothers (who volunteer and the long-term international success outreach to disseminate information to as ambassadors), the hcs, and the broader of the EPI has resulted in significant and Integrated Child Development families living in remote rural areas. Equal community (e.g., universities, other educa- measurable reductions in preventable disease. Services (icds) Access creates customized communication tional centers, not-for-profit organizations). The long-term success and scale of the EPI is strategies and outreach solutions on a range Each ambassador works with five families in now providing a framework within which to Another similar initiative in India, Integrated of topics including prevention of hiv/aids, her neighbourhood and provides the mothers introduce other children’s health services. Child Development Services (icds), is a women’s health, and early child development. with information and advice about child The scale of the who’s epi, as well as multi dimensional, community based effort By designing and producing compelling local health, nutrition, and development in a range its near-universal coverage, are now being aimed at improving the quality of life of language audio and multimedia programs in- of settings such as in peoples’ homes or at a recognized as potentially valuable opportuni- women and children living in poverty. The country, the program educates and catalyzes local market. Monthly training sessions (on ties with which to bundle other child health program grew out of the recognition that all behavior change in target audiences. issues such as family life, child development, promotion activities. The time at which 90% infants require developmental assessment, A new ecd radio program called Kheldai infant care, etc.) and meetings are held in local of the world’s children receive immunization, and that the established immunization clinic Sikdai (“Learning While Playing”) is now departments of health to update the ambas- usually within their first two years of life, this offered a point of contact with the hcs. As broadcast in Nepal via FM and satellite radio sadors on new information and materials in is a potential contact point for other health such, a more comprehensive early childhood to ecd centers and a broadcast audience of relation to children health and development. interventions or monitoring. Kenya has been development program was established. The millions. Kheldai Sikdai helps parents and The approach is especially useful because especially proactive in utilizing this early clinics function in connection with health communities create positive environments older children frequently provide some care contact point. The Kenyan Ministry of Health facilities’ during babies’ immunization visits, for children under the age of six. Through the for their younger siblings or neighbours in has recently decided to collect information mothers are given information about develop- program, parents learn about the importance Thailand. The ambassadors also provide about developmental indicators during ment, a Developmental Observation Card of their children’s intellectual and emotional necessary information about the importance immunization visits as a way of monitoring (doc) to help them monitor their infant’s development. This entertaining and engaging of child health, nutrition, and developmental the progress of ecd in Kenya, on a population development, and an opportunity to seek program reaches out to parents and workers issues to these older children. In one of the basis. Immunization visits are also viewed detailed assessment guidance if necessary. in children’s centers with ways to better more “hands-on” lessons, students in the 5 th as an opportunity to distribute information The aim of the plan is to empower families, in identify, address, and support the needs and 6 th grades work with and learn from the about ecd and infant health to parents. Other particular mothers, to learn more about their of children. By bringing together educa- ambassador about how to determine the innovative projects that use immunization infants’ health and developmental issues by tors, parents and trained ecd facilitators, vaccination status and developmental visits as the key contact point within the offering on-site education and the possibility “Learning while Playing” transforms the progress of the younger children in their health sector include the large-scale distribu- of follow-up home visits. underlying lack of knowledge about early families. All these educational and training tion of insecticide-treated bed nets in Togo, As immunization programs become childhood development that perpetuates initiatives are coordinated through the designed to further reduce the spread of coupled with other child health services, such cycles of poverty throughout Nepal. While Ministry of Public Health. diseases like malaria. as early childhood interventions and ecd frankly discussing and contextualizing the (Herscovitch, L. (1997) Moving Child and The importance of universal immuniza- monitoring, there may be increased oppor- impact of child rights, play-based learning, Family Programs to Scale in Thailand: tion programs, both in terms of reducing tunities to find permanent public funding for and parental and community roles in a child’s Integrated Program for Child and Family childhood disease and providing oppor- these programs. education, the programs work to transform Development. Bangkok, Thailand: unicef. ) tunities for additional early childhood (India Development Observation Card the way in which children’s early education
