Lessons in Early Childhood Development
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Lessons in Early Childhood Development:
An Analysis of Early Childhood Development Programs in Developing Countries
Prepared for United Nations Children’s Fund (UNICEF)
Written By:
Razan Aldagher
Sam Alhadeff
Alison Harrell
Ryan LeCloux
John Moen
PA 869: Workshop in International Public Affairs
Spring 2018
©2018 Board of Regents of the University of Wisconsin System
All rights reserved.
For an online copy, see
http://www.lafollette.wisc.edu/outreach-public-service/workshops-in-public-affairs
publications@lafollette.wisc.edu
The Robert M. La Follette School of Public Affairs is a teaching and research department
of the University of Wisconsin–Madison. The school takes no stand on policy issues;
opinions expressed in these pages reflect the views of the authors.
The University of Wisconsin–Madison is an equal opportunity and affirmative-action educator and employer. We
promote excellence through diversity in all programs.
UNICEF Office of Research - Innocenti ii
Acknowledgments
We would like to express our deepest gratitude to all the faculty, staff, and students at the
La Follette School of Public Affairs. Without their technical expertise, academic insight, and
dogged belief in our abilities, this report would not have been possible. We are grateful to
Professor Timothy Smeeding for his patience and guidance throughout the semester. We would
also like to thank Lisa Hildebrand for her sharp eye and red pen. Finally, we would like to thank
our client Dominic Richardson, as well as the UNICEF Office of Research – Innocenti and the
UNICEF country offices in Ghana, India, Jamaica, Moldova, Peru, and South Africa, for giving
us the opportunity to make a difference for children around the world.
UNICEF Office of Research - Innocenti iii
Foreword from Professor
This report is the result of collaboration between the La Follette School of Public Affairs at the University
of Wisconsin–Madison, and the United Nations International Children’s Fund (UNICEF) Office of
Research – Innocenti in Florence, Italy. The objective of our program is to provide graduate students at
La Follette the opportunity to improve their policy analysis skills while providing the client an analysis of
policies and practices for financing early childhood development programs in low- and middle-income
countries.
The La Follette School offers a two-year graduate program leading to a Master’s degree in International
Public Affairs (MIPA). Students study policy analysis and public management, and they can choose to
pursue a concentration in a policy focus area. They spend the first year and a half of the program taking
courses in which they develop the expertise needed to analyze public policies. The authors of this report
are all in their final semester of their degree program and are enrolled in Public Affairs 860, Workshop in
International Public Affairs. Although acquiring a set of policy analysis skills is important, there is no
substitute for actually doing policy analysis as a means of experiential learning. Public Affairs 860 gives
graduate students that opportunity.
This year workshop students in the MIPA program were divided into three teams. The other teams
performed analyses of a rural health care facility in Ahuas, Honduras, and a program to improve
agricultural entrepreneurship in Nepal.
UNICEF seeks to reduce global poverty through targeted social and economic initiatives aimed at low-
and lower middle-income countries. UNICEF has asked the MIPA team to help them understand how
these nations fund and conduct sustainable early childhood development (ECD) programs in health,
education and family-support. In order to achieve these ends, the team investigated six case countries:
Ghana, India, Jamaica, Moldova, Peru, and South Africa, chosen from a larger set of nations. They found
that while every country varies in governance of and investment in ECD programs, their findings are
exportable and implementable in other nations.
The report makes several recommendations for less wealthy countries interested in ECD programs. In all
the countries analyzed, ECD programs are underfunded and require additional investment to meet the
desired reach and outcomes. In the short-term, they recommend utilizing existing infrastructure if
available, to minimize the costs of a new program, and seeking funds from third party actors to spur initial
investment in ECD. In the long-term, they recommend integrating ECD policies and programs under one
or a few agencies and establishing formal mechanisms for coordination and targeting programs to serve
those who would benefit the most from ECD services.
Timothy M Smeeding
Lee Rainwater Distinguished Professor of Public Affairs and Economics
May 2018
Madison, Wisconsin
UNICEF Office of Research - Innocenti ivTable of Contents
Copyright page ii
Acknowledgments iii
Foreword iv
Table of Contents v
List of Tables and Figures vi
List of Abbreviations vii
Glossary ix
Executive Summary x
INTRODUCTION 1
SECTION 1: EMERGENCE OF EARLY CHILDHOOD DEVELOPMENT PROGRAMS 1
SECTION 2: COUNTRY SELECTION METHODS 2
SECTION 3: PROGRAM ANALYSIS OF CASE COUNTRIES 4
Overview 4
Education 6
Health 9
Family-Support Policies 11
SECTION 4: FINANCIAL ANALYSIS OF CASE COUNTRIES 14
Overview 14
Education 15
Health 18
Family-Support Policies 23
SECTION 5: DISCUSSION 25
SECTION 6: LIMITATIONS 29
SECTION 7: RECOMMENDATIONS & CONCLUSION 30
REFERENCES 34
APPENDICES 44
Appendix A: ECD Programs, Interventions, Governance, Financing, and Funding 44
Appendix B: Elimination Criteria 46
Appendix C: Details on Family-Support Policies 49
Appendix D: Estimating Overall ECD Spending 50
Appendix E: Estimating Health Expenditures for Young Children 51
Appendix F: Education Spending Tables 53
Appendix G: Health Spending Tables 54
Appendix H: Country Information Sheets 56
UNICEF Office of Research - Innocenti vList of Tables and Figures
Table 1: Overview of ECD Programs 5
Table 2: Early Childhood Education in Six Case Countries 6
Table 3: Early Childhood Health Programs in Six Case Countries 9
Table 4: Family Leave Policies in Six Case Countries 13
Table 5: Child Allowances in Six Case Countries 17
Table 6: Financing Overview for Education Programs 20
Table 7: Financing Overview for Health Programs 22
Table 8: Health Insurance Funding Schemes 23
Table 9: Financing Overview for Maternity Leave 24
Table 10: Financing Overview for Child Allowances 21
Table 11: Recommendations 31
Figure 1: Components of Government Expenditures on ECD- 2014 estimates 4
Figure 2: Government Expenditures on Components of ECD as Percent of GDP- 2014 estimates 14
Figure 3: Pre-Primary Education Spending as a Percent of GDP 16
Figure 4: Public Health Expenditures as Percent of GDP 19
