Stepping up Early Childhood Development Investing in Young Children for High Returns Amina D. Denboba, Rebecca K. Sayre, Quentin T. Wodon, Leslie K. Elder, Laura B. Rawlings, and Joan Lombardi Acknowledgements This report was prepared in 2014 by the authors in the Human Development Network at the World Bank under the guidance of Harry Patrinos (Manager, Education), Elizabeth King (Acting Vice President, Human Development Network), as well as Claudia Costin (Senior Director for Education), Arup Banerji (Senior Director, Social Protection and Labor) and Timothy Grant Evans (Senior Director, Health, Nutrition, and Population). Guidance from Nicole Klingen (Manager, Health, Nutrition, and Population), Anush Bezhanyan (Manager, Social Protection and Labor) is also much appreciated. The task manager was Quentin Wodon. Financial support from the Children’s Investment Fund Foundation is gratefully acknowledged. The authors are also grateful to Sachiko Kataoka (Education) and Peter Holland (Education) who served as peer reviewers and provided valuable comments and suggestions. Members of the World Bank Early Childhood Development Community of Practice also provided valuable inputs, including Amanda Devercelli (Education) and Julieta Trias (Human Development Network), as well as Robin Horn (Director, Education, Children’s Investment Fund Foundation) and Ruslan Yemtsov (Social Protection and Labor). Finally, members of the Institute of Medicine Forum on Investing in Young Children Globally also provided valuable comments. Contents Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Introduction Investing in Young Children for High Returns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Five Packages Family Support Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Pregnancy Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Birth Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Child Health and Development Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Preschool Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Summary of the Five Integrated Packages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Four Principles Key ECD Policy Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Conduct an ECD Diagnostic and Establish a Comprehensive Strategy . . . . . . . . . . . . . 14 Coordinate and Implement Widely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Integrate Services to Achieve Synergies and Cost Savings . . . . . . . . . . . . . . . . . . . . 17 Monitor, Evaluate, and Scale Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Investing in Young Children for High Returns iii Preface Investing in young children is not only the right thing to do from an ethical point of view, but it is also the smart thing to do from an economic point of view for the children, as well as for their families, their communities, and society at large. Early Childhood Development (ECD) interventions are essential for a child’s growth and development. The returns to those interventions also tend to be higher than the returns to investments in human capital taking place later in life. Today ECD is increasingly recognized as one of the most important investments that countries and families can make to prosper and help all children lead productive lives. In recognition of the strong evidence on the positive impact of ECD interventions on young children, investments in ECD projects at the World Bank (grants and loans) as well as in analytical and capacity building work related to ECD have increased considerably in the last few years. But more can and has to be done to convince policy makers and practitioners to truly place ECD policies and programs at the core of their national development strategies. This document provides a simple guide for policy makers and practitioners about how to invest in young children. It identifies 25 essential ECD interventions that can be delivered through five integrated packages at different stages in a child’s life, spanning the education, health, nutrition, water, sanitation, and social protection sectors. These five packages of interventions are: (i) the family support package, (ii) the pregnancy package, (iii) the birth package, (iv) the child health and development package, and (v) the preschool package. The document also lays out four simple principles that countries can follow to design and implement successful ECD strategies: (i) prepare an ECD diagnostic and strategy; (ii) implement widely through coordination; (iii) create synergies and cost savings through integrated interventions; and (iv) monitor, evaluate, and scale up successful interventions. We hope this document will prove to be a valuable reference to policy makers and practitioners in our client countries as well as for all those interested in giving every child the opportunity to fulfill their full potential. Claudia Costin Senior Director, Education Arup Banerji Senior Director, Social Protection and Labor Timothy Grant Evans Senior Director, Health, Nutrition, and Population Investing in Young Children for High Returns v Stepping up Early Childhood Development Investing in Young Children for High Returns Investing in young children is one of the best and lactating mothers, as well as investments that countries can make. A child’s earliest young children and their years present a unique window of opportunity to families. These services are address inequality, break the cycle of poverty, and meant to address the improve a wide range of outcomes later in life. health, nutritional, Recent brain research suggests the need for holistic socio-emotional, approaches to learning, growth, and development, cognitive, and recognizing that young children’s physical and linguistic needs intellectual well-being, as well as their socio-emotional during this age and cognitive development, are interrelated.1 To fully period. They are benefit from future opportunities in life and become essential because productive members of society, by the end of early a child’s early life childhood, young children must be: healthy and well- forms the basis for nourished; securely attached to caregivers; able to future learning, good interact positively with families, teachers, and peers; health, and well-being, able to communicate in their native language; and as well as the ability of the ready to learn throughout primary school2. child to work well with others in adulthood. Early gaps in childhood development jeopardize a child’s capacity to reach these important milestones There is an emerging consensus that investments in and achieve full potential in life. Interventions in the ECD should be a priority and could also have very high early years have the potential to offset negative trends returns. A growing body of literature demonstrates and provide young children with more opportunities that the returns on investments in young children for optimal quality learning, physical growth and are substantial, particularly when compared to health, and eventually increased productivity in life. investments made at later stages in life. By contrast, New biological and social science evidence provides failure to invest can lead to long-term and often a wealth of resources to inform innovative strategies irreversible costs not only for individuals and their that promote optimal child growth and development. families, but also for communities and society at large. Programs that combine services (such as nutrition and psychosocial stimulation) can have especially large Why are countries falling short in their investments beneficial impacts and rates of return.2 Unfortunately, in ECD? One factor is the fact that countries usually most countries fall short in their delivery of essential operate under strict budgetary constraints. But services for young children and their families. The experience also suggests that another factor is related challenge ahead is to develop scalable, cost-effective to the fact that ECD is highly complex and multi- models for delivering these services in low- and sectoral. There is still lack of awareness of the benefits middle-income countries. of ECD and how countries can design successful policies and scalable programs in this area. While various definitions of early childhood development (ECD) have been proposed, in this Several development