Welcome to Scaling Early Childhood Development – what to read this month!
In this monthly blog – also available as a newsletter – we highlight recent advances in research, materials, tools, and practices related to how to design, implement, monitor, and evaluate scalable early childhood development (ECD) programmes in low- and middle-income countries (LMICs) worldwide. The inspiration for this new series came from Ugo Gentilini’s excellent Weekly Social Protection Links.
Scaling Early Childhood Development – what to read this month is curated by Bet Caeyers (Lead Editor, Chr. Michelsen Institute), Erika Williams (Editor, Oxford Policy Management) and Meghan Taylor (Editor, Oxford Policy Management).
Let’s begin this month with what is arguably the most complex issue related to scaling ECD programmes in LMICs: financing. A new paper by Lei Wang, Scott Rozelle and co-authors elicits Chinese parents’ willingness to pay for a one-month pass to psychosocial parenting centres offering weekly one-to-one counselling sessions, daily group reading/play activities and unlimited use of toys and books. The findings show highly elastic demand – meaning small price increases significantly reduce programme participation. This result shows that cost-sharing models – increasingly considered to achieve financial sustainability at scale – can deter participation, especially among less affluent families. Those more generally interested in parenting programmes may also want to read another new paper by the same lead authors, forthcoming in World Development, zooming in on parental preferences and practices as mediators behind the impacts of psychosocial parenting programmes.
Figure 1. Early childhood stimulation by fathers and mothers. Source: Evans and Jakiela (2024). The outcome is no. of distinct stimulating activities (e.g. singing, storytelling, playing) done with children ages 3-4 in the 72 hours before the survey.
On the theme of parenting, a new literature review by David Evans and Pamela Jakiela at the Center for Global Development offers a comprehensive review of the emerging literature regarding the involvement of fathers in parenting in LMICs. As shown in Figure 1, while early stimulation by both mothers and fathers is substantially lower in sub-Saharan Africa than in all other regions, fathers spend less time stimulating their children’s development than do mothers in almost every country in the paper’s study sample. While most parenting interventions continue to target mothers or primary caregivers, the number of programmes including or targeting fathers has increased substantially in recent years. The review reveals that interventions aimed at increasing father participation, while facing challenges in uptake, effectively enhance fathers' knowledge and participation in nurturing practices. These insights underline the untapped potential of engaging fathers more comprehensively in early childhood programmes.
There is new evidence related to centre-based care too. As urban families in LMICs increasingly move away from traditional support systems and adapt to longer working hours, the demand for quality childcare has surged. In response, informal unregulated private day-care centres are booming. In a short new editorial, Nampijja et al. bring this global challenge to the attention of academics and policymakers and collect a range of papers exploring how childcare centre models can feasibly, sustainably and effectively be delivered in low-income and complex urban-poor neighbourhoods in the global south. The study highlights how many existing facilities, often informal and privately run, struggle to provide comprehensive care, revealing significant gaps in governmental coordination and policy support. The authors call for innovative and sustainable policy interventions, community engagement, and better integration with local government structures to enhance the quality of childcare services in these challenging environments.
Moving on to social protection – a study from Côte d'Ivoire reveals the substantial benefits of unconditional cash transfers in enhancing economic stability and alleviating maternal stress among vulnerable mothers in rural communities. Led by Sharon Wolf, the research demonstrates that weekly cash transfers with no conditions attached, coupled with participation in local savings groups, markedly improve economic outcomes – increasing savings and decreasing food insecurity. While these transfers also reduce maternal stress, they appear to have minimal influence on educational engagement and maternal aspirations for children's education. This study highlights the potential of cash transfers as a tool for economic improvement in low-resource settings, though it suggests that additional strategies may be needed to impact educational outcomes directly.
More on cash transfers! A new paper by Essa Chanie Mussa, Dessie Agegnehu and Emmanuel Nshakira-Rukundo provides insights into the effectiveness of combining the conditional cash transfers of the Productive Safety Net Programme – Ethiopia's flagship social protection programme – and community-based health insurance in enhancing food security among female-headed households in the Amhara region. The study demonstrates that households enrolled in both programmes experienced significant improvements in dietary diversity and food consumption scores, as well as a notable decrease in food insecurity. “In all assessments, a combination of CBHI [community-based health insurance] and CCT [conditional cash transfers] always produced results of a larger magnitude than each of CHBI and CCT alone.” These findings advocate for policies that leverage the combined benefits of multiple social support mechanisms to effectively address food insecurity in low-resource settings.