Figure 5: Out-of-Pocket Health Expenditure as a Percent of Total Health Expenditures 21
Figure 6: External Resources for Health as Percent of Total Health Expenditures 22
UNICEF Office of Research - Innocenti viList of Abbreviations
AWC Anganwadi Centre
AEJ African Evaluation Journal
BCG Bacille Calmette-Guerin
BE Basic Education
CCT Conditional Cash Transfer
CDC Centers for Disease Prevention and Control
CSG Child Support Grant
DFID Department for International Development
DOH Department of Health
DPT Diphtheria, Pertussis, and Tetanus
DSD Department of Social Development
ECC Early Childhood Commission
ECCD Early Childhood Care and Development
ECCE Early Childhood Care and Education
ECD Early Childhood Development
ECE Early Childhood Education
ECI Early Childhood Institutions
EPI Expanded Program of Immunization
GDP Gross Domestic Product
GET Ghana Education Trust
GHS Ghanaian Cedi
GNI Gross National Income
GPE Global Partnership for Education
HepB Hepatitis B
Hib Haemophilus Influenzae Type B
HIC High-Income Country
ICDS Integrated Child Development Services
ILO International Labour Organization
IMF International Monetary Fund
INR Indian Rupee
JMD Jamaican Dollar
KG Kindergarten
LEAP Livelihood Empowerment Against Poverty
LIC Low-Income Country
LMIC Lower-Middle Income Country
MACHEquity Maternal and Child Health Equity
MDL Moldovan Leu
MEF Ministry of Economy and Finance
MHFW Ministry of Health and Family Welfare
MHIF Mandatory Health Insurance Fund
MIC Middle-Income Country
UNICEF Office of Research - Innocenti viiMoE Ministry of Education
MoH Ministry of Health
NHIA National Health Insurance Authority
NHIS National Health Insurance Scheme
ODA Official Development Assistance
OECD Organisation for Economic Co-operation and Development
OOP Out-of-Pocket
OPV Oral Poliovirus Vaccines
PATH Programme for Advancement through Health and Education
PEN Peruvian Sol
PPP Purchasing Power Parity
RED Reaching Every District
SABER Systems Approach for Better Education Results
SIB Social Impact Bond
SIS Seguro Integral de Salud (Comprehensive Health Insurance)
SSIB State Social Insurance Budget
SSNIT Social Security and National Insurance Trust
UMIC Upper-Middle Income Country
UN United Nations
UNESCO United Nations Educational, Scientific, and Cultural Organization
UNICEF United Nations International Children's Emergency Fund
USAID United States Agency for International Development
USD U.S. Dollars
VAT Value-Added Tax
WDI World Development Indicators
WHO World Health Organization
ZAR South African Rand
UNICEF Office of Research - Innocenti viiiGlossary
Gross Domestic Product (GDP)
Total domestic and foreign output claimed by residents of a country
Gross National Income (GNI)
Total value of goods produced and services provided in a country
High-Income Country
A country with a GNI per capita of USD 12,236 or more, calculated using the World Bank Atlas
method in 2016
Lower-Income Country
A country with a GNI per capita of USD 1,005 or less
Lower-Middle Income Country
A country with a GNI per capita between USD 1,006 and USD 3,955
Upper-Middle Income Country
A country with a GNI per capita between USD 3,956 and USD 12,235
UNICEF Office of Research - Innocenti ixEXECUTIVE SUMMARY
In low- and middle-income countries around the world, leaders are actively searching for
ways to improve the economy and make their nation more prosperous. Early childhood
development (ECD) programs have proven to be among the most effective ways to invest in a
country’s human capital and break the intergenerational poverty cycle. ECD programs are
characterized as preventative interventions targeted at children and families with children
preschool-age and younger. Today, most world leaders should no longer debate whether to create
ECD programs but how to run and finance these programs. While ample literature on the value
and benefits of ECD programs exists, this report focuses on how to govern and sustainably
finance ECD programs in low- and middle-income countries. To evaluate the successes of ECD
programs around the world, we conducted in-depth research for six case countries: Ghana, India,
Jamaica, Moldova, Peru, and South Africa. While each country differs in its implementation and
financing schemes, the recommendations from this report are designed to be exportable and
implementable elsewhere, giving low- and middle-income countries a roadmap for financing
sustainable early childhood development programs.
We chose our six case countries after a thorough selection process designed to identify
countries who would best represent the global population. Because our focus is on low- and
middle-income countries, we first eliminated all high-income countries. We also eliminated
fragile countries because their stream of funding is unsustainable for the creation and longevity
of ECD programs. To focus our study on countries who face more serious threats to
sustainability, we eliminated all countries with a median household daily income above USD 10
as households in these countries are significantly less likely to fall back into poverty. To increase
the report’s external validity, we eliminated countries with populations of less than 500,000 and
countries with scarce data. Finally, we analyzed financial trends, data quality, and health and
education expenditures. The selected countries represent diversity in governance structures,
funding streams, and geography.
Our report focuses on three main categories of early childhood development: education,
health, and family-support programs. In all three categories, we found variance among the
countries in both governance and funding structure. For each ECD category, we explain the
specific programs, key components, and governance structures in each country. We also analyze
the coverage and participation rates for every program to better understand how these programs
are implemented. Where it was relevant, we also assess each country’s plans and goals in all
three categories. Finally, we dedicate an entire section for an analysis of the funding sources and
financial structure in each country across all three ECD categories. In this section, we identify
overall ECD spending, trends, and funding sources.
For each case country, we discuss the challenges faced by local and federal governments
as well as the various ways in which ECD programs are funded, governed, and implemented.
Importantly, we also look at the sustainability of each of these programs, analyzing the
availability of infrastructure, whether the programs are universal or targeted, centralized or
decentralized, and the extent of integration between agencies. Our most common finding was
that ECD programs are underfunded due to a variety of factors, including constrained
government resources and lack of government prioritization of ECD programs.
