Objetivo general

A healthy start in life gives each child an equal chance to thrive and grow into an adult who can make a positive contribution to society. In contrast, it becomes increasingly difficult to create a successful life course if the window of opportunity presented by the early years is missed (in terms of both time and resources).

ECD is a social determinant of health but it in turn is determined by the quality of the environments around the child – from the intimate sphere of the family to the broader spheres of governments, international agencies and civil societies which influence and play a key role in ECD outcomes (Fig. 6.2). Governments can make major and sustained improvements in the quality of environments experienced by children in society by implementing policies that take note of this powerful body of research while, at the same time, fulfilling their obligations under the CRC.

Fortunately, policy-makers are starting to understand the need to integrate ECD into public policy agendas. There is recognition of an absolute economic efficiency in investing in early years, and an understanding that the gain is large, with no risk of potential loss if the investment is done properly. The evidence from research on early years is so convincing that there is an emergent

Fig. 6.1 Development of inequalities

Source: Walker et al., 2011 (6).

Prenatal Birth Early childhood Adolescence Adulthood

10

Age

Below potential

Risk factors > protective factors Protective > risk factors

Reduction in risk factors, increase in protective factors, or intervention during a sensitive period Behavioural

competence trajectories

Brain function

Optimum Recovery Below potential Optimum

agreement among economists that the most cost-effective human capital interventions occur among young children. James Heckman, Nobel Laureate in Economics, argues: “A major refocus of policy is required to capitalize on knowledge about the life cycle of skill and health formation and the importance of the early years in creating inequality in America and in producing skills for the workforce” (

9

A key question is: which policies should countries consider implementing to improve the situation? Investment in ECD does not require a series of arcane policies but, rather, initiatives in a wide range of relevant sectors that are connected to reinforce each other. At the national level, comprehensive and intersectoral approaches to policy and decision-making work best for ECD, recognizing the importance of contextual factors as both enablers and barriers for policy implementation (see Case studies 6.1 & 6.2 and section 6.2). Although ECD outcomes tend to be more favourable in rich countries, countries such as Cuba have exemplary ECD success and tell a different story. It is clear that a commitment of 1.5–2.0% of GDP, intelligently deployed, can effectively support ECD (15). The UNICEF Innocenti Report Card is testimony to this claim. Providing a comparative analysis of the status of early childhood education and care in the top 25 affluent countries, the report ranks Scandinavian countries highest (15). Closer consideration reveals that Denmark spends 1.2% of GDP on ECD, and Sweden spends close to 2% of GDP on all preschool and school-aged children (11, 15).

Fig. 6.2 Spheres of influence on ECD

Source: Irwin, Siddiqi & Hertzman, 2007 (10).

Global environment Nation Region Re

sidential area

Individual child Family Individual child

ECD Services & Programs Relational Community

Family-friendly policies and practices clearly benefit children and families but also result in economic benefits to larger society. Globally, those societies that invest in children and families in the early years –rich or poor – have the most literate and the largest populations. These are the societies that have the best health status and lowest levels of health inequality in the world. Success in promoting ECD does not depend upon a society being wealthy. ECD programmes rely primarily on the skills of caregivers so the cost of effective programmes varies with the wage structure of a society (see Case study 6.1).

Through child- and family-friendly policies, governments must assist families to fulfil their obligations to their children by providing:

• time (e.g. adequate paid maternity leave)

• resources (e.g. income assistance)

• services (e.g. high quality ECD child-care and education programmes) to enable families of young children to create healthy and stress-free home environments for children to be born, grow and develop to their full capacity.

Case study 6.1 Child and family friendly policies in Sweden

Within the continuity of policies in a decades-long process of pioneering development of the welfare state, Sweden’s approach to early childhood is based on the underlying assumption that the life course of an individual is, in part, determined by the early years. Approximately 1.7% of GDP is invested in early childhood programmes beyond traditional health care, double the OECD average (12). For this investment, Sweden provides a truly universal access system featuring: high-quality, high-coverage prenatal care; near-monthly developmental monitoring in the first 18 months of life such that all vision, hearing, speech/language and dental problems are identified and addressed before the child starts school; universal, non- compulsory access to publicly-funded high-quality early learning and care programmes (attended by 80–90% of pre-school age children) funded and monitored nationally but organized and delivered locally, run by university educated staff; and a gradual transition from play-based to formal learning at school age that serves to avoid privileging January babies and girls or disadvantaging December babies and boys. These programmes and services are complemented by an income policy that brings virtually all families with young children above the poverty line; as well as up to 18 months paid parental leave with incentives for fathers’ participation. Internationally comparable outcomes for child development are not available but basic health outcomes are very impressive. By 2008, infant mortality had dropped to 2.3 per 1000 live births (13). Among the OECD countries, Sweden had

The environments in which children grow and develop are not strictly hierarchical but rather are truly interconnected. The family environment is the most intimate level. Residential communities (such as neighbourhoods), relational communities (such as those based on religious or other social bonds) and the ECD service environment exist at a broader level. Each of these environments (where the child actually grows up, lives and learns) is situated in a broad socioeconomic context shaped by factors at regional, national and global level. We now understand that the transactional1 _{nature of young}

children’s relationships is far more important for their growth and development than has traditionally been recognized.

Socioeconomic inequalities in developmental outcomes result from inequities in the degree to which the experiences and environmental conditions for children are nurturing. Thus, all recommendations for action stem from one overarching goal: to improve the nurturing qualities of children’s experiences in the environments in which they grow up, live and learn. A broad array of experiences and environmental conditions matter. These include those that are

1 Represents people’s ability to ‘negotiate’ different environments (based on an ecological perspective) and make decisions along the life course.

the lowest low-birth-weight rate (4.2% of live births), about half those of the United Kingdom of Great Britain and Northern Ireland (7.4%) and the United States of America (8.2%). This important predictor of child health is significantly determined by the living conditions and health of the mother (14). Finally, by 2008, Sweden was the only country to meet all of ten UNICEF benchmarks for early learning and care (15).

Sweden’s comprehensive public system for the early years evolved gradually over several decades, starting with the welfare state reforms of the post- Second World War era.  By the 1950s, a consensus emerged that social welfare programmes would never be enough to keep mothers and children out of poverty.  Therefore, mothers needed unfettered access to the labour market and policies for families with young children needed to support that goal. This consensus held throughout the period of Social Democratic political domination in Sweden. Each component of the system was developed as resources allowed, buttressed by emerging insights into the importance of the early years and the commitments made under the CRC. In the ‘neo- liberal’ political era, beginning in the 1980s, the benefits of the system and the underlying social consensus proved difficult to dislodge. Accordingly – across Finland, Sweden, Norway and Denmark – the ‘Nordic model’ of social policy has mostly survived attempts to undermine it.

intimately connected to the child, and therefore readily identifiable (e.g. quality of time and care provided by parents and caregivers; physical conditions of the child’s surroundings), but also more distal factors that in various ways influence the child’s access to nurturing conditions (e.g. whether government policies provide families and communities with sufficient income and employment, health-care resources, early childhood education, safe neighbourhoods, decent housing).