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Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Integrated childhood development

Dr. Mary Eming Young
Public Health Specialist

The following document was prepared for Bank's World by Dr. Mary Eming Young, Public Health Specialist in the Population, Health & Nutrition Department. It draws from staff appraisal reports on child health and education projects in Bolivia, Colombia and Mexico with additional information from The Twelve Who Survive, by R. Myers and M. Alva's Children's First.

"A child is born without barriers. Its needs are integrated and it is we who choose to compartmentalize them into health, nutrition, or education. Yet the child itself cannot isolate its hunger for food, from its hunger for affection or its hunger for knowledge" Alva, 1986

Three specific international events have given new visibility to the child which cast institutional and organizational challenges facing early childhood programs at the national levels: (a) the Convention on the Rights of the Child was adopted by the United Nations General Assembly in November 1989; (b) the World Conference on Education for All, held in March 1990 under the sponsorship of the World Bank, UNDP, UNESCO, and UNICEF, placed special emphasis on the expansion of early childhood care and development through family involvement and community interventions, especially for poor and disadvantaged children; and (c) the World Summit for Children, held at the UN in September 1990, brought together 158 presidents and prime ministers. These meetings have expressed a new awareness of the importance of early education on the part of international donors and given additional impetus and commitments on the part of governments in favor of early childhood development.

Today at least 12 of every 13 children born will live to see their first birthday, compared with the 1960 figure of five for every six children born. What happens to the "12 who survive"? Many of the same conditions of poverty and stress that previously put children at risk to die now put them at risk of impaired physical, mental, social and emotional development in their earliest months and years. Delayed or debilitated development in the early years can affect all of later life. It can also be prevented.

Not only are more children surviving but social changes create conditions that require new ways of thinking about child care and development. We need to look beyond mere survival to a program of early childhood care and development. More women are entering the labor force. Family structures are changing, urbanization requires some different skills than those in the past. The highest level of labor participation is in Southeast and East Asia where 50 to 60 percent of the women aged 15 and over are economically active. In sub-Saharan Africa, the percentage is slightly below 50 percent. In contrast, in Latin America and the Caribbean 32 percent of women are economically active. With changing family structures more women have sole responsibility for supporting their families. In Latin America and the Caribbean almost 30 percent of households are headed by women, over 20 percent in sub-Saharan Africa and 15 percent in East and South East Asia.

There is increasing evidence that early investments in development of the "whole child" can bring improvements in the life of the child and benefits to the larger society. Cumulative research evidence continues to indicate that most rapid mental growth occurs during infancy and early childhood and that, on the whole, the early years are critical in the formation and development of intelligence, personality and social behavior. Fifty percent of development of intelligence is established by age 4. Furthermore, inadequate intellectual stimulation and affective care, as well as early malnutrition, are likely to result in severe and possibly irreversible damages to physical and emotional capabilities, which are crucial to further learning. In this sense, elementary and even kindergarten can be too late an opportunity to develop these capacities in children.

Why should we invest in early childhood development?

·Efficiency·. Early childhood education increases the return on primary and secondary school investments, contributes to human capital formation, raises participants' productivity and income levels and reduces public expenditures (i.e. lower welfare, health and education costs). In the U.S. Perry Preschool Program, in operation since 1962, a $1 investment yielded $6 in eventual savings due to lower educational and welfare expenditures and higher productivity among participants. In the U.S. Head Start Program, $1 spent is worth $4 in costs saved later. Similarly, studies carried out in Asia, the Middle East and particularly Latin America suggest that early childhood education increases school readiness skills, promotes timely school enrollment, lowers primary repetition and dropout rates, and improves overall academic skills. The beneficial impact of early education is particularly pronounced among the traditionally disadvantaged groups (e.g., girls and children with rural, indigenous, and lower-level socio-economic backgrounds).

Furthermore, increased primary school attendance decreases the availability of older siblings to act as supplementary caretakers. Where sibs have been forced to drop out of school to provide such care, there is strong argument for child care.

Evidence suggests that health- and nutrition-related programs are positively associated with physical growth, basic cognitive abilities, school readiness and positive classroom behavior. A 10-year study in Mexico shows the negative effect on school readiness of severe malnutrition and lack of home stimulation, evident in delayed language development. Child care and development programs are potentially useful as vehicles for extending primary health care. Child physical growth can be influenced by not only the food intake but also by how well a child is developing socially and psychologically and by how free a child and the child's care-giver are from stress and illnesses.