Based on our research and findings, we make several recommendations for countries
interested in beginning or reforming the funding structure of ECD programs. First and foremost,
countries hoping to achieve maximum benefits from their ECD programs need to invest more
UNICEF Office of Research - Innocenti xresources into them. To get these ECD programs off the ground in the short-run, we recommend
utilizing existing infrastructure where available and relying on third-party sources like
international organizations to fund initial investment into these programs. A notable example of
third party funding is social impact bonds, where a donor funds the initial stages of a
preventative ECD program and the host country is only liable if the program is successful. While
using these short-run sources to get ECD programs off the ground, governments should expand
their tax base, for example with a value-added tax, to prepare for their eventual takeover of the
programs. Earmarked taxes are another effective way to ensure sustainable funding for ECD
programs. Finally, for countries to reach the goal of long-run sustainability, we recommend they
integrate their ECD programs under one or a few agencies, target programs to vulnerable
populations, encourage formal employment, and promote a national consensus to invest in ECD.
By following these recommendations and adapting them to their unique domestic
situations, world leaders can invest in a sustainable and comprehensive early childhood
development program and unlock the human capital and poverty reduction potential of ECD
programs.
UNICEF Office of Research - Innocenti xiINTRODUCTION
Our client, UNICEF Office of Research – Innocenti, requested an analysis of early
childhood development (ECD) programs and their financing and governance structures for six
case countries. ECD policies differ from other child interventions based on two criteria: 1)
eligibility based on being a preschool-age child or a family with preschool-age children, and 2)
the policies or programs are primarily preventive interventions rather than acute treatments. The
eligibility age-range is approximately birth to age 5. After a methodical elimination process, we
selected Ghana, India, Jamaica, Moldova, Peru, and South Africa for our analysis. Our goal in
conducting this analysis is to provide guidance to UNICEF country offices and national
governments that seek to begin ECD programs or develop sustainable funding mechanisms for
existing ECD programs.
Section 1 describes the emergence of early childhood development programs. In Section
2, we explain the methods used for selecting the six case countries. Section 3 details each
country’s ECD program, including its administration and governance. In Section 4, we analyze
the financing of the case countries’ ECD programs, assessing the general funding structure,
trends, and sources. Each analysis section includes four subsections: Overview, Education,
Health, and Family-Support Policies. Section 5 summarizes our findings, and Section 6 briefly
describes the limitations to our research. Finally, Section 7 offers recommendations for
sustainable ECD program financing.
SECTION 1: EMERGENCE OF EARLY CHILDHOOD
DEVELOPMENT PROGRAMS
In the past few decades, ECD programs have emerged as an effective method for
combating poverty, malnutrition, infant mortality, and education shortfalls in developing
countries. International organizations such as the World Bank and the United Nations (UN) have
put their full weight behind the evaluation and improved effectiveness of such programs, and the
positive results of ECD programs benefit the countries that effectively implement them.
Robust ECD programs will contain many, if not all, of the following development goals:
1) nutrition, 2) education, 3) healthcare, 4) physical security, and 5) emotional development and
well-being. Positive results in these five sectors are the most important factors in determining
whether children achieve their potential through primary school and beyond. Experts in child
development agree that the first few years of a child’s life are the most important in terms of
many forms of development. Children with access to adequate care and stimulation are more
likely to succeed later in life, and children of healthy weight and physical development are more
likely to develop normally (World Bank 2017). Additionally, the importance of a strong and
stable family and community environment cannot be overstated; at-risk infants and young
children lack important healthcare, nutritional, and educational opportunities that children in
UNICEF Office of Research - Innocenti 1stable homes are more likely to receive. Investment in ECD programs helps break the
intergenerational poverty cycle by reducing inequality (Economic Commission for Latin
American and the Caribbean, Latin American and Caribbean Demographic Centre and UNICEF
2010). Additionally, ECD investment has a high cost-benefit ratio and return on investment,
ranging from 7% to 16% annually (Rolnick and Grunewald 2007; Heckman et al. 2009).
However, governments interested in providing ECD programs face vast challenges. Less
than half of the world’s children ages 3-6 have access to pre-primary education, and government
expenditures on pre-primary schooling are often a fraction of spending on primary education
(World Bank 2017). Additionally, in developing countries, governments often have less
flexibility to allocate the appropriate resources to create effective ECD programs. Often,
governments work with local and international aid groups like the World Bank, International
Monetary Fund (IMF), and UN to procure the requisite funding for effective ECD programming.
Many developing countries have created and maintained relatively robust ECD programs by
effectively using international aid in tandem with their own budget (UNESCO 2006).
Developing countries interested in improving children’s education, health, future wage
earnings, and other long-term benefits should focus on three program areas: 1) establishing an
enabling environment through legal and financial frameworks, 2) implementing the programs
widely and equitably, and 3) monitoring the quality of programs through data collection and
collaboration between government sectors (World Bank 2017).
ECD programs have had positive impacts on the lives of hundreds of thousands of
children around the world (World Bank 2017). Developing countries interested in providing
robust ECD services can expect strong returns on their investments in children if their financing
and governance structures are effective and focused on long-term investments.
SECTION 2: COUNTRY SELECTION METHODS
In this section, we describe the methods used to select the six case countries and the
reasoning for why we excluded some countries and kept others. We used several criteria to
narrow the list of target countries. First, we eliminated high-income countries, fragile states, and
countries with a median household daily income above USD 10. To filter the list further and
before conducting a trend analysis on ECD program spending, we considered countries'
population size and data availability. Appendix B includes the countries eliminated and the 37
countries for which we performed trend analyses.
Country Selection Criteria
Our focus on middle-income countries (MICs) was purposive, to focus on countries
presently seeking guidance on ECD program expansion. We used World Bank country income
classifications to identify and exclude high-income countries. Next, we eliminated fragile states,
which often are not fully in control of their budgets and are unlikely to have sufficient
infrastructure or government focus on ECD programs (World Bank 2018; Fund for Peace 2017).
