Originally published in the Saturday Weekend Argus on 16 September 2017.
It’s time for a major shift in how we plan for Early Childhood Development (ECD), as a government and a country to ensure the best outcomes for our children. ECD has been one of the government’s development priorities since 2010. Since then, we have seen increased budgets and systems allocated to a massification programme. So, why have we not seen the promised returns, such as improved education outcomes and lower levels of inequality?
ECD massification is the government’s main approach primarily making more centres and ECD subsidies available but it hasn’t worked. South Africa adopted the National Integrated Early Childhood Development Policy in 2016. It says that ECD is a period of development from birth until children enter formal school. During that time, they and their parents must receive appropriate supportive services, especially in the first 1 000 days of life. Why is ECD so important, and especially in the first two years? The brain develops faster in early childhood than at any other period, laying the foundations for learning and education potential later in life. During this phase, exposure to risk and adversity has the most potential for harm, but it is also the period during which preventive and protective interventions have the greatest benefit.
The majority of children in South Africa are exposed to development risks and need appropriate care from birth. Young children require the correct nutrition, caring interactions with parents and caregivers, and a safe and stimulating environment. Parents need support to offer their babies optimal health, growth and development. ECD centres are not best placed to provide care in the first two years. Care at home by a parent or caregiver is better, and where there are no other options, it should be well-supported to ensure good quality of care. Therefore, the ECD massification approach is a poor fit with the science and the country’s needs. Where then should we invest our time and money for quality essential services in the early years?
Early childhood development plans are important for our children’s future.
Investing in our health system’s scope for ECD services during pregnancy and the first two years of life is easier, less costly and more effective than trying to intervene later in preschool and formal education settings. By the time children reach three years old, and enter ECD centres, it is too late. We invest so much time and money in these centres, yet we have missed the window of opportunity. We then face the risk that their brains will not have developed optimally to support future learning and development it is a case of too little too late. The health system, because it already reaches nearly every mother and child, is the most feasible platform from which to launch services. Its extensive primary health care platform includes both home-based and clinic visits just at the right time in a child’s life. Can the health system do this? Yes, the policy and service delivery footprint is in place. The foundations just need to be strengthened.
But, a major gap is parenting support. There is strong evidence that an expanded health package which includes support to parents is feasible, cost-effective and improves outcomes for children. These should be integrated into the standard package of maternal and child health services provided. In addition, health workers should ensure early identification of developmental difficulties and disabilities, as well as access to early intervention for these children and their families. It is for these reasons that the National Integrated ECD Policy requires the Department of Health to develop and implement an integrated and expanded national home, community and facility-based support programme for pregnant women, mothers and infants in the first two years of life. These would strengthen the positive developments already in place: For example, the Road to Health Booklet given to all infants at birth is being revised to ensure that all infants receive developmentally supportive services. But, there are missed opportunities for increasing access to ECD services through the health system.
The Minister of Health recently spoke of two initiatives, the NHI funding model and the Primary Health Care (PHC) re-engineering initiatives which are the department’s responses to ensuring equity in access to health care. In the case of children, there is a strong focus on school health as the entry point for prevention and promotion. In his Budget speech in May 2017, the minister noted that 3.2 million schoolchildren had been screened for language, vision, hearing, and oral health. Of these, 119 340 were identified as having vision problems, 34 094 hearing problems, and 8 891 have speech problems. For these children, this may be the first time these difficulties have been identified and for many it may be too late for effective remediation to overcome the barriers to learning.
Let us take the case of vision as an example. Vision impairment in the early years of a child’s life comes at an enormous cost for the child and the country’s development. Almost all of children’s early development depends on their vision. If they cannot see, their development and learning will, without early identification and appropriate support, be severely compromised. The major health systems-strengthening initiatives that are taking place must be revisited through the early child development lens. Early child development, and not just survival, should be at the centre. The public health system should be re-engineered to ensure the delivery of all essential ECD services through the public health system.
The shifts that should take place within the health system are clear. Achieving them is a more complex task. It requires leadership within the health sector, and at the highest levels of government. To ensure ECD is a priority it should be included in the service delivery agreement between the Presidency and the Minister of Health. Parliament too should be more vocal in profiling and monitoring ECD through the health system. Civil society is an equally important leader. It has moved to play this role more effectively by establishing a child development working group within the South African Civil Society for Women’s, Adolescent and Children’s Health SACSoWACH. This is a national coalition for coordinating civil society’s advocacy for more effective women, children’s and adolescent health and development systems.
Martin, Orbis Africa and Slemming’s Division of Community Paediatrics at the University of the Witwatersrand, write in their capacity as members of SACSoWACH.