  • 34. Early Child Development : A Powerful Equalizer is conceived and implemented. A large part was a village engagement agreement signed by we have been unable to locate prior efforts to of this effort is working with educators and village members and the village development Appendix C: frame ecd in this manner. The reason seems parents to move beyond the traditional rote committee. It was based on a child rights to be that, until now, ecd research has been teaching methods often referred to as the framework and included actions that could be Population-based Measure- an individual-oriented field, dominated by “three R’s: Reading, Riting and ‘Rithmatic” taken immediately while waiting for needed ment of Early Child Devel- psychological and educational approaches and to convince parents that quality play- external assistance. (Description taken from: and focused on curriculum and programme based programs, stories, and songs are Programming experiences in ecd; First opment from a National implementation strategies. The advent ofAppendix B Appendix C appropriate, valid, and accelerate children’s intellectual development. Additionally, the edition, November 2006, unicef. p. 23. and World Bank, Early Childhood Counts: Perspective the Knowledge Network on ecd, under the auspices of the who, provides an oppor- programs use interviews with community Programming Resources for Early Childhood tunity to add a different perspective—the members and education specialists, as well as Care and Development (cd-rom), The population health perspective—to the mix. In the international development community, songs and stories, to transform the mentality Consultative Group on eccd, World Bank, Population health sees ecd as a social deter- there have been multiple efforts to assess of educators, the government, and—most Washington DC, 1999.) minant of health, requiring that we come to social welfare in ways that facilitate compari- importantly—the parents of young children understand, through acts of measurement, son across societies. To date, many approaches throughout Nepal, by creating an understand- where systematic differences in the prospects have been developed, each with its own set of ing of the appropriateness and long-lasting for healthy child development are emerging assumptions regarding the factors that con- positive benefits of ecd programs for children among clearly defined populations of children tribute to, and reflect, well-being. The World prior to attending primary school. Episodes around the world. Once identified, these Health Organization (who) Commission on also discuss topics like safe motherhood, systematic differences become the basis for Social Determinants of Health, Knowledge nutrition, and immunization. (Source: understanding the modifiable determinants Network on Early Child Development, Equal Access, Global Program Report 2006. of ecd, for measuring progress in ecd over proposes that early child development (ecd) http://qwww.equalaccess.org) time, and for measuring equity of access to is an outcome (or rather, a set of outcomes) the conditions that support healthy child that is fundamentally reflective of the social village-based ecd curriculum   development. success of societies. ecd is also an indicator of development in lao pdr Coming to agreement on an internation- future societal success, as it is associated with ally comparable ecd indicator will not be learning skills, health, and other measures of The Women’s Development Project worked easy. The indicator must meet the following well-being throughout the lifecourse; as such, to promote various development initiatives criteria: it can be considered a fundamental measure for women in five provinces of Lao pdr. After • encompass those domains of early child of the potential for societies to flourish in five years, interest developed and a need was development that influence health, multiple social domains. The extent to which identified to more directly address child well-being, learning, and behaviour a nation provides opportunities for healthy development issues. The Early Childhood across the lifecourse child development is the extent to which the and Family Development Project (ecfd) well-being of its most vulnerable members is grew out of this experience. Project Planning • be based upon a common international supported. Workshops for ecfd were organized in conception of the relevant domains Prior literature suggests that individuals villages in the initial steps of development of ecd, consensus as to the specific within societies are differentially affected and implementation. Village-level planning elements within each domain that must by adverse conditions such as lower levels of resulted in agreement on needs and objec- be measured the same way everywhere gdp, high levels of income inequality, and the tives, an understanding of overall design, in the world, and recognition of those like. We suggest here that children are often assessments of resources and constraints, elements that are distinct in different a vulnerable group, due to a variety of factors, activity planning, setting up the project contexts from their stage of biological development, committee, and criteria for selecting village • notwithstanding the above challenges, to their compromised ability to exercise life volunteers. The community-based cur- be transferable to diverse global con- choices. Knowledge of ecd levels in a society riculum development process focused on texts, recognizing that the conditions provides a direct measure of societal welfare participatory input at the local level to create under which children are dying are the by highlighting well-being during the early a curriculum that could be adapted to the same conditions under which children years, but in the process also addresses societ- particular needs of different ethnic groups. are living ies’ future prospects for well-being. Thus, we The process focused on village data collection are promoting population-based measure- and needs assessment. Analysis of existing • provide valid and comparable infor- ment of ecd with the aim of constructing a traditional knowledge was used as a basis for mation for children of a given age, globally accepted social indicator. curriculum development. One of the most regardless of whether or not they are in Despite an extensive literature review, unique activities in the Lao pdr experience school 60 6
