lessons in early childhood development...these nations fund and conduct sustainable early childhood...

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

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©2018 Board of Regents of the University of Wisconsin System All rights reserved.

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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

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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.

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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

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Table 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

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List 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

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List 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

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MoE 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

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Glossary 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

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EXECUTIVE 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

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resources 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.

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INTRODUCTION 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


stable 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).


We 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


of 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

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

56.02

21.57 28.67

81.89

51.47

7.73

43.71

64.0329.81

17.66

27.20

36.37

0.2614.40

41.53

0.4521.34

55.90

0

20

40

60

80

100

Ghana India Jamaica Moldova Peru South Africa

Components of Government Expenditures on ECD, 2014

% of ECD expenditures on education % of ECD expenditures on health

% of ECD expenditures on family support


is 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 KG: ages 4-5

Free targeted healthcare Immunizations

Maternity leave Conditional cash transfer

India Preschool: ages 3-6 Health check-ups/referrals Nutrition programs Immunizations


Jamaica ECIs: ages 0-3 Pre-primary/ECI: ages 4-5

Free universal healthcare Nutrition Programs Immunizations


Moldova Pre-primary: ages 3-6 Free universal healthcare Nutrition programs Immunizations

Maternity, paternity, & parental leave Childcare and birth allowances

Peru Nurseries: ages 0-2 KG: ages 3-4 Pre-primary: ages 5-6

Free targeted healthcare Nutrition programs Immunizations

Maternity & paternity leave Conditional cash transfer

South Africa

Preschool: ages 0-6 Free targeted healthcare Immunizations

Maternity & parental leave Conditional cash transfer

KG: kindergarten and ECI: early childhood institution


Education  

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 Gender, Children, Social Protection

Free meals KG part basic education

Enrollment has improved but gaps exist

Investments in transportation and infrastructure

India Ministry of Women and Child Development

Universal for children age 3-6

70% enrollment in preschool

Government committed to universal pre-primary education

Jamaica Early Childhood Commission

National Curricula for age 0-3 and 4-5

72% enrollment in pre-primary school, gaps between children 1-3 and 4-5.

Improve and certify ECI centers

Moldova Ministry of Education, Culture, and Research

Universal pre-primary, compulsory at age 5

85.3% enrollment in pre-primary school, gaps for rural, Roma, and disabled children

Education 2020: increase quality and services for pre-primary school

Peru Ministry of Education, Youth, and Culture

Nurseries for children 0-2, preschool 3-6, mandatory 5-6

80% of children 3-5 enrolled; enrollment increasing

Bicentennial Plan to eradicate illiteracy

South Africa

Department of Basic Education

Grade R, similar to KG 70,000 children in Grade R 100% enrollment not met

Further implement Grade 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


manages 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


universally. 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


Commission (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

Care Nutrition & Immunization Insurance Coverage &

Disparities

Ghana 74% births attended by skilled attendant (2014)

Free meals in schools Vaccinations for children

NHIS spread across national, regional, and district levels- covered 40% of population

India Health/nutrition services for children and lactating/pregnant women at AWCs

Supplementary Nutrition Programme 88% of children immunized in 2016

ICDS health services reach half of children under 6 (2015)

Jamaica Free prenatal check-ups, labor and delivery, child checkups

Nutrition support for children in ECIs Free immunizations for children ages 5-6 conditional on school registration

Universal healthcare system; accessible more by the rich

Moldova Free services for children and pregnant/lactating women

Government covers ⅔ of lunch cost at preschools Free immunizations

98% of children ages 0-18 enrolled in free Mandatory Health Insurance (2012)

Peru Free prenatal check-ups, labor and delivery, child checkups

Integral Nutrition Program High vaccination rates (>90%) Prioritize vaccines for low-income children

38.6% enrolled in free health insurance plan; 33.3% more enrolled in national health insurance

South Africa

Provision of information for pregnant women

Free meals for children in preschool 90% of children ages 0-6 are fully immunized (2011)

Universal healthcare system; 77% of children ages 0-6

NHIS: National Health Insurance Scheme, AWC: Anganwadi Centre, SNP: Supplementary Nutrition Programme, ICDS: Integrated Child Development Services, ECI: early childhood institution


Definition 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.


Insurance 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.


Table 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 for 8 weeks

None None None

Moldova 18 weeks, 100% paid 14 days, 100% paid Sick childcare leave, 180 days, 60-90% paid, must be insured

3 years

Peru 14 weeks, 100% paid 4 days, 100% paid None 1 year

South Africa

17 weeks, 38%-60% paid

10 days (expected) Family Responsibility Leave, 3 days per year, 100% paid

6 months, split into 2 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).


Table 5: Child Allowances in Six Case Countries

Country Type of Allowance

Type of Program Conditions Governance

Ghana Child allowance Family allowance

Targeted CCT

Low-income Health check-up & school attendance

Department of Social Welfare

India Birth allowance CCT Informally employed & health check-up, first child only

Ministry of Women & Child Development

Jamaica Family allowance CCT Health check-up Ministry of Labor and Social Security

Moldova Birth allowance Child allowance

Universal Universal, 2x more benefits if insured

Proof of birth Insured: until age 3 Uninsured: until age 1.5

Social insurance

Peru Family allowance CCT Health check-up Ministry of Development & Social Inclusion

South Africa

Child allowance Targeted Low-income Social Security Agency

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


other 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

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

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8


Government Expenditures as % of GDP- 2014

Pre-primary education Health for children ages 0-5 Family-support policies


expenditures 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


not 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

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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0.25

0.5

0.75

1

1.25

1.5

1.75

2

04 05 06 07 08 09 10 11 12 13 14

Year

Pre-Primary Education Spending as Percent of GDP



Table 6: Financing Overview for Education Programs in Case Countries Country Public Funding Entity Funding Source

Ghana Education sector plan, funded over 90% from domestic sources

Government of Ghana, GET Fund (VAT, central government revenue, and fund investments), internally generated funds at district-level agencies, and funds from external donors and HIPC

India Ministry of Women and Child Development through ICDS

Funding for preschool allocated through ICDS funding scheme: national and state governments split funding 60:40 in most states

Jamaica National government - Early Childhood Commission

Early Childhood Commission: national government, foundations, bilateral aid agencies, companies; Jamaica Social Investment Fund (development agencies, government of Jamaica)

Moldova Central government, budget set by Ministry of Finance

Majority of funds come from central government transfers (98.5%); local governments and external aid (UNICEF, GPE, governments of Romania and Czech Republic) make up the rest

Peru National and regional governments

Mostly general government revenue funds, split evenly between national and regional governments

South Africa

Provincial governments; center-based provision

Provincial government, general government revenue

GET: Ghana Education Trust, VAT: value-added tax, HIPC: heavily-indebted poor country, ICDS: Integrated Child Development Services, GPE: Global Partnership for Education

An analysis of government funding sources reveals that ECE is financed quite differently by level of government in each country. In Moldova, Jamaica, and Ghana, the national government determines the budget and provides funding for most pre-primary education. Moldova is unique in that the Ministry of Finance sets the budget and allocates the funds for the majority of pre-primary education, but the Ministry of Education, Culture, and Research sets policy (Melestean and Martins 2018). Other case countries rely more on provincial or regional governments to fund and manage pre-primary education. India and Peru split funding relatively equally between the national and provincial governments. In India, this leads to disparate levels of funding for ECE because some states can allocate more funds than others (Rao and Kaul 2017). However, the central government provides 90% of funding to the most impoverished states (India Ministry of Women and Child Development 2017). In South Africa, provincial governments are entirely in charge of funding pre-primary education, which has led to substantial inequity in preschool funding across the provinces (UNICEF 2016).

While the government tends to be the main funding source for pre-primary education in all six countries, private and external aid also contribute to funding in each country, to varying degrees. Certain countries saw significantly higher spending by private households than others. Although there are no estimates of private preschool expenditures in India, significant enrollment rates in private preschools suggest that private household spending is substantial. In Ghana, private sector spending contributes to 19% of overall spending on kindergarten (Ghana Ministry of Education 2013). Even in Moldova, where public preschool is tuition-free and enrollment in


government-run preschools is nearly universal, households typically still contribute financially to cover other costs such as building maintenance and repairs (Gutan and Fuior 2014).