partners have introduced document, ECD refers to a child’s growth and comprehensive frameworks to address the holistic development starting from a woman’s pregnancy needs of young children. UNICEF focuses on key through the child’s entry to primary school. ECD areas of intervention for ECD, including basic health, interventions therefore include services for pregnant nutrition, HIV/AIDS, education, and protection Investing in Young Children for High Returns 1 services3. The World Health Organization (WHO) has to interventions and integrated services that could established specific guidelines for each developmental help policymakers and practitioners think about how phase, including pregnancy, postnatal, baby, infant, to effectively invest in ECD. and young child health care. These guidelines assist In addition to identifying key interventions, the service professionals in delivering improved health document outlines four principles that can help outcomes for the intended beneficiaries during the specific sub-periods. Additionally, the Partnership for countries design and implement strong ECD policies Maternal, Newborn, and Child Health (PMNCH), led by and programs. Countries should: (i) prepare an the WHO and Aga Khan University, provides policy- ECD diagnostic and strategy; (ii) implement widely makers with specific information on the essential through coordination; (iii) create synergies and cost health interventions to address the main savings through integrated interventions; and causes of maternal, newborn, and (iv) monitor, evaluate, and scale up child deaths4. At the World successful interventions. Bank, the Early Childhood In terms of interventions, Development Guide for within the ECD period, Policy Dialogue and Project 25 key interventions are Preparation2 presents identified as essential strategic entry points for for a child’s growth effective ECD program and development implementation in (summarized in Figure countries, including 1). For each intervention, center-based programs, illustrative costs and home-based programs, impacts are provided. and conditional cash These are based on transfer and communication existing evidence and are and media campaigns targeting only intended to be indicative. families with young children. The document suggests that Building on a review of the research these interventions can be delivered evidence and practical experiences, in 2010 the World through five integrated packages at different stages Bank developed the STEP5 framework as a simple way in a child’s life. The five packages of interventions to think about how countries can help individuals include: (i) the family support package, which should to lead productive lives. STEP stands for Skills Toward be provided throughout the ECD period, (ii) the Employment and Productivity. The framework identified pregnancy package, (iii) the birth package (from birth five steps through which individuals can progress and to six months), (iv) the child health and development learn throughout their life. This document elaborates package, and (v) the preschool package. on ECD, the first of those five steps. We hope that the approach suggested in this This document draws on these existing frameworks document for investments in integrated ECD and broad evidence on the impacts of ECD interventions will be useful to policymakers and interventions. It summarizes some of the existing practitioners by providing them with a set of simple literature on this topic with the aim to identify key yet powerful messages so that all young children will interventions needed for children. The document is reach their full potential and have the chance to live intended to provide an easily accessible introduction healthy and productive lives. 2 Stepping up Early Childhood Development FIGURE 1: 25 Key Interventions for Young Children and their Families Pregnancy Birth 12 Months 24 Months 36 Months 54 Months 72 Months Counseling on adequate diet during pregnancy Exclusive Complementary feeding Adequate, nutritious, and safe diet breast NUTRITION feeding Therapeutic zinc supplementation for diarrhea Iron-folic acid for pregnant mothers Prevention and treatment for acute malnutrition (moderate and severe) Micronutrients: supplementation and fortification Antenatal visits Immunizations Attended Delivery Deworming HEALTH Planning for family size and spacing Access to healthcare Prevention and treatment of parental depression Access to safe water WATER & Adequate sanitation SANITATION Hygiene/Handwashing Maternal education EDUCATION Education about early stimulation, growth, and development Early childhood and preprimary programs Continuity to quality Birth primary education Registration Parental leave and adequate childcare SOCIAL PROTECTION Child protection services Social assistance transfer programs Source: Authors. Note: The idea of presenting interventions by sector and/or age has been used by a number of previous authors. Investing in Young Children for High Returns 3 Family Support Package Conception to 6 Years Major gains: improved a direct impact on her health and well-being as well physical, socio- as on the outcome of each pregnancy.8 emotional, and 3. Education about early stimulation, growth, cognitive development and development: Reaching parents and caregivers through parenting support and home-visiting can The family is the promote early stimulation, optimal caregiving, and very first and healthy feeding practices and thereby improve most effective outcomes for children. Home visiting programs can support system deliver messages to parents about the health, growth, to ensure and overall development of young children. Parenting young children’s support programs can improve responsiveness healthy growth in feeding9,10 and early stimulation.11,12 “Serve-and- and development. return” interactions between parents and young The wellbeing children can enhance physical development as well and involvement of as development of cognitive and socio-emotional families play a critical role skills13, which influence academic achievement and in addressing children’s holistic employment later in life.14 In addition to home visits, development needs because young children social networks of support and community education depend entirely on their families and spend the most campaigns about ECD can be an effective strategy to time with them in the home environment. While a reach parents and caregivers with messages on young range of ECD interventions are age-specific, many are children’s growth, development, and safety. necessary throughout the early years. Based on a two- 4. Social assistance transfer programs can help generation approach6 creating opportunities for, and parents provide for their children’s needs and invest addressing the needs of, both parents and children, the in their children’s nutrition, health, and education. family support package consists of 12 different clusters These programs are often targeted to poor and of interventions and services provided to support both vulnerable families, providing a gateway to reaching young children and their families. those most in need and a corresponding entry point for coordinated service provision, including Parental support for vulnerable families for ECD. Social protection programs can also serve 1. Maternal education: Evidence demonstrates as vehicles for counter-cyclical crisis response, the importance of girls’ education for ECD. When helping to protect families from income shocks and girls attain a higher level of education, it can have a children from a range of consequences including powerful influence on their future children.6,7 toxic stress. In addition to supporting income, social protection programs often leverage investments 2. Planning for family size and spacing: Planning in human capital. For example, conditional cash for family size and spacing allows parents to anticipate transfers (CCTs) incentivize parents to invest in the and attain their desired number of children and health and education of their children, and safety net the spacing and timing of their births. It is achieved programs in very low income settings are increasingly through use of contraceptive methods and the combining cash or food assistance with capacity treatment of infertility. According to the WHO, a building for parents in core areas of health, nutrition, woman’s ability to space and limit her pregnancies has and education. 