Early child development and the global strategy for women’s, Children’s and Adolescents’ health

Early childhood development is crucial to achieving the Sustainable Development Goals. Target 4.2 of Goal 4 addresses the subject directly, but more broadly meeting the goals will require young children not only to survive but also to thrive. In this article, the World Health Organization’s Flavia Bustreo explains how the Global Strategy for Women’s, Children’s and Adolescents’ Health links to the SDGs, providing a platform for governments and stakeholders to act together for young children.

Significant gains have been made in the past quarter of a century in reducing child mortality. There are an additional 48 million children alive today than would have been were the child mortality rate to have remained at its 1990 level (UNICEF, 2015). These gains are remarkable by any metric but as the global health community began considering the transition from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs) it became increasingly clear that more than simply survival was at stake. We will not achieve the SDGs by only focusing on the survival agenda – of course, children need to survive, but they also need to be healthy and develop to their full potential in order to contribute meaningfully to the transformation needed to achieve the SDGs.

More than 200 million children globally will fail to reach their full physical, cognitive, psychological and/or socio-emotional potential due to poverty, poor health, insufficient care and stimulation, and other risk factors to early childhood development (Grantham-McGregor et al., 2007). In addition, many other children do not reach their full potential due to lack of access to essential interventions or the lack of quality care. New health threats also impose a toll as currently demonstrated by the Zika virus outbreak. Not only do parents and caregivers want their children to survive, they want them to thrive and to become economically productive, emotionally stable and socially competent citizens (Chan, 2013).

Today, the evidence about the lifelong benefits of investing in early child development (ECD) is stronger than ever before and the cost of inaction is massive (Chan, 2013). In this context, ECD is now recognised as a domain of global importance that requires increased attention and funding and, to this effect, specific targets and indicators have been included in the Sustainable Development Goal framework and the United Nations Secretary General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (Chan, 2013; Lake and Chan, 2014).

Recent advances in neuroscience and what has become known as the ‘new science of child development’ have provided evidence of the foundational importance of the period from pre-conception to the end of the third year of life. Significant brain development, socio-emotional development, and nutritional status all have their foundations laid during this period and in many cases – particularly in environments characterised by toxic stress – interventions to protect, promote and support child development have the potential to generate a massive dividend (Garner et al., 2012; Shonkoff et al., 2012). It is during the early years that the architecture of the brain is built, with the neural connections forming at the greatest speed, affecting the capacity to learn and engage in mutually reinforcing social interactions with others. In addition, young infants and children develop self-regulation skills essential for reducing aggression and improving social cooperation (Murray, 2014).

Nurturing care in the home, with caregivers who are sensitive and responsive to children’s needs, is essential. Evidence increasingly shows how implementing early interventions that strengthen caregiver–child interactions, such as integrated early stimulation and nutrition interventions (Walker et al., 1991) or home visiting by nurses or by paraprofessionals (Olds et al., 2002; Cooper et al., 2009), can improve academic attainment, reduce violence and crime (Reynolds et al., 2001) and can reduce health inequities (Marmot et al., 2008). Importantly, there is a burgeoning evidence base on how early interventions are cost-effective (Heckman, 2006), and lead to improvements in adult economic productivity (Campbell et al., 2014), with estimated annual social rates of return between 7% and 10% (Heckman et al., 2010) and an increase of 25% in the earnings in adulthood of people who received an early stimulation and nutrition intervention (Gertler et al., 2014). While the scientific evidence is clear, the donor and policy neglect of ECD has been striking. There are many reasons for this, including the fact that programmes to support early child development require the inputs from multiple stakeholders across sectors such as health, education and social protection. Furthermore, differences around terminology and framing of ECD have prevented governments and development partners from taking authoritative action (Frameworks Institute, 2007).

The launch of the Sustainable Development Goals has provided a new impetus to the early child development target (Target 4.2: by 2030 ensure that all girls and boys have access to quality early childhood development) (United Nations, 2015). Linked to the SDGs is the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) where one of the core objectives is to ensure that all women, children and adolescents have an equal chance to thrive (and not simply survive) (Every Woman, Every Child, 2015). Not only Target 4.2 but all 17 targets and nine action areas in the Global Strategy are in one way or another related to ECD. They provide a roadmap for countries to develop comprehensive national plans with effective interventions that optimise early child development, within the health sector and in other sectors that address critical determinants of health. Moreover, early child development is essential for attaining multiple SDGs and unless ECD is prioritised, so as to inform policy and programmatic implementation, it is unlikely that many of the SDG targets will be reached (Britto, 2015).

