Elsevier

The Lancet

Volume 389, Issue 10064, 7–13 January 2017, Pages 103-118
The Lancet

Series
Investing in the foundation of sustainable development: pathways to scale up for early childhood development

https://doi.org/10.1016/S0140-6736(16)31698-1Get rights and content

Summary

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Introduction

The first Sustainable Development Goal (SDG) is to “ensure that all human beings can fulfil their potential in dignity and equality”.1 Protecting, promoting, and supporting early childhood development is essential to enable everyone to reach their full human potential.

In 2007, a Lancet Series estimated that 200 million children younger than 5 years in low-income and middle-income countries (LMICs) were at elevated risk of not reaching their human potential.2 A second Lancet Series in 2011 identified risks and protective factors, and growing evidence of the effectiveness of interventions to prevent loss of human potential.3, 4

In this Series on early childhood development, Paper 1 takes stock of what has been achieved in the era of the Millennium Development Goals (MDGs).5 Paper 2 reviews effective interventions and new findings in neuroscience and genetics.6 Scientific evidence confirms conception to age 3 years as the time during which adverse exposures exert the greatest harm, and effective interventions the greatest benefit. The development of young children has been neglected to date in favour of emphasis on survival and preparation for school. For this reason, the focus in this paper is on optimisation of development at scale during early childhood.6

We argue that the burden of poor development is larger than currently estimated because we lack global data to include additional risk factors. This burden makes it imperative to scale up effective interventions to protect, promote, and support early childhood development. We identify crucial elements of the pathways to successful scale-up, including political prioritisation, creation of supportive policy environments, the use of existing delivery systems to build further efforts, and affordability. Action in all sectors is important to promote early childhood development, particularly in education and in social and child protection.

Key messages

  • The burden of poor child development is currently underestimated because risks to health and wellbeing go beyond stunting and extreme poverty.

  • Effective interventions for early childhood development are now available and can feasibly be integrated into existing systems in health, education, and social and child protection.

  • The scale-up of early child development programmes rests on political prioritisation of efforts to address deep social problems such as poverty, inequality, and social exclusion through interventions starting early in the life course.

  • Policies that alleviate poverty and buttress family resources create a supportive environment to promote, protect, and support early childhood development at scale.

  • Health and nutrition services are ideal starting points to scale up interventions for early childhood development. Efforts to promote nurturing care of young children built onto existing services for maternal and child health and nutrition are affordable.

  • Societies around the world pay a high price, now and into the future, for not acting to protect children and promote early child development. The 43% of children younger than 5 years of age in low-income and middle-income countries, who are at elevated risk of poor development because of stunting or extreme poverty, are likely to forego about a quarter of average adult income per year. The benefits forfeited at a country level can be up to two times the gross domestic product spent on health.

  • Services and interventions to support early childhood development are essential to ensuring that everyone reaches their potential over the life course and into the next generation, the vision that is core to the Sustainable Development Goals.

In this paper, we highlight the role of the health and nutrition sector as an entry point to scaling up of programmes for early childhood development. It has extensive reach to women and children during the crucial period from conception throughout early childhood, and is thus well placed to deliver early childhood development services to women, families, and the youngest children, together with education, and social and child protection. Further, there is good evidence of effectiveness, feasibility, and affordability of inclusion of interventions for early childhood development in reproductive, maternal, newborn, and child health (RMNCH) services. UNESCO,7, 8, 9 UNICEF,10 the World Bank,11 and other agencies12 are committed to promotion of early childhood development, and WHO's commitment is expressed in leadership of the Global Strategy for Women's, Children's and Adolescents' Health 2016–2030. Finally, the Strategy, supported under the UN Secretary General's Every Women Every Child initiative, offers new opportunities for linking child health, nutrition, and development.13

We address affordability by estimating the additional costs of including two scalable, evidence-based interventions for child development in the existing maternal and child health package, and the probable costs of inaction to both individuals and societies. We conclude with a call for actions that are essential for enabling all children to begin life with improved prospects for health, prosperity, and equality, essential to achieve the SDGs in “strengthened global solidarity”.

Section snippets

Millions of young children are at risk of falling behind

“There can be no equality of opportunity without…appropriate stimulation, nurturing, and nutrition for infants and young children. Conditions of poverty, toxic stress and conflict will have produced such damage that they may never be able to make the best of any future opportunities. If your brain won't let you learn and adapt in a fast changing world, you won't prosper and, neither will society.”

World Bank Group President Jim Yong Kim, Oct 1, 2015

250 million children (43%) younger than 5 years

A multi-sectoral framework to promote the development of young children across the life course

Child development is part of the life course, including preconceptual health and wellbeing of adolescents and continuing into the next generation of young people who grow up and become parents. Promotion of health and wellbeing across the life course requires interventions through services and programmes of several sectors, most notably health and nutrition, education, and child and social protection, in the context of a supportive environment of policies, cross-sectoral coordination, and

Overview

We identify several elements critical to scale up programmes,23, 24 including political prioritisation, implementation of policies that enable families to provide young children with nurturing care, delivery systems through which effective interventions can be scaled feasibly, governance structures to ensure that young children's holistic needs are addressed, and affordability.

Political prioritisation of early childhood development and financing

Many HICs have long-running, large-scale programmes for early childhood development that are led and financed by

The personal and societal costs of inaction

Interventions to integrate and promote child development within RMNCH services are feasible (panel 3) and affordable (table 2). In this section, we demonstrate that the costs of not acting immediately to expand services to improve early childhood development are high for individuals and their families, as well as for societies.

To estimate the lifelong disadvantage for individuals of global inaction, we updated the average percentage loss of adult income per child at risk of suboptimal

Pathways to scaling

“The Sustainable Development Goals recognise that early childhood development can help drive the transformation we hope to achieve over the next 15 years.”

UN Secretary-General Ban Ki-moon, Sept 22, 2015.

In line with global strategies and action frameworks that support the SDGs,87, 88 we suggest five actions to accelerate global scale-up of early childhood development across multiple sectors that reach the most disadvantaged children.

Strengthen multisectoral coordination in support of early childhood development and facilitate community engagement

In many countries, services for early childhood development are provided through a disjointed set of non-governmental organisations that can be brought together with government services, as has been done in the Chile Crece Contigo programme (panel 2). Bridges must be built between health and nutrition, education, and social and child protection, among others, to address the multiple needs of young children, especially the most vulnerable.

Often, even when high-level horizontal coordination is

Conclusion

Strong biological, psychosocial, and economic arguments exist for intervening as early as possible to promote, protect, and support children's development, specifically during pregnancy and the first 2–3 years.5, 6 An emphasis on the first years of life is articulated within a life course perspective that also requires quality provisions at older ages, especially during child day care and preschool, following on through schooling and into adolescence so as to capitalise on dynamic

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