93207 EDUCATION NOTES November 2014 Investing in Young Children: Key Interventions and Principles to Ensure All Young Children Reach their Full Potential Investing in young children is one of the best investments that on the essential health interventions to address the main causes of maternal, newborn, and child deaths. At the World countries can make. A child’s earliest years present a unique Bank, the Early Childhood Development Guide for Policy window of opportunity to address inequality, break the cycle Dialogue and Project Preparation presents strategic entry of poverty, and improve a wide range of outcomes later in life. points for effective ECD program implementation in countries, A growing body of literature demonstrates that the returns including center-based programs, home-based programs, on investments in young children are substantial, particularly and conditional cash transfer and communication and media when compared to investments made at later stages in life. campaigns targeting families with young children. Yet while there is an emerging consensus that investments in early childhood development (ECD) should be a priority and This note, which is based on Denboba et al. (2014), provides can have high returns, countries continue to fall short in their an accessible introduction to key interventions and broader investments in ECD. This is due in part to budget constraints, principles that can help policy makers and practitioners think but also to the fact that ECD is complex and multi-sectoral. about how to effectively invest in ECD. There is still lack of awareness of how countries can design successful policies and scalable programs in this area. Several development partners have introduced comprehensive 25 Key Early Childhood Development frameworks to address the holistic needs of young children. Interventions UNICEF focuses on key areas of intervention for ECD, including basic health, nutrition, HIV/AIDS, education, and Within the ECD period, 25 key interventions have been protection services. The World Health Organization (WHO) identified as essential for a child’s growth and development has established specific guidelines for each developmental (see Figure 1). These interventions can be delivered through phase, including pregnancy, postnatal, baby, infant, and five packages at different stages in a child’s life: (i) the family young child health care, assisting professionals in delivering support package to be provided throughout the ECD period, (ii) improved health services for the intended beneficiaries the pregnancy package, (iii) the birth package (from birth to 6 during the specific sub-periods. The Partnership for Maternal, months), (iv) the child health and development package, and Newborn and Child Health, led by the WHO and Aga Khan (v) the preschool package. Some of the high returns to many of University, provides policymakers with specific information these interventions as packages is shown in Box 1. For the reduction of extreme poverty and for shared • Family Support Package. The family is the first and most effective support system to ensure young prosperity, investments in ECD are among the best children’s healthy growth and development. While a investments that countries can make. range of ECD interventions are age-specific, many EDUCATION NOTES others are necessary throughout the early years. diets for pregnant mothers. If these services are not Based on a two-generation approach, which focuses provided during pregnancy, women and their newborns on creating opportunities for and addressing the needs face several risks, including maternal and neonatal of parents and children, the family support package mortality, anemia, and low birth weight, as well as the provides parental support for vulnerable families through associated impact on the child’s future growth and clusters of interventions and services, including: (1) development. maternal education; (2) planning for family size and spacing; (3) parenting and social networks of support and • Birth Package. The birth package covers the first critical community education about growth and development; post-natal stage of the “windows of opportunity” in ECD, (4) social assistance transfer programs; (5) prevention i.e. from birth to 6 months. It consists of three main sets and treatment of parental depression; (6) parental leave of activities: (16) skilled attendance at delivery; (17) and adequate child care; (7) child protection services birth registration; and (18) exclusive breastfeeding. In and provision of health, nutrition, and sanitation facilities the absence of the provision of this package, newborns for families; (8) access to health care, including for and mothers may face increased risks of morbidity and prevention and treatment of critical public health issues mortality. Beyond survival, ensuring optimal growth and such as malaria; (9) micronutrient supplementation and development is necessary. fortification; (10) access to safe water; (11) adequate sanitation; and (12) hand washing education. • Child Health and Development Package. The child health and development package of ECD services covers • Pregnancy Package. The pregnancy package consists the period from birth to 5-6 years. This package consists of a number of key services from conception to birth: (13) of six main interventions/services: (19) immunizations; prenatal care; (14) iron and folic acid supplementation (20) adequate, nutritious, and safe diet; (21) therapeutic for pregnant mothers; and (15) counseling on adequate zinc supplementation for diarrhea; (22) prevention and Figure 1: 25 Key Interventions for Young Children and Families Source: Denboba et al. (2014) November 2014 treatment of acute malnutrition; and (23) deworming. should be mindful of four policy principles: They should The main risks of not providing essential services (1) prepare a multi-sectoral ECD diagnostic and strategy; during this period are stunted growth, anemia, (2) implement widely through effective coordination impaired cognitive development, and child mortality. mechanisms; (3) create synergies and cost savings among interventions; and finally (4) monitor, evaluate, and scale up • Preschool Package. The quality of a child’s successful interventions. early learning experience makes a difference for school preparation, participation, completion, and • ECD Diagnostic and Strategy. Countries need to build achievement. The preschool package consists of an ECD strategy from the ground up by conducting a two main interventions: (24) pre-primary education diagnostic of existing ECD programs and policies in order or preschools; and (25) continuity through primary to identify gaps. The World Bank’s Systems Approach education (smooth transition into formal schooling). for Better Education Results (SABER) tool for ECD Quality improvement in early primary grades can can inform such diagnostics. On the basis of the ECD improve learning outcomes, school attendance, diagnostic and taking into account costs and available pass rates, and promotions, while reducing dropout funding, countries should prioritize interventions with and repetition rates. Well-trained and high-quality three considerations