Financing Investments in Young Children Globally: Summary of a Joint Workshop by the Institute of Medicine, National Research Council, and The Centre for Early Childhood Education and Development, Ambedkar University, Delhi (2015)

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Linking Financing and Outcomes in Early Childhood Development

Speakers reflected on the ways to link financing to outcomes. Some speakers focused on an essential package of services for children and the need to evaluate sets of outcomes, taking a holistic approach to evaluating programs for young children. Others emphasized the need to build local evidence to inform policy makers. Speakers also looked to results-based financing as a model to achieve desired outcomes.

THE COST OF INACTION: A PRIORITY-SETTING FRAMEWORK FOR INVESTMENT¹

Chris Desmond of the Human Sciences Research Council noted the difficulty in developing an essential package of services in early child development because of the challenge of prioritizing some outcomes over others. He noted that those in the field of early childhood development tend to prefer to talk about where they would like to end up rather than how to get there from where they are now. In that regard, he proposed three points of consideration when setting investment priorities.

First, interventions should be evaluated in sets, not individually, and across a range of outcomes. Child development involves several different inputs, many of which are added collectively and balanced together to achieve desired outcomes. Evaluating sets of interventions therefore

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¹ This section summarizes information presented by Chris Desmond, Human Sciences Research Council, South Africa.

makes more sense and adds more value than evaluating individual interventions on their own. Desmond analogized this concept by comparing early childhood development initiatives to following a recipe. When baking, a cook adds all the ingredients at the beginning, balancing each item and ensuring that all complementary ingredients are present. Once completed, if prepared incorrectly, the dish cannot be saved by having the cook go back in time and add more elements. Desmond said this example is truer for early childhood development than the common idea of a production line—adding one item and then another at a later date, hoping for optimal results.

Further stressing a collective evaluation of initiatives, Desmond stated that interventions often occur in contexts where other services are already in place, and interaction with those other services might yield synergistic long-term outcomes. For example, children who receive early childhood services and have better access to primary and secondary education will benefit more from that early intervention than students who lack the later interventions, according to Desmond. If evaluating the early childhood intervention on its own, this evidence could lead stakeholders to prioritize children who are likely to receive the additional services, for example in an incentive-based financing model, thus further widening inequities, Desmond stated. On the other hand, if early childhood services are evaluated in conjunction with primary and secondary school interventions, stakeholders would have a more accurate picture of child development along the life span, causing them to shift resources to those who need them the most.

In discussing methods used to evaluate outcomes for children, Desmond questioned the status of the randomized control trial as the “gold standard.” Although randomized control trials are suitable for clinical research, he noted that interventions “on the ground” are rarely implemented in isolation, and “everything affects everything.” He suggested that traditional observational studies might, at times, be more useful because econometric analysis can be useful in unpacking all the factors that might affect outcomes.

Second, in setting priorities, Desmond said he believes interventions should be evaluated holistically. For him, the cost-effectiveness approach can be extremely narrow because it focuses only on one set of outcomes to maximize. This small set of outcomes is then prioritized, resulting in vertical programming, and interventions that take a broader perspective are not seen as valuable. Conversely, when applying a cost–benefit analysis to interventions, all outcomes are included but are assigned a monetary value. He said that stakeholders must then monetize conditions such as stunting, or decide on a value for having access to education, which is controversial.

In The Cost of Inaction (Anand et al., 2012), Desmond highlights a more holistic approach to evaluation, exploring the full range of benefits and laying them out in a framework. The “cost of inaction” model does not rank the outcomes; instead, it leaves the task of making value judgments to policy makers and program implementers. These value judgments, he said, are extremely important. There is no automated way to decide what should be done first to improve child development. Stakeholders must carefully weigh outcomes and all of their nuances, rather than attempting what Desmond described as an “economic technical exercise” in decision making.

Third, framing matters, according to Desmond. He explained that inaction necessarily implies a lack of action, and as discussed above, in early childhood development, there are numerous benefits to action, such as improved health, development, and education. Therefore, the child development community must show stakeholders the benefits lost and consequences incurred from inaction. Desmond commented that presenting the same information in two different ways results in two different responses. He said missing out on benefits garners one response, but talking about the consequences of failing to act links that to a “sin of commission,” that is, the consequences are still linked to an action, even if the action is inaction. In his work, he achieved greater positive response when illustrating the consequences of not investing in young children, highlighting that maintaining the status quo is a choice. Framing the issues this way illuminates the value of funding and implementing essential services, Desmond concluded.

In response to a question about building simulation models to guide investment, Desmond cautioned that the state of the science in early childhood development is not at a point where predicting the future is possible, but trying to build models around prediction can help in understanding the present and examining current data better. However, in thinking about why evaluations are done, he emphasized that a great deal of knowledge already exists on what works in child development. What matters most is finding ways to reduce the cost of successful interventions without portraying the care of poor children as cheap.

EARLY CHILDHOOD EDUCATION AND PARENTAL EDUCATION IN WESTERN AND CENTRAL AFRICA²

Mariavittoria Ballotta of UNICEF described a program that UNICEF is piloting in 10 countries in west and central Africa. She began by noting challenging circumstances of conflict, epidemics, and chronic mal-

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² This section summarizes information presented by Mariavittoria Ballotta, UNICEF.

nutrition, which are competing priorities for governments in this region. Because of these other important priorities, Ballotta noted, creating local evidence is key. Although the global evidence is strong, it is not convincing enough when resources are limited.