4 Stepping up Early Childhood Development 5. Prevention and treatment of parental Health, nutrition, and sanitation for families depression: Maternal and paternal depression 8. Access to health care contributes to achieving is also likely to have adverse effects on ECD and universal health coverage for a population regardless quality of parenting.15 Where feasible, prevention of income or social status. Equitable access to health and treatment of parental depression is important, services increases the demand for care, especially beginning with prevention during pregnancy, and among the poor, by making those services more prevention and treatment throughout the early years affordable. Health services such as malaria prevention of parenthood. 16,17 and treatment are critical for reducing the risk of 6. Parental leave and adequate child care: Without childhood mortality. sufficient income and adequate flexibility, vulnerable 9. Micronutrient supplementation and fortification: parents are unable to cater to the needs of their Deficiencies in micronutrients such as vitamin A, children.18 Where feasible, families with young children iodine, iron, and zinc can cause irreversible deficits should benefit from income support programs, and parental leave and adequate child care should be in physical and mental development. Micronutrient available for working parents. According to the OECD, supplementation and fortification of staple foods well-structured child care support policies can pay can prevent and/or treat micronutrient deficiencies. for themselves19 since without support, parents face Universal salt iodization is an especially cost-effective obstacles to labor force participation which can lead to way to deliver iodine to the population.21 higher welfare expenditure, lost tax revenues, inhibited 10. Access to safe water; 11. Adequate sanitation; growth, and wasted human capital. and 12. Hand washing: Nearly nine out of ten 7. Child protection services: Domestic violence diarrheal deaths among young children are linked to during pregnancy is associated with low birthweight, poor hygiene practices, unsafe drinking water, and and exposure to violence in early childhood negatively inadequate access to sanitation.22 One-third of the affects a young child’s socio-emotional development.20 world’s population lacks access to basic sanitation The effect of violence exposure can be reduced and more than one billion people defecate in the through supportive parental reactions and positive open. Latrines can reduce health risks for pregnant family routines.16 Child protection provisions within law women and young children. Adequate hygiene and enforcement and judicial systems can protect children hand washing can significantly reduce the incidence from violence and exploitation. of diarrhea. Investing in Young Children for High Returns: In Africa and Asia, access to safe water in rural areas can have a 3.4:1 benefit-to-cost ratio, and basic sanitation can have a 5-8:1 benefit-to-cost ratio.23 In Africa, South America, Europe, and Southeast Asia regions, food fortification with iron and other micronutrients can have a benefit-to-cost ratio as high as 37:1. 24 Estimates from Africa, East Asia and the Pacific, and South Asia regions indicate that salt iodization can have a benefit-to-cost ratio as high as 30:1.21 In these same regions, vitamin A can cost $3-16 per DALYa saved25,26,27 a The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death. It is estimated as the sum of the present value of future years of lifetime lost through premature mortality. Investing in Young Children for High Returns 5 Intervention Illustrative Costs Illustrative Impacts 1. Maternal education Vary substantially by country Maternal education is a significant predictor of children’s enrollment in early childhood care and education (ECCE) programs with the highest enrollment found among those children whose mothers were more highly educated6. 2. Planning for family Vary substantially by country Family planning services decrease likelihood of death due to maternal causes: control over size and spacing fertility decisions, indicated by desire for pregnancy, can lead to reduced risk of maternal mortality23. 3. Education about $13 (Mauritania)-$1,393 (Qatar) Increased parenting knowledge leads to more home stimulation and learning activities for early stimulation, per child per year for home-visiting children (effect size from 0.32 to 0.86), and in turn higher child development outcomes, growth, and program 24 including higher cognitive and language development (effect size from 0.32 to 0.97).26 development $4 (Bangladesh)-$10 (India) per child per year for national community-based programs25 4. Social assistance $156-432 per household per year Targeted income support through CCTs may reduce poverty; increase household food transfer programs for CCT programs with nutrition consumption and dietary diversity28; yield higher rates of school attendance, birth registration, component (Latin America)27 access to health services, and parental concern about the health and education of their children; they also have been found to reduce child labor and domestic violence.29 5. Prevention & Vary substantially by country Community-based interventions with paraprofessionals can reduce depressive symptoms (effect treatment of size from 0.21 to 0.62), improve maternal sensitivity and infant attachment, infant health, and parental depression time spent playing with infants.15 6. Parental leave & Vary substantially by country Parental leave for 10 weeks is associated with a reduction in rates of neonatal mortality, infant child care mortality and under-five mortality30; Government-supported childcare provision is associated with higher rates of women’s labor force participation and lower gender inequality.17 7. Child protection Vary substantially by country Violence-prevention interventions can reduce stress reactions in young children (effect size from services 0.56 to 0.91); Improving institutional environment of non-parental group residential care can lead to significant benefits in child cognitive and social-emotional competence.15 8. Access to Vary substantially by country Access to healthcare and health insurance that covers basic services positively affects the health healthcare and nutritional status of children.31 9. Micronutrient $0.20 per person per year for flour Micronutrient supplementation for pregnant women can reduce risk of low birthweight supplementation & fortification with iron, folic acid, zinc32; babies by 88% and preterm births by 97%34 ; Vitamin A supplementation can reduce risk fortification $1.20 per child per year for vitamin A of child mortality (6-59 months) by 24%20; Children whose mothers consumed iodized salt supplementation33; $0.05 per person may have 10-20% higher developmental scores and higher birth weight (3.82-6.3)38 ; Iodine per year for salt iodization20 b supplementation for pregnant mothers can reduce risk of cretinism (severely stunted physical/ mental growth) at 4 years by 27%38. 10. Access to safe $2 per household per month for rural In Latin America and Africa, improved water quality may reduce the risk of diarrhea in children water water interventions in Africa and under 5 years old by 60%.36 Asia22; $20-80 per household for water piping network35 11. Adequate $3-5 per person for community Adequate sanitation may reduce open defecation by 20% and is associated with a 0.1 standard sanitation led sanitation program; $20-50 for deviation increase in child height.37 community toilets- $100-200 per household per year for sewerage systems with treatment (South-East Asia)22 12. Hygiene and hand Negligible additional cost if included in Hygiene and hand washing may reduce incidence of diarrhea by 30%-47%.38,40 washing community nutrition programs b These illustrative costs have derived from experience in South Asia, East Asia and the Pacific, and Africa regions. 