UNICEF Office of Research - Innocenti 2We then eliminated countries with a median household daily income above USD 10. Households
below this threshold are susceptible to falling into or remaining in poverty and are less likely to
sustain their level of income (Birdsall 2010; Lopez-Calva and Ortiz-Juarez 2011). On a national
scale, countries with a median household daily income above USD 10 have fewer challenges to
the sustainability of social and economic development. Because the goal of our report is to
provide recommendations to low- and middle-income countries, we used this threshold to
identify countries whose citizens face significant challenges to overcoming poverty and where
our recommendations would be most salient. Finally, we excluded countries with fewer than
500,000 people because experiences in smaller countries are less generalizable to MICs due to
lower absolute levels of demand for ECD programs and unique differences in the governance
and funding of small countries.
Case Country Selection
After using these exclusion criteria, 37 countries remained. For each one, we performed
financial trends analysis on the two main components of ECD (if spending data was available):
education and health. We found data from UNICEF, the United Nations Educational, Scientific,
and Cultural Organization (UNESCO), the World Bank's World Development Index (WDI) and
Systems Approach for Better Education (SABER), World Health Organization (WHO), the
Maternal and Child Health Equity data center, and individual countries' ministries of education
and health (or related department).
For education, we analyzed public-spending trends for total education spending as a
percent of total government expenditures and as a percent of gross domestic product (GDP); pre-
primary education spending as a percent of total government expenditures and of GDP; and pre-
primary education spending as a percent of total government expenditures on education.
We could not find reliable estimates for health expenditures disaggregated by age or type
of services, so we used broader measures of health expenditure to conduct the initial financial
trends analysis. After selecting the case countries, we estimated the percent of health spending on
preschool-age children. We examined spending trends among total public health expenditures as
a percent of total government expenditures and public health and out-of-pocket health
expenditures as a percent of total health expenditures. We created tables and charts using
spending data from 2000 to the most recent available year, 2014. We analyzed the data to
observe trends, irregularities, and overall range of spending.
Because availability of data is crucial for analyzing ECD program sustainability, we
excluded countries that did not have sufficient data or did not keep records of education and
health spending as a portion of their GDP. We primarily considered the availability of pre-
primary education expenditure data. Even countries that reported education spending data since
2013 still had large amounts of missing data.
After eliminating countries due to low data availability, we considered regional diversity
and spending trends in making our final selection. First, we divided the remaining countries into
regional groups to ensure a representative sample. For each country, we then indicated the types
UNICEF Office of Research - Innocenti 3of spending trends for education and health as well as the beginning level of spending and
whether it increased, decreased, or remained stable.
Our final six case countries are Ghana, India, Jamaica, Moldova, Peru, and South Africa.
These six countries have reliable data, represent geographic diversity, and demonstrate our
desired variety of spending trends. During our trends analysis, we noticed that Moldova spends a
substantial amount on pre-primary education and has a low fertility rate, relative to the other case
countries. We chose to study Moldova to learn more about its high spending on pre-primary
education and to include a former Soviet republic, which have unique financing and governance.
SECTION 3: PROGRAM ANALYSIS OF CASE COUNTRIES
Overview
Unlike other child interventions, ECD programs must be preventive in nature and must
focus on children from prenatal to primary-school age. We identified three main components of
ECD programs: education, health, and family-support. Figure 1 demonstrates the percent of
government expenditures on ECD that are allocated to education, health, and family-support.
Figure 1
Components of Government Expenditures on
ECD, 2014
100 0.26 0.45
14.40 17.66 21.34
80 43.71 41.53
55.90
27.20
60
64.03
40 29.81 81.89
56.02 51.47 36.37
20
21.57 28.67
0 7.73
Ghana India Jamaica Moldova Peru South Africa
% of ECD expenditures on education % of ECD expenditures on health
% of ECD expenditures on family support
Source: Authors calculations based on UNESCO Institute of Statistics; Ministry of Gender, Children, and Social
Protection; National Treasury Republic of South Africa; Economic Times; Jamaican Information Service; Moldova
Annual Social Report; and Peru Ministry of Development and Social Inclusion
Similarities and differences abound across ECD programs in Ghana, India, Jamaica,
Moldova, Peru, and South Africa. One characteristic found across five of the six countries is the
relatively recent creation of a department dedicated specifically to child development. In India,
the Ministry of Women and Child Development (MWCD) gained independence as a separate
agency in 2006, suggesting that ECD is a priority for the country (Rao and Kaul 2017). The same
UNICEF Office of Research - Innocenti 4is true for Ghana’s Ministry of Gender, Children, and Social Protection, founded in 2013.
Jamaica established its Early Childhood Commission in 2003 to coordinate all activity in the
childhood sector (Early Childhood Commission 2016), and Peru founded the Ministry of
Development and Social Inclusion in 2011 (Huicho et al. 2015). The Department of Social
Development (DSD) in South Africa is unique from its counterparts, as the oldest department,
founded in 1937. Moldova is the only case country without a designated development agency.
A few unique elements of ECD programs do not fit well into education, health, or family-
support but are encouraging examples of countries prioritizing ECD. India runs the world’s
largest ECD program through the Integrated Child Development Services Scheme, an example
of a robust integrated ECD program and a national priority (Rao and Kaul 2017). At the National
Agreement Forum in Peru in 2001, government and civil society representatives chose to
prioritize increasing access to health and education across all income and regional divides
(Huicho et al. 2015). The rest of this section overviews the different components and governance
of education, health, and family-support programs across all six countries.
Table 1: Overview of ECD Programs in Six Case Countries
Country Education Health Family-Support
Ghana Nurseries: ages 0-4 Free targeted healthcare Maternity leave
KG: ages 4-5 Immunizations Conditional cash transfer
India Preschool: ages 3-6 Health check-ups/referrals Maternity leave
Nutrition programs Conditional cash transfer
Immunizations
ECIs: ages 0-3 Free universal healthcare Maternity leave
Jamaica
Pre-primary/ECI: ages 4-5 Nutrition Programs Conditional cash transfer
Immunizations
Moldova Pre-primary: ages 3-6 Free universal healthcare Maternity, paternity, & parental leave
Nutrition programs Childcare and birth allowances
Immunizations
Peru Nurseries: ages 0-2 Free targeted healthcare Maternity & paternity leave
KG: ages 3-4 Nutrition programs Conditional cash transfer
Pre-primary: ages 5-6 Immunizations
Preschool: ages 0-6 Free targeted healthcare Maternity & parental leave
South
Africa Immunizations Conditional cash transfer
KG: kindergarten and ECI: early childhood institution
UNICEF Office of Research - Innocenti 5Education
A strong pre-primary education system is one of the backbones of an effective ECD
program. As a result, governments and international organizations have expended significant
effort to improve education systems and invest in the potential of their youth.