While the program has generated evidence in a number of sectors, Ballotta shared data on school readiness. On average, about 25 percent of children have access to preschool education in west and central Africa, with the majority of them coming from urban, high-income families. Ballotta was also careful to note that in some countries, however, the number is far lower, around 2 to 3 percent.

She stated the program has three tools for rollout:

1. The parental behavior survey assesses the quality of the interactions between caregivers and children, looking at a number of factors, including the availability of time for caregivers to spend with children (which is not something that is usually costed). The survey also looks at social and cultural norms, some of which might be harmful, and some of which are beneficial and can help shape education programs.
2. The early learning assessment tool analyzes the impact of outputs and supply and demand on child outcomes. The sample consists of two cohorts—those who attended preschool and those who did not.
3. The costing model, based on one used for education, uses the newly generated evidence to determine the costs of implementing new early childhood development strategies in the region.

These tools are very localized, with questions based on inputs from civil society; surveys vary from country to country. Ballotta noted that the evidence is not surprising to those in the field—those children who attended preschool were more prepared to enter primary school than those children who did not. More specifically, as discovered in the Togo assessment, 90 percent of the outcomes required to start primary school come from 2 years of preschool; nearly 60 percent of outcomes come from only 1 year of preschool (see Figure 8-1). In addition, preschool teachers do not need to be high-level university teachers—specific short-term training for community teachers can contribute to good outcomes. Although community-based options have been uncertain in quality, these findings are promising. This pilot shows the impact of school readiness programs, and the strong local evidence can go a long way in ensuring that preschool is included in national budgets.

FIGURE 8-1 Optimum length of preschool education with regard to school readiness (Togo).
NOTE: Created using the early learning assessment tool with data from Togo.
SOURCE: Ballotta, 2014.

RESULTS-BASED FINANCING³

A. K. Shiva Kumar of Know Violence in Childhood: A Global Learning Initiative spoke about several key aspects of results-based financing, a funding approach in which payments are made only after agreed-on results are achieved. First, he raised the question of what should be included in an essential early childhood package in terms of direct or complementary services, staffing, resource requirements, and standards. Second, he underscored that adequacy of public financing is a prerequisite of results-based financing. According to Shiva Kumar, current under-financing is a contributing factor to inequity, lack of access to services, poor quality of programs, and neglect of children with special needs. Third, he said that efficiency of spending requires further exploration, especially in terms of necessary systems reforms to reduce leakage and waste. Fourth, in building mechanisms for results-based financing, Shiva Kumar pointed out that both short- and long-term outcomes need to have a clear method of monitoring and tracking performance, both in terms of budget and expenditure and in terms of linking these expenditures

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³ This section summarizes information presented by A. K. Shiva Kumar, Know Violence in Childhood: A Global Learning Initiative.

to outputs and outcomes. And finally, in order to improve outcomes, he stated, there needs to be a focus on evaluation, including evaluation of processes and impacts.

Shiva Kumar also raised two additional points for discussion. The first point was related to cost—to determine how much funding to allocate, governments usually compute a unit cost. However, Shiva Kumar said, this often translates into a uniform unit cost when, in practice, geographic, demographic, and other differences generate varied costs. He raised the possibility of considering other means of determining cost on a needs basis. In his second point, Shiva Kumar stated that in countries where some provinces enjoy better fiscal health than others, the federal government should ensure that children living in provinces facing financial constraints do not get penalized. For this to happen, the federal government needs to devise appropriate compensatory and incentive mechanisms to enable provinces to offset the fiscal deficits and fulfill their obligations to children.

INVESTING TO IMPROVE OUTCOMES⁴

Vesna Kutlesic of the U.S. National Institutes of Health and a member of the Forum on Investing in Young Children Globally reported on the discussions from the breakout group that considered the question of where best to direct investment for the purpose of improving outcomes. One theme mentioned by several participants was the importance of advocacy and awareness at all levels, but in particular at the grassroots level. Many times the approach is top-down from the government level, but community-level input, starting with the child, can be just as vital. Kutlesic noted that, from her experience at UNICEF, children are often knowledgeable about their own needs. Focusing on the child and his or her experience could serve as a useful guide for investment. In working with children, she reported, participants recommended considering the involvement of the family. In particular, she reported that the group discussed what sort of exposure the family receives in terms of education, training, or capacity building. In thinking about the family, group members noted that parents are often key participants in the child’s development. Traditionally, childrearing is considered the mother’s responsibility because she is the cultural focal point in the family, but several discussants thought that fathers should not be excluded and that other family members, such as grandparents, could play a role too.

One group member mentioned that the strategy of using a celebrity as the “public face” of an issue can often help bring attention to the issue

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⁴ This section summarizes individual remarks by participants in concurrent session 1.

among the general population. Others disagreed, saying that endorsements from local leaders can result in more immediate, actionable progress because they often know what is needed to mobilize resources. In addition, some group discussants called for improved ongoing training and education of frontline workers, as well as garnering support for other human resources development.

Other important themes raised echoed points made by various speakers throughout the workshop—promoting good governance; enhancing transparency and accountability; providing the means for monitoring and evaluation; and sharing data and information, particularly to families and communities, on how to use resources and advocate for themselves and their children. In the discussion following Kutlesic’s reporting, several audience participants raised other possible areas of investment, including the following:

• An increase in the wages of employees in the child development sector, because underpayment shows a lack of value;
• Identification of a set of indicators, particularly around quality, responsive to current demographic and epidemiologic issues emerging in the target population;
• Creation of guidelines (a “how-to”) on localizing and contextualizing global best practices on building an essential package of early childhood development services; and
• A platform for interdisciplinary dialogue among stakeholders.

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