The Global Partnership for Education (GPE) estimates that the governments of low- to lower-middle countries cover 88% of their total education budgets (Global Partnership for Education n.d.). The largest external sources of ECE funding are multilateral entities, primarily the World Bank, UNICEF, and GPE. In the countries we analyzed, official development assistance (ODA) funds typically comprise a minor portion of overall ECE funds. One country, Moldova, has even established a Sectoral External Assistance Council to track and manage projects implemented with external assistance (Moldova Ministry of Education 2014).

Funding Sources An analysis of early childhood education systems in the six case countries revealed a lack of information and data on specific revenue sources. The majority of ECE funds come from general government revenue sources, with exact revenue streams not specified. Moldova and India fund ECE from general government budgets. Other countries, such as Ghana, have more complicated funding structures. In Ghana, national government funds, internally generated funds by district-level government agencies, and Ghana Education Trust (GET) funds support ECE efforts (Ghana Ministry of Education 2013). Jamaica primarily funds its preschool system through government funds managed by the Early Childhood Commission, but it also receives assistance from the Jamaica Social Investment Fund – a company that invests in community development projects that derives its funds from the government of Jamaica, foreign governments, and bilateral and multilateral aid agencies (Jamaica Social Investment Fund n.d.).

Most of the six case countries distribute general government funds directly to school districts or institutions on a per-pupil basis. In South Africa, the provincial departments of education provide grants on a per-pupil basis to school governing bodies (UNICEF 2017). Moldova changed to a per-pupil spending model for preschool in 2013, citing transparency and efficiency as the main reasons for changing to this model (Moldova Ministry of Education 2014). Jamaica also allocates funds based on the number of students attending an institution, but it has numerous other criteria that an institution must meet to be registered and receive funds for teacher stipends, nutrition grants, and materials (SABER 2013). Health Overall Expenditures and Trends There are significant differences among the six case countries regarding overall expenditures on health and spending trends. The World Health Organization (WHO) found that when government expenditure on health is greater than 5% to 6% of GDP, fewer households experience financial risk in paying for health services (Xu et al. 2010). In 2001, the Abuja Declaration and its African Union signatories, including Ghana and South Africa, committed to


spending at least 15% of total government expenditures on health (Xu et al. 2010). Such thresholds are useful for governments to strive towards a specific level of spending, but the thresholds should be taken only as guidelines since they do not ensure the funds spent on health are spent effectively.

To standardize the overall expenditures, we look at spending estimates from 2014, the last year of consistent data for all six countries and consider public health spending as a percent of GDP (Figure 4). We were unable to find reliable totals for the percent of health expenditures focused on preschool children, so we estimated these figures using methods explained in Appendix E.

Figure 4

Source: “Health Expenditure, Total (% of GDP) | Data.” World Bank

Moldova is the only country within the WHO-recommended range of health expenditures as a percent of GDP, all other countries spend less than 5% of GDP on health (World Bank 2018f). Ghana and South Africa are both below the Abuja Declaration threshold and spend less than 15% of total government expenditures on health (World Bank 2018f). Funding Structure Health expenditures in most of the case countries are funded by various sources within the government. Table 7 outlines funding entities and sources for the case countries.

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1

2

3

4

5

6

7

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Year

Public Health Expenditures as Percent of GDP



Table 7: Financing Overview for Health Programs in Case Countries

Country Funding Entity Funding Source

Ghana Government and international partners

General government revenue for health expenditures Immunizations funded through general government revenue and international partners (Governments of Japan and Norway, USAID, DFID, UNICEF, WHO)

India Government ECD health services are funded through ICDS schemes and several other national health insurance programs

Jamaica Government ECD health spending directly from federal budget Free public hospitals funded by general and earmarked taxes

Moldova Government

Funds for children and pregnant women come from general government funds through transfers

Peru Government Financed through Seguro Integral de Salud (Comprehensive Health Insurance)

South Africa

Government General tax revenue CDC and Global Fund contribute to National Health Indirect Grant

USAID: United States Agency for International Development, DFID: Department for International Development, WHO: World Health Organization, ECD: Early Childhood Development, ICDS: Integrated Child Development Services, CDC: Centers for Disease Prevention and Control

In Ghana, Jamaica, Moldova, and Peru, most health funding comes from the government. Over the time-period analyzed, public funds have comprised a higher percentage of health expenditures in Ghana than any other country, making up 72% of total health spending in 2010 (Wang 2017). However, this amount has since dropped to approximately 60%. Public funds in Jamaica, Moldova, and South Africa comprise about half of the total health expenditures (World Bank 2018d).

Healthcare in Jamaica is financed through a mix of public and private resources, though the government is the main provider (Williams 2008). In Moldova, the national government fully funds health and social insurance for children from birth to age 18 and pregnant women (Velea and Tamburlini 2014). Peru’s central government funds most ECD-related programs through the Department of Health, although administration of such programs is becoming more regional (Huicho et al. 2016).

Although most health expenditures in India are not public, India’s supplementary nutrition service and health interventions through Integrated Child Development Services (ICDS) are completely funded by the government. Funding for the supplementary nutrition service is split between central and state governments except for the North Eastern and Himalayan states, where the central government covers 90% of costs (Ministry of Women and Child Development Government of India n.d.). In South Africa, the Department of Health (DOH) provides free healthcare to all children from birth to age 6 (Ilifa 2016). Through a public-private partnership with the Department of Social Development (DSD), DOH, and the University of Cape Town, the


Bertha Centre for Social Innovation and Entrepreneurship uses social impact bonds (SIBs) to improve health outcomes (University of Cape Town 2016).

Figure 5

Source: “Out-of-Pocket Health Expenditure, Total (% of Health Expenditures | Data.” World Bank

The WHO has found that catastrophic health expenditure and impoverishment remain

low in countries where out-of-pocket (OOP) payments are 15% to 20% or less of total health expenditures (Toure 2013; Xu et al. 2010). In 2014, the only case country to have OOP payments less than 15% to 20% is South Africa, an upper-middle-income country (World Bank 2018h). In sharp contrast, OOP payments comprise 71% of total healthcare expenditures in India due to the vast majority of the population being uninsured (Prinja et al., 2012). Although the government is the main insurance provider in Jamaica, individuals use OOP payments for access to health care at private hospitals and clinics (Williams 2008). In Moldova, OOP expenditures as a percent of health spending are quite high and twice as much as the EU-15 average (Vian et al. 2015). It is important to understand how much of health is financed from out-of-pocket payments because, in countries where OOP payments comprise a significant portion of health financing, low-income individuals and families suffer more than their high-income counterparts.

All six case countries receive some external resources for health that contribute to total health expenditures. This is not just for ECD programs, but for all health. In Ghana, external resources for health make up 15% of total health expenditures in 2014, which brings unique benefits and challenges for the country (Toure 2013). In Moldova, external resources for health comprise 5.71% of total health expenditures. All other four case countries rely on less than 3% of external resources for health expenditures. External funding amounts and trends are presented in Figure 6.

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Year

Out-of-Pocket Health Expenditure as Percent of Total Health Expenditures



Figure 6

Source: “External Resources for Health as Percent of Total Health Expenditures” (% of Total Expenditure on Health) | Data.”

World Bank Funding Sources The six case countries use various financial mechanisms to fund health-related ECD programs. National health insurance schemes are common and are financed through general government revenue, earmarked taxes, and private contributions. The specific funding entities and sources for each country are shown in Table 8.