Table 2: Early Childhood Education in Six Case Countries
Country Governance Key Components Reach Goals
Ghana Ministry of Free meals Enrollment has improved Investments in
Gender, Children, KG part basic but gaps exist transportation and
Social Protection education infrastructure
India Ministry of Universal for children 70% enrollment in Government committed
Women and Child age 3-6 preschool to universal pre-primary
Development education
Jamaica Early Childhood National Curricula for 72% enrollment in pre- Improve and certify ECI
Commission age 0-3 and 4-5 primary school, gaps centers
between children 1-3 and
4-5.
Moldova Ministry of Universal pre- 85.3% enrollment in pre- Education 2020: increase
Education, primary, compulsory primary school, gaps for quality and services for
Culture, and at age 5 rural, Roma, and disabled pre-primary school
Research children
Peru Ministry of Nurseries for children 80% of children 3-5 Bicentennial Plan to
Education, Youth, 0-2, preschool 3-6, enrolled; enrollment eradicate illiteracy
and Culture mandatory 5-6 increasing
South Department of Grade R, similar to KG 70,000 children in Grade R Further implement Grade
Africa Basic Education 100% enrollment not met R and increase funding
KG: kindergarten and ECI: early childhood institution
Definition and Governance
Pre-primary education is defined as schooling gained before entry into primary school.
While the general ages for children enrolled in pre-primary school are birth to 5 years old, some
children are enrolled at age 6 or older due to issues with access to childcare centers or
educational achievement gaps. In the countries studied, pre-primary education varies widely in
terms of cost, accessibility, and quality.
Pre-primary education programs are often managed at several levels of government.
Commonly, a national body develops and administers regulations and provides guidance to
lower entities that implement the programs. The six case study countries use various governance
structures that are representative of the different ways pre-primary education programs are
managed. While Jamaica's Ministry of Education (MoE) works with other ministries, the MoE
UNICEF Office of Research - Innocenti 6manages the Early Childhood Commission and pre-primary education more generally. This
differentiates Jamaica's ECD programs from the other case countries in that Jamaica’s entire
battery of ECD programs are all under one legislative umbrella with the MoE at its head (Early
Childhood Commission 2016).
Ghana was the first country in Sub-Saharan Africa to make pre-primary education
compulsory when the government included two years of kindergarten in basic education, which
is overseen by the Ministry of Education. In India, the Ministry of Women and Child
Development offers preschool services through various childcare centers and works with the
Ministry of Health and Family Welfare to manage ECD programs (Rao and Kaul 2017). India is
the only case country that does not provide preschool services in a dedicated education facility
but instead provides it as one of several services in ECD centers.
Key Components
Each of our case study countries has developed programs for use in their pre-primary
educational institutions. In 2002, Moldova declared that early childhood education would be one
of its top priorities for development. In South Africa, non-governmental organizations comprise
many of the early learning centers. The “Grade R” program is instrumental for early learners in
that country. Peru has taken a more divided approach by creating separate schooling programs
for children in different age groups.
In 2013, India enacted the National Early Childhood Care and Education (ECCE) Policy,
which states a commitment to universal access to early childhood education (UNICEF India
2018). In Jamaica, the federal government has implemented several programs designed to benefit
preschool children in the country, including separate national curricula for infants and those
preparing for primary school (Jamaica Ministry of Education, n.d.).
Reach and Participation
ECD education programs have different target populations. While many strive for
universal access, some focus on achieving equity between rural and urban children and between
wealthy and poor students. Both Moldova and Ghana have increased access to early childhood
education, but still face challenges creating equitable access. Rising from 42.5% enrollment in
2000 to 85.3% enrollment in 2017, the Moldovan pre-primary education system has seen a vast
increase in its reach (Fusu et al. 2016). However, a major enrollment gap remains for Moldova’s
rural, Roma, and disabled children (Fusu et al. 2016). In Ghana, access to pre-primary education
has improved, but ECD services for children ages 0-3 are limited, and the poorest families do not
have equitable access to ECD programs (Silver and Singer 2014). Over the past decade,
enrollment has increased, likely due to the increased spending, but the education system was not
prepared for the influx of students. This has led to issues of insufficient staffing and
infrastructure (Silver and Singer 2014).
The “Grade R” program in South Africa caters to 5-year old children and is available
UNICEF Office of Research - Innocenti 7universally. South Africa’s early childhood education program takes major steps to address
disadvantaged learners. The 2001 ECD Pilot Project started nearly 2,800 non-governmental ECD
centers that serve more than 70,000 South African children. Although “Grade R” was created to
serve disadvantaged children from low socioeconomic backgrounds, an impact evaluation
conducted by the African Evaluation Journal found that “Grade R” was associated with
negligible enhancement of literature and mathematics skills (AEJ 2015).
Peru’s Ministry of Education has developed a separate national curriculum for each age
group of children. In 18 of the 24 departments in the country, enrollment in pre-primary school
has surpassed 90%, likely due to the introduction of compulsory enrollment for all 5-year-olds,
also incorporated into Peru’s conditional cash transfer (CCT) program (Peru Ministry of
Education 2018; Sanchez et al. 2016). Additionally, Peru’s Ministry of Education has prioritized
including Andean native communities, who have faced language barriers in the past, into the
education system. Jamaica also created a national curriculum for children up to 3 years old and
another for children ages 4 and 5 to increase positive educational outcomes for its youngest and
most vulnerable citizens (Jamaica Ministry of Education). Enrollment rates have been mixed;
children ages 1 to 3 are enrolled in pre-primary schools at a relatively low rate (20%), but
between ages 4 and 6, enrollment in pre-primary education has reached 98% (UNICEF n.d.).