On the topic of bundling ECD services, in a new commentary, Maureen Black and Alyssa Kowalski critically reflect on the findings of the recent EFFECTS study, a randomised controlled trial (RCT) in Tanzania studying the importance of bundling responsive caregiving and nutrition interventions. The opinion piece recognises that bundling interventions together can produce synergistic effects and create economies of effort for the workforce and families. It also cautions, however, about the complexities of implementing such comprehensive approaches and the risk of potentially attenuating rather than enhancing parenting impacts because of overwhelming or confusing caregivers. Black and Alyssa make a call for evaluations that include and compare the effectiveness of both single and bundles of interventions as well as for implementation and systems research on how to integrate successful evidence-based ECD interventions at scale.
Talking about systems research – Gupta and Khan provide an interesting comparison of the maternal healthcare-related role of community health workers in 7 developed countries and 7 South Asian developing countries (see Table 1 and Table 2, pp. 3–8 for a detailed breakdown of the roles and responsibilities of community health workers in the respective countries). The review highlights that 99% of newborn babies in high- and upper-middle-income nations benefit from the presence of a qualified midwife, doctor or nurse, while only 68% of low-income countries and 78% of LMICs receive the equivalent skilled assistance. Moreover, in developed countries, community health workers are salaried [SH1] and have good employment benefits, whereas up to 60% of community health workers in low- and lower-middle-income countries do not receive any remuneration. This highlights the choices faced by LMIC policy makers in their approach to the sourcing, selection, recruitment, training, supervision and performance management of service providers, and the implications that these have for costs, coverage and pace of scaling.
What about maternal mental health? A Nature Medicine News & Views article by Daisy Singla explores recent RCT findings on the use of anxiety-focused therapy delivered by non-specialists to prevent postnatal depression to draw lessons about how to expand the reach and scalability of perinatal mental health interventions. Singla concludes that there needs to be an increase in global pragmatic[SH2] trials that compare two or more active, evidence-based treatment approaches to determine opportunities for scaling. In addition, significant others, including fathers and extended family members, have a critical role in maternal mental health (and child development) and perinatal maternal health offers a unique opportunity to treat the family as a unit. Finally, testing for causal mediation could simplify complex treatment packages which could be more suitable for scaling. For more on mental health, also check out Janet Currie’s new article sampling the growing body of literature on the economics of child mental health.
Another important aspect related to scaling is equity and inclusion. In a new UNESCO thematic report, Soukakou et al. provide us with a comprehensive synthesis of inclusive practices of promoting quality inclusion in early childhood care and education across the following five areas: learning environments; instructional practices; relationships and supportive interactions; partnerships with families; and professional collaboration. Key takeaways? The need for a consensus on competencies for quality inclusion and the importance of multi-professional collaboration to ensure service continuity and consistency. The report also emphasises the importance of developing a monitoring assessment system to evaluate the quality of inclusive practices and to ensure continuous quality improvement efforts.
Finally, measurement! Merchant et al. assess the feasibility and acceptability of the implementation of the World Health Organization’s Global Scales for Early Development (GSED) for children aged 0–3 years in Bangladesh, Pakistan and Tanzania. This study highlights the importance of careful forward- and back-translation, the role of training in promoting data quality and the importance of designing data collection to reflect the needs and cultural priorities of research participants. Stay tuned: a second phase of this study will validate the measures in Brazil, China, Côte d'Ivoire and the Netherlands. On the topic of population-level ECD monitoring tools, Enelamah et al. share some critiques on the psychometric properties of UNICEF’s Early Childhood Development Index (ECDI) in tracking the development milestones among 3–4-year-olds in Nigeria. If you are interested in ECD assessment tools for programme evaluation, have a look at a new review by Seibel et al. of child development assessments for 0–6-year-olds in Latin American countries.