·Social equity·. A large part of cognitive achievement differentials between lower socioeconomic and higher income groups can be attributed to low levels of psychological stimulation among poor children, malnutrition and lack of sanitation, all of which are directly associated with, or can be positively affected by, education. Early childhood education can help reduce societal inequalities rooted in poverty, by giving children from disadvantaged backgrounds a fair start, especially those living in rural and urban-marginal areas.

·Intersecting needs of women and children·. Increased numbers of women-headed households and of women who must work create a major need for complementary child care. If care is available, the earnings of these women are more likely than would be the earnings of men to go toward improving and helping distressed families with very young children. There is a kind of vicious circle particularly in the cities in which low paying jobs prevent mothers from purchasing adequate child care, and the absence of adequate child care prevents mothers from seeking more stable, higher paying employment. This circle is particularly acute in resource poor households where the effect on families of not working is highest. Provision of subsidized care that meets women's need could help to break this circle, raising earnings and productivity and benefiting both women and children.

What can we do?

Non-formal early childhood education has been a major area of innovation worldwide. The Bank has already invested in several such projects-for example, in India, the Integrated Child Development Services and the Tamil Nadu Nutrition Projects; in Colombia, the Community Child Care and Nutrition Project; in Mexico, the Initial Education Project; and in Bolivia, the Integrated Child Development Project. This fiscal year, Viet Nam is preparing a project on early childhood development project this fiscal year. Other multinational agencies, UNICEF and UNESCO, and non-governmental agencies, such as the Bernard van Leer Foundation and the Aga Khan Foundation, have had extensive experiences on implementation of early child care and development projects.

Early child care and development projects can be carried out through two modalities, formal and nonformal (center-based or home-based). The non-formal modality has received increasing attention in recent years because formal educational programs have failed to reach the population most in need, are costly and do not address specific community needs. However, there are also problems with the non-formal strategies. The ISSUEs are: insufficient institutional capacity, inadequate targeting mechanisms, poor educational inputs, loosely defined supervision, inadequate incentives for community educators, inconsistent community support, and sporadic linkages with complementary programs (health and nutrition). Moreover, we need proper and ongoing evaluation of the non-formal programs in developing countries to assess their cost-effectiveness and determine what are the minimum inputs of such programs.

Finally, we do have an emerging strategy for going to scale in programming for early childhood care and development. This involves a rather deliberate, focused, phased approach. It requires not only political commitment and resources but flexibility and continuous leadership and supervision capable of fitting programs to existing environmental, organizational and material resources. It would also be well to remember that the primary school graduates of the year 2000 have already been born and are being prepared for their lives. What seems so far away is being influenced now. Child development, growth, and the struggle to survive are simultaneous, inseparable and mutually reinforcing processes. We need to re-examine policies and approaches to enhancing early childhood care and development. We need not only sustain our effort to increase child survival but also enhance the development potential of the child with a smile.

[Reprinted with the author's permission from Bank's World, Volume 12/Number 10 October 1993]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Women, Health, and Development

Here are excerpts from a paper presented by Anne Tinker, Senior Health Advisor during a conference on Women's Health and Nutrition held last May at the Rockefeller Foundation Center in Bellagio, Italy:

Since the 1960's several initiatives have influenced women's health status in developing countries. Understanding of the important, but previously largely undervalued, role of women has increased greatly during the past 15 years, stimulated in large part by the United Nations Decade for Women. The Safe Motherhood Initiative, launched in Nairobi in 1987, successfully focused world attention on the magnitude of maternal mortality in developing countries and the need to improve maternal care.

Family planning efforts are increasingly oriented toward providing women with reproductive choice and the ability to avoid unwanted and poorly timed pregnancies. Recently, child survival efforts have recognized the significant impact of maternal health and nutritional status on infant outcome; this is reflected in the inclusion of maternal mortality goals in the recommendations of the World Summit for Children, held in 1990. While the family planning and child survival initiatives have been successful in bringing about dramatic reductions in fertility and infant mortality, there has not been comparable progress in improving women's health and nutrition, not even in reducing maternal mortality, which has received specific attention. Since the Nairobi Safe Motherhood Conference, over three million women have died from pregnancy-related causes. The annual number of maternal deaths has actually increased; although women's risk of dying as a result of pregnancy or childbirth has fallen by five percent during the past five years, the number of births has increased by seven percent over the same period.

