4

Policies Supporting Family and Community Investments

The workshop drew on global and regionally specific expertise to explore policies supporting family and community investments in young children. Perspectives were assembled to include the African scientific community with the president of the African Academy of Sciences. Ethiopian state ministries, with representation from the State Ministry of Health (MOH), the Ministry of Education (MOE), and the Ministry of Women, Children and Youth Affairs (MOWCYA) were also included. The discussion was moderated by the former Minister of Health of Chile to connect the dialogue to other regions around the world.

The president of the African Academy of Sciences, Aderemi Kuku, opened the session by stating that the Ethiopian national perspective was particularly adept to weigh in on the benefits and costs of financial and human capital investments in young children and their caregivers. Yet in looking to the Ethiopian example, Kuku stated it was important to first mention the challenges confronting early childhood development in sub-Saharan African countries. Kuku broadly categorized these challenges to include infectious diseases, malnutrition, lack of early childhood education, and poverty more generally. Kuku argued that for effective solutions, broad participation will need to come from parents, family, communities, local governments, state governments, national government, and the global community. He called for an integrated approach in how the relevant actors address these pervasive problems facing the African continent. He also called on the social justice systems embedded

within the governance structures of each level listed above, stating that when children are not brought up well, the burden is felt across society.

Kuku remarked that a number of countries in sub-Saharan Africa do have policies based on some intersectoral collaboration among various sectors of the society, which among other advantages provide cost-sharing benefits across resources to avoid duplication. Kuku referenced the intersectoral collaboration among 10 different ministries in Kenya. He proposed that other African countries would be able to emulate this approach in formulating policies for children.

POLICIES SUPPORTING FAMILY AND COMMUNITY INVESTMENTS IN ETHIOPIA

In her remarks, Helia Molina, Vice Dean of Research and Development, Faculty of Medical Sciences, University de Santiago de Chile, and former Minister of Health of Chile, stated that investing in young children needs to be as much a key issue on the political agenda as it is among families and communities. She noted political will is crucial, but political will alone is not enough. Funding, a budget, and ongoing political and government support also need to be in place. Molina stated political support behind early childhood development is complicated by the fact that measurement of impact does not always coincide with the political timeline. Molina concluded with the overarching challenge, which is how to simultaneously put early child development as a key issue on both the political and community agendas.

In Ethiopia, national ministries are working together on policies to address the most pervasive challenges to young children: infectious diseases, malnutrition, education, and acute poverty. Yasabu Birknen, Director of Early Childhood Education in the MOE, opened by stating that supporting young children and families is an investment in which the return comes later, as seen in reduced early dropout from formal primary school, improved achievement in children, and emotional and psychological development. In turn, a well-designed package of investments in children will improve the health, scholastic achievement, and opportunity for future economic success of both the children and the country, Birknen said. The Ethiopian government understands these factors and has committed to develop a policy framework on early childhood care and education based on these principles. Birknen maintained that the policy was the antecedent for the interventions and placed primacy on development of sound national policies.

Birknen pointed out the role of the policy is to provide a coordination mechanism and to explicitly define the roles and responsibilities of partners, parents, communities, and value sectors. The government has

also developed a strategic operational plan and guidelines that function to put the general framework into action. Birknen outlined the roles and responsibilities of key actors. The Minister of Health assumes the lead for the young children from the prenatal period to 3 years of age, including all service deliveries; and the Minister of Education is responsible for children age 4 to 6 where interventions surrounding early childhood care and education occur.

Shifting to modalities, Birknen outlined that the early childhood care and education program in Ethiopia formally covers kindergarten, yet there are other informal modalities as well. He finds preparatory services like the Ethiopian School Readiness Initiative are also critical to reaching children who do not otherwise engage in a structured learning environment because they are too young for the formal education system.¹ While improving access to early childhood care and education increased the baseline growth of gross domestic product (GDP), according to Birknen, there are still children who are not able to access these formal programs and services. Finally, Birknen noted the quality of services and facilities and awareness of parents also pose barriers to access.

Yayesh Tesfahuney, Director of Child Rights and Promotion Directorate, the MOWYCA, focused on how community initiatives are investing in children by stating that effective solutions need to come from the interweaving of parents, families, and communities; local, state, and the national government; and the global community. Tesfahuney pointed out the Constitution of the Federal Democratic Republic of Ethiopia, which includes family, penal, and civil law, aligns with the United Nations Convention on the Rights of the Child International and Child Rights Convention and African Child Rights Charter. Furthermore, policies such as the Social Protection Policy, Comprehensive National Child Policy, Social Protection Strategies, and the Gross Transformational Plan enable national investments in children. Tesfahuney surmised the agenda on young children reaches across the MOH, the MOE, and the MOWCYA. Despite the breadth of child-centric policies, there are alternative care mechanisms in place to give care and support for the country’s most vulnerable children. Tesfahuney’s efforts are focused on how the community alone contributes and offers solutions for their children, including those most vulnerable.