6 Stepping up Early Childhood Development Pregnancy Package Conception to Birth Major gains: prevention of maternal and deaths are caused by neonatal mortality, reduced risk of anemia hemorrhages, which are and low birthweight closely linked to anemia If they are not provided with a prenatal package of during pregnancy.44 essential services during pregnancy, women and their Iron and folic acid newborns face several risks, including maternal and supplementation neonatal mortality, anemia, and low birthweight, as for pregnant well as the associated impact on the child’s future women can growth and development. The pregnancy package reduce anemia consists of a number of key services. as well as the risk of low 13. Antenatal care: Antenatal care visits provide birthweight opportunities for healthcare providers to deliver babies. a package of services including screening tests, counseling on reduced workload, treatment for 15. Counseling identified complications and behavior change on adequate diets communication to increase women’s skills in for pregnant mothers: identifying danger signs and potential complications. Undernutrition during pregnancy UNICEF and WHO recommend a minimum of four can affect fetal growth and development. An antenatal care visits during pregnancy. Parenting estimated 800,000 newborn deaths each year can be education for expectant mothers is also important to attributed to the increased risk associated with fetal provide future mothers with key parenting skills to growth restriction.44 Counseling women on healthy improve outcomes for newborns. diets and lifestyles during pregnancy can help to 14. Iron and folic acid supplementation for ensure that they have an adequate diet, including pregnant mothers: Nearly one-quarter of maternal nutrient-rich food. Investing in Young Children for High Returns: Iron supplementation for pregnant mothers costs from $66 (African sub-region with very high rates of adult and child mortality) - $115 (Southeast Asian sub-region with high rates of adult and child mortality) per disability-adjusted-life- year (DALY) saved.45 Intervention Illustrative Costs Illustrative Impacts 13. Antenatal care $6.70–7.34 per pregnancy Antenatal visits reduce the risk of maternal and neonatal death. 21 (Uganda)41 14. Iron and folic acid $3.00 (Indonesia, Kenya, and Iron and folic acid for pregnant mothers can yield a gain of 58 g in birthweight and reduce supplementation for Mexico) per pregnancy23 the risk of anemia at term by 21%.38 pregnant mothers 15. Counseling on Vary substantially by country Counseling on adequate diet for pregnant mothers reduces the risk of low birth weight adequate diet for and stillbirths.38 pregnant mothers Investing in Young Children for High Returns 7 Birth Package Birth to 6 Months Major gains: prevention personnel are present during delivery and referral of infant morbidity facilities equipped with quality emergency obstetric and mortality, care are available. Skilled attended delivery can address and maternal the risks of birth defects and maternal mortality. mortality 17. Birth registration: Worldwide, as many as one in The ECD birth three children below the age of five are not currently package covers recorded.51 the first critical post-natal stage Birth registration is a first step to reach children with of the ‘window the services they need to fully develop. Some form of opportunity’ of birth registration is generally required for children in ECD, i.e. from to obtain a birth certificate and access to services, birth to six months. protection and opportunities throughout life. In the absence of the provision of this 18. Exclusive breastfeeding: Following early initiation package, newborns and of breastfeeding within one hour of birth, exclusive mothers may face increased breastfeeding for the first six months contributes to a risks of morbidity and mortality. child’s short and long-term health and development Beyond survival, ensuring optimal growth and through the provision of rich nutritional inputs and development is necessary. The birth package consists positive socio-emotional interaction between mother of three main sets of activities and services. and child,52 as well as avoiding diseases caused by contact with contaminated food or water. Promotion 16. Skilled attendance at delivery: Most of the of exclusive breastfeeding is one of the most promising direct causes of maternal mortality related to obstetric interventions for improving child survival in the first six complications can be addressed if skilled health months of life. Investing in Young Children for High Returns: In South Asia and sub-Saharan Africa, a package of maternal and neonatal health services costs $3,337-$6,129 per death averted and $92-$148 per DALY averted.48 Breastfeeding promotion programs cost $527-$2,000 per DALY.52 Intervention Illustrative Costs Illustrative Impacts 16. Skilled attendance Costs of attended delivery vary Clean delivery practices can prevent infections (which account for approximately 35 percent of at delivery substantially by country; newborn deaths). Institutional/skilled attended delivery can prevent asphyxia (which causes 23 $1.67 for clean birthing kits for percent of newborn deaths)21. women45 17. Birth registration $0.23 (Tanzania)-$0.83 (India) Birth registration protects children’s right to identity and access to services including access to per event of civil registration42 immunizations and healthcare, education, and social assistance. Identification can safeguard children’s rights and help protect against violation of rights, such as child labor or early marriage.43 18. Exclusive $0 to breastfeed; Infants who are breastfed are six times more likely to survive, six times less likely to die from breastfeeding $0.30-0.40 per birth to promote diarrhea, and 2.4 times less likely to die from acute respiratory infections in the first six months44; breastfeeding20 breastfeeding is also associated with higher intelligence scores (mean difference: 4.0 points).45 8 Stepping up Early Childhood Development Child Health and Development Package Birth to 5-6 Years Major gains: prevention of child mortality, supplementation can reduce reduced risk of stunting and anemia, improved deaths from diarrhea by cognitive development almost one quarter.22 The third package of ECD services covers the period 22. Prevention and from birthc to 5-6 years. The main risks of not providing treatment of acute essential services during this period are stunted malnutrition: growth, anemia, impaired cognitive development, Proven and child mortality. This package consists of six main interventions interventions/services. include complementary 19. Immunizations: Starting at birth, a complete and therapeutic course of childhood immunizations is essential in feeding to provide reducing child morbidity and mortality. According micronutrient- to the WHO, increasing coverage of PCV, Rota, and fortified and/or Hib vaccine could have prevented 1.5 million deaths enhanced complementary of children under 5 in 2002.54 According to the foods for the prevention Copenhagen Consensus, expanded immunization and treatment of moderate coverage for children is among the top ten most malnutrition among children 6–23 months of age, productive investments for countries. and community-based management of severe acute 20. Adequate, nutritious, and safe diet: After malnutrition among children under five years of age. six months of exclusive breastfeeding, mothers Community-based management of acute malnutrition should continue to breastfeed through 24 months includes (a) in-patient care for children with severe while providing complementary feeding with age- acute malnutrition with medical complications and appropriate amounts, frequency, consistency and infants under six months of age with visible signs variety of safely prepared foods. Responsive feeding of severe acute malnutrition; (b) outpatient care for practices are important, as is adequate feeding during children with severe acute malnutrition without and after illness. After two years, young children medical complications; and (c) community outreach.43 continue to need adequate, nutritious, and safe diets. 