Editorial — Partnership between health and education in early childhood

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The Lancet Child & Adolescent Health
Jun 2019 Volume 3Number 6p365-436, e4
Partnership between health and education in early childhood
The Lancet Child & Adolescent Health
While primary school enrolment rate in developing regions reached 91% at the end of the Millennium Development Goal era, 60% of children and adolescents worldwide (617 million) are not achieving basic proficiency in reading and mathematics expected of their school year. One reason for this disappointing outcome is that many young children are not developmentally on track at the time they enter primary school because of scarce investment in preschool education, according to UNICEF in their latest report, A World Ready to Learn.

UNICEF’s analysis found that “attending an early childhood education programme is one of the strongest predictors for supporting a child’s readiness for school, regardless of household or national income level”. Evidence shows that positive stimulation in early childhood affects brain development and the neurobiological pathways that underlie functional development. Quality preschool education supports a child’s cognitive, physical, social, and emotional development, providing a safe and nurturing environment for young children to learn and interact with their peers. It can also ameliorate some of the vulnerability stemming from early adversity such as poverty, and offer a powerful opportunity to break intergenerational cycles of inequity in future health, academic, and economic outcomes.

Despite the well recognised importance of investment in these formative years, only half of the world’s preschool-aged children are enrolled in pre-primary education (from age 3 years up to the start of primary education, often age 6 years). In low-income countries, only two in ten have this privilege, and barriers are even higher for marginalised groups (eg, indigenous populations, rural communities, and children with disabilities). Given the current situation, UNICEF warns that a “business as usual” approach will not reach the target of universal, quality pre-primary education in Sustainable Development Goal (SDG) 4.2.

This target is achievable, but only if there is a substantial increase in investment alongside strong political commitment. Globally, 38% of countries, most of which are low and lower-middle income, invest less than 2% of their education budgets in pre-primary education—a huge gap from the 10% recommended internationally. Distribution of these scarce resources highly favours the wealthy within these countries. The shortfall in funding is also apparent at the donor level, with less than 1% of international aid for education being allocated to the preschool years. Even among upper-middle-income and high-income countries, nearly a third will need to accelerate their progress to be on track for 2030.

Early childhood education needs to be prioritised and recognised as a core strategy for strengthening a country’s education system and population health. To accelerate progress towards multiple SDGs, the synergy between the health and education sectors—alongside nutrition, child protection, and social protection—should be leveraged. Such intersectoral collaboration is crucial to ensure that every child receives the nurturing care that will allow them to reach their full developmental potential. Building on the foundations of quality antenatal care, child health professionals, community workers, and early-years practitioners can support responsive parenting, conduct regular health and developmental milestone checks, and deliver nutritional and other interventions as necessary. Preschools provide an important setting for deworming, vaccination, early identification of developmental disorders, and other health screening and interventions; distributing nutritious meals; and establishing lifelong healthy habits such as handwashing and personal hygiene.

Equity and quality must be at the heart of such a multisectoral response. The most disadvantaged children must be considered at the start—not as an afterthought. UNICEF recommends that resource-constrained countries should start with providing one year of universal free pre-primary education, before expanding to include additional years. Quality should be upheld with clear standards, indicators, and expenditure tracking. Capacity building through training more qualified teachers is needed to progressively reach the recommended ratio of no more than 20 children per teacher.

Education and health are integral to human capital development. Given their synergy, the two sectors should forge deeper partnerships to accelerate progress towards the ambitious, but not unreachable, SDGs. The period between the first 1000 days of life and the start of primary school is an important window of opportunity for nurturing care that should not be overlooked. Sustainable investment in the preschool years is the foundation of future population health, prosperity, and social equality—and must be prioritised.