A rights-based approach, centred on marginalized communities, is imperative for the purpose.
The year is young, holding out much promise for a better tomorrow. Our young children are showing a preparedness, even a degree of eagerness, for going “back to schooling”. Our policymakers and leaders have begun the discussion on national priorities ahead of the budget season, with the word “tomorrow” assuming much significance. How should we be looking at tomorrow, then?
For me, it is about all children growing up into the future they want. One likes to believe that all children have hopes and dreams, that all children are born equal and have rights. We believe also that with a constitutional guarantee to rights, all children have equal opportunities for development. Amidst the current discourse on Sustainable Development Goals (SDGs) for all and leaving no one behind, one finds wide gaps in the development of our children.
Nowhere are the differences more palpable than in the case of children with special needs in resource-constrained community settings. Deprived of a fair chance, many of our children experience violation to their rights due to lack of resources and attitudinal barriers. Today is bleak; what does “tomorrow” hold for these children?
A whole body of research in brain sciences informs us how children develop and how the challenges that societies face today, whether it is to be healthy or to work productively, have their roots in the early years. Science is also clear about the first 2,000 days being the period when foundations are laid for life-long health, learning, productivity and social cohesion. The period of human development from the prenatal period (before birth) to the time a child begins primary schooling is when the brain development is the most rapid, and most sensitive to environmental influence – both enriching and adverse environment.
Economists and educationists are familiar with the studies by James Heckman and the oft-quoted Heckman’s equation that established beyond doubt that the rates of returns to society are generally higher if we invest in the early years of life when the brain architecture is developing. The cost-benefit studies showed that in addition to the direct benefits to the lives of children and families, the benefits accrued in a generation due to the investments in early childcare and education were significant for governments, especially in terms of reduction in the money spent on welfare.
If it is no longer about evidence to inform policy, then the question should be: How can we strengthen the ongoing efforts for building a healthy and prosperous nation?
Many countries have been working for over three to four decades now to improve children’s health and education in these critical years of development. The Millennium Development Goals also placed much emphasis on maternal and child health. While substantive progress has been made in improving child survival, many young children and youth are unable to thrive in the modern societies today. India’s flagship programme for early child development, the Integrated Child Development Scheme (ICDS), is a good initiative to improve nutrition, health and learning in early years. What then explains our struggle after all these years to meet the goal of improving outcomes in building human capabilities? We need to pause, and ask ourselves, is there something we can do better for healthy futures?
Look around and notice who are the children doing well at school and developing into young adults with the competencies to meet the challenges of adulthood. Working in an inclusive community initiative for early childcare and development of children with special needs, I see that despite providing the same services to all children, there are some who fare better than the others in the school-readiness programme. Even more insightful is the fact that not all typically growing children without disabilities do well, and a few children with developmental difficulties also catch up well with the ECD interventions helping them overcome the developmental lag.
The children who perform better seem to have a few things in common, the most important determinants being loving relationships in the family, a steady family income, at least one parent with some education or skills that made them employable, a stable home environment. The parents who invested in creating a learning environment for their children could recall good experiences and responsive caregiving during their own childhood years.
As against this, children with no obvious disabilities but lagging behind in developmental outcomes came from families dealing with many of the poverty correlates such as poor health, malnutrition, lack of a steady family income. They also have problems accessing public welfare schemes and programmes meant to give social protection for the vulnerable groups.
These observations are not restricted to a particular community. The single-most important factor for adverse outcomes not just in our community settings but also from several studies in other developing countries such as Ghana, Kenya, Uganda, Columbia, Peru and Bangladesh, is poverty, with its correlates of poor health, lack of education, poor living conditions having intergenerational effects. These become more pronounced in families experiencing toxic stress from the cumulative impact of multiple adversities such as migration, child abuse, child labour and other difficult circumstances.
Evaluation science studies from Harvard University and elsewhere looking at programmes for ECD in developing countries are showing that interventions for the child are more successful in changing the trajectories of children’s lives when combined with parent education and family support. Often, ECD programmes overlook the obvious fact that one cannot think about interventions or services for children under five without thinking about the primary caregivers in children’s lives. Of the many things we need to do differently to ensure greater impact of ECD programmes, one may be to give attention to the development of adult skills for parenting and childcare as an important component of any ECD programme.
Many of our current programmes for ECD may have to incorporate family-centric services to strengthen nurturing care and social protection. One of the practical and efficient ways to improve parenting skills may be to have educational sessions for the mother soon after delivery. Another window of opportunity exists in newborn clinics and follow-up visits for primary immunisation during the period that experiences are shaping the brain.
The new National Education Plan (NEP) is promising, especially in making the preschool component strong. Here again lies an opportunity to strengthen parent education and create an enabling environment. Preschools can be set up, linked to existing schools, but with particular attention to foundational aspects of child development domains. A three-tiered approach recommended for Early Childhood Programme Effectiveness by the Centre on the Developing Child, Harvard University, envisages science-based interventions directed at fostering healthy circuitry in brain architecture when the nervous system is highly plastic for all children, including those with developmental disabilities. The base of the pyramid is provision of basic health and childcare, which has to be the most important, of course.
The other tiers required to make the programme holistic comprise targeted interventions for toxic stress that children from disadvantaged backgrounds experience and extra support for low- income families. Public expenditure in these areas must be seen as a long-term investment and important also in the journey being undertaken for sustainable development. We can, in our context, consider preschools in marginalised community settings to have budgetary allocation to ensure staffing with qualified, well-compensated personnel and establish community libraries to provide a rich learning environment to all. Training caregivers and preschool teachers for developmentally appropriate responsive care has been shown to make children with developmental delays healthy and school-ready while contributing to inclusive and sustainable ECD initiatives with parents as partners in participatory learning.
Addressing inequities is a matter of urgency. Even as the rights-based approach to health, education, livelihoods and more has been gaining strength with an increased awareness among the vulnerable sections, we need to recognise that social justice as fairness requires a whole society approach, especially for including all in the development discourse, leaving no one behind.
Investing in healthy futures calls for addressing the social determinants of health and well-being beyond the care that our health systems can provide. This means that early child development must integrate work in several domains – adequate nutrition, clean and safe environment to grow in, supportive services for integration of responsive care and early learning, habilitation, promotion of healthy behaviours and more — into a multilevel health system with an emphasis on convergence at the primary healthcare level.
All this is not going to be easy, considering the size and population of our country but, with political will and resource allocation for ECD work in all policies, this can happen in a generation. If policymakers can desist from the routine ways of preparing budgets with an eye on the next election, and plan instead for the next generation with a programmatic approach within a policy-assisted framework, this imperative can be met. It needs to be done, and with a sense of urgency.
The importance of involving civil society organisations that are already working in low-resource community settings, with local stakeholder empowerment for a positive impact has perhaps been one of the takeaways of the COVID-19 phase. Supporting such work need not be seen only as CSR. Scaling up requires policy facilitation to support smaller community initiatives in becoming a part of the public health system. Technological advances can facilitate health practitioners and implementation researchers to scale up. However, we need to harness the potential of frontline workers by declaring groups such as ASHAs and anganwadi workers as essential health service personnel for knowledge, skills and sustainable services to reach the unreached.
It should no longer be about patching the cracks in the wall to cover up the widening gaps between children and children. Building back better and fairer is the only way to maximise the developmental potential of every child and the adult that she is to become.
Written by: Sunanda K. Reddy is a developmental pediatrician in Delhi