Tesfahuney described a particular community-centered initiative that invokes religious leaders, children, teachers, and communities to identify vulnerable children in their community and develop an action plan as a way of setting priorities at the community level. A community council provides a governance structure and committees are in place to mobilize resources. There are now 3,700 community care coalitions across seven

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¹ The Ethiopian School Readiness Initiative is outlined in Chapter 5.

regions in Ethiopia. At the Ministry level, there is an effort to scale up the initiative, but also to ensure care is delivered to children in a sustainable way from the core community unit.

The Honorable State Minister of Health, Kebede Worku, outlined how the MOH is working in the areas of maternal, newborn, and child health services by providing an integrated delivery mechanism at all levels, including the community level. Worku argued that the state has a responsibility to invest aggressively in integrated services at all levels, which includes communities. He emphasized the political commitment, particularly through the efforts of the MOH and community-level participation in the implementation of its programs and initiatives. Although Ethiopia achieved Millennium Development Goal 4 (reduce child mortality) and is on track to achieve Millennium Development Goal 5 (improve maternal health), Worku lamented that many children and mothers still die each year from easily preventable diseases.

Worku also described a national program that provides integrated services in a deployment-based approach at the community level. Households are networked as a way to provide support to neighbors through a model that seeks to scale up best community practices. Strategies addressing reproductive and adolescent health at all levels of health care are offered where participation happens because of community mobilization. The Health Development Army has been particularly helpful in improving service optics at the community level. Worku maintained that bottlenecks in infrastructure, supplies, and institutional capacities are alleviated because of this systemic mobilization from the national to local level.

Worku stated care for mothers and newborns has been a priority, as has been the sexual and reproductive health of adolescents and women through inexpensive but sensitive tools. Additionally, the National Nutrition Strategy was developed and is being implemented and integrated into other sectors. Worku stated this is important because the annual cost associated with malnourished children was equal to 16.5 percent of GDP in 2009.

Worku indicated the MOH is working to decentralize low-cost, high-impact programs at the community level, such as community-based newborn care and integrated community case management of common childhood illnesses. These services are provided by the health station workers, who are government employees, meaning they are formally trained but deployed at a community level. Vision control interventions and a series of other minor strategies have been implemented to target mothers and children. HIV services are also being provided through integrated services. Worku surmised the sum of these gains represents political commitment, community participation, and effective partnerships.

Worku congratulated Ethiopia’s national achievements across educa-

tion, health, reducing harmful traditional practices, and overall poverty reductions, yet he still called on the international community to scale up effective interventions that can be implemented at the community level to provide care and support for Ethiopia’s most vulnerable children. Worku urged the government and international community to scale up implementation of effective interventions by increasing high-quality investment in children and women’s health to achieve maximum benefits.

POLICIES SUPPORTING FAMILY AND COMMUNITY INVESTMENTS GLOBALLY

Panning out to a global view provided workshop participants the chance to visualize policy impacts by examining systems and governance structures that facilitate or create barriers to financial and human capital investments in young children by their caregivers. By simultaneously looking in-depth at individual countries and at the global level, Jody Heymann, Dean of the Fielding School of Public Health at the University of California, Los Angeles, grounded arguments for resources and change in global data. Through a series of data visualizations presented by Heymann, her method facilitated a process to look at policies across 193 countries and more specifically, outcomes for families in these countries.

Heymann prefaced her global analysis of policies with two vignettes that added primacy and relevancy to her method. The first told the story of a widowed mother who often worked 15- to 20-hour shifts while she had a toddler at home. Heymann argued that however remarkable the woman’s parenting skills were, or comprehensive the programs were that her young child participated in, ultimately the mother’s working conditions limited the toddler’s time with a primary caregiver. The second vignette told the story of a father who lost his job because he missed work to care for a sick infant. The infant came down with pneumonia when his mother had to stop breastfeeding because she had to return to her work, which did not provide paid maternity leave. Heymann stated these two examples illustrate all-too-real scenarios where parents’ time devoted to caring for their children and the children’s healthy development were dramatically shaped by the policy environment in which they lived (Heymann, 2006).