Table 8: Health Insurance Funding Schemes in Case Countries Country Funding Entity Funding Source

Ghana National Health Insurance Authority

Import levy, payroll deductions, VAT revenue, employees, Parliament funds, investment income, and donations/loans

India Universal Health Insurance Scheme

General revenue from central and state governments

Jamaica Jamaican National Health Fund Parliament funds, tobacco tax, special consumption tax, loans, income investments, and donations

Moldova Mandatory Health Insurance Fund Funded by payroll taxes and government revenue transfers

Peru Seguro Integral de Salud (Comprehensive Health Insurance)

Financed by the MEF through general tax revenue; paid by government for extremely low-income families. Other low-income families receive subsidies

South Africa

National Health Insurance Fund General tax revenue and private medical spending

VAT: value-added tax and MEF: Ministry of Economy and Finance

0

5

10

15

20

25

04 05 06 07 08 09 10 11 12 13 14

Year

External Resources for Health as Percent of Total Health Expenditures



Ghana, Moldova, and Peru use taxes to fund insurance schemes. The National Health Insurance Scheme (NHIS) is Ghana's main mechanism to provide health-related ECD services. The National Health Insurance Levy comprises 60% of the NHIS funding, and the remainder comes from payroll contributions to the Social Security and National Insurance Trust, employees, other funds voted by Parliament, income from investments, donations or loans, and development partners (Witter and Garshong 2009; Ghana Revenue Authority 2018; Wang 2017). In Moldova, health insurance funds come from the Mandatory Health Insurance Fund (MHIF) within the national budget (Social Security Administration 2016). The government uses payroll taxes in addition to government revenue transfers to fund the MIHF (Mathauer et al. 2016). Health services for children and pregnant women (55% of the health insurance budget in 2015) are funded by government transfers, (Mathauer et al. 2016). In Peru, the Ministry of Economy and Finance (MEF) fully funds the Comprehensive Health Insurance program, Seguro Integral de Salud (SIS) through general tax revenue (Class et al. 2014; Huicho et al. 2016).

Most of Jamaica's ECD health spending comes directly from the federal budget (Cushnie 2010). In the 2018 budget, South Africa’s national health insurance is funded through adjustments to the medical tax credit. Over the next three years, the government plans to increase the medical tax credit to help fund the national health insurance. India funds ECD health programs through the same ICDS scheme using the same cost-share formulas.

Family-Support Policies Overall Expenditure and Trends

Total government expenditures on child and family allowances vary greatly in each case country. According to our estimates, no country spends more than 1% of GDP on cash transfers or CCTs for families with preschool children. The cost of maternity leave is not included in this estimate, because that is borne by employers in each case country. Funding Structure & Sources

Table 9: Financing Overview for Maternity Leave in Case Countries

Country Funding Entity Funding Source

Ghana Employer Employer is fully liable for funds

India Employer Employer is fully liable for funds

Jamaica Employer Combination of contributions from insured people and employers

Moldova Employer Social insurance; insured people and employers contribute funds

Peru Employer Employer is fully liable for funds

South Africa

Employer Employer is fully liable for funds; South African moms contributing to the Unemployment Insurance Fund are eligible for 38% to 60% of their salary


All six case countries rely on employer-funded maternity leave. In Ghana, India, and

South Africa, the employer is fully liable for maternity leave (Social Security Administration 2017; Chandran 2017). In Moldova and Jamaica, maternity leave is funded by contributions from both employers and employees, but in Moldova, funds are collected and allocated through a social insurance program (Social Security Administration 2016). Peru’s maternity benefits are fully funded through the social security health insurance program, EsSalud, funded by employer contributions (Social Security Administration 2017).

Table 10: Financing Overview for Child Allowances in Case Countries Country Funding Entity Funding Source

Ghana Government and development partners

Government transfers and external support from World Bank and DFID, and technical support from UNICEF

India Government Central and state governments

Jamaica Government Social assistance funds PATH, fully funded by the government

Moldova Government Social insurance and assistance fund childcare allowances and birth grants. Paid from the SSIB

Peru Government Central government revenue

South Africa Government South African Social Security Agency

DFID: Department for International Development, PATH: Programme for Advancement through Health and Education, SSIB: State Social Insurance Budget

Cash-transfer funding varies across the six case countries. India’s Maternity Benefit Program, directed at informally employed women, is entirely paid for by the government, split between central and state governments (Press Information Bureau Government of India Cabinet 2017). Juntos, Peru’s CCT program, is funded through central government revenue (Sanchez et al. 2016). Ghana’s LEAP 1000 program was fully funded through general government revenues when it began in 2008 and expanded in 2009-2010. Since 2010, the program has received support from development partners (Anas 2018; LEAP 2016). Jamaica’s PATH program receives a mixture of government funding, as well as loans from the World Bank and the Inter-American Development Bank (Jamaica Ministry of Labor and Social Security, 2018) Moldova and South Africa have child allowances that are funded through social assistance funds, where the government pays the program’s full cost; Moldova’s child allowances are targeted, and South Africa’s is universal. Moldova’s birth grants and child allowances also are funded through employer- and employee-funded social insurance (Social Security Administration 2016).


SECTION 5: DISCUSSION From our analysis, we have discerned certain patterns and unique characteristics of the

six case countries pertaining to governance and financing structures. This section will discuss two types of issues related to the sustainability of ECD programs: distinctions in governance and financing systems in the case countries and the sustainability of specific funding mechanisms.

Governance and Financing Systems

Early in our analysis, we learned that ECD programs are underfunded in all of the case countries. Even though Moldova spends more than the recommended amount on pre-primary education, further analysis revealed that several aspects of Moldova’s pre-primary education system are underfunded (International Commission on Financing Global Education Opportunity 2016). Evaluations have shown that existing funds are inadequate to address pressing needs, including lack of pre-primary education facilities, poor maintenance of many existing buildings, and very low teacher salaries that are unsustainable (van Ravens 2017). Underfunding of ECD programs has led to less than universal coverage of most programs, poor quality of services, inefficiency in using resources, and inequality in distributing resources. ECD programs are underfunded for several reasons. Most commonly, constrained government resources and a lack of government prioritization lead to low expenditures on ECD services (International Commission on Financing Global Education Opportunity 2016). Given that ECD programs are preventative in nature, governments may be more focused on responding to other priorities in a reactive manner rather than investing in ECD. Another issue is the inefficient use of existing funds. This is a key problem in Moldova and India. Based on expenditure data, Moldova spends enough on pre-primary education to have universal enrollment, but the current distribution of funds precludes that from happening. There are many empty seats at schools in rural areas and certain areas without preschool facilities at all (van Ravens et al. 2017). Lack of coordination between administering agencies is also a common problem that has led to underfunding of ECD programs.

One of the fundamental differences among the ECD programs studied is the overall governance structure. ECD program governance is either integrated (managed by one central agency) or administered by several government entities. India and Jamaica are the only two countries with integrated systems. There are pros and cons to both governance systems. One clear benefit from an integrated system is better service coordination (International Commission on Financing Global Education Opportunity 2016). India’s ICDS program provides nutrition supplements, preschool education, immunizations, and other services in a single center. Additionally, for countries with a central administrative agency, it is easier to estimate ECD expenditures. Countries with a diverse network of governing agencies often encounter coordination challenges and lack cohesive data on ECD program expenditures. Some countries without integrated systems, such as Ghana and Peru, utilize committees to coordinate the provision of ECD services. However, despite these committees, coordination remains a key issue for Ghana (Silver and Singer 2014).


Despite the advantages of integrated systems, ECD services under these systems still suffer in quality and efficiency. Evaluations of India’s ICDS program reveal that many staff at AWCs typically lack the required skills to provide all necessary services, and centers are typically understaffed and under-resourced (Rao and Kaul 2017). This has led many middle- and upper-class families to send their children to private preschools instead (Rao and Kaul 2017). Jamaica has similar issues with poor quality and inefficient use of resources at its early childhood centers, with some preschools serving as few as four students (Early Childhood Commission, n.d.). In Peru, local workers administering ECD programs often become frustrated with their workload and poor quality of materials (Josephson et al. 2017). The administration of specific services by unique government ministries provides an advantage in ensuring better quality of services. South Africa has attempted to expand access to pre-primary education in a cost-effective way with management by the Department of Basic Education. While an integrated system may have an advantage at coordinating services, ensuring quality remains a challenge.

Another key difference is how centralized or decentralized administration and financing of ECD programs are. All of the case countries rely on various levels of government to administer and finance services, but the degree of decentralization varies. Moldova and South Africa are very decentralized with provincial governments entirely in charge of administration and funding of pre-primary education. However, the funding source for the two countries is entirely different. The provincial governments in South Africa are entirely responsible for generating funds for ECE, while Moldova’s central government accounts for 98.5% of pre-primary education funding (van Ravens et al. 2017).

Both centralized and decentralized systems have advantages and disadvantages for ensuring effectiveness and sustainability of ECD programs. One key advantage for centralized systems is the ability to manage and allocate funds; it is easier to allocate funds for new capital projects such as ECD centers. Decentralized systems find it more difficult to fund new capital investments. In Moldova, the central government provides funds to local governments based on the existing infrastructure, which leads to local governing agencies lacking adequate funds to invest in new infrastructure (van Ravens et al. 2017). This also was a problem in India until the Ministry of Women and Child Development began earmarking specific funds for building new centers through its Strengthening and Restructuring of ICDS plan (Rao and Kaul 2017). Despite this disadvantage, decentralized systems can provide more authority to local governments, which are more aware of their individual challenges and can better direct resources to where they are needed most. Additionally, decentralized systems might be necessary due to geographic barriers to implementation.