  • 35. Early Child Development : A Powerful Equalizer In light of these challenges, the ecd indica- Appendix D: preschoolers, they have similar answers: ‘Grandparents play a large role in our culture.’ tor cannot be a single attribute, like infant mortality; instead, it must tap into multiple Children and Families in When pressed, they make clear that they mean grandmothers. What about when attributes of child development. Perhaps the most notable successful precedent on Global Perspective: grandmothers aren’t available, you ask? the international stage to date is the Human Discussion of and excerpts ‘There’s lots of informal care,’ they inevitably reply, ‘other family members, neighbours,Appendix C Development Index (hdi), introduced by the United Nations Development Programme from Heymann’s Forgotten women in the community.’ ‘Many mothers Appendix D (undp) in 1990. The hdi assesses the status Families can bring their children to work.’ The answers are vague because they describe a world that of societal welfare using a composite score based on three measures: life expectancy, has been kept out of sight, unexamined. adult literacy, and purchasing power adjusted Introduction “[When stating to a large teaching hospital per capita gross domestic product. It is fair to in Gabarone that] we were looking at the With the tremendous connectedness of conditions that working families face … say that the hdi has had a marked influence people and societies worldwide, a global a hand went up. ‘Those issues don’t affect on discourse regarding international develop- perspective on the issues facing children us here. Everyone has extended family ment. With respect to ecd, the multiple and their families is critical. There are two members they can rely on so they never have attributes must be broad enough to meet the primary factors that serve as the impetus for any problem getting care for their children.’ first criterion above; that is, to encompass a global lens of examination. First, that with Though the belief was satisfying, the problem those domains of early development that greater links between societies comes better was that the experience of the families we influence health, well-being, learning, and information about the state of people and had interviewed in Botswana belied it. We behaviour across the lifecourse. In practice, their environments everywhere. Second, interviewed many families in which parents there are three broad domains of development that with increased complexity of the had no choice but to leave young children that meet this criterion: physical, language/ global economy, the policy decisions made home alone, pull older children out of school cognitive, and social/emotional. in one nation or region have far reaching to provide free care, or take children to the The process of reducing such diverse implications all over the world. In these workplace even when doing so threatened domains as physical, social/emotional, and regards, the work of Jody Heymann has made the children’s health and development or the language/cognitive development to a single, major contributions. Studies conducted parents’ jobs. But before I could respond to the transferable, and comparable index is known by Heymann’s Project on Global Working fantasy the first speaker relayed by sharing the as “commensuration.” That is to say, by Families have ranged from in-depth inter- experiences of some of the 250 we had already reducing each domain to a number, we can views of more than 1,000 families in Latin interviewed, a Motswana surgeon raised his then compare them directly with one another America, Africa, Asia, North America, and hand and interjected: ‘A lot of parents have no and, by reducing these numbers to a single Europe, to analyzing survey data on 55,000 one they can rely on. I see the children who, multi-attribute index, we can compare ecd families around the world, to examining the because of that, end up being left home alone across societies, just like we currently do with extent of public policies supporting working when they come into the emergency room or infant mortality. Calls for commensuration parents and their children in 180 countries. into my operating room with broken bones are obviously controversial and have caused The following are some highlights from and burns.’” intellectual divisions for as long as there has Forgotten Families: Ending the Growing Crisis been intellectual discourse. For example, Confronting Children and Working Parents in Plato was in favour of commensuration and Empirical Findings on Caregiving the Global Economy (Oxford University Press, Aristotle was opposed to it. Not surprisingly, Patterns for Young Children 2006). More information can be found at this division is alive and well in the ecd www.mcgill.ca/ihsp/. international development community today. The four criteria listed above reflect a compro- extended family mise between—on the one hand—the need to Popular Misconceptions on “What, then, is the global reality? There succeed in an act of commensuration, in order Caregiving for Young Children is no doubt that both having two parents to allow ecd to compete with other childhood in a nuclear family and having extended priorities (like survival) on an “epistemologi- One of the primary ways in which the global family can make an enormous difference to cally level playing field” while—on the other economy affects children and families is children’s care. Among families we inter- hand—not letting the reductionist tendency through the patterns of caregiving that viewed, 33 percent of single parents had left necessary for commensuration to somehow prevail under various societal circumstances. their young children home alone compared defeat global diversity by making ecd appear “When you ask the leaders in most countries with 2 2 percent of parents living with a to be a matter of “one size fits all.” who is caring for infants, toddlers, and 6 6