Interventions are needed for children that ensure adequate nutrition, optimal physical and mental health, as well as the support and materials to enhance their cognitive, socio-emotional development. The health sector has a crucial role to play, given its reach to families and children in particular from conception, through pregnancy and through to the early years of a child’s life. A promising intervention to improve responsive care and stimulation among young children are the WHO/UNICEF Care for Child Development package (2012). Care for Child Development is an evidence-based package and is currently being implemented in countries in five continents: Africa, Asia, Australia and the Western Pacific, Europe, and Central and South America, including among refugee communities such as those in Lebanon. The intervention is uniquely well placed to be integrated within existing maternal and child health services and enhances the quality of care. It enables trained healthcare providers to assess caregiver–child interactions, counselling caregivers on appropriate childcare practices including child stimulation and opportunities for early learning, and offering help to solve problems. The intervention has also been effectively included in childcare services, preschool education, child protection services, and social protection schemes, with positive results (Yousafzai and Aboud, 2014).

This highlights the need for a life course approach, including pre-conception and mental health. Rates of depression and anxiety disorders across the perinatal period are of particular concern in many low- and middle-income countries and addressing them is a fundamental public health issue both for the mother or caregiver, and for the infant and child (Honikman et al., 2012; Tsai and Tomlinson, 2015). The WHO’s Thinking Healthy Programme is a low-intensity, evidence-based psychological intervention where community health workers are trained to reduce prenatal depression through cognitive behavioural techniques (Rahman et al., 2008) and is currently being implemented in a host of countries. Cross-sectoral approaches with education and nutrition are essential – the health sector cannot do this alone. Leadership needs to be strengthened in order to ensure a coherent programme across the continuum of care rather than separate vertical interventions that address a single health concern (Tomlinson et al., 2014).

Strong programmes are also essential because new risk factors for child development can arise at any time. Since the middle of 2015, thousands of infants have been born with microcephaly due to infection with Zika virus – the epicentre of the outbreak being in Brazil (Adibi et al., 2016). The consequences of congenital Zika virus infection are lifelong and infants and children with microcephaly are likely to suffer from seizures, intellectual disability, feeding problems, developmental delay and hearing and vision problems (Miranda- Filho et al., 2016). Developmental delay places a significant economic burden on societies, and children and adults with intellectual disabilities face discrimination and violations of their human rights and are vulnerable to experiencing extensive health inequalities (Ouellette-Kuntz, 2005). Mitigating the impact on affected women and caregivers is essential and countries must be helped to strengthen care for pregnant women and families of infants and children with microcephaly and other neurological complications (WHO, 2016).

We are now at a unique moment in time as the Sustainable Development Goals and the Global Strategy for Women’s, Children’s and Adolescents’ Health provide the platform for governments and all relevant stakeholders to engage in concerted action for early child development. The goals and targets are clear and new financing opportunities, such as the Global Financing Facility, have been established (Desalegn et al., 2015). The time is right for all stakeholders to make firm commitments and translate these into action. Countries such as Chile and South Africa, through their programmes of ‘Crece Contigo’ and First Grade respectively, have demonstrated that it is possible to establish broad- based government-led programmes in support of early child development and implement them at scale. The High-level Advisory Group and the Independent Accountability Panel established by the UN Secretary-General in support of women’s, children’s and adolescents’ health are future channels to elevate the attention to ECD and monitor progress towards the relevant goals and targets (United Nations, 2015; Every Woman, Every Child, 2016). The evidence is clear: compromised early child development is a threat to human well-being and is central to national economic and social development, security and peace. We know enough to move from small projects to fully fledged national programmes. At the same time, we must continue to demonstrate, learn and enhance our knowledge of what works and how to reduce inequities in health and developmental outcomes of young children, thereby promoting human capital along the life course. The future of mankind depends on whether we succeed; the lives of current and future generations are hanging in the balance.

References can be found in the PDF version of the article.