All of the case countries offered a mix of universal and targeted programs. For pre-primary education services, all case countries offer free or heavily subsidized preschool education to all children of eligible age. This also is the case for immunizations. Other interventions like supplementary nutrition or cash transfers tend to be more targeted at individuals experiencing need. The benefit of universal services is that they ensure widespread access to the service. However, they also tend to be more expensive because everyone receives


the service for free or at a highly subsidized rate. Targeted programs reach fewer people than universal programs but can be just as effective at achieving desired outcomes, in a more cost-effective way. Additionally, targeting services to low-income individuals tends to have a larger return on investment since resources are being allocated to the individuals most in need. One important consideration for targeted programs is that they also require a more robust management and evaluation system to determine program eligibility and ensure that services are effectively reaching the intended recipients. Thus, targeted programs run the risk of being ineffective if managed incorrectly but can be extremely cost-effective if managed well. A reform of Moldova’s social assistance system has changed the provision of cash transfers from being based on a specific population category to income, with the goal of allocating funds more efficiently to individuals most in need (The World Bank 2012).

Whether a service should be targeted or universal depends on the nature of the service, governance and financial capabilities, and demographics. Due to the nature of immunizations, it is logical to provide these universally, free of charge. For other services, providing free provision to all children may be extremely expensive and infeasible for governments to fund. One way to provide this service universally is to use a tiered fee system where families pay different amounts based on their level of income. This would allow a government to reach more individuals in a cost-effective manner since the state would be spending less on a per-child basis. In Moldova, an evaluation of its pre-primary education system suggests that charging different food fees using a means-tested scale and waiving the fee for low-income children could lead to a more inclusive service (van Ravens et al. 2017). Ghana’s LEAP 1000 program was created in response to LEAP not serving the needs of poor families with young children (LEAP 2016). This is an example of how targeting can ensure that people most in need of benefits receive them. Infrastructure is vital to delivering ECD services. Several countries have significantly expanded the services and beneficiaries of ECD programs, which has brought increased investment in service-delivery infrastructure. India, Jamaica, and Moldova have invested substantial resources in independent ECD infrastructure, like separate facilities for ECD services or preschool. Expansive infrastructure poses a challenge to financial sustainability because it requires substantial funds to maintain and staff. South Africa provides a model for delivering ECD services that is more sustainable because it utilizes existing infrastructure. South Africa used its existing school system to scale up the “Grade R” preschool program (International Commission on Financing Global Education Opportunity 2016). Another option is to incorporate preschool and other ECD services into the existing program structure. By incorporating pre-primary education into the formal education cycle and budget, resources and funds can be allocated more equally (Lewin 2008). Because many low- to middle-income countries face resource constraints, reducing infrastructure costs should be a priority for ensuring sustainability. Funding Mechanisms

The main funding source for ECD programs in all six countries is general government revenues, but governments take different approaches in allocating and administering funds for


ECD programs. Central governments typically allocate funds in two ways: on a per-capita basis or as a block grant. The type of service partially determines how funds are allocated. For preschool programs, funds commonly are allocated on a per-capita basis. Moldova recently changed from a block transfer to a per-capita funding model, citing increased transparency and efficiency as the main reasons (Moldova Ministry of Education 2014).

A per-capita model makes it easier to determine and track funding because it is allocated on a per-student basis. However, per-capita funding tends to favor urban districts over rural districts (Moldova Ministry of Education 2014). One remedy may be to allocate additional funds for rural students, because it is more expensive to provide preschool to these students (van Ravens et al. 2017). Another issue with a per-capita model is that it is difficult to allocate funding for system needs or capital investments. In these situations, block grants provide an advantage because they typically allow more flexibility on how districts spend the funds. On the other hand, block grants are less transparent and less able to respond to growing enrollment. For example, Peru’s free national insurance program has a fixed budget, which leads to de facto service rationing (Class et al. 2013). Whichever a country uses, it is important that the model is consistent, transparent, and provides adequate funding.

Central governments often transfer funds to lower levels of government for specific services such as preschool or health. These funds have varying levels of stipulations that determine how local governments can spend the money. In countries that earmarked funds for specific purposes, programs saw more sustained funding and longevity. An evaluation of different social assistance programs established in Moldova by external agencies revealed that most social assistance programs funded at the local level were phased out or combined with other programs (Melestean and Martins 2018). However, programs that had earmarked funds from the central government continued to offer services (Melestean and Martins 2018). One downside of earmarked funds is that they provide less flexibility on how they are spent and typically must be spent in a given year or are forfeited. This can result in inefficient use of funds if they are not allocated effectively.

Conditional cash transfers (CCTs), cash transfers dependent upon school attendance and/or receiving health treatment, are a popular funding mechanism used by governments to reduce poverty and ensure equity for low-income households. CCT programs’ sustainability mainly depends on the efficiency of distributing funds among provinces and government sectors. CCT programs have found success at improving outcomes for recipients. Juntos, Peru’s CCT program, increased children age 5-6 school enrollment to more than 90% after attendance became mandatory to receive benefits (MINEDU 2018). Additionally, Juntos’s health check-up requirements are a major contributor to halving the rate of undernutrition in the decade after it was founded in 2005 (Sanchez 2016; Huicho et al. 2015). The PATH program in Jamaica found significant increases in school and health check-up attendance (Levy and Ohls 2010). Finally, participants in Ghana’s LEAP 1000, although an unconditional cash transfer, were still more likely to enroll their children in preschool (Ministry of Gender, Children, and Social Protection 2016). Overall, conditionality has had a positive impact on the reduction of child labor,


efficiency in time allocation, health, and education (ODI 2016). Despite these benefits, others claim CCTs are unsustainable and paternalistic (World Bank 2010). Nevertheless, CCTs have remained sustainably financed for over a decade in all three case countries where they currently exist.

Results-based financing (RBF), also known as pay for results, funds programs conditional on achieving desired outcomes. In 2008, Peru passed a law directly linking their entire budget to measurable results (MEF et al. 2014). Tying the funds to outcomes means that after a program fails to reach the goal, the funding stream is cut. An example of this is social impact bonds (SIBs). SIBs are a public-private partnership where governments contract with third-party donors to finance a preventative social program. The third-party only receives repayment if the program is successful. These bonds can shift a government’s focus to preventive services and ensure the government is only liable to fund an ECD program that meets its desired results. The Bertha Centre for Social Innovation and Social Finance in South Africa uses social impact bonds to meet certain ECD outcomes. The Palladium Group in India is designing a SIB in the state of Rajasthan to focus on maternal and child health (Liu et al. 2008). There is not enough evidence to support a causal relationship between RBF and improvements in education. Other challenges with RBF include that extensive impact evaluations are required, and governments may not have the capacity to conduct these. Also, governments interested in using SIBs or other RBF mechanisms should consider the possibility of manipulation by third-party actors since there is an incentive to cherry-pick certain measures in a pay for results setting. While these critiques are valid, and governments should consider if they have the means to conduct evaluations, RBF is a promising and innovative tool to invest initial capital in ECD programs (Toonen et al. 2009).

Non-governmental organizations (NGOs), international organizations, and the private sector also fund ECD programs. All six case countries rely on some form of external assistance. However, sustainability can be compromised because external sources can end their funding at any point. One example is the social assistance program in Moldova that was started by NGOs and discontinued shortly after the funding authority was transferred to local governments (Melestean and Martins 2018).

The six case countries face significant challenges in ensuring ECD program sustainability. All struggle to meet key development indicators, provide universal coverage of health, education, and nutrition needs for their respective populations, and provide adequate funding to ensure quality service delivery and expansion. Innovative funding mechanisms can raise initial funds for new programs, but to sustain funding, governments must allocate funds in their budgets (International Commission on Financing Global Education Opportunity 2016).