23. Deworming: Worm infections are a chronic Undernutrition leads to weakened immune systems condition that affect children’s health, nutrition, of babies and young children, putting them at a and development, and as a consequence, limit greater risk of falling sick from preventable illnesses like their ability to access and benefit from education. pneumonia and diarrhea. Nearly one-fifth of under-five Worms can cause children to become anemic and deaths could be prevented with optimal feeding.22 malnourished and can impair their mental and 21. Therapeutic zinc supplementation for diarrhea: physical development.59 Deworming is simple, Approximately 1.5 million children in the developing safe, inexpensive, and has beneficial effects on world die from diarrhea each year. Therapeutic zinc educational outcomes. c Zinc supplementation and optimal feeding should start at 6 months. Children typically receive their first deworming at one year (pregnant women should also receive deworming interventions when necessary). Investing in Young Children for High Returns 9 Investing in Young Children for High Returns: Immunizations can have a benefit-to-cost ratio up to 20:153 Zinc supplementation for diarrhea management may cost $73 (Tanzania) per DALY saved.55 Estimates from Africa, East Asia and Pacific, and South Asia regions indicate that optimal feeding may cost $500-$1,000 per DALY saved 42 and deworming can have a benefit-to-cost ratio as high as 6:1.20 Intervention Illustrative Costs Illustrative Impacts 19. Immunizations $30 (low income countries) per Immunization reduces child morbidity and mortality.53 live birth50 20. Adequate, nutritious, $40-80 per child per year42 Optimal feeding practices can reduce stunting (height-for-age Z score) by 0.25 (without food and safe diet supplements/cash transfers) to 0.41 (with food supplements/cash transfers).51 21. Therapeutic zinc $1 (India) per child per year59 Therapeutic zinc supplementation can lead to 14% fewer episodes of diarrhea and 15% fewer supplementation for episodes of severe diarrhea or dysentery; 25% fewer episodes of persistent diarrhea; 9% diarrhea reduced risk of mortality.20 22. Prevention and $200 per child for treatment of Treatment of acute malnutrition is associated with a 55% reduction in mortality.52 treatment of acute severe acute malnutrition through malnutrition community-based approach42 23. Deworming $0.25 (developing countries Deworming is associated with a 5-10% reduction in anemia in populations with high rates of globally) per child/year53 intestinal worms; one-dose of deworming drugs may increase weight by 0.58 kg.38 10 Stepping up Early Childhood Development Preschool Package 3 to 6 Years Major gain: early learning 25. Continuity to primary: During the period of time The fourth package of ECD services covers the when children move from period from 3 to 6 years. A broad range of evidence either home or an early has demonstrated that the quality of a child’s early childhood program learning experience makes a significant difference to into primary school, school preparation, participation, completion, and they experience achievement. Without adequate early childhood demanding education, young children do not have the necessary changes.67,68 skills to fully benefit from the education they receive For the transition at the primary level. The preschool package consists of to be smooth, two main interventions. children need to 24. Preprimary education: Young children be ready for school need sustained access to supportive, nurturing and, equally important, environments that provide a high degree of cognitive schools need to be ready stimulation and emotional care throughout the early for children.69,70 Evidence years.61 Compared to children who attend quality suggests that failure in the first year preprimary programs, children who enter school or two of schooling to establish basic literacy without adequate preparation are more likely to skills creates inefficiencies that reverberate through a have poor academic performance, repeat grades, child’s progression through the education system.71 and drop out of school.62,63,64,65 Beyond access, quality Young children should possess the school readiness in preprimary education is equally critical. Children skills necessary - physical health and well-being, will only benefit from increased access to ECCE if the social competence, emotional maturity, language services being provided meet core quality standards. and cognitive development, communication skills Box 1 defines quality in ECCE.61 Quality preprimary and general knowledge - in order to be able to learn programs are linked to life-long benefits for individuals effectively in school.72 Ensuring continuity between and society at large. They reduce the need for remedial early childhood and primary years is important to education or rehabilitative actions later on, including counter potential fade-out of the impact of preschools in terms of reducing the risk of incarceration and in primary school. Quality improvement in early improving welfare in adulthood.66 primary grades (integrating ECCE/early primary BOX 1: Definition of Quality Early Childhood Care and Education (ECCE) UNESCO defines the quality of the ECCE learning environment as well as the broader regulatory system. Quality in the learning environment includes various aspects such as the tone and content of teacher–child interactions, the range of play materials available, the safety and atmosphere of the physical space, the attention paid to health and nutrition, the child-centered approaches to learning, and the level of parental engagement. In addition to the learning environment itself, policies and regulations related to child-adult ratios, class or group size, teacher qualifications and training, inclusive education, and ECCE funding also are linked to ECCE quality. Adapted from UNESCO (2014) Investing in Young Children for High Returns 11 experience, teacher training on classroom strategies high-quality experienced teachers in the early grades for young children, smaller class size, etc.) can improve of primary school can help close the readiness gaps learning outcomes, school attendance, pass rates, and that young children may face.73,74 reduce dropout and repetition rates.73 Well-trained and Investing in Young Children for High Returns: Increasing preschool enrollment to 50 percent of all children in low- and middle-income countries could result in lifetime earnings gains of $14-$34 billon.31 High quality ECD programs targeting vulnerable groups in the United States have an annual rate of return of 7-16%.75,76 Intervention Illustrative Costs Illustrative Impacts 24. Preprimary $58 (Mauritania) to $3482 Quality early childhood education programs increase child development scores on one or more education (Qatar) per child per year for measures of child development (literacy, vocabulary, math, quantitative reasoning) with an effect size ECCE for 3-5 year- olds 29 ranging from 0.13 to 1.68; Preschool is associated with improved school performance in second and third grades and effects can be even larger in adolescence.31 25. Continuity to Vary substantially by Quality improvement in early primary grades (integrating ECCE/early primary experience, teacher primary country training on classroom strategies for young children, smaller class size, etc.) can improve learning outcomes, school attendance, pass rates, and reduce dropout and repetition rates.73 Summary of Integrated Packages 25 Key Interventions Development in early childhood is a multi-dimensional periods as well as throughout a child’s early years that and sequential process, with progress in one domain yield high returns and generate positive impacts on acting as a catalyst for development in other domains. the child’s growth and development. The ability of While development across the four interrelated countries to implement all 25 interventions will vary, domains of physical, cognitive, socio-emotional, and but ideally in order to address the needs of young linguistic development is cumulative throughout children and their families, a well-developed ECD early childhood, some interventions are critical during system should combine those 25 interventions which specific age sub-periods or windows of opportunity. require the contribution of multiple sectors. Figure 2 shows how the five packages of essential interventions The five packages presented above combine a total and services should be provided at different stages in a of 25 essential interventions during specific age sub- child’s life. 12 Stepping up Early Childhood Development FIGURE 2: Five Packages of Essential Interventions for Young Children and Families