Placing nurturing care at the centre of global initiatives to improve child health and development

The 2016 Lancet Series ‘Advancing early childhood development: from science to scale’ estimated that 250 million children (43%) younger than 5 years of age in low- and middle-income countries are at risk of suboptimal development into adulthood because of exposure to the risk factors of poverty and stunting alone.^[1] The addition of exposure to other adversities, such as household or country violence, would increase considerably the numbers of children at risk.

Over the last three decades, scientific findings from a range of disciplines have confirmed that the most critical elements of child, adolescent and adult health, well-being and productivity take shape in the early years.^[2] The period from conception to around a child’s third birthday is foundational in this regard, including the so-called first 1000 days of life. This is when the brain develops most rapidly and massive numbers of neural connections are made in response to stimulation, affection and comfort from caregivers.^[3] Importantly, though, brain development does not stop at the end of these early years and therefore a life-course and inter-generational approach is important. The health of young people before pregnancy influences foetal development, and optimal early childhood development has a positive impact on adolescents and young adults and, in turn, their own children.

Risk factors for sub-optimal child development include low rates of exclusive breastfeeding and inadequate complementary feeding; stunting; limited cognitive stimulation; caregiver mental health problems; child neglect and maltreatment; disabilities; and exposure to environmental toxins and pollution. Risk factors cluster in households and thus, exposure to one risk commonly means a child is exposed to multiple risks.

Children need nurturing care for their innate capacities to flourish. This means providing young children with a secure environment that is sensitive to their health and nutritional needs, which protects them from danger and abuse, and provides them with opportunities for early learning and interactions that are responsive, emotionally supportive, and developmentally stimulating. Nurturing care consists of five interrelated components: health, nutrition, safety and security, responsive caregiving and early learning.

Children who do not experience nurturing care are more likely to grow poorly; be less healthy; learn less and complete fewer grades at school; have difficulties relating confidently to others; and be less productive as adults. They may earn close to a third less than the average annual income of their peers, leading to a debilitating, inter-generational cycle of poverty.^[4] When early childhood development is compromised, it threatens economic development, security and peace as well as human well-being. Conversely, investments in early childhood health and development can yield benefit- to-cost ratios of around 10:1, boost learning, adaptability and earnings, and substantially reduce mental health disorders, violence, unintentional injuries, and non-communicable diseases later in life.^[5]

The health sector has an important role in determining how children develop their intellectual capacities and socio-emotional skills. Many health and nutrition interventions important for child growth and survival have a direct impact on childhood development.^[6] Moreover, the health sector has substantial reach to pregnant women, caregivers and families, and young children, in particular in the period from pregnancy to age 3. The global responses to conditions that threaten early childhood development need to be firmly situated within a number of global initiatives where the World Health Organization (WHO) plays an instrumental role.

The Sustainable Development Goals (SDGs) and the Global Strategy for Women’s, Children’s and Adolescents’ Health

The WHO is committed to the 2030 Agenda for Sustainable Development.^[7] This involves a commitment to achieve Goal 3 – Ensure healthy lives and promote well-being for all at all ages – but also support for countries in reaching other SDG targets related to health, nutrition, equality, gender and protection. The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) aims to ensure that all women, children and adolescents have an equal chance to thrive.^[8] Its 17 targets derived from the SDG framework and its nine action areas are all relevant for children’s development.

Universal health coverage

Universal health coverage (UHC) exists when all people receive the quality health services they need but do not undergo financial hardship in order to receive those services. The objective has an important equity dimension and aims to ensure that everybody in a country can access a full range of health services, from promotion and prevention to palliative services. The WHO’s work is fully aligned with SDG target 3.8, which focuses on achieving UHC, including financial risk protection, access to quality essential health services and access to safe, effective, quality and affordable vaccines for all. Universal health coverage, reaching the most vulnerable groups, and leaving no one behind, is central to ensuring that all children reach their developmental potential. Without UHC, marginalised families and children in rich and poor countries will experience difficulty in receiving basic health services and children will be deprived of essential interventions for their healthy growth and development.

The role of the WHO in the nurturing care agenda

The purpose of the 13th general programme of work (2019–2023) of the WHO is to dramatically improve the health of all people.^[9] The WHO aims to improve human capital by using innovation throughout a life course approach, with a special focus on women, children and adolescents, to provide integrated services, and to enable people to access the information, goods and services they need to survive and thrive at all ages. Getting it right from the beginning and continuing to get it right across the life course will have substantial dividends, as shown by the evidence that healthy ageing depends on epigenetic adaptations occurring during early childhood development.

The WHO through its member states will assist in creating enabling environments for early childhood development, through high-level and sustained political commitment, an appropriate policy and legal framework, availability of adequate financing and monitoring systems, and inter-sectoral mechanisms for coordination and accountability that are deeply embedded in systems at all levels, down to communities. Engaged communities, relevant information, and quality health services will provide parents and caregivers with the support they need to ensure that their young children grow well, are healthy, learn creatively and are free from violence and injury.

Caring for children is a human rights issue and the Convention on the Rights of the Child places childhood development at the centre of the global agenda. Programming and policy development must have child rights at its core in order to achieve equity. Only with this foundation will we be able to ensure that children with disabilities and young children in conflict and humanitarian settings are not left behind.

It is essential that the approach is one of universal health coverage with interventions and programmes integrated across sectors, including education, social protection and child protection. The WHO will play its role by opening its platforms, facilitating research, developing evidence-based guidelines, and using implementation science to enable countries to scale-up effective interventions that promote early childhood development. The WHO will also address measurement issues, including through supporting the development of new indicators to assess development in children from birth to 3 years of age.

The WHO and UNICEF, supported by the Partnership for Maternal, Newborn, Child and Adolescent Health (PMNCH) and the ECD Action Network, have developed a global Nurturing Care Framework to provide guidance and directions for action.^[10] The Framework describes how a whole-of-government and a whole-of-society approach can promote and strengthen the nurturing care of young children, what the guiding principles for doing so are, what strategic actions are needed, and the monitoring of milestones essential to progress. We commit to working with our member states and all relevant stakeholders to put the Framework into action, linking survive and thrive to transform human potential.

Acknowledgements
I thank Dr Bernadette Daelmans, Dr Tarun Dua, Professor Linda Richter and Professor Mark Tomlinson for their valuable contributions to this paper.