Heymann projected a series of maps to illustrate how national laws and policies shape the social conditions that allow parents to invest in their children (Earle et al., 2011; Heymann and Earle, 2010). The geography of policies provides both global and individual country data to map how policies change health outcomes for children and parents and economic outcomes for families. Heymann provided by way of example the nearly global coverage for paid maternity leave (see Figure 4-1)

across 185 countries, but far less global coverage for paid paternity leave (see Figure 4-2). Paid paternity leave is associated with fathers having increased involvement in their children’s lives for years after the paid paternity leave, lower rates of maternal depression, and generally better child outcomes (Heymann and McNeill, 2013).

Heymann pointed out only about half of countries offer paid leave for fathers and only one-quarter offer 3 weeks or more. There was global agreement on maternity leave, albeit significant diversity in length globally. Heymann emphasized the need for that same kind of global agree-

ment for fathers because this critical window is when fathers set the tone as to whether they will be involved long term in the child’s life.

Heymann turned next to a series of maps on breastfeeding breaks at work globally, citing the evidence that breastfeeding lowers infant mortality and is one of the most powerful interventions in early childhood to promote health and well-being (Atabay et al., 2014, 2015; Heymann et al., 2013a). Heymann pointed out that for working mothers, encouraging breastfeeding is more complicated than communicating the importance—particularly for women in low-wage jobs. Heymann noted when mothers are asked if they want to breastfeed, overwhelmingly the answer is yes, but for those mothers who work in the paid labor force, the reality is that they stop. In answering questions around how to ensure women continue breastfeeding when they return to work, Heymann discussed both the role of maternity leave and paid breastfeeding breaks. While breastfeeding breaks support mothers who choose to return to work or for whom leave is unaffordable, they only work when mothers have adequate time to travel from work to their infant or have facilities for pumping and refrigeration. Heymann displayed a map that revealed 141 countries globally allow breastfeeding breaks at work. Heymann pointed out there are 48 countries around the world that neither have paid breastfeeding breaks nor paid maternity leave for 6 months.

Heymann illustrated a series of compounded challenges of time and caring for children for working parents in a series of in-depth studies that were presented. Time off from work to care for sick children did not fare as well as the nearly global coverage for paid sick leave for adults. Heymann argued the fact that paid sick leave has been achieved for working adults should also be in place for these working adults’ young children (Earle and Heymann, 2006; Heymann et al., 2013b,c; Schliwen et al., 2011).

Heymann presented minimum wage as a form of investing in young children globally. She stated most parents exit poverty through their work, and while most countries around the world now have some form of minimum wage in place, what persists is that in one-quarter of countries, working adults earning the minimum wage will not lift themselves and their children out of the 2.00 purchasing power parity–adjusted USD per person per day demarcation of poverty (Heymann and Raub, 2014; Mendoza et al., 2014).

Heymann then turned to data gaps, particularly in children from birth to age 3, stating that progress in policies is also important to map. According to Heymann, comparative policy tools help countries see how they and their peers are performing, and link to specific health, education, nutrition, and social protection outcomes. She also highlighted that comparative quantitative data make possible rigorous examination of which

national policies are most effective at improving outcomes for children (Hajizadeh et al., 2015; Heymann et al., 2011; Quamruzzaman et al., 2014). Heymann emphasized the importance of measuring national progress around policy implementation, stating that only by showing every year when countries are starting to move toward better supports for families investing in their own children can policy makers and the leaders who are providing services be rewarded for advancing efforts and those who have yet to make effective changes happen be stimulated to take action.

ECONOMIC IMPACTS AND COST OF CHILD MARRIAGE ON YOUNG CHILDREN

Quentin Wodon, Lead Economist with the Education Global Practice at the World Bank, presented the economic impacts and costs of child marriage, which he stated is a multisectoral issue, much like early childhood development, that affect young children. Wodon suggested that child marriage and early pregnancy are topics that should be given more attention when discussing investments in young children. Child marriage has large effects on child health, including under age 5 malnutrition and mortality.

Through a conceptual framework Wodon presented, he proposed that child marriage directly impacts labor force participation, education attainment, involvement in decision making, violence, and health. He then proposed a common economic metric for those impacts through earnings and productivity losses, investments losses, and out-of-pocket costs. His findings revealed that the largest economic cost of child marriage is through the impact on fertility, demographic growth, poverty, and GDP growth.

Wodon found that in terms of measuring cost, some of the largest impacts in reducing child marriage are not necessarily evident in higher earnings and productivity for adolescent girls who do not marry early. Rather, he stated his findings reveal that the largest benefit comes from the fact that there are simply less children to feed. As a result, Wodon noted that per capita income will increase. He went on to say there were also budget savings for governments in terms of service delivery in education and health.

