Early child development, or ECD, is fundamental for the health and wellbeing of every child; however, almost 250 million children worldwide risk not reaching their full developmental potential1, 2. Recent policy frameworks, such as the Sustainable Development Goals3, the Nurturing Care Framework4, and the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-20305, envisage a world in which every child can survive and thrive. These global frameworks emphasise ECD as a gap for research and action and highlight the vast potential economic and social benefits that could occur from investing in programmes and interventions that promote ECD.
This section discusses what ECD is and why it is an important topic within global maternal and newborn health. Key global frameworks for ECD are presented, and current evidence for programmatic approaches outlined.
2. What is early child development?
Early childhood covers ages 0 to 8 years; however, the pre- and postnatal periods, particularly from pregnancy to 3 years, are the most important for children’s biological, emotional, social and physical development6, 7. At these ages, children’s brains grow very quickly – by age 3, a baby’s brain is 80% formed – and this rapid development is influenced by a child’s first experiences6. Touch, sight, taste, smell and sound are first experienced during pregnancy and early childhood, and a child’s early adaptive learning of their surroundings modifies patterns and timing of genetic expressions6. The effects of these early developmental processes last long into adulthood and have been shown to influence later social and emotional wellbeing, education attainment and economic productivity, and physical and mental health1, 6, 7. Intervening during these periods therefore provides high returns on investments.
Figure 1. The five components of the Nurturing Care Framework
The Nurturing Care Framework6, launched by the WHO, UNICEF and World Bank in 2018, outlines five components necessary for improving and promoting ECD (Figure 1). Nurturing care, which encapsulates all of these components, both optimises children’s development and protects them from the effects of adversity by enabling and encouraging their coping mechanisms. To develop socially, emotionally, physically and mentally, children need all five components of nurturing care. Caregivers are most able to provide these components when they themselves are healthy and secure, and so the concept of nurturing care must also include their health and wellbeing.
Exposure to biological and psychosocial risk factors during the pre- and postnatal periods, such as iron deficiency, intra-uterine growth restriction, environmental toxins, violence, maternal depression, family disruption, and HIV, can compromise development. Multiple and/or persistent risk factors during early childhood can lead to cumulative exposure, increasing the risk of poor health and wellbeing later in life7. Children who live in poverty, a humanitarian or crisis setting, or who have a disability, are more vulnerable and face an even greater risk and burden, and the effects of climate change, migration and economic recession are likely to increase the number of vulnerable children7, 8.
3. Informing design and implementation for early child development programmes: a series
In 2019, a series of papers titled Informing Design & Implementation for Early Child Development Programmes9 was published in Archives of Disease in Childhood. The series involved over 30 authors from more than 20 institutions and was coordinated by a team of researchers at the London School of Hygiene & Tropical Medicine. The series aimed to provide guidance to policymakers, programmers and researchers who are asking ‘how to’ – how to design, how to implement, how to monitor and evaluate, and how to finance. The series built on the evaluation of the Grand Challenges Canada® Saving Brains® portfolio and additional analyses to provide a programme cycle of key decisions for scaling up implementation, as well as actions for health professionals, researchers, and policymakers.
The series is framed around an adapted programme cycle (Figure 2); each paper corresponds to one or more steps on the cycle, providing an overview of the problem, in-depth analyses of available data, discussion of new findings, and recommendations for future action and research. The following section discusses some of the evidence and results from this series.
Figure 2. Programme cycle for design, implementation and scaling of early child development
3.1 Programmatic approaches to early child development: how to and what next?
There are multiple evidence-based programmes and interventions across the globe aimed at improving ECD. However, these are largely small-scale; to achieve the vision of a world where children can thrive, there is a need for sustainable and equitable scale-up of these programmes.
During pregnancy and early childhood, the health sector provides a key platform for reaching young children and their parents, caregivers and families to promote the domains of the Nurturing Care Framework. Early monitoring of ECD outcomes via the health sector can help to identify children who have or are at risk of developmental difficulties and can support their access to appropriate interventions and programmes10.
While the health sector provides a crucial platform during early childhood, promoting ECD requires an intersectoral approach, with strong linkages between health, education and social care sectors that tie to other national and international movements such as Universal Health Coverage and Primary Health Care. Programmes that promote ECD also require targeted contextualisation, for example within different cultural settings. This complexity has prevented standardisation of a care package for ECD. Development of more structured tools for programme design and contextual adaptation, alongside promotion of intersectoral relationships could help programme scale-up at local and national levels8, 11.
There are over 100 tools available for measuring ECD at individual and population-level, however, only a few are both accurate and feasible for use within low- and middle-income settings and there remain gaps in optimal measurement of outcomes10. Despite this plethora of tools, there has been little attention focused on measuring ECD programme coverage12. ‘Coverage’ combines both measurement of the numerator (those within the programme) and the denominator (the population in need of the programme)11. Measuring both is crucial for sustainable and equitable scaling, to ensure that programmes reach the whole population, and particularly vulnerable groups such as children with disabilities. However, this is often inconsistently defined and measured within programmes and should be a priority for scaling up ECD.
The complex and intersectoral nature of ECD is reflected in the global donor funding landscape. Between 2007 and 2016, almost US$80 billion were dispersed to programmes in low- and middle-income countries13. While this represents a large investment in ECD, the majority of these funds (US$79.1 billion) were directed at programmes addressing health and nutrition; programmes addressing child disability and early learning received much smaller amounts (US$0.7 and US$1.4 billion, respectively). This gap demonstrates imbalances in global-level funding priorities for addressing ECD13 and may hinder scale-up of programmes within some domains of the Nurturing Care Framework such as early learning and safety and security.
There are still questions surrounding large-scale implementation for ECD, and many of these relate to translation of policy into programming and action, and how to build effective partnerships and leadership across sectors8. Long-term contextual analysis of programmes and partnerships alongside improved population-level data will help develop sustainable feedback mechanisms for interventions and programmes within their context to help them to scale8, 11. Additionally, prioritising strategic partnerships across sectors, organisations, countries and regions could lead to improved cohesiveness amongst ECD implementers, helping programmes move to scale11.
ECD is a complex global issue that requires urgent and innovative solutions. The time during pregnancy and early childhood is crucial for a child’s development, and intervening during these periods provides large and sustainable returns on investment. However, too many children experience high levels of adversity and risk during these periods and are not able to access appropriate and suitable care. Current global risks such as climate change, humanitarian crises and inequality are likely to contribute to this burden, and strong intersectoral linkages as well as accountable and transparent monitoring tools are needed at all levels to maximise impact of current and new interventions and programmes.
© London School of Hygiene & Tropical Medicine 2019