SECTION 6: LIMITATIONS

Our analysis has several limitations. First, it was challenging to find reliable estimates for health expenditures broken down by age group, so we estimated these expenditures using data


from the World Development Index (WDI), UNICEF country offices, WHO, and the Global Vaccine Alliance (GAVI). Second, not all ECD programs provided information on specific funding sources; most indicated the governing body and general source of funding (i.e. government, private, external funds) but not all described the exact financing mechanisms in place for each program. Third, we found it challenging to compare ECD program characteristics and funds because the six case countries define, govern, and fund ECD programs distinctly. Similarly, not all countries have the same amount or depth of information. Fourth, we had to rely on external online sources, and not all the data may be consistent or current. To address this limitation, we consulted with each country’s ECD programs and financing schemes to UNICEF country officers for their expert input and revisions, for quality assurance. We received responses from Ghana, Jamaica, and Moldova. SECTION 7: RECOMMENDATIONS & CONCLUSION General Recommendations

The goal of this report is to provide recommendations on implementing sustainable and effective ECD programs so that low- and middle-income countries may enhance their children’s well-being. Specific goals for an ECD system include decreased infant and maternal mortality, improved health outcomes for ECD target population (including nutrition and immunization), greater educational attainment, and increased future wage earnings. These goals are also reflected in the United Nations Sustainable Development Goals (SDG) which include to eliminate poverty, improve health, end hunger, and ensure a quality education. SDG 4.2 states, “By 2030, ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education,” (Britto 2015). ECD programs are foundational to sustainable development but many countries do not invest enough in ECD programs, leaving economic and personal gains unrealized. Increasing investment in ECD programs is challenging for countries where government revenue is constrained and divided among many priorities. To address these challenges, we have designed our recommendations to help countries finance their programs in the short-run, improve funding mechanisms to pay for their programs, and prepare for their long-term sustainability. Differences in country characteristics and ECD sectors will demand specific recommendations to ensure sustainable ECD financing, including the rates of informal and formal employment, the condition of existing infrastructure, the extent to which services are privatized, and the level of socioeconomic inequality. We outline these recommendations in Table 11 and the remainder of this section.


Table 11: Recommendations

General Recommendations Short-Run Financing

- Invest more into Early Childhood Development - Collect more data - Conduct more evaluations and prioritize results-based financing

- Utilize existing infrastructure - Capitalize on third-party support - Social impact bonds

Funding Mechanisms Long-Run Sustainability

- Increase government revenue - Value-added tax (VAT) - Earmark taxes - Trust funds

- Integrate ECD under one or a few agencies - Target low-income and/or rural families - Promote national commitment to ECD - Encourage formal employment

Short-Run Financing In the short-run, countries have access to a portfolio of opportunities to launch their ECD programs. First, developing countries should utilize their existing physical and programmatic infrastructure to minimize the costs of a new program. Capital is expensive to develop and could be prohibitive for countries to initiate their ECD programs. As an alternative, countries can use current infrastructure in the short-run while investing in long-run capital. However, countries should be wary of relying too heavily on existing infrastructure as servicing costs could surpass the cost of new capital. In countries with elaborate infrastructure systems like Moldova, governments will likely have to spend significant funds in maintaining and renovating these institutions. For countries with little or no existing infrastructure, governments should invest funds into new capital and start-up costs but also consider innovative ways to deliver ECD services. For example, a government could run a robust education-focused CCT program and distribute the funds at a health facility or distribute immunizations and other health services at schools or childcare centers.

Second, low- and middle-income countries should rely on third-parties such as country aid offices, international organizations, NGOs, and other private donors to fund an ECD program’s creation while the government develops a program budget. Common development-focused third-parties include the U.S. Agency for International Development (USAID), the United Kingdom’s Department for International Development (DFID), UNICEF, the World Bank, the United Nations Development Programme, and the Global Partnership for Education. One way these third-party donors support ECD programs is through social impact bonds that provide up-front capital to invest in preventive ECD programs where the host country is only liable if the program achieves its stated goals. Nevertheless, impact bonds are a relatively new option, and more research on their sustainability should be conducted. Generally, third-party support, including SIBs, presents a sustainability risk if the host country does not prepare to


finance the program itself. These short-run financing strategies are solely intended to get ECD programs off the ground, while countries improve their funding mechanisms and prepare to sustain the program long-term. Funding Mechanisms

At the outset of this study, we expected to find a diverse funding base for most ECD programs; instead, a majority of the ECD programs included in this study were funded through general revenue. Therefore, increased funding for ECD programs can be achieved by increasing government revenue. Each case country had a varied portfolio of taxes to collect government revenue, which means there is no single taxation scheme relatively more useful for ECD program financing. Instead, countries should focus on increasing their government revenue through new sources like a value-added tax (VAT). Since they are consumption-based and more resilient to economic shocks, the VAT is a more stable source of government revenue, which is important for long-term planning (Hodge 2015). A VAT is especially useful for countries with low formal employment where income taxes are insufficient to raise enough government revenue. However, due to the regressive nature of a VAT, countries should lessen the burden on low-income households by exempting basic goods from this tax.

Although most ECD programs are funded by general revenue, programs financed by an earmarked tax are more likely to be sustainable. Regardless of the actual mechanism of the earmarked tax, the security of this tax scheme ensures valuable ECD programs will receive a consistent stream of revenue long into the future. ECD programs also can be sustainably financed by creating a trust fund. These trust funds, which invest general government resources and private sector funds to maintain a strong foundation, help secure funding for ECD programs.

Long-Run Sustainability Along with implementing new funding mechanisms, countries should adopt the following strategies to ensure their ECD programs are sustainable in the long-run. First, ECD programs should be integrated under one or a few agencies, and formal mechanisms for coordination should be established and rigorously utilized. When one agency controls social development policy, redundancies and inter-agency conflict are reduced and resources are allocated more efficiently. While integration is key, problems in ECD implementation can still arise when programs are not administered well. Governing agencies must always maintain a commitment to quality assurance and proper training and support for the staff implementing ECD programs. There is no clear advantage between centralized and decentralized governance, as long as inter-agency coordination is prioritized.

Second, all ECD programs should collect and report data to conduct evaluations of which programmatic elements are successful. Implementing data collection and evaluation would help countries who want to use results-based financing have the proper systems in place.


Third, sustainable ECD programs are often characterized by continuous support regardless of the current administration’s political ideology. When a national consensus is built around investing in ECD, the question each new administration asks is not whether to invest in ECD but how to invest in ECD. By promoting this national commitment, countries can ensure their ECD programs will remain sustainable even as new leaders are elected.

Fourth, for many governments with constrained resources, providing universal ECD programs would be prohibitively expensive. Therefore, sustainable ECD programs should focus on traditionally vulnerable populations – usually rural and poor communities – where the programs are likely to have the biggest impact. For programs that would benefit from universality, countries should adopt a means-tested, tiered system of fees where families with higher incomes contribute more to sustaining the ECD program. While in many countries pre-primary school is free and universal, there are still informal fees for books, uniforms, or food. A tiered fee system would ensure children from low-income households are not deterred from attending school and would encourage their ability to access public education. This tiered system would also work well in countries with significant inequalities among groups such as a rural-urban divide.

Fifth and finally, governments should adopt policies that promote formal employment. While the exact policies are outside the scope of this report, formal employment has the benefit of developing a larger, more sustainable tax base and ensuring all workers have access to benefits attached to employment, such as family leave. Additionally, once a country has achieved a high level of formal employment, it can begin to rely on a progressive income tax to fund its ECD programs. Countries with high formal employment should use this system to enhance health and family support policies. Conclusion

Given the economic and societal benefits realized by early childhood development programs, national governments should invest in these ECD programs and consider how to provide for their long-term success. By utilizing existing infrastructure and third-party funds to initiate and finance ECD programs in the short-run, resource-constrained governments can develop sustainable financing mechanisms to pay for the programs in the long-run. Countries that integrate and target their programs, promote formal employment and a national commitment to ECD, and prioritize data collection and evaluation can have sustainable ECD programs. By adopting these short- and long-run ECD program-financing practices, low- and middle-income countries can reap the human capital benefits; break intergenerational poverty cycles; and ensure a happier, healthier, and more educated population.