  • 36. Early Child Development : A Powerful Equalizer spouse or partner. When single parents have the care they can provide.” for normal growth are often degraded daily. solution. It’s clear that low-income families no other adult caregivers in the household, Further, these factors are patterned by Amalia Montoya, born and reared in Cancun, and many middle-income ones cannot young children are even more likely to be left parents’ socioeconomic resources. “Low Mexico, was raising her son as a single mother. currently afford or find space in formal home alone (56 percent versus 23 percent). … income parents are less likely to receive help She had been cleaning houses since age fifteen childcare programmes for all of their children. But the myths that extended families alone from and more likely to need to provide and never had the chance to finish school. But it’s also clear that there is a large and solve the problem are mistaken in at least caregiving assistance to extended family.” Living far from her family, she had no one to apparently less-expensive informal sector three ways. First, many working parents and 32% of those parents who earn less than 10 turn to for help. Without sufficient publicly market for care. Public policy makers oftenAppendix D Appendix D their young children have sporadic, limited, dollars per day (purchasing power parity supported slots available, childcare was far ask, without beginning to examine the double or no contact with extended-family members adjusted) can rely on extended family for beyond her economic reach. Amalia took her standard implied as they support formal early they might ever turn to for help. Worldwide, help (and do not need to provide assistance infant son to work with her because she had childhood care and education programmes with urbanization and the increasing mobility to them) compared to 46% of those parents no other choice. ‘It was really difficult because in higher-income nations, ‘Isn’t informal required to get and keep jobs, the number of earning more than 10 dollars per day. 47% it’s not the same as being in your own house. care the solution for young children in poor working adults who live near enough to their of parents earning fewer than 10 dollars per When he began to cry because he was hungry, countries?’ These experts argue that it is less own parents to be able to turn to them for day (purchasing power parity adjusted) need I couldn’t tend to him at the same time as expensive and assume it is as good as formal regular assistance is rapidly declining. to provide assistance to extended family working.’… She went on to describe how she care. Our experience is that, in the majority “Second, even among those who continue compared to 42% of those earning more than grew depressed over the situation and her of cases, parents reported only that it was to live near their children’s grandparents, 10 dollars daily. son’s consequent malnutrition…. cheaper…. many cannot rely on them for help. “Beyond Amalia’s inability to feed her son “While in theory, care provided by adults Grandparents themselves may need to work parents taking their children to work regularly, she couldn’t care for him adequately in informal care settings could be of equal and may be as constrained as parents in their when he was sick. When Amalia gained access quality to formal settings, this was not the ability to provide routine care or even to When family is unavailable, another common to a childcare center, perhaps the most telling common experience of most parents we inter- take time off to care for a grandchild who is global response is parents taking their summary of her son’s experience was her viewed, and in particular, this was not the sick. Third, all too often those adult family children to work. “While some policy makers delight in the most basic elements: ‘I dropped experience of low-income families. Though members who might be able to help—because acknowledge the improbability of such safe him off at seven-thirty in the morning and many countries have some degree of subsidy they are close by and are not working them- care in factories and the unlikelihood that picked him up at five o’clock in the afternoon. for low-income families using formal child- selves or already caring for a full house—face parents will be given permission to bring He ate there and everything.’ She was grateful care settings, far fewer subsidies and little physical and mental health constraints. In children to work elsewhere in the formal even for care that consisted of the most public provision or supervision exist in infor- fact, when extended family members are sector, they assume it is not only possible fundamental features: enabling her to work, mal settings. As a result of this and of parents’ close, they are as likely to be in need of care as but a decent solution in the informal sector. providing her son with adult supervision, and low wages, those low-income parents using to be able to assist with it.” The image conjured up is of a parent—nearly ensuring that he could eat… informal care typically could afford to pay universally a mother—working with an infant “The same stories echoed among the little. This resulted in their having extremely when extended family is not an option swaddled tenderly on her back or a toddler parents we interviewed in Botswana and limited choices in childcare providers. The playing happily at her side as she sells goods Vietnam. What differed across national low wages they could afford to provide meant “In situations where extended-family in a market or cleans a home. … In our studies, borders and economic circumstances was not that, in general, they were hiring either adults members are in need of care, preschool we met many women who had lost formal the nature of the problem but the level of the who could not find other work or adults who children often get less care than if no extended sector, decent paying jobs in order to care for parents’ desperation. … This is also similarly provided the informal care while working at family were nearby. When mothers or fathers their children. … patterned along socioeconomic lines. One in another job. The low skill level of those hired are caring for other sick family members, “At times, they subsequently found four parents earning less than 10 dollars per and the fact that those hired were, at times, children are twice as likely to be left home informal sector jobs which allowed them to day (purchasing power parity adjusted) have simultaneously doing other work led to poor- alone. Forty percent of working parents caring bring their children, but even those women, to take their children to work regularly, as do quality care when it was provided. Moreover, for a sick spouse and 41 percent of parents who had the better experiences of the lot, did one in four parents who have only primary or problems that began with the poor quality caring for extended family had to leave a child not have any romanticized fantasy of their middle-school education themselves. Parents of childcare providers in the informal sector home alone (compared with 2 2 percent not children’s lives spent at their mother’s side who work in the informal sector are the least were exacerbated by the lack of supervision in caring for a sick spouse and 21 percent not while they worked. Most shared a bleak view likely to have access to formal childcare; as a the informal sector. Parents we interviewed caring for other sick family members). When of children at work with their mothers who result, half of the parents we interviewed who repeatedly recounted stories of going home to extended-family members don’t require assis- had started in the informal sector because worked in the informal sector needed to bring find that informal childcare providers had left tance, they may still be too physically limited, of lack of education and job choices and had their children regularly.” their children home alone for all or part of the frail, or sick to provide adequate care for their never been able to leave because of caregiving day. … grandchildren, nephews, nieces, and other responsibilities… informal care “In countries we studied, many parents dependents because the same constraints on “Even when children taken to work are reported that they had to leave their young age and health that limit extended-family not at high risk of sustaining sudden life- “[Another] fiction about preschool childcare children in the ‘care’ of other children. In members’ ability to work affect the quality of threatening injuries, their opportunities is that inexpensive informal care is a viable Vietnam, 19 percent of the working parents 64 6
  • 37. Early Child Development : A Powerful Equalizer we interviewed had to leave children home as were parents with a high school education had children enrolled in ECE programmes, Conclusion alone or in the care of an unpaid child, and 4 or more.” compared to 25% in Botswana. In Vietnam, percent relied on a paid child for childcare. In 46% of children living in extended-family Governments have begun to employ potential Mexico, 27 percent of the parents we inter- Developmental Consequences of households with all resident adults working solutions. Vietnam, with a higher availability viewed had to leave children alone or in the were enrolled in ECE programmes, compared of public childcare services, had, overall, more care of an unpaid child, and 9 percent left their Poor Quality Childcare with 30% in Brazil and 19% in Botswana. families with access to formal childcare as sons and daughters with another child who Forty-two percent of children living in well as the smallest differences across incomeAppendix D The developmental consequences of lack Appendix D was paid as a provider. While Botswana had a extended-family households with not all groups in use of formal childcare. “Fifty- of quality childcare are tremendous. In nearly identical gdp per capita to Mexico and resident adults working were enrolled in ECE seven percent of lower-income families in Ho Botswana, 53% of parents responded that one that was more than seven times as high as programmes in Vietnam, compared with 31% Chi Minh City were able to send a child to their children had experienced accidents or Vietnam’s, Botswana families had the highest in Brazil and 11% in Botswana. formal childcare, as were 62 percent of higher- emergencies while a parent was at work, as did rate of leaving children home alone. With income families.” In Mexico, the government 47% in Mexico and 38% in Vietnam. Thirty- next to no publicly supported childcare, 48 Effects on Families has a mandate to provide childcare for five percent of parents in Botswana reported percent of working parents in Botswana had employees in the formal sector to help narrow a negative impact