Due to India’s large population, the task of providing universal pre-primary education is a
difficult one. Preschool services are available for all children ages 3 to 6 at approximately 90%
of Anganwadi Centres (AWC), and over 36 million children were enrolled in 2015 (Rao and
Kaul 2017). While this represents about one-quarter of the eligible population, it is a significant
increase from 2002, when only 16.7 million children were enrolled (Rao and Kaul 2017).
Additionally, India has a robust private school system in which most urban children and 30% of
rural children are enrolled (Rao and Kaul 2017). UNICEF estimates that 7 in 10 children are
enrolled in some type of preschool.
Plans and Goals
Each case country has plans and goals for their ECD programs. These plans are evidence
of growing national prosperity and the importance of investments in health and education at
young ages to benefit the social and economic growth of these countries. Some of these goals are
outlined below.
Moldova’s government has set a goal to increase access and services for pre-primary
education by 2020. The “Education 2020” plan includes a USD 4.35 million grant from the
Global Partnership for Education (GPE) designed to help raise the quality of services and
inclusiveness of Moldova’s pre-primary schools (GPE 2017). Ghana’s government also has a
2020 plan to expand and improve ECD programs for disadvantaged children by making basic
education available for all, ensuring health and safety standards, and providing transportation for
kindergarten students who live far from schools (GPE 2016; Ministry of Education 2012a).
One major goal for Jamaica’s education system is to have its Early Childhood Institutions
(ECI) meet more of the national standards for services provided as set by the Early Childhood
UNICEF Office of Research - Innocenti 8Commission (ECC). The government of Jamaica also has plans to improve and certify hundreds
of schools by the end of 2018 and incorporate private schools under the MoE’s regulatory
umbrella to streamline access to services for young children across the country (Early Childhood
Commission Certified ECI List n.d.; Jamaica Ministry of Education 2018). South Africa had a
goal of enrolling all young students in “Grade R” programs by 2010, but this goal has not been
met (UNESCO 2016). Peru’s Bicentennial Plan aims for universal school enrollment for children
ages 5 and 6 and for eradicating illiteracy by 2021 (MEF et al. 2014). India does not have any
particular “future goals” in its ECD education programs, but the government remains committed
to pre-primary education.
Health
Health is a prevalent ECD component in all the case countries. However, not all ECD
programs provide health services. Table 3 is an overview of the services offered in each country
and the population coverage.
Table 3: Early Childhood Health Programs in Six Case Countries
Country Prenatal & Postnatal Nutrition & Immunization Insurance Coverage &
Care Disparities
Ghana 74% births attended by Free meals in schools NHIS spread across national,
skilled attendant (2014) Vaccinations for children regional, and district levels-
covered 40% of population
India Health/nutrition services Supplementary Nutrition Programme ICDS health services reach
for children and 88% of children immunized in 2016 half of children under 6
lactating/pregnant (2015)
women at AWCs
Jamaica Free prenatal check-ups, Nutrition support for children in ECIs Universal healthcare system;
labor and delivery, child Free immunizations for children ages accessible more by the rich
checkups 5-6 conditional on school registration
Moldova Free services for children Government covers ⅔ of lunch cost 98% of children ages 0-18
and pregnant/lactating at preschools enrolled in free Mandatory
women Free immunizations Health Insurance (2012)
Peru Free prenatal check-ups, Integral Nutrition Program 38.6% enrolled in free health
labor and delivery, child High vaccination rates (>90%) insurance plan; 33.3% more
checkups Prioritize vaccines for low-income enrolled in national health
children insurance
South Provision of information Free meals for children in preschool Universal healthcare system;
Africa for pregnant women 90% of children ages 0-6 are fully 77% of children ages 0-6
immunized (2011)
NHIS: National Health Insurance Scheme, AWC: Anganwadi Centre, SNP: Supplementary Nutrition Programme, ICDS:
Integrated Child Development Services, ECI: early childhood institution
UNICEF Office of Research - Innocenti 9Definition and Governance
Low- and middle-income countries often rank poorly on preventive healthcare measures,
provision of universal health insurance, and support for pregnant women and lactating mothers
compared to high-income countries. In this section, we discuss how the provision of health-
related ECD services is governed and expand on key components of ECD health services such as
prenatal and postnatal care, child health, nutrition, and immunization. We also look at the reach
and participation rates of these programs, whether they are universal or targeted. Finally, we
discuss the countries’ plans for improving child and maternal health.
In most of the case countries, a central government agency focused on health oversees
the provision of health services for underserved populations. However, in Moldova and India,
several agencies oversee the provision of these services. In Moldova, the Central Public Health
Authority manages and evaluates policy on mandatory health insurance while the National
Health Insurance Company manages the insurance funds and programs (Moldova Ministry of
Finance n.d.). In India, the governance structure varies between services, with nutrition and
health education services managed by the Ministry of Women and Child Development and
health services provided by the Ministry of Health and Family Welfare (MHFW) and
administered through the National Rural Health Mission (Ministry of Women and Child
Development Government of India 2016-17).
Key Components
Key prenatal and postnatal care services include preconception care, pregnancy visits,
and risk assessment. In Moldova, children and pregnant women receive a more comprehensive
benefits package than the general population, including first-time visits and nutrition plans
(Mathauer 2016). Peru and Jamaica provide all essential health services for young children and
mothers, including prenatal check-ups and labor and delivery (World Bank 2013).
Nutrition and child health play a secondary role in the ECD programs studied, except for
Ghana and India, which provide extensive nutrition services. As a national strategy, the
government of Ghana introduced the capitation grant policy to provide free meals to
disadvantaged children in schools (Agbenyega 2008). In India, the 2013 ECCE Policy and
National Food Security Act mandated an expansive Supplementary Nutrition Programme (SNP)
at childcare centers (Mobile Creches 2016).
Immunizations are critical for ensuring low mortality rates and the six case countries
provide various schemes to administer vaccinations. For example, in Peru and India,
immunization is provided through ECD programs and at AWCs, respectively, with
a persistent increase in immunization rates (Sanchez et al. 2016; World Bank 2018j). As stated in
Table 3, the six case countries provide free immunizations with an overall average of 90%
coverage rate.