Pregnancy Birth 12 Months 24 Months 36 Months 54 Months 72 Months 1. Parental Support for Vulnerable Families: Planning for family size and spacing; Maternal education; Education about early stimulation, growth, and development; Parental leave and adequate childcare; Prevention and treatment Family of parental depression; Social assistance transfer programs; Child protection regulatory frameworks Support Package Health, Nutrition, and Sanitation for Families: Access to healthcare; Access to safe water; Adequate sanitation; Hygiene/handwashing; Micro-nutrient supplementation and fortification 2. Pregnancy Package 3. Antenatal care; Iron and folic acid; Birth Package Counseling on Attended delivery; adequate diets Exclusive breast feeding; Birth registration 4. Immunizations; Deworming; Prevention and treatment of acute malnutrition; Child Health and Complimentary feeding and adequate, nutritious, and safe diet; Therapeutic zinc Development Package supplementation for diarrhea 5. Preschool education early Preschool childhood and preliminary Package programs; Pre-primary education; Continuity to quality primary schools Key ECD Policy Principles While these interventions can be delivered by Given the holistic needs of young children and the individual sectors, packaging several interventions variety of settings and services in which these needs together can often be more efficient and it may yield can be met, thinking multi-sectorally in policy design greater impact. The entry points to influence young and coordinating interventions between sectors children’s development are diverse and involve improves service delivery. The following section of multiple stakeholders. Interventions in a variety of this document outlines four key principles that can sectors and areas affect ECD outcomes, including: help countries design and implement strong ECD health care and hygiene, nutrition, education, child policies and programs. Countries should (1) Prepare protection, social protection, and poverty alleviation. a multisectoral ECD diagnostic and strategy; (2) These programs can be aimed at the pregnant woman, Implement widely through effective coordination the child, the caregiver or the family as a whole. In mechanisms; (3) Create synergies and cost savings addition, interventions can take place in a variety of among interventions; and finally (4) Monitor, evaluate, environments, including: the home, at a preschool and scale up successful interventions. or child care center, a hospital or health post, or a community center. Investing in Young Children for High Returns 13 Principle 1 Conduct an ECD Diagnostic and Establish a Comprehensive Strategy In order to create well performing ECD systems, of the ECD diagnostic and taking into account costs and countries should be mindful of four policy principles. funding, countries should prioritize interventions with The first principle highlights the need to three considerations in mind: build an ECD strategy from the ground up by conducting a • Start early: The needs of the very young are key, diagnostic of existing ECD especially during the first 1,000 days of life between programs and policies in conception and 24 months. Interventions during that order to identify gaps. period have lifelong impacts on a child’s ability to As part of the Systems grow, learn, and rise out of poverty. Approach for Better • Address risk factors for poor growth and Education Results development: Four main risk factors affecting at (SABER), the World least 20-25 percent of infants and young children in Bank has recently developing countries are: (1) stunting and wasting; developed the (2) inadequate cognitive stimulation; (3) iodine SABER-ECD tool to deficiency; and (4) iron-deficiency anemia.78 Other help countries conduct priority risk factors include malaria, intrauterine such diagnostics. growth restriction, lead exposure, maternal The tool is structured depression, and exposure to violence.16 around three policy goals: (1) Establishing an Enabling • Target the most vulnerable: While a system Environment; (2) Implementing Widely; providing universal coverage for ECD interventions and (3) Monitoring and Assuring Quality. For each goal, is ideal, under budget constraints countries should three policy levers are analyzed (see Box 2), ranging from first target the most vulnerable.79 For example, home the legal framework for ECD services to the extent to visiting programs could focus on households with which service providers such as care centers or pre- stunted children and those facing higher risks of schools comply with national standards.77 On the basis delayed cognitive development. BOX 2: SABER-ECD ECD Policy Diagnostic Tool The Systems Approach for Better Education Results (SABER) was launched to help countries systematically examine their education policies. One of the domains within this initiative is SABER-Early Childhood Development (SABER-ECD), which is designed to present countries with a holistic multi-sectoral assessment of programs and policies which affect young children’s development. SABER-ECD presents three core policy goals: Establishing an Enabling Environment, Implementing Widely, and Monitoring and Assuring Quality. For each policy goal, based on evidence from impact evaluations and a benchmarking exercise of top-performing systems, a set of policy levers are presented that decision- makers can act upon in order to strengthen ECD. These policy goals and levers address the range of issues that generally constrain ECD outcomes and form a coherent package that all countries should address to improve ECD outcomes and services. Since SABER-ECD was launched in 2010, more than 35 countries have participated in the initiative. SABER- ECD has allowed Bank staff and policymakers in each of these countries to view the respective ECD system through a comparative lens and discern policy options to strengthen ECD at the national and sub-national level. In some cases, SABER-ECD analysis has led to new Bank and government investments in a country’s ECD system. 14 Stepping up Early Childhood Development BOX 3: Multiple Entry Points to Reach ECD Beneficiaries Multiple entry points to reach pregnant women, children, and their families A diverse range of entry points exist to influence young children’s development. Policies and programs in a variety of sectors and areas affect early childhood outcomes in nutrition, health care and hygiene, education, child protection, social protection, and poverty alleviation. These policies and programs can be aimed at the pregnant woman, the beneficiary child, the caregiver, or the family as a whole. Multiple stakeholders and service providers are involved in providing the 25 key interventions listed previously. In addition, early childhood interventions can take place in a variety of environments, including: the home, a preschool or child care center, a health post or hospital, or a community center. While each country may have its own multi-sector approach and established institutional arrangements and coordination mechanisms, it is important to strategically identify existing service delivery entry points to synergistically address young children’s development needs. Typically, young children can be reached through different channels and, depending on the context and age group, ECD interventions can be provided in a range of environments: center-based programs mostly focus on children ages 4 and 5 (just before their entry into primary school) and can be provided in classrooms, community centers, religious establishments, private homes, or even under a tree. Home-based ECD interventions focus on services delivered to mothers and young children to promote behavior change in health, nutrition, and parenting within the home environment. Communication campaigns targeting families with young children can also be effective strategies to influence behavior change for parents and caregivers to enhance children’s growth and development. Adapted from Nadeau et al. (2011). Principle 2 Coordinate and Implement Widely Given that children’s growth and development cannot and responsibilities are key be adequately addressed through interventions in a to avoid inefficiencies single sector, the ECD policy framework must involve and duplication. multiple ministries and