It is appropriate that development policies and programs to improve women's health place special emphasis on pregnancy and childbirth in developing countries, due to the proportion of the life span spent in reproduction, its associated risks, and the high mortality and morbidity that result from largely preventable and/or manageable pregnancy-related complications. At the same time, these activities need to be increasingly complemented over the longer term by efforts to improve women's health and nutritional status more broadly. This requires attention to problems that often begin in infancy due to the lower status of girls, such as poor nutritional status due to discrimination in the allocation of food. Reproductive health problems include unplanned pregnancy and sexually transmitted diseases (STDs).

Several other gender-specific health ISSUEs will require increased attention in certain cultures, such as chronic diseases in transition societies where older women form a growing proportion of the population, occupational hazards that place women at particular risk, and violence in societies where physical or sexual abuse are prevalent.

Women's Health: A Neglected Development Issue

That women's health has received scant attention in development programs is reflected in high levels of persistent, but largely preventable, morbidity and mortality. In sub-Saharan Africa, a woman runs a one in 21 risk of dying from pregnancy-related causes during her lifetime; in Asia, it is one in 54; and in Latin America, it is one in 73. This compares to one in 10,000 in Northern Europe. Over 50 million women in developing countries are estimated to suffer acute pregnancy-related complications every year, and an uncounted number of women suffer pregnancy-related disabilities long after delivery. In addition, some of the deleterious effects of infectious diseases common to both men and women, such as malaria and hepatitis, are exacerbated by pregnancy.

The majority of women in the developing world go through pregnancy with no prenatal care and deliver without the assistance of appropriately trained health care providers. Most women of reproductive age also lack regular access to a range of modern methods of contraception. This frequently results in poorly timed or unwanted pregnancies [which] lead to between 36 and 53 million abortions around the world every year. Pregnancy termination under unsafe conditions is the cause of 115,000 to 200,000 maternal deaths each year. In Latin America, the complications of unsafe abortion are the main cause of death among women between the ages of 15 and 39 and absorb as much as 50 percent of some hospital maternity budgets.

In addition to problems associated with pregnancy, other conditions such as anemia, malnutrition, AIDS and other sexually transmitted diseases, and reproductive cancers impose a high toll on women's health and productivity. The number of women with HIV/AIDS is accelerating rapidly. In Africa alone, nearly four million adult women were already infected by the end of 1992.

Current estimates are that equal numbers of women and men are infected in Africa, and predictions suggest that more women than men will be infected by the end of the decade. Women with HIV risk passing the virus to their newborns, and they themselves usually die while their children are still growing up. Cervical cancer is the leading cause of death from all cancers (affecting both men and women) in developing countries-about half a million new cases are diagnosed each year worldwide, more than three-quarters of which are found in developing countries. Virtually only women are affected by breast cancer, yet it is the third most common cancer worldwide.

It is estimated that less than 20 percent of government health budgets are allotted to maternal and child health and family planning, and most of that amount is for child health. The resources allocated for women's health are not commensurate with the clearly demonstrated need.

Women's Status and Women's Health

Women's poor health is a reflection of their low status in many developing countries. Worldwide, women have a longer life expectancy than men [but] despite this, females have higher morbidity and physical disability levels than males throughout the life cycle. The differential in health status often begins in childhood, when girls receive less nutrition and health services than their brothers.

Women's lack of education and disadvantaged social position help perpetuate poor health and high fertility, as well as a continued cycle of poverty. Because women tend to be less educated and have less access to information, they are less apt to recognize problems or understand the value of or seek out preventive and curative care. Among other benefits, female education, especially through the secondary level, is associated with greater use of contraception and increased age of marriage, both of which improve women's health by reducing their exposure to pregnancy and early childbearing.

Families and communities also frequently underestimate the social and economic worth of women, and, therefore, their health needs. In Senegal, for example, a study which examined the low utilization of maternal health services found that only two percent of the women interviewed said they would decide for themselves to seek care in the event of pregnancy-related complications.

A number of other health problems associated with women's low socioeconomic status must also be addressed by health and development programs. Gender-specific violence provides an example. In Papua New Guinea, a survey found that 67 percent of rural women were victims of wife abuse. Dowry deaths and bride burning in India and female circumcision in parts of Africa and the Middle East are further examples of gender-specific cultural practices deleterious to women's health. Occupational health hazards are also an increasing concern. Women's low status, particularly lack of education, exacerbated by economic hardship, is leading to increasing prostitution, for example. This, in turn, is contributing to the rapid spread of STDs, including AIDS.

The health of women is integrally related to their overall status in society. Expanded opportunities in health and education will allow women greater control over their health and lives and enable them to exercise more productive and visible roles in socioeconomic development.