In looking at the most significant impact in trying to determine an intervention strategy, Wodon took existing data for three countries to show the impact of early marriage on a number of different indicators, and then assigned a dollar value to these impacts. The impacts of early marriage on fertility rates revealed that if the age of marriage for an adolescent girl is delayed to 18, over the span of the childbearing years, this will reduce the number of children the woman has by 1 to 1.5 children on average. Wodon estimated that by eradicating child marriage in a country

such as Bangladesh, the population growth rate as of 2013 would decrease by 0.31 percent. He noted child marriage is a phenomenon that is decreasing in many countries around the world in the absence of any targeted intervention. Yet in looking at the cumulative impacts of change in the total population growth that occurs in countries because of the eradication of child marriage, the population growth for the world as a whole would decrease by 3 percent.

There are cumulative impacts on GDP, quasi-income generation and poverty reduction, government spending, and government savings across health and education services. Furthermore, Wodon pointed out that with lower population growth, it would be feasible to reallocate resources toward interventions for those children who are born and in need of services.

Regarding the relationship between two areas of investments, Wodon articulated that currently some of the most vulnerable young children are born to girls marrying before age 18. To prioritize investments in either early childhood or prevention of early marriage are difficult choices, stated Wodon. While there are economic impacts in terms of health and educational outcomes, the economic impacts of preventing child marriage in adolescent girls is largest on fertility. In terms of what types of interventions are best to reduce child marriage, Wodon referenced the importance of education and providing meaningful alternatives for employment opportunities for adolescent girls. If child marriage is considered an investment decision by a family, Wodon argued, then it is important to change local marriage markets and gender roles in combination with economic incentives and programs to encourage adolescent girls to pursue alternatives beyond marrying at an early age.

REACTIONS TO GLOBAL POLICIES SUPPORTING FAMILY AND COMMUNITY INVESTMENTS

Abubakar provided perspective, drawing particular attention to the implications on the aforementioned policy impacts on the informal sector. Using time as an example of a resource, Abubakar illustrated a typical schedule of a rural Kenyan woman, where time is scarce and allocations to early childhood development are not possible when such women wake up early in the morning to walk 1.5 hours to get water; walk another hour to get firewood; work in the field; quickly cook for the children so they can go back to school; and wash clothes by hand. Through this illustration, Abubakar noted that quickly one can see how the whole day fills up.

As opposed to paid maternity or paternity leave, Abubakar argued, these women need policies that support their involvement in the informal sector and in raising their children—particularly if they have children

with disabilities. Policies that take into consideration families that need to give extra time to care for the most vulnerable children need to be highlighted.

Abubakar stated that policies for working mothers do not protect teenage mothers and child brides because these women have not yet entered the job market. She cautioned that teenage pregnancy should not be a life sentence, but rather there should be mechanisms in place to empower these young mothers to become independent. Drawing on the science of brain development that occurs all the way into early adulthood, Abubakar encouraged that advocating for early childhood development should be the foundation by which investments are made throughout the life course, particularly for girls and women.

Angela Diaz, Jean C. and James W. Crystal Professor in Adolescent Health and Professor of Pediatrics and Preventive Medicine at the Icahn School of Medicine at Mount Sinai, provided her perspective on the presentations of global policies around adolescents, families, and communities. Diaz stated that in addition to investments in early childhood development, it is important to invest in adolescents to sustain and to advance the impact of early childhood investments. Adolescence is a critical stage of life. Both Diaz’s and Abubakar’s reactions underlie the importance in ensuring the parents of tomorrow are prepared, healthy, protected, and well-educated, so that when they become parents themselves, interventions are no longer necessary.

POLICY TOOLS FOR SUPPORTING FAMILY AND COMMUNITY INVESTMENTS

Decision-support tools help governments measure and monitor country-level progress when the types of initiatives outlined in the section above are scaled up. Three policy tools were presented to breakout groups at the workshop. The session provided the space to identify audiences, uses, and feasibility to integrate into existing policy platforms for each of the three tools.

Guru Madhavan of the U.S. National Academies of Sciences, Engineering, and Medicine presented the SMART Tool, originally developed for vaccines, and how it could be applied to investment decisions in young children, based off a decision-support tool developed at the Institute of Medicine and the National Academy of Engineering (see Box 4-1). Constanza Alarcon, Coordinator of the Intersectoral Commission for Early Childhood Comprehensive Care in Colombia, presented a series of intersectoral tools used in Colombia (see Box 4-2); and Ann Masten, Distinguished McKnight University Professor at the University of Minne-

sota, presented a policy tool originally developed by Emily Vargas-Barón (2005) to assist policy makers in making investments in young children across sectors (see Box 4-3). A summary of the tools and their potential applications to support family and community investments in young children globally is provided.

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