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APPENDICES

Appendix A: ECD Programs, Interventions, Governance, Financing, and Funding

Programs and Interventions ● Health:

○ Immunizations ○ Maternal depression ○ Deworming ○ Home visits ○ Healthcare facility visits (prenatal and postnatal)

■ Prenatal: visits, maternal leave before birth, prenatal health booklets ■ Birth: hospitalization, birth grants, baby-friendly hospitals ■ Postnatal: universal preventive postnatal care

○ Child health booklets ● Nutrition:

○ Micronutrients supplementation ○ Nutrition voucher programs ○ Nutrition education ○ Exclusive breastfeeding ○ Zinc supplementation for diarrhea

● Safety and Security: ○ Access to safe water ○ Adequate sanitation/hygiene

● Responsive caregiving/family support ○ Paid paternal leave ○ Family cash benefits ○ Paid leave for parents to care for sick children ○ Breastfeeding breaks at work ○ Income support/minimum wage

● Education/early learning: ○ Childcare ○ Preschool ○ School Based Management (SBM) Programs

Governance Structures

● Sectors can serve children/families independently, shared responsibility (China, Cameroon)

● Under a single ministry, collaborating with other sectors, multi-sectoral committee (South Africa, India, Bangladesh, Jamaica, Brazil)

● Coordination through a high-level central council (Colombia, Chile, Ghana, Rwanda)

Financing Structures ● Comprehensive Universal ● Universal – open to all families with children prenatal until primary school ● Comprehensive Targeted


● Targeted – services directed to specific populations (typically high-need) ● Hybrid

Funding: Early childhood development programs in low- to middle-income countries have been consistently underfunded and relied on aid. Compared to other sectors and services, ECD programs have a higher mix of public and private spending, with a heavy reliance on private household contributions. The proportion of public to private funding varies widely, with some countries financing almost all programs with public funds and others relying heavily on private household spending.

● Public: at both national and local level, often supported by multilateral and bilateral aid ● Private (majority of which is household spending) ● Semi-private

Innovative sources of funding include social impact bonds, taxes (payroll and sin), lottery/gaming revenue, block grants, vouchers, and conditional cash transfers.

Key factors for scaling up ECD programs ● Political prioritization – do countries prioritize ECD programs? ● Policies that enable families to care for their young children ● Delivery systems that allow for effective scaling of interventions ● Governance structures ● Affordability ● Political commitment and popularity, operational ease, advances in information

technology and banking, rigorous evidence of program effectiveness, and support from international organizations

● National scale-up can be achieved by building on existing systems, typically from existing reproductive, maternal, newborn, and child health services


Appendix B: Elimination Criteria

Fragile States Median Income

Above $10/HH/Day Population under

500,000 Insufficient Data

Countries Where We Performed

Trends Analyses

Afghanistan Belarus American Samoa Albania Algeria

Angola Bosnia & Herzegovina Dominica Azerbaijan Argentina

Burundi Brazil Maldives Bangladesh Armenia

Cameroon Bulgaria Nauru Bhutan Belize

Central African Republic Costa Rica Samoa Botswana Benin

Chad Croatia St. Lucia China Bolivia

Comoros Iran St. Vincent and the

Grenadines Cuba Burkina Faso

Congo, Dem. Rep Kazakhstan Tonga Equatorial Guinea Cabo Verde

Congo, Rep. Malaysia Vanuatu Georgia Cambodia

Côte d'Ivoire Montenegro Guyana Colombia

Djibouti Panama Honduras Dominican Republic

Eritrea Paraguay Jordan Ecuador

Ethiopia Russian Federation Lesotho Egypt, Arab Rep.

Gambia, The Serbia Madagascar El Salvador

Guinea Thailand Malawi Fiji


Guinea-Bissau Turkey Mongolia Gabon

Haiti Ukraine Namibia Ghana

Iraq Nicaragua Guatemala

Kenya Philippines India

Korea, Dem. P. R. Sao Tome & Principe Indonesia

Kosovo Sri Lanka Jamaica

Kribati Tanzania Kyrgyz Republic

Lebanon Tunisia Lao PDR

Liberia Turkmenistan Macedonia, FYR

Libya Venezuela, RB Mauritius

Mali Zambia Mexico

Marshall Islands Moldova

Mauritania Morocco

Micronesia Peru

Mozambique Romania

Myanmar Senegal

Nepal South Africa

Niger Suriname

Nigeria Swaziland

Pakistan Tajikistan

Papua New Guinea Uzbekistan

Rwanda Vietnam

Sierra Leone

Solomon Island

Somalia

South Sudan

Sudan

Syria

Timor-Leste


Togo

Tuvalu

Uganda

West Bank and Gaza

Yemen

Zimbabwe Note: high-income countries not considered


Appendix C: Details on Family-Support Policies1

Country Maternity Leave Benefits Child Allowance & Conditional Cash Transfer Benefits

Ghana Unclear if there are minimum or maximum level of benefits

Ranges from GHS 64 (USD 15) for families with one eligible member up to GHS 106 (USD 24) for families with four or more children every two months for up to three years

India Minimum daily benefit: INR 25 (USD .38)

INR 6,000 (USD 92) via three installments

Jamaica Maximum earnings used to calculate: JMD 1,500,000 (USD 11,888) per year

JMD 900 (USD 7) per month for pregnant/nursing mothers JMD 750 (USD 6) per month for children up to age six

Moldova Maximum earnings used to calculate: national average monthly wage, MDL 4,500 (USD 271)

MDL 3,100 (USD 188) for first-born child. MDL 3,400 (USD 206) for each subsequent child. MDL 1,234 (USD 75) per month (up to age of three) for insured family MDL 540 (USD 33) per month (up to one and a half years old) for uninsured family

Peru Minimum earnings used to calculate: monthly minimum wage, PEN 750 (USD 232)

PEN 200 (USD 62) bi-monthly

South Africa

Maximum earnings used to calculate: ZAR 17,712 (USD 1,473) per month The maximum daily benefit is ZAR 221.28 (USD 18)

ZAR 380 (USD 32) per month until the child turns eighteen years old

GHS: Ghanaian cedi, INR: Indian rupee, JMD: Jamaican dollar, MDL: Moldovan leu, PEN: Peruvian sol, ZAR: South African rand, USD: U.S. dollar

1 All USD figures use 2018 USD value. https://www.reuters.com/finance/currencies


Appendix D: Estimating Overall ECD Spending

Because most of the case countries’ ECD programs were not integrated systems, with different governance structures and financing mechanisms, we had trouble comparing overall trends in ECD program spending. To address this gap in the data, we used ECD-related health, education, and family-support expenditures to estimate overall ECD program spending in each country. We can add the estimated health spending on children from birth to primary school age with the total spent on pre-primary education and family-support programs to estimate the total ECD program spending.

Total ECD spending = Health spending on children from birth to primary school age + Pre-primary education spending + Family-support spending

With this estimate of overall ECD program spending in each case country, we compared them in three ways: (1) estimated ECD program spending on health, education, and family-support programs; (2) estimated spending in one area (health, education, family-support), and percent spent on children from birth to primary school age; and (3) percent of GDP spent on pre-primary education, health, and family-support policies.

1. % of ECD spending on pre-primary education = (Total spending on pre-primary education / Total ECD spending) ˟ 100 % of ECD spending on health = (Total health spending on children from birth to primary school age / Total ECD spending) ˟ 100 % of ECD spending on family-support = (Total spending on family-support / Total ECD spending) ˟ 100

2. % of Education spending on pre-primary: UNESCO Institute of Statistics database % of Health spending on children 0-5 = (Total health spending on children from birth to primary school age / Total health spending) ˟ 100 We did not estimate what percent of social assistance policies are family-support policies (specifically related to ECD) due to double-counting concerns.

3. % of GDP spent on pre-primary education: World Development Indicators (WDI) database % of GDP spent on health for children age 0-5 = (Total health spending on children from birth to primary school age / Total value of GDP) ˟ 100 % of GDP spent on family-support = (Total spending on family-support / Total value of GDP) ˟ 100


Appendix E: Estimating Health Expenditures for Young Children

It was difficult to assess the level of ECD-related health spending in the case countries because most health expenditure data was not disaggregated by age group. To ameliorate this, we estimated health spending on children from birth to primary school age. We calculate each country’s average per-capita spending on health and then add two services that specifically apply to young children.

We begin by calculating the per-capita health spending for each country.

Using the World Bank’s World Development Indicators (WDI) database, we found the percent of gross domestic product (GDP) each country spent on health, the total value of GDP in each country, and the total population, all for 2014 – the most recent year that all countries had spending data.