agencies. Recognizing the The most efficient holistic needs of young children and the variety of way to achieve settings and services in which these needs can be intersectoral met, thinking multi-sectorally in policy design and coordination coordinating interventions between stakeholders is is to have a key to ensure effective and comprehensive ECD service contextualized delivery. Coordination must be maintained both and country- horizontally between sectors and vertically between specific approach the central government and local authorities. in accordance with the existing Typically, a Ministry of Health may be responsible for institutional the earliest years of life and a Ministry of Education arrangements. While may take over the role from preschool through basic there is no one-size-fits-all education. Institutional arrangements may vary, approach to coordination, some but each country must take a pragmatic approach clearly defined coordination mechanisms to work through existing entry points. Clear roles across sectors and institutions are essential. The Investing in Young Children for High Returns 15 intersectoral ECD commission in Jamaica illustrates transfers can provide a unique bridging function across how coordination mechanisms can work (see Box 4). sectors. These programs not only provide income support to disadvantaged families but also empower While education or health ministries often have the them to break the cycle of poverty and disadvantage lead in coordinating ECD policies, other agencies can by improving their children’s health, education, also play a leading and coordinating role. For example, and development. One example of this approach is integrated programs can be spearheaded by social Programa Juntos (see Box 5) in Peru which reaches protection agencies targeting vulnerable families. vulnerable families with a package of multisectoral Social welfare programs such as conditional cash services that has reduced child malnutrition.80 BOX 4: Early Childhood Coordination in Jamaica Multisectoral institutional arrangements for ECD In 2003, the government of Jamaica established the Early Childhood Commission (ECC) as an official agency to govern the administration of ECD programs and policies. Operating under the Ministry of Education, the ECC assists in the preparation, monitoring, and evaluation of ECD plans and programs. It acts as a coordinating agency to streamline ECD activities, manages the national ECD budget, and supervises and regulates early childhood institutions . The ECC is supervised by a Board of Commissioners, and it operates with seven subcommittees representing governmental and non-governmental organizations. All relevant sectors, including education, health, local government and community development, labor, finance, protection, and planning are represented on the Board of Commissioners. The seven subcommittees that provide technical support to the ECC board are comprised of 50 governmental and non- governmental agencies. BOX 5: Coordination of Targeted Interventions in Peru The catalyzing role of the social protection sector in ECD Social protection agencies can help coordinate targeted interventions for vulnerable children and families. In Peru, the Juntos (“together”) program launched in 2005 now reaches more than half a million disadvantaged families. The program provides conditional cash transfers worth US$38 per month (15 percent of household consumption) to mothers to help them access health, nutrition, and education services. Pregnant and breastfeeding mothers are expected to attend antenatal and postnatal check-ups (tetanus vaccination, folic acid, iron supplementation, and anti-parasite checks) and have a medically-assisted delivery. Families with under-five children must have regular check-ups for growth monitoring, receipt of fortified complementary food and vitamin supplements, vaccinations, and deworming. An evaluation suggests that the program has improved the nutritional status of children.70 Part of Juntos’ success has been credited to Grupo Apurimac, a multisectoral inter-agency working group that coordinates the delivery of transfers and packages of health and nutrition services. 16 Stepping up Early Childhood Development Principle 3 Integrate Services to Achieve Synergies and Cost Savings In order to ensure that the appropriate package of ECD of these interventions, often of the interventions is delivered to families, it is important order of 7% to 16%.75,76 Not only to take advantage of every contact with mothers and do quality ECD investments young children, and to build synergies between various have a high benefit-cost types of interventions. Integrated ECD interventions ratio, but they also have that address multiple needs of young children are a higher rate of return likely to yield the greatest results.13 For example, than interventions cognitive benefits tend to be larger with interventions directed at older combining stimulation or learning components as children and adults.83,84 compared with education or economic assistance However, investments interventions only.81 In Jamaica, stunted children who in ECD remain limited received nutritional supplements and psychosocial today. The OECD suggests stimulation scored higher on developmental tests that countries should spend than children who received only one or neither.82 While at least one percent of GDP on the positive effect of the nutrition-only intervention ECCE to ensure quality services, faded out after age 7, children who received both but most countries fall short. simulation and nutrition maintained cognitive and In a context of tight budgets, integrated or co-located educational gains over time.13 Box 6 describes the Care services can help reduce the unit cost of providing for Development approach for integrated ECD services services, among others by reducing the time and travel adopted by WHO and UNICEF. costs needed to reach beneficiaries.79 Synergies through ECD interventions are among the most cost-effective integrated service delivery are particularly important in investments a country can make in its population. The contexts where mothers and young children are difficult evidence suggests high annual rates of return to many to reach, for example, because they live in remote areas. BOX 6: Care for Child Development Approach Coordinated efforts to address health, education, and nutrition The Care for Child Development (CCD) approach considers health care encounters with young children and women as opportunities to strengthen families’ efforts to help their children grow. The CCD package provides guidance to health workers, other counselors, and community service providers on how they can help parents and other caregivers in caring for their children at home. The CCD package provides simple recommendations that health workers can share with families, for example on: 1) how to improve play, communication, and responsive feeding activities that stimulate learning of their children; and 2) how to be sensitive to the needs of children and respond appropriately. Advice is also given on how to provide targeted social support to vulnerable families to help them solve problems related to the care of young children. Advocacy materials and guidance on monitoring and evaluation are also available. An assessment of the implementation of the CCD module of Integrated Management of Childhood Illness in Central Asia led to higher developmental scores for children in intervention districts as compared to control. Improvements were also noted in parental activities with children and in health worker recommendations. In addition, two studies assessed the CCD module and identified substantial effects on home stimulation and child development. The most effective parenting programs had a well-developed curriculum, adequate training of workers, a balance of health, nutrition, and early child development components, and they benefitted from community and governmental (local or national) support.2 Investing in Young Children for High Returns 17 Principle 4 Monitor, Evaluate, and Scale Up Comprehensive monitoring and Information is needed on the volume and allocation evaluation (M&E) systems help of public financing, staff recruitment and training, as track ECD investments and well as quality and adherence to