of their working conditions to leave a child home alone some or all of the “Clearly, the dramatic changes in adult work income disparities. The figures show that, on their children’s health. In Mexico and time or in the care of an unpaid child… lives are transforming the lives of children indeed, the gap in the use of formal childcare Vietnam, these figures were 21% and 25% “There was a clear social class gradient in around the world. … but what effect has between poorer and middle-income parents is respectively. “We as a global community, informal care. Parents who were poor and the labor force transformation, the rise of less in the formal sector, where child care is have agreed that all children have a right to a parents who had the least educational oppor- urbanization, and an increasingly globalized part of social security (58% compared to 39%) free public primary education. However, by tunities themselves were the most likely to economy had on the economic [and related than in the informal sector (58% compared doing nothing for most children in the critical have to leave their preschool children in the social] well-being of families?” Each brings to 2 2%). developmental years from birth to five, we care of another child. Parents with a middle opportunities and risks, but it is critical to “When young children are left home have effectively left hundreds of millions of school or less education were twice as likely reiterate that the negative impact of these alone or in substandard care, the potential children globally with little chance to succeed (2 2 versus 9 percent) to have to leave their factors fall disproportionately on those for tragedy is real.” This includes the risk of in school. Before they are six, they have no children in the care of other, unpaid children with fewer socioeconomic resources, and on children suffering accidents or emergencies adequate chance to develop in a healthy way, as parents with a high school education or women. while their parents were at work and becom- let alone learn the requisite basic skills for more, who as a result earned more money … “On nearly every measure, from the ing the victims of violence. “But there is beginning school.” The calculus is cruel: 2.7 billion people live on availability of paid leave to adequate flexibil- another, slower, but equally devastating type less than $2 a day, and 1.1 billion live on less ity at work, the parents living in poverty we of tragedy that is transforming the lives of than $1 a day. Even those who manage to feed The Need for Early Child interviewed were facing worse working con- tens of millions of preschool children. Unable their children on less than $2 a day simply Development Programmes ditions.” Among those parents who earned to find or afford decent care, needing to work cannot afford to pay, on their own, even for less than 10 dollars per day (purchasing power and only finding jobs under the worst condi- informal care of their preschoolers that will “We need to ensure that all children have parity adjusted), only 50% were granted paid tions, these parents are forced to leave their ensure the children’s safety and good health.” access to early childhood care and education. leave from work for caregiving. Ten percent of preschool children in care which jeopardizes The public sector in some countries and the those earning less than 10 dollars could alter their health and development as well as their children home alone private nonprofit sector in others have begun their work schedules and were able to get paid safety. The quality of the care they receive is to address this problem. However, the gap leave for caregiving, compared to 18% of those so poor that with each day that passes, their “When parents were poor and couldn’t afford between the care that is available and the earning more than 10 dollars. Only 36% of health and development slowly deteriorate, to pay for childcare, when parents had limited number of families that need it is enormous.” parents earning less than ten dollars per day and their life-chances decline further.” education themselves and therefore fewer job Household surveys in several nations provide had access to health insurance through their opportunities, and when parents faced costly contrasting information on the percentage jobs, compared with 75% of those earning penalties at work for caring for their children, of children three to five years of age in more than 10 dollars per day. they were more likely to leave children home early childhood education programmes. In Single working mothers are much more alone on either a regular or an intermittent Vietnam, where a national programme has likely to work longer hours than single men. basis…. Forty six percent of those who lost been developed, 51% of children from single Data from national living standards surveys pay because of caregiving responsibilities working-parent families are enrolled in early demonstrates that in Brazil, 65% of single ended up having to leave children home alone childhood education (ECE) programmes, working mothers average sixty or more hours versus 21 percent who did not face penalties. compared to 40% in Brazil, where municipali- of paid and unpaid work weekly. This propor- Parents with a middle school or less education ties have programmes, and 21% in Botswana, tion drops to 43% for single working fathers. were more than twice as likely (39 versus 18 where there are no major public early In Mexico, the numbers are 76% and 64% percent) to have to leave their children home childhood programmes. In both Vietnam respectively. alone or in the care of other, unpaid children and Brazil, 4 4% of dual-earner families 66 6
  • 38. Abstract 6

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