We used these figures to calculate the baseline per-capita health spending in each case country:

Value of total health spending = % of GDP spent on health ˟ Value of GDP

Baseline per-capita health spending = Value of total health spending / Total population

We wanted to include an estimate for the per-capita cost of having a skilled healthcare attendant at birth and the percent of births that have a birth attendant present for each country. Though we found the percent of births that have a birth attendant present, we were not able to find reliable estimates for these costs in any of the six countries. If we had these numbers, we would have multiplied these to get the average per-capita cost of having a skilled healthcare attendant present at birth.

Average per-capita cost of skilled attendant = % of births with a skilled attendant present ˟ per-capita cost of skilled attendant

Then, we calculated the cost of immunizing a child according to World Health Organization (WHO) and UNICEF guidelines. For a child to be considered fully vaccinated, a basic package includes one dose each of Bacille Calmette-Guerin (BCG) and measles, three doses of polio vaccine, and three doses of DPT (Diphtheria, Pertussis, and Tetanus)- HepB - Hib combination. We use WDI to find the immunization rates of each case country and multiply those by the cost per vaccine dose. We use Global Vaccine Alliance (GAVI) and Pan American Health Organization Revolving Fund (PAHO-RF) eligibility status to estimate the cost of each vaccine. For Moldova and South Africa, which are neither GAVI- or PAHO RF-eligible, we use the GAVI-ineligible and non-PAHO-RF prices. To calculate the immunization rate for DPT-HepB-Hib combination, we take an average immunization rate for the three separate immunization rates for DPT, HepB, and Hib. All case countries except India have very similar, if not the same rates, across the three vaccines.

Average per-capita cost to fully immunize a child = (% immunization rate BCG ˟ average price per BCG ˟ 1 dose) + (% immunization rate DPT-HepB-Hib) ˟ average


price per DPT-HepB-Hib) ˟ 3 doses) + (% immunization rate measles ˟ average price per measles ˟ 1 dose) + (% immunization rate polio ˟ average price per polio ˟ 3 doses)

Finally, to estimate the per-capita health spending on a child from birth to primary school age, we add the baseline per-capita spending and the average per-capita cost to fully immunize a child. We calculate these costs for five years, with the immunization costs in the second year because WHO/UNICEF guidelines recommend that children receive these immunizations before 23 months.

Per-capita health spending on one child through age 5 = (Baseline per-capita spending ˟ 5) + Average per-capita cost to fully immunize a child.

To calculate the total health spending on children from birth to primary school age in one year, we multiplied the per-capita health spending on one child through age 5 by the total number of children age 5 and under in each case country, and then divided that number by 5. We found the number of children age 5 and under in the WDI database.

Total health spending on children 0-5 in one year = (Per-capita health spending on one child through age 5 ˟ Total number of children from birth to primary school age) / 5


Appendix F: Education Spending Tables We obtained the data in the following tables from the World Development Index (WDI) and the United Nations Educational, Scientific, and Cultural Organization (UNESCO) Institute of Statistics database.

Pre-Primary Education Spending as Percent of GDP

Country 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ghana 0.50 0.44 0.29 0.27 0.32 0.26 0.34 0.30 0.66 0.39 0.45

India 0.04 0.04 0.04 - - 0.04 0.04 0.05 0.05 0.06 -

Jamaica 0.22 0.22 - 0.38 0.34 0.51 0.25 0.21 0.20 0.21 0.20

Moldova - - 1.19 1.31 1.46 1.77 1.78 1.77 1.83 - 1.57

Peru 0.25 0.23 0.25 0.25 0.30 0.37 0.35 0.33 0.39 0.49 0.61

South Africa 0.02 0.03 0.03 0.03 0.03 0.05 0.06 0.08 0.09 - 0.09

Pre-Primary Education Spending as Percent of Total Government Spending

Country 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ghana 6.61 5.95 5.53 4.92 5.60 4.96 6.05 3.67 8.39 6.38 7.30

India 1.33 1.28 1.14 - - 1.22 1.06 1.18 1.21 1.59 -

Jamaica 5.58 4.85 - 6.84 5.51 8.23 3.95 3.40 3.26 3.40 3.37

Moldova - - 15.84 15.85 17.75 18.60 19.48 20.66 21.92 - 20.99

Peru 8.56 8.11 9.55 9.70 10.47 11.70 12.04 12.27 13.40 14.99 16.58

South Africa 0.31 0.60 0.53 0.60 0.67 0.92 1.08 1.28 1.36 - 1.53


Appendix G: Health Spending Tables

We obtained the data in the following tables from the World Development Indicators (WDI) database.

Public Health Expenditures as Percent of GDP

Country 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ghana 2.40 2.92 3.04 3.73 3.22 3.67 3.83 3.58 3.14 3.24 2.13

India 1.02 1.13 1.11 1.10 1.16 1.22 1.16 1.18 1.18 1.29 1.41

Jamaica 2.72 1.99 2.31 2.53 2.89 2.89 2.99 2.80 3.27 3.38 2.81

Moldova 4.18 4.18 4.72 4.92 5.39 6.06 5.62 5.31 5.52 5.03 5.30

Peru 2.54 2.69 2.39 2.41 2.45 2.98 2.79 2.62 2.85 3.05 3.32

South Africa 3.22 3.32 3.36 3.40 3.60 3.95 3.99 4.13 4.28 4.20 4.24

Private Health Expenditures as Percent of GDP

Country 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ghana 1.56 1.58 1.59 1.57 1.63 1.50 1.51 1.23 1.65 1.38 1.43

India 3.20 3.15 3.14 3.13 3.18 3.15 3.12 3.16 3.21 3.24 3.28

Jamaica 2.08 2.08 1.91 2.34 2.51 2.26 2.31 2.42 2.38 2.53 2.55

Moldova 4.30 4.98 5.91 5.96 6.02 6.43 6.46 5.30 6.36 5.02 5.02

Peru 2.02 2.02 2.08 2.18 2.28 2.38 2.24 2.30 2.33 2.19 2.15

South Africa 4.71 4.45 4.21 4.13 4.15 4.44 4.51 4.48 4.52 4.57 4.55


Public Health Expenditures as Percent of Total Health Expenditures

Country 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ghana 60.62 64.86 65.66 70.37 66.45 71.04 71.78 74.38 65.57 70.08 59.85

India 24.23 26.49 26.15 26.02 26.79 27.90 27.13 27.14 26.97 28.41 30.04

Jamaica 56.69 48.81 54.73 52.03 53.54 56.10 56.45 53.64 57.87 57.23 52.38

Moldova 49.28 45.62 44.41 45.20 47.22 48.52 46.53 50.06 46.47 50.04 51.38

Peru 55.76 57.10 53.54 52.50 51.84 55.65 55.53 53.26 55.00 58.20 60.64

South Africa 40.60 42.68 44.41 45.11 46.41 47.07 46.92 47.99 48.62 47.92 48.24


Appendix H: Country Information Sheets

We created two-page information sheets for each of the six case countries to highlight the strengths and challenges in each ECD program area, explain the main governance and funding structures, and show the coverage and enrollment rates of the various services.