standards. Integrated assess performance, systems that track vulnerable children are especially thereby supporting useful to promote effective targeting, referrals, and effective program follow-up. The Chile Crece Contigo program is an management and example of a comprehensive monitoring and referral policymaking. system that tracks every child in the country and Collecting high facilitates the delivery of targeted health, nutrition, quality data across education, and family support services to vulnerable sectors on young families (see Box 7). children’s needs, In addition to monitoring, evaluations can provide their access to ECD an objective assessment of a project, program, or services, the delivery policy.85 Evaluations may generally address three types and performance of those of questions: descriptive, normative, and cause-and- services, and the results effect.86 Descriptive questions assess processes and are of ECD investments provides useful in identifying areas for improvement in program valuable information to program design. Normative questions assess implementation, managers and policymakers as they adjust and adapt determining whether input, activity, and output targets policies and programs. are met. Both normative and descriptive assessments Monitoring systems should include data from multiple can take into account variables such as adult-child sources. Household and child surveys are needed to ratios, program intensity, caregiver training, curriculum, assess the overall well-being of young children, their or caregiver-child interactions, to inform improvements home environment, and their health, nutritional, and in the quality of ECD program design and cognitive development. National administrative data implementation.2 Finally, cause-and-effect questions must also be compiled on levels of service delivery can be answered by impact evaluations, which and unit costs, ideally for various population groups. determine the impact a particular ECD intervention BOX 7: The National Monitoring and Referral System in Chile Chile Crece Contigo (Chile Grows with You or CCC) is a comprehensive child protection system to provide intersectoral support to children from 0 to 4 years. One innovative component of CCC is the Biopsychosocial Development Support Program which tracks the individual development of children with an online monitoring system that follows each child through the CCC system. The system tracks the child’s eligibility for and receipt of services, as well as his or her developmental outcomes. It allows service providers and policymakers to monitor the delivery of benefits and assess program impacts. Tracking starts during the mother’s initial prenatal check-up, at which point an individual scorecard is created for the child. Each of the primary actors within the CCC service network – including the family support unit, public health system, public education system, and other social services – have access to the child’s file and are required to update it as the child progresses through the different ECD services. If there is a risk of vulnerability, such as inadequate nutrition, the system identifies the required service to address the risk. Through the integrated approach to service delivery and information management, services are delivered efficiently and in time in function of each child’s needs. 18 Stepping up Early Childhood Development has on outcomes. Impact evaluations are particularly scalability of programs. Program outcome data and useful when a model (or alternative design) is being impact evaluations help in understanding what works developed and needs to be evaluated with respect to and therefore what should be scaled up. This analysis its cost-effectiveness or cost-benefit. of outcomes is particularly useful when combined with Evidence suggests that the benefits of ECD relevant cost-effectiveness and cost-benefit analysis. interventions may be large, but if programs are not For example, M&E systems in many CCT programs have of high quality, the benefits may be negligible and played an important role in informing the scale up of the programs may even be detrimental. Robust M&E CCTs and in increasing the focus of CCT programs on systems based on the regular collection and analysis ECD.87 The World Bank’s Strategic Impact Evaluation of high quality data are particularly important both in Fund is one of the funds that support impact tracking program quality and in informing the potential evaluations for ECD (see Box 8). BOX 8: ECD in the World Bank’s Strategic Impact Evaluation Fund The Strategic Impact Evaluation Fund (SIEF), launched with funding from the UK’s Department for International Development, invests in impact evaluations of innovative human development programs, and works with governments to use the findings for more effective policymaking. The fund focuses on four areas critical to healthy human development, including early childhood development programs affecting the nutritional status and cognitive, physical, and socio-emotional development of children aged 0-2 in low income countries. Supporting more than a dozen early childhood development impact evaluations across Africa, South Asia, and Latin America, the SIEF portfolio emphasizes integrated at-scale programs that package nutrition and stimulation interventions, as well as multi-sectoral programs that combine ECD interventions with existing health, social protection, and sanitation programs. Investing in Young Children for High Returns 19 Conclusion The earliest years of a child’s life failure to invest early can lead to irreversible damage represent a unique window for children. Unfortunately, most countries today fall far of opportunity to improve short of commonly accepted targets for investments individual and societal in ECD. Despite investments in the early years of life outcomes in the bringing the highest returns, this is typically the period future. For the with the lowest level of budget allocations. reduction of extreme poverty and for This document has provided a simple framework for shared prosperity, thinking about ECD investments. Five packages of investments in interventions have been identified: the family support, ECD are among the pregnancy, birth, child health and development, best investments and preschool packages. Together they comprise that countries can 25 essential interventions for optimal growth and make. When young development. children and their families In addition to these interventions, four principles have access to essential have been outlined to help countries implement health, nutrition, education, their ECD strategies: (1) Prepare an ECD diagnostic and protection services, they are and strategy; (2) Coordinate and implement widely; afforded the opportunity to learn and lead healthy (3) Integrate services to achieve synergies and and productive lives. Programs combining services can cost savings; and finally (4) Monitor, evaluate, and have especially large beneficial impacts. scale up successful interventions. By following The returns to many interventions for young children this step-by-step approach for ECD interventions, have repeatedly been shown to be larger than those policymakers and practitioners will ensure that all taking place later in a child’s life. This is in part because young children will reach their full potential. 20 Stepping up Early Childhood Development Acronyms CCC Chile Crece Contigo CCD Care for Development CCT Conditional Cash Transfer DALY Disability-Adjusted-Life-Year ECCE Early Childhood Care and Education ECD Early Childhood Development GDP Gross Domestic Product GMP Growth Monitoring and Promotion M&E Monitoring and Evaluation OECD Organization for Economic Cooperation and Development SABER Systems Approach for Better Education Results SIEF Strategic Impact Evaluation Fund UNICEF United Nations Children’s Fund WHO World Health Organization Investing in Young Children for High Returns 21 References 1 Shonkoff, J., L. Richter, J. van der Gaag, and Z. Bhutta, Z. 2012. 16 Walker, S. P., T. D. Wachs, S. Grantham-McGregor, N. N. Black, C. An integrated scientific framework for child survival and early A. Nelson, S. L. Huffman, H. Baker-Hennningham, S. M. Chang, childhood development. Pediatrics 129: 460-72. J. D. 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