in mind: (i) Start early – interventions experienced teachers in the early grades of primary during the first 1,000 days have lifelong impacts on a school can help close the readiness gaps that young child’s ability to grow, learn, and rise out of poverty; (ii) address risk factors for poor growth and development – children may face. four key risk factors affecting at least 20-25 percent of infants and young children in developing countries are Four Policy Principles Help Create stunting and wasting, inadequate cognitive stimulation, iodine deficiency, and iron-deficiency anemia; and (iii) Well-Performing ECD Systems target the most vulnerable – while a system providing universal coverage for ECD interventions is ideal, countries under budget constraints should first target In addition to key interventions and integrated packages, the most vulnerable. in order to create well-performing ECD systems, countries Box 1: Examples of Interventions with High Returns Family Support Package: In Africa and Asia, access to safe water in rural areas can have a 3.4 to 1 benefit-to- cost ratio, and basic sanitation can have a 5-8 to 1 benefit-to-cost ratio. In the 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. Estimates from the 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. In these same regions, vitamin A can cost $3-$16 per disability-adjusted life year (DALY) saved. Pregnancy package: Iron supplementation for pregnant mothers costs from $66 (African sub-region with very high adult and high child mortality) to $115 (Southeast Asian sub-region with high rates of adult and child mortality) per DALY saved. Birth Package: In South Asia and Sub-Saharan Africa, a package of maternal and neonatal health services costs from $3,337 to $6,129 per death averted and between $92 and $148 per DALY averted. Breastfeeding promotion programs cost from $527 to $2,000 per DALY. Child Health and Development Package: Immunizations can have a benefit-to-cost ratio up to 20:1. Zinc supplementation for diarrhea management may cost $73 (Tanzania) per DALY saved. Estimates from the Africa, East Asia and the Pacific, and South Asia regions indicate that optimal feeding may cost $500-$1,000 per DALY saved, and deworming can have a benefit-to-cost ratio as high as 6:1. Preschool Package: Increasing preschool enrollment to 50 percent of all children in low- and middle-income countries could result in lifetime earnings gains from $14 billion-$34 billon. High quality ECD programs targeting vulnerable groups in the United States have an annual rate of return of 7-16 percent. February 2012 EDUCATION NOTES • Coordination and Wide Implementation. Given include data from multiple sources, including household that children’s growth and development cannot be and child surveys and national administrative data. adequately addressed through interventions in a Integrated systems that track vulnerable children single sector, the ECD policy framework must involve are especially useful to promote effective targeting, multiple ministries and agencies. Coordination must referrals, and follow-up. In addition to monitoring, be maintained both horizontally between sectors and evaluations provide objective assessments of a project, vertically between the central government and local program, or policy. authorities. Institutional arrangements may vary, but each country must take a pragmatic approach to work through existing entry points. Clear roles and responsibilities are key to avoid inefficiencies and Ensuring All Young Children Reach duplication. their Full Potential • Integration of Services. In order to ensure that The earliest years of a child’s life represent a unique window appropriate packages of ECD interventions are of opportunity to improve individual and societal outcomes in delivered to families, it is important to take advantage of the future. For the reduction of extreme poverty and for shared every contact with mothers and young children, and to poverty, investments in ECD are among the best investments build synergies between various types of interventions. that countries can make. The returns to many interventions Integrated ECD interventions that address multiple have been shown to be larger than those taking place later needs of young children are likely to yield the greatest in a child’s life. This is in part because failure to invest early results. For example, cognitive benefits tend to be can lead to irreversible damage for children. When young larger with interventions combining stimulation or children and their families have access to the essential health, learning components as compared with education or nutrition, education, and protection services, they are afforded economic assistance interventions only. In a context the opportunity to learn and lead healthy and productive lives. of tight budgets, integrated or co-located services can Programs combining services can have especially large help reduce the unit cost of providing services, among beneficial impacts. others by reducing the time and travel costs needed to reach beneficiaries. Synergies through integrated This note has provided a simple framework for thinking about service delivery are particularly important in contexts ECD investments. The five packages presented combine 25 where mothers and young children are difficult to reach essential interventions that are age-specific. The ability of (for example, because they live in remote areas). countries to implement all 25 interventions will vary, but ideally, in order to address the needs of young children and their • Monitoring, Evaluation, and Scaling Up. families, well-developed ECD systems should invest in those Comprehensive monitoring and evaluation (M&E) interventions. In addition, four principles have been outlined to systems help track ECD investments and assess help countries implement ECD strategies: (1) prepare an ECD performance, thereby supporting effective program diagnostic and strategy; (2) implement widely and coordinate; management and policymaking. Countries should (3) create synergies and cost savings among interventions; collect high-quality data across sectors on young and finally (4) monitor, evaluate, and scale up successful children’s needs, their access to ECD services, the interventions. Following such an approach can help policy delivery and performance of those services, and the makers and practitioners ensure that all young children will results of ECD investments. Monitoring systems should reach their full potential. Reference Denboba, A., Sayre, R., Wodon, Q., Elder, L., Rawlings, L., and Lombardi, J., 2014, Stepping up Early Childhood Development: Investing in Young Children for High Returns. Washington, DC: The World Bank. Education Notes is a series produced by the World Bank to share lessons learned from innovative approaches to improving education practice and policy around the globe. Background work for this piece was done with support from the Children Investment Fund Foundation. For additional information or hard copies, please go to www.worldbank.org/education. Authors: A. Denboba, R. Sayre, Q. Wodon, L. Elder, L. Rawlings, and J. Lombardi. Photo Credit: © Aisha Faquir/World Bank