The Effects of Women's Ill Health on the Family, Community and Economy

A woman's ill health or death affects not only her own opportunities and potential but those of her children. A mother's death in childbirth is a virtual death knell for her newborn, and it often has severe consequences for her other young children. At least 60 percent of women who die from pregnancy-related complications are already mothers, and a study in Bangladesh found that when a mother died, the chances that her children up to the age of 10 would die were sharply increased-by more than three times for her girl children.

Women's poor health also affects the welfare and productivity of their households and communities. Ironically, the poorer the family, the greater its dependence on women's economic contribution. Women are the sole breadwinners in some 30 percent of the world's households, and at least 25 percent of other households depend on female earnings for more than 50 percent of total income.

Women also play a critical role in their national economies, and their physical well-being determines their ability to be productive. Data on women's contribution to development, while still tentative, indicate that women are responsible for up to three-quarters of the food and cash crops produced annually in the developing world. In Africa, women produce 80 percent of the food consumed domestically and at least 50 percent of export crops. Women also constitute one-third of the world's wage labor force and one-fourth of the industrial labor force. However, women's wages for the same or similar work are substantially lower than men's. In parts of Asia and Africa, women earn 50 percent less than men. Women work longer hours than men in every country except Australia, Canada and the United States. Therefore, female ill health has a substantial impact on productivity and economic development.

Ill health impedes women's ability to work and earn money, and burdens them and the economy with increased health care costs. Investments in women's health programs not only improve a woman's health status and the survival and health of her family, such investments increase the labor supply, productive capacity and economic well-being of communities.

Cost-Effective Interventions to Improve Women's Health

Improvements in women's health are not only critical to development, they are feasible and affordable. Of the many health sector interventions discussed in the World Development Report, safe motherhood interventions were found to be among the most cost-effective. Safe motherhood interventions include family planning to raise age at first delivery, space births, and prevent unwanted pregnancy, tetanus toxoid immunization, micronutrient supplementation, and improved prenatal and delivery care.

Strategies to protect women from sexually transmitted diseases can also have a cost-effective impact. Biologically, women are more susceptible to STDs; the probability of transmission in a single contact of unprotected vaginal intercourse is greater from infected male to uninfected female than the reverse. Moreover, because the duration and severity of STDs (other than HIV) are greater in women than in men, preventing a single case of an STD in a woman is estimated to be 20 percent more effective than preventing a single case in a man. Preventing and curing STDs in women also helps to reduce prenatal transmission. The most cost-effective strategy is to combine information, education, and communication with condom subsidies and STD treatment targeted to core groups of males or females who engage in unsafe sex with multiple partners.

The evidence suggests that improving women's health is a sound investment. Women's health programs are not only feasible and cost-effective, but their broader benefits stretch far beyond the woman and have important effects on the household and community development.

Women's Health and Development: Priorities for Action

Despite their higher life expectancy, women suffer from more health problems than men. Beginning in infancy, females often receive less and lower-quality food and, when sick, receive treatment less often and at a more advanced stage of disease. Because of their reproductive function, women run risks of morbidity and mortality which men do not face. Their health is also adversely affected by gender-specific cultural practices, such as female circumcision and physical abuse.

The development response must be a life cycle approach to women's health. Policies and programs need to address both the biological and cultural determinants of women's poor health status. To address gender discrimination that begins in infancy and childhood, education, communications and health service outreach strategies will be needed to promote more equitable intra-household food allocation and health service use. To reduce the prevalence of early childbearing and improve adolescents' productive potential and reproductive health, strategies must be developed to target them with information and services on reproductive health, family planning and nutrition, as well as to expand educational opportunities and postpone age of marriage.

Innovative approaches are needed since traditional maternal and child health and family planning programs have had limited impact on adolescents. For all women of reproductive age, an integrated approach is necessary to ensure protection against unwanted pregnancy, AIDS and other sexually transmitted diseases. Appropriate food and micronutrient supplementation, prenatal health services, safe delivery and referral care are essential services for pregnant women. Detection and treatment of cervical cancer (and in some countries, breast cancer) will need to be considered as a priority for older women.

Improvements in women's health, while beneficial in their own right, contribute to development through improved productivity, reduced costs of medical care, and a healthier generation to follow. At the same time, development leads to improved health of women if the benefits of development are shared equitably.

Women comprise over one-half the human race. Investing in their health is an investment in development today; it is also an investment in the generations of tomorrow.

[Reprinted with the author's permission from Bank's World, Volume 12/Number 11, November 1993]