Measuring and forecasting progress in education: what about early childhood?

A recent Nature article modelled within-country inequalities in primary, secondary, and tertiary education and forecast progress towards Sustainable Development Goal (SDG) targets related to education (SDG 4). However, their paper entirely overlooks inequalities in achieving Target 4.2, which aims to achieve universal access to quality early childhood development, care and preschool education by 2030. This is an important omission because of the substantial brain, cognitive and socioemotional developments that occur in early life and because of increasing evidence of early-life learning's large impacts on subsequent education and lifetime wellbeing. We provide an overview of this evidence and use new analyses to illustrate medium- and long-term implications of early learning, first by presenting associations between pre-primary programme participation and adolescent mathematics and science test scores in 73 countries and secondly, by estimating the costs of inaction (not making pre-primary programmes universal) in terms of forgone lifetime earnings in 134 countries. We find considerable losses, comparable to or greater than current governmental expenditures on all education (as percentages of GDP), particularly in low- and lower-middle-income countries. In addition to improving primary, secondary and tertiary schooling, we conclude that to attain SDG 4 and reduce inequalities in a post-COVID era, it is essential to prioritize quality early childhood care and education, including adopting policies that support families to promote early learning and their children's education.

The principles of Nurturing Care promote human capital and mitigate adversities from preconception through adolescence.

A comprehensive evidence-based framework is needed to guide policies and programmes that enable children and adolescents to accrue the human capital required to meet the Sustainable Development Goals (SDGs). This paper proposes a comprehensive, multisectoral, multilevel life-course conceptualisation of human capital development by building on the Nurturing Care Framework (NCF), originally developed for the foundational period of growth and development through the age 3 years. Nurturing care (NC) comprises stable environments that promote children's health and nutrition, protect from threats, and provide opportunities for learning and responsive, emotionally supportive and developmentally enriching relationships. NC is fostered by families, communities, services, national policies and beyond. The principles apply across the life course, endorse equity and human rights, and promote long-term human capital. This paper presents an evidence-based argument for the extension of the NCF from preconception through adolescence (0-20 years), organised into six developmental periods: preconception/prenatal, newborn/birth, infancy/toddlerhood, preschool, middle childhood and adolescence. The proposed framework advances human capital within each developmental period by promoting resilience and adaptive developmental trajectories while mitigating negative consequences of adversities.Attaining the SDGs depends on strengthening human capital formation, extending throughout childhood and adolescence and supported by NC. Embedded in enabling laws, policies and services, the dynamic NCF components can mitigate adversities, enhance resilience and promote the well-being of marginalised groups. The life-course extension of the NCF is strategically positioned to enhance human capital, to attain the SDGs and to ensure that children or adolescents are not left behind in reaching their developmental potential.

Inequalities in early childhood care and development in low/middle-income countries: 2010-2018.

Background: Inequalities in early childhood development (ECD) tend to persist into adulthood and amplify across the life course. To date, little research on inequalities in early childhood care and development in low/middle-income countries has been available to guide governments, donors and civil society in identifying which young children and families should be targeted by policies and programmes to improve nurturing care that could prevent them from being left behind. Methods: Using data from 135 Demographic and Health Surveys and Multiple Indicator Cluster Surveys between 2010 and 2018, we assessed levels and trends of inequalities in exposure to risks of stunting or extreme poverty (under age 5; levels in 85 and trends in 40 countries), early attendance of early care and education programmes (36-59 months; 65 and 17 countries), home stimulation (36-59 months; 62 and 14 countries) and child development according to the Early Childhood Development Index (36-59 months; 60 and 13 countries). Inequalities within countries were measured as the absolute gap in three domains-child gender, household wealth and residential area-and compared across regions and country income groups. Results: 63% of children were not exposed to stunting or extreme poverty; 39% of 3-4-year olds attended early care and education; and 69% received a level of reported home stimulation defined as adequate. Sub-Saharan Africa had the lowest proportion of children not exposed to stunting or extreme poverty (45%), attending early care and education (24%) and receiving adequate home stimulation (47%). Substantial gaps in all indicators were found across country income groups, residential areas and household wealth categories. There were no significant reductions in gaps over time for a subset of countries with available data in two survey rounds. Conclusions: Available data indicate large inequalities in early experiences and outcomes. Efforts of reducing these inequalities must focus on the poorest families and those living in rural areas in the poorest countries. Improving and applying population-level measurements on ECD in more countries over time are important for ensuring equal opportunities for young children globally.