UNICEF Office of Research - Innocenti 10Insurance Coverage and Disparities
We analyzed the coverage of each country’s health insurance to understand potential
disparities in access among population groups. Inequality in access to health services and
coverage is a prominent issue in the countries studied. Only 10% of India’s population has health
insurance, which makes the free ECD services provided by the government essential for ensuring
early childhood development (Doshi 2018). In 2015, health and nutrition services offered at
AWCs covered just over half of the children younger than 6 (Rao and Kaul 2017).
After the removal of user fees in Jamaica, there has been little to no difference in
healthcare utilization between poor and non-poor families in the medium- to long-term (World
Bank 2013). Peru provides free and subsidized healthcare to only the poorest families; low-
income families, making up 38.6% of the population, receive comprehensive coverage with only
0.1% of enrollees required to contribute. Additionally, Peru runs an unsubsidized healthcare
service, called EsSalud, with mandatory enrollment for all formal workers; this covers an
additional 33% of the population (Class et al. 2013).
Ghana’s National Health Insurance Scheme (NHIS) is offered universally but is targeted
at low-income populations. However, the NHIS does not always provide equitable coverage for
poor people due to problems of income identification (USAID 2016). In 2014, the NHIS covered
10.5 million people, 40% of Ghana’s total population (Wang et al. 2017). In comparison, South
Africa’s universal healthcare program reaches around 77% of preschool-age children who live in
households that use public hospitals or clinics (UNICEF 2015). Moldova’s 2004 Law on
Mandatory Health Insurance provides free healthcare for children younger than 18 and pregnant
women, which has resulted in 98% of children younger than 18 being insured as of 2012 (Hone
et al. 2014).
Family-Support Policies
Family-support policies provide assistance to parents prior to birth, during birth, and
throughout the child’s lifetime. By providing financial support for parents to care for their
children, these programs can improve early childhood development. There are two main types of
family-support: leave and child allowances. Leave is usually split into maternity, paternity, and
parental (to care for a sick child) leave, with mothers tending to get longer paid leave than
fathers. Child allowances are payments to help cover costs of parenthood. These allowances can
be universal or targeted, one-time or recurring, and unconditional or conditional. Another family-
support policy is breastfeeding breaks for nursing mothers at work. Table 4 provides an overview
of family leave in the case countries. Specific amounts of leave and cash allowance benefits can
be found in Appendix C.
UNICEF Office of Research - Innocenti 11Table 4: Family Leave in Six Case Countries
Country Maternity Leave Paternity Leave Parental Leave Breastfeeding Breaks
Ghana 12 weeks, 100% paid None None 1 year
India 26 weeks, 100% paid None None 1.25 years, plus
provision of creches
Jamaica 12 weeks, 100% paid None None None
for 8 weeks
Moldova 18 weeks, 100% paid 14 days, 100% paid Sick childcare leave, 180 days, 3 years
60-90% paid, must be insured
Peru 14 weeks, 100% paid 4 days, 100% paid None 1 year
South 17 weeks, 38%-60% 10 days (expected) Family Responsibility Leave, 3 6 months, split into 2
Africa paid days per year, 100% paid half-hour breaks
Key Components
As is shown in Table 4, maternity leave exists in all six countries but varies in length and
amount. India guarantees the most leave at 26 weeks. The other countries provide 12 to 18 weeks
of paid leave. South Africa is the only country that does not pay 100% of missed wages but
rather a range from 38% to 60% (Department of Labour 2016). Peru and Moldova have paid
paternity leave policies at 4 and 14 days, respectively (Montoya 2016; Virtosu 2018). A bill
introducing 10 days of paternity leave passed South Africa’s National Assembly in late 2017
(Gerber 2017). A final form of leave is parental leave, offered by only South Africa and
Moldova. Moldova’s benefit provides 180 days of coverage compared to South Africa’s three
days every 12 months. However, in Moldova, benefits only cover 60% to 90% of wages
depending on how many years a beneficiary is insured (Social Security Administration 2016).
Moldova is also unique because its National Office of Social Insurance administers maternity
benefits. For Ghana, India, Jamaica, and South Africa, the Ministry of Labor administers
maternity benefits. In Peru, the office of the Comptroller General provides maternity leave
supervision.
Finally, all case countries mandate the provision of breastfeeding breaks except for
Jamaica. Eligibility for this benefit ranges from six months in South Africa to three years in
Moldova. In addition to these breaks, India requires all employers to provide creches, a workday
nursery for children, for all employed mothers (Chandran 2017).
UNICEF Office of Research - Innocenti 12Table 5: Child Allowances in Six Case Countries
Country Type of Type of Program Conditions Governance
Allowance
Ghana Child allowance Targeted Low-income Department of Social
Family allowance CCT Health check-up & school Welfare
attendance
India Birth allowance CCT Informally employed & health Ministry of Women &
check-up, first child only Child Development
Jamaica Family allowance CCT Health check-up Ministry of Labor and
Social Security
Moldova Birth allowance Universal Proof of birth Social insurance
Child allowance Universal, 2x more Insured: until age 3
benefits if insured Uninsured: until age 1.5
Peru Family allowance CCT Health check-up Ministry of Development
& Social Inclusion
South Child allowance Targeted Low-income Social Security Agency
Africa
All six case countries have some form of a child allowance. Moldova is unique among
these countries in the universality of its child allowance policy. Moldova provides a universal
birth allowance for each child, a universal one-time cash allowance for the birth of a child, and a
monthly child allowance for families. Ghana and South Africa provide a recurring child
allowance targeted at low-income families. India offers informally employed women a birth
allowance if the mother attends regular health check-ups (World Social Protection Report 2017).
Another common family-support program is conditional cash transfers (CCTs). Three of the
countries in the study, Ghana, Jamaica, and Peru, provide support for families, conditional on
attending health check-ups and school (Owusu-Addo 2016).
Reach and Participation
The biggest problem countries face in terms of participation is the absence of many
workers, especially women, from formal employment. Instead of working in salaried jobs where
these policies would obligate employers to provide paid leave, most women work outside the
legal structure and are not guaranteed access to leave benefits. For example, in India, only 17%
of women are formally employed (World Bank 2018b). Additionally, most women in informal
employment tend to live in poverty; low-income families are disproportionately excluded from
maternity leave (Jüttingand de Laiglesia, 2009).