Global research priorities to accelerate programming to improve early childhood development in the sustainable development era: a CHNRI exercise.

BACKGROUND: Approximately 250 million children under the age of five in low and middle-income countries (LMICs) will not achieve their developmental potential due to poverty and stunting alone. Investments in programming to improve early childhood development (ECD) have the potential to disrupt the cycle of poverty and therefore should be prioritised. Support for ECD has increased in recent years. Nevertheless, donors and policies continue to neglect ECD, in part from lack of evidence to guide policy makers and donors about where they should focus policies and programmes. Identification and investment in research is needed to overcome these constraints and in order to achieve high quality implementation of programmes to improve ECD. METHODS: The Child Health and Nutrition Research Initiative (CHNRI) priority setting methodology was applied in order to assess research priorities for improving ECD. A group of 348 global and local experts in ECD-related research were identified and invited to generate research questions. This resulted in 406 research questions which were categorised and refined by study investigators into 54 research questions across six thematic goals which were evaluated using five criteria: answerability, effectiveness, feasibility, impact, and effect on equity. Research options were ranked by their final research priority score multiplied by 100. RESULTS: The top three research priority options from the LMIC experts came from the third thematic goal of improving the impact of interventions, whereas the top three research priority options from high-income country experts came from different goals: improving the integration of interventions, increasing the understanding of health economics and social protection strategies, and improving the impact of interventions. CONCLUSION: The results of this process highlight that priorities for future research should focus on the need for services and support to parents to provide nurturing care, and the training of health workers and non-specialists in implementation of interventions to improve ECD. Three of the six thematic goals of the present priority setting centred on interventions (ie, improving impact, implementation of interventions and improving the integration of interventions). In order to achieve higher coverage through sustainable interventions to improve ECD with equitable reach, interventions should be integrated and not be sector driven.

Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus.

Health systems are critical for health outcomes as they underpin intervention coverage and quality, promote users' rights and intervene on the social determinants of health. Governance is essential for health system endeavours as it mobilises and coordinates a multiplicity of actors and interests to realise common goals. The inherently social, political and contextualised nature of governance, and health systems more broadly, has implications for measurement, including how the health of women, children and adolescents health is viewed and assessed, and for whom. Three common lenses, each with their own views of power dynamics in policy and programme implementation, include a service delivery lens aimed at scaling effective interventions, a societal lens oriented to empowering people with rights to effect change and a systems lens concerned with creating enabling environments for adaptive learning. We illustrate the implications of each lens for the why, what and how of measuring health system drivers across micro, meso and macro health systems levels, through three examples (digital health, maternal and perinatal death surveillance and review, and multisectoral action for adolescent health). Appreciating these underpinnings of measuring health systems and governance drivers of the health of women, children and adolescents is essential for a holistic learning and action agenda that engages a wider range of stakeholders, which includes, but also goes beyond, indicator-based measurement. Without a broadening of approaches to measurement and the types of research partnerships involved, continued investments in the health of women, children and adolescents will fall short.

Scaling early child development: what are the barriers and enablers?

The Sustainable Development Goals, Global Strategy for Women's, Children's and Adolescents' Health (2016-2030) and Nurturing Care Framework all include targets to ensure children thrive However, many projects to support early childhood development (ECD) do not 'scale well' and leave large numbers of children unreached. This paper is the fifth in a series examining effective scaling of ECD programmes. This qualitative study explored experiences of scaling-up among purposively recruited implementers of ECD projects in low- and middle-income countries. Participants were sampled, by means of snowball sampling, from existing networks notably through Saving Brains®, Grand Challenges Canada®. Findings of a recent literature review on scaling-up frameworks, by the WHO, informed the development of a semistructured interview schedule. All interviews were conducted in English, via Skype, audio recorded and transcribed verbatim. Interviews were analysed using framework analysis. Framework analysis identified six major themes based on a standard programme cycle: planning and strategic choices, project design, human resources, financing and resource mobilisation, monitoring and evaluation, and leadership and partnerships. Key informants also identified an overarching theme regarding what scaling-up means. Stakeholders have not found existing literature and available frameworks helpful in guiding them to successful scale-up. Our research suggests that rather than proposing yet more theoretical guidelines or frameworks, it would be better to support stakeholders in developing organisational leadership capacity and partnership strategies to enable them to effectively apply a practical programme cycle or systematic process in their own contexts.

Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on.

OBJECTIVE: To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. SETTING: The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). METHODS: We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI's three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. PARTICIPANTS: In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. RESULTS: Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). CONCLUSION: This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.

A life-course approach to health: synergy with sustainable development goals.

A life-course approach to health encompasses strategies across individuals' lives that optimize their functional ability (taking into account the interdependence of individual, social, environmental, temporal and intergenerational factors), thereby enabling well-being and the realization of rights. The approach is a perfect fit with efforts to achieve universal health coverage and meet the sustainable development goals (SDGs). Properly applied, a life-course approach can increase the effectiveness of the former and help realize the vision of the latter, especially in ensuring health and well-being for all at all ages. Its implementation requires a shared understanding by individuals and societies of how health is shaped by multiple factors throughout life and across generations. Most studies have focused on noncommunicable disease and ageing populations in high-income countries and on epidemiological, theoretical and clinical issues. The aim of this article is to show how the life-course approach to health can be extended to all age groups, health topics and countries by building on a synthesis of existing scientific evidence, experience in different countries and advances in health strategies and programmes. A conceptual framework for the approach is presented along with implications for implementation in the areas of: (i) policy and investment; (ii) health services and systems; (iii) local, multisectoral and multistakeholder action; and (iv) measurement, monitoring and research. The SDGs provide a unique context for applying a holistic, multisectoral approach to achieving transformative outcomes for people, prosperity and the environment. A life-course approach can reinforce these efforts, particularly given its emphasis on rights and equity.

Une approche sanitaire fondée sur le parcours de vie englobe des stratégies tout au long de la vie des individus qui optimisent leur capacité fonctionnelle (en prenant en compte l'interdépendance de facteurs individuels, sociaux, environnementaux, temporels et intergénérationnels), assurant ainsi le bien-être et l'exercice des droits. Cette approche s'inscrit parfaitement dans les efforts déployés pour parvenir à une couverture sanitaire universelle et atteindre les objectifs de développement durable (ODD). Lorsqu'elle est correctement appliquée, une approche fondée sur le parcours de vie peut accroître l'efficacité de la première et aider à concrétiser l'ambition des seconds, en assurant notamment la santé et le bien-être pour tous à tous les âges. Sa mise en œuvre exige une compréhension commune par les individus et les sociétés de la manière dont la santé est façonnée par de multiples facteurs tout au long de la vie et d'une génération à l'autre. La plupart des études réalisées ont porté sur des maladies non transmissibles et le vieillissement des populations dans les pays à revenu élevé, ainsi que sur des aspects épidémiologiques, théoriques et cliniques. L'objectif de cet article est de montrer que l'approche sanitaire fondée sur le parcours de vie peut être élargie à toutes les tranches d'âge, toutes les questions de santé et tous les pays en s'appuyant sur une synthèse des données scientifiques existantes, les expériences de différents pays et l'avancement des stratégies et programmes en matière de santé. Un cadre conceptuel de l'approche est présenté ainsi que les conséquences de sa mise en œuvre sur: (i) la politique et l'investissement; (ii) les services et systèmes de santé; (iii) les actions locales, multisectorielles et multipartites; et (iv) les mesures, la surveillance et la recherche. Les ODD fournissent un contexte unique pour l'application d'une approche globale et multisectorielle en vue d'obtenir des résultats porteurs de transformation pour les individus, la prospérité et l'environnement. Une approche fondée sur le parcours de vie peut renforcer ces efforts, notamment parce qu'elle met l'accent sur les droits et l'équité.

Un enfoque basado en la salud para toda la vida engloba estrategias durante la vida de las personas, que optimizan su capacidad funcional (teniendo en cuenta la interdependencia de los factores individuales, sociales, ambientales, temporales e intergeneracionales), permitiendo así el bienestar y la realización de los derechos. El enfoque encaja perfectamente con los esfuerzos por lograr una cobertura sanitaria universal y cumplir los objetivos de desarrollo sostenible (ODS). Si se aplica correctamente, un enfoque para toda la vida puede aumentar la eficacia del primero y ayudar a alcanzar la visión de este último, especialmente para garantizar la salud y el bienestar en todas las edades. Su aplicación requiere una comprensión compartida entre individuos y sociedades sobre cómo la salud depende de múltiples factores presentes a lo largo de la vida y entre generaciones. La mayoría de los estudios se han centrado en las enfermedades no contagiosas, en el envejecimiento de la población en los países con ingresos altos y en cuestiones epidemiológicas, teóricas y clínicas. El objetivo de este artículo es mostrar cómo el enfoque basado en la salud para toda la vida se puede extender a todos los grupos de edades, temas de salud y países, mediante la creación de una síntesis de las pruebas científicas existentes, la experiencia en diferentes países y los avances en estrategias y programas de salud. Se presenta un marco conceptual del enfoque junto con las implicaciones para la aplicación en los siguientes campos: (i) política e inversión; (ii) servicios y sistemas de salud; (iii) acción local, multisectorial y de varias partes interesadas; y (iv) medición, supervisión e investigación. Los ODS proporcionan un contexto único para aplicar un enfoque holístico y multisectorial a fin de alcanzar unos resultados transformadores para las personas, la prosperidad y el medio ambiente. Un enfoque para toda la vida puede intensificar estos esfuerzos, sobre todo por su énfasis en los derechos y la equidad.

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

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.

Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment.

BACKGROUND: Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons. METHODS: International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990-2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies. RESULTS: The Policy and Programme Timeline tool shows that Tanzania's RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold. CONCLUSIONS: These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.

Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival.

Conceived in 2003 and born in 2005 with the launch of its first report and country profiles, the Countdown to 2015 for Maternal, Newborn, and Child Survival has reached its originally proposed lifespan. Major reductions in the deaths of mothers and children have occurred since Countdown's inception, even though most of the 75 priority countries failed to achieve Millennium Development Goals 4 and 5. The coverage of life-saving interventions tracked in Countdown increased steadily over time, but wide inequalities persist between and within countries. Key drivers of coverage such as financing, human resources, commodities, and conducive health policies also showed important, yet insufficient increases. As a multistakeholder initiative of more than 40 academic, international, bilateral, and civil society institutions, Countdown was successful in monitoring progress and raising the visibility of the health of mothers, newborns, and children. Lessons learned from this initiative have direct bearing on monitoring progress during the Sustainable Development Goals era.

Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions.

BACKGROUND: The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns. RESULTS: The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems. CONCLUSIONS: Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.

Enhancing the child survival agenda to promote, protect, and support early child development.

High rates of child mortality and lost developmental potential in children under 5 years of age remain important challenges and drivers of inequity in the developing world. Substantive progress has been made toward Millennium Development Goal (MDG) 4 to improve child survival, but as we move into the post-2015 sustainable development agenda, much more work is needed to ensure that all children can realize their full and holistic physical, cognitive, psychological, and socio-emotional development potential. This article presents child survival and development as a continuous and multifaceted process and suggests that a life-course perspective of child development should be at the core of future policy making, programming, and research. We suggest that increased attention to child development, beyond child survival, is key to operationalize the sustainable development goals (SDGs), address inequities, build on the demographic dividend, and maximize gains in human potential. An important step toward implementation will be to increase integration of existing interventions for child survival and child development. Integrated interventions have numerous potential benefits, including optimization of resource use, potential additive impacts across multiple domains of health and development, and opportunity to realize a more holistic approach to client-centered care. However, a notable challenge to integration is the continued division between the health sector and other sectors that support child development. Despite these barriers, empirical evidence is available to suggest that successful multisectoral coordination is feasible and leads to improved short- and long-term outcomes in human, social, and economic development.

Countdown to 2015 and beyond: fulfilling the health agenda for women and children.

The end of 2015 will signal the end of the Millennium Development Goal era, when the world can take stock of what has been achieved. The Countdown to 2015 for Maternal, Newborn, and Child Survival (Countdown) has focused its 2014 report on how much has been achieved in intervention coverage in these groups, and on how best to sustain, focus, and intensify efforts to progress for this and future generations. Our 2014 results show unfinished business in achievement of high, sustained, and equitable coverage of essential interventions. Progress has accelerated in the past decade in most Countdown countries, suggesting that further gains are possible with intensified actions. Some of the greatest coverage gaps are in family planning, interventions addressing newborn mortality, and case management of childhood diseases. Although inequities are pervasive, country successes in reaching of the poorest populations provide lessons for other countries to follow. As we transition to the next set of global goals, we must remember the centrality of data to accountability, and the importance of support of country capacity to collect and use high-quality data on intervention coverage and inequities for decision making. To fulfill the health agenda for women and children both now and beyond 2015 requires continued monitoring of country and global progress; Countdown is committed to playing its part in this effort.