Jamaica and South Africa have restrictions on leave eligibility based on length of
employment, which further decreases the number of women eligible to receive benefits. On the
UNICEF Office of Research - Innocenti 13other hand, Jamaica, Peru, and South Africa all have protections against firing women for taking
maternity leave (Maternity Leave Act 1979; Unemployment Insurance Act 2001).
In contrast, eligibility for child allowances is almost exclusively available to low-income
and/or informally employed families. For example, India’s Maternity Benefit Program offers the
birth cash transfer only to informally employed women (The Economic Times 2017). Child
allowances in Ghana and South Africa have income caps on eligibility to ensure they reach low-
income recipients.
SECTION 4: FINANCIAL ANALYSIS OF CASE COUNTRIES
Overview
ECD Funding and Trends
Spending on ECD programs often occurs at multiple levels of government and within
various agencies, making it difficult to track precisely the amount spent and the sectors providing
funds (Putcha and van der Gaag 2015). Because most case countries did not provide estimates on
total ECD program spending, we estimated these amounts in Figure 2. Appendix D explains our
method for calculating expenditures.
Figure 2
Government Expenditures as % of GDP- 2014
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
Ghana India Jamaica Moldova Peru South Africa
Pre-primary education Health for children ages 0-5 Family-support policies
Source: Authors calculations based on UNESCO Institute of Statistics; Ministry of Gender, Children, and Social
Protection; National Treasury Republic of South Africa; Economic Times; Jamaican Information Service; Moldova
Annual Social Report; and Peru Ministry of Development and Social Inclusion
As indicated in Figure 2, India spends the least on ECD programs as a percentage of
GDP, spending 0.58% of GDP on ECD programs in 2013 (Das and Kundu 2014). In Moldova,
Peru, and Ghana, pre-primary education accounts for the majority of ECD expenditures.
Moldova’s expenditures on pre-primary education are disproportionately higher than
UNICEF Office of Research - Innocenti 14expenditures by any other country in any ECD sector. India is the only country for which health
comprises the highest amount of ECD expenditures, due to its focus on supplementary nutrition
(Zubairi and Rose 2017). South Africa and Jamaica spend the highest proportion of ECD funds
on family-support programs. India and Jamaica have five-year plans to increase ECD program
funding.
Funding Structure and Sources
Funding for ECD programs tends to have more of a mix of government and private
sources than other sectors, with household expenditures comprising a significant amount of ECD
program spending globally (International Commission on Financing Global Education
Opportunity 2016). All countries we analyzed receive some financial support from multilateral
and/or bilateral aid agencies for their ECD programs.
However, the structure and source of ECD program funding vary widely among the six
case countries. Moldova and Jamaica predominantly fund and manage their ECD programs at the
national government level. In Peru and India, funding for ECD programs is split fairly evenly
between the national and provincial governments. In both countries, the financial burden is
increasingly shifting away from the national government to the provincial governments. India
has seen a drastic shift in financing responsibilities, from a 90:10 central government to state
government funding ratio in 2010 to a 60:40 funding ratio in 2017 (India Ministry of Women and
Child Development 2017). Ghana and South Africa have the most diverse funding structures and
sources and rely heavily on private funding sources for ECD programs.
In the case countries, ECD funds typically come from tax-generated government
revenues. Funds for specific sectors often are part of the governing ministries’ budgets. Most
funds for pre-primary education are allocated from the general education budget, funds for health
are generally covered by insurance schemes, and family-support programs often are funded
through social insurance and welfare programs. The remainder of this analysis assesses funding
trends, structures, and sources for education, health, and family-support programs.
Education
Overall Expenditure and Trends
Government investment in pre-primary education has varied in the countries studied, but
half of the countries, Peru, South Africa, and India, have shown a fairly consistent increase in
pre-primary education funding. Figure 3 shows trends in pre-primary education spending. Peru
has made the most significant increases in ECE investment over the time period studied. Ghana
and Jamaica have shown variation in their public ECE spending over the years studied and have
invested a similar percentage of their GDPs in pre-primary education in 2014 as they did in
2004. While Moldova continues to increase absolute funding for ECE, spending as a percentage
of GDP is predicted to fall from 6.5% in 2015 to 5.3% in 2020 (van Ravens et al. 2017). This is
UNICEF Office of Research - Innocenti 15not necessarily a worrisome trend given Moldova spends substantially more than other countries
largely due to investment in an extensive pre-primary education network.
Most middle-income countries underinvest in pre-primary education. It is estimated that
governments need to spend a minimum of 1% of GDP on early childhood education (ECE) to
ensure quality universal pre-primary education (International Commission on Financing Global
Education Opportunity 2016). Based on estimates by the UNESCO Institute of Statistics, only
one of the countries in our analysis, Moldova, meets or surpasses that threshold at a rate of
1.57% in 2014, which is well above the OECD average of 0.5% (UNESCO Institute of Statistics
2018a; Gutan and Fuior 2014). In 2014, two of the six countries, South Africa and India, spent
less than 0.10% of GDP on pre-primary education, which is well below the 1% threshold
(UNESCO Institute of Statistics 2018a). While this threshold is a useful benchmark for
considering whether countries spend enough on pre-primary education, spending 1% of GDP on
pre-primary education is not a guarantee that a country is adequately providing ECE services to
its children. Moldova, for example, suffers from aging preschool infrastructure, has a shortage of
adequately trained and paid teachers, and struggles to allocate resources efficiently as seen by
overcrowding of pre-schools in urban areas and a surplus of open seats in rural schools, despite
spending over 1.5% of its GDP on pre-primary education (van Ravens et al. 2017).
Figure 3
Pre-Primary Education Spending as Percent of GDP
2
1.75
1.5
1.25
1
0.75
0.5
0.25
0
04 05 06 07 08 09 10 11 12 13 14
Year
Ghana India Jamaica Moldova Peru South Africa
Source: “Expenditure on Education as % of GDP (from Government Sources)” UNESCO 2018a
Funding Structures
In the six case countries, public funds comprise the majority of total expenditures on pre-
primary education. However, the actual financing structure and funding sources vary widely.
Table 6 provides an overview of the main funding entities and sources.
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