Ghana

STRENGTHS

27,499,924

- NHIS free maternal care - widespread

immunization programs

through national EPI policy

POPULATION

CHALLENGES

- access for rural,

marginalized, and

extremely poor

individuals

3,859,961

Childrenage 0-5

Ove

rvie

w

0

1

Pre-Primary Ed. Health (age 0-5) Family-Support

ECD Components

Percent of GDP Spent on ECDComponents

04 05 06 07 08 09 10 11 12 13 140

1

Year

117% GER

94% NER

71%

Ed

uca

tion

of all births with a skilledbirth attendant present

EDUCATION FUNDING SOURCES

96%

of children immunized

according to WHO basicimmunization package

government funds

15%

of public health

expenditures spent onpreschool-aged children

GhanaEducation

Trust (GET)Fund

40%

internallygenerated

funds

of population enrolled inNHIS

Internationalpartners

Heavily-Indented

Poor Country(HIPC) funds

government expenditures: 95.1%

external funds: 4.9%

CHALLENGES

- pre-primary is under-

funded - inequitable access

among rural and

marginalized children

STRENGTHS

- kindergarten is part of

basic education cycle

- capitation grant policy

alleviates costs for families

and provides food

Pre-primary Education as aPercent of GDP

governed by: Ministry of Education

Hea

lth

H

ealt

h

HEALTH FUNDING SOURCES

NationalHealth

InsuranceLevy (NHIL)

Payrolldeductions

Other:individual

contributions,Parliament

funds,investment

income

National Health Insurance Scheme (NHIS)

National Expanded Program of Immunization (EPI)

Generalgovernment

revenues


governed by: Ministry of Health

MAIN ECD SERVICES: -maternal healthcare

-immunizations -nutrition in schools

04 05 06 07 08 09 10 11 12 13 140

1

2

3

4

Year

Public Health Expendituresas a Percent of GDP

Sources include: CIA World Factbook; Ghana Education Sector Plan; Social Security Administration; Ministry ofGender, Children, and Social Protection; LEAP.gov; the World Health Organization; the World Bank's WorldDevelopment Index, UNESCO; UNICEF; and papers by Wang et al. (2017); Witter and Garshong (2009); andWitter et al. (2009)

Fam

ily-S

up

por

t

governed by: Ministry of Gender, Children, &Social Protection

governed by: Ministry of Employment &Labor Relations

STRENGTHS

- LEAP 1000 targetsinfants and mothers

- maternal leave isguaranteed

- 1 hour nursingbreaks provided atwork

CHALLENGES

- limited formal

employment - government spends

very little on family-

support

LEAVE POLICIES

CASH TRANSFERS

Maternity

12 weeks

100% of earnings

FAMILY-SUPPORT FUNDING SOURCES

LEAP 1000 pregnant women and

HHs with infants under15 months

Range from GHS 64-106(USD 15-24) bi-monthlyper HH depending onthe number of eligiblebeneficiaries

0.002% of GDP spent on

family-supportpolicies

Employer

Generalgovernment

revenue


India 1,293,859,294

POPULATION

04 05 06 09 10 11 12 130

1

Year

124,348,347

Childrenage 0-5

13% GER

Ove

rvie

w

Ed

uca

tion

EDUCATION FUNDINGSOURCES

General

government revenue

Privatehouseholds

CHALLENGES

- inadequate supplies and

provision of resources - staff are underpaid

and not adequately trained - facilities are understaffed

STRENGTHS

- preschool and ECD

services offered at

most Anganwadi

Centres (AWCs)

0

1


ECD Components



*missing datain '07, '08, '14

Hea

lth

STRENGTHS

- integrated program - majority of services offered

at centers - supplementary nutrition

program is widespread (in

>90% of centers)

CHALLENGES

- inadequate infrastructure - AWC workers are

overburdened and

underpaid - public program serves

small portion of eligible

population

81%


70%



10%

Allocated through Integrated Child DevelopmentServices (ICDS):

60% from national government 40% state government

90:10 split for select states

100% from national government for union territories

of public health


50%

of eligible children enrolledin ICDS

governed by: Ministry of Womenand Child Development

World’s largest ECD program; launched in 1975


Out-of-pocket

payments

Generalgovernment

revenue

SERVICES OFFERED THROUGH ICDS: - supplementary nutrition

- nutrition and health education - immunizations

- health check-ups - referral services

04 05 06 07 08 09 10 11 12 13 140

1

2

Year


governed by: Ministry of Women andChild Development and Ministry of

Healthy and Family Welfare

Sources include: CIA World Factbook; Social Security Administration; the World Health Organization; the WorldBank's World Development Index, UNESCO; UNICEF; Ministry of Women and Child Development; InternationalLabour Organization; Government of India Press Information Bureau and a paper by Rao and Kaul (2017)

Fam

ily-S

up

por

t

governed by: Ministry of Women and Child Development

STRENGTHS

- birth grant reacheswomen ineligible formaternity leave

- conditions of CCTencourage women toseek ECD services

CHALLENGES

- very few women

qualify for maternity

leave since the majority

of women are informally

employed

LEAVE POLICIES

CASH TRANSFERS

Maternity

26 weeks

100% of earnings


Birth grant for informally

employed pregnantand loctating mothers

INR 6,000 (USD 92) viathree installmentsconditional on healthvisits andimmunizations



Employer

Generalgovernment

revenue

Hea

lth

Allocated through Integrated Child Development Services (ICDS)

Allocated through Integrated Child Development Services (ICDS)

Jamaica 2,862,087

POPULATION

04 05 07 08 09 10 11 12 13 140

1

Year

213,652 Children

age 0-5

113% GER

82% NER

Ove

rvie

w

Ed

uca

tion


Generalgovernment

revenue-earmarked

PrivateHouseholds

CHALLENGES

- lack of quality

educational centers - poor government

oversight of early

childhood institutions

STRENGTHS

- high enrollment forchildren age 3-5

- concerted governmenteffort to improve accessand quality of education

0

1


ECD Components



governed by: Ministry of Education,Early Childhood Commission

*missing datain 2006

STRENGTHS

- no user fees for health

insurance through National

Health Fund - high immunization rates

CHALLENGES

- poor quality public

hospitals

- costly private hospitals - low coverage for

prescription medications

99%


92%



8%

of public health


Hea

lth


Generalgovernment

revenue

JamaicaNational

Health Fund

Out-of-pocket

payments

governed by: Ministry of Health, Early ChildhoodCommission

MAIN ECD SERVICES: - prenatal and postnatal care

- immunizations - free public clinics and hopstpials

04 05 06 07 08 09 10 11 12 13 140

1

2

3

4

Year


Parliamentfunds

Tobaccotax

Consumptiontax

Other: loans,investments,

donations

Hea

lth

Sources include: CIA World Factbook; Jamaica National Health Foundation; UNICEF; the World Bank; SocialSecurity Administration; the World Health Organization; the World Bank's World Development Index, UNESCO;Ministry of Labour and Social Security; Ministry of Justice

Fam

ily-S

up

por

t

governed by: General Jamaican Legislature, Early Childhood Commission

STRENGTHS

- maternity leaveguaranteed by law

- PATH program - roving caregivers

program

CHALLENGES

- maternity leave pay

only guaranteed for 8

weeks - no paternity leave

- low formal

employment

LEAVE POLICIES

CASH TRANSFERS

Maternity

8 weeks

100% of earnings


PATH pregnant women and

nursing mothers andchildren up to age 6

JMD 900 (USD 7) permonth perpregnant/nursing mother

JMD 750 (USD 6) permonth per child



Employer

Generalgovernment

revenue-earmarked

World Bankfunds

can take up to 12weeks but without

100% of pay

Socialassistance

funds

Insuredindividuals

Moldova 3,556,397

POPULATION

06 07 08 09 10 11 12 140

1

2

Year

224,989 Children

age 0-5

87% GER

85% NER

Ove

rvie

w

Ed

uca

tion


Centralgovernment

transfers(Ministry of

Finance)

Localgovernments


CHALLENGES

- enrollment gap between

rich/poor and urban/rural - deteriorating

infrastructure - poor pay for teachers

- shortage of schools in

some areas

STRENGTHS

- high enrollment rate

- pre-primary education is

a priority for government

-focus on reaching

disadvantaged students

0

1

2


ECD Components



governed by: Ministry of Education,Culture, and Research

*missing datain '13

Hea

lth

STRENGTHS

- high coverage of

children - extensive services for

mothers and children

CHALLENGES

- high rate of

individuals livings and

working overseas,

ineligible for

insurance

100%


92%



6%

of public health


98%

of children enrolled ingovernment-provided

health insurance

Unique challenges due to a low fertility rate

98.5%

Hea

lth


Generalgovernment

revenue

National Health Insurance Company

MAIN ECD SERVICES: - nutrient supplementation

- immunizations - government-provided insurance

04 05 06 07 08 09 10 11 12 13 1401234567

Year


governed by: Ministry of Health, Labour, and SocialProtection

Sources include: CIA World Factbook; Social Security Administration; the World Health Organization; the WorldBank's World Development Index, UNESCO; UNICEF; National Bureau of Statistics of the Republic ofMoldova; Ministry of Finance; Ministry of Education; and papers by Hone et al. (2016); Mathauer et al.(2016); Valentina and Fuior (2014); van Ravens et al. (2017); and Petoria and Cara (2015)

Fam

ily-S

up

por

t

STRENGTHS

- extensive leaveoptions

- childcare allowancefor up to 3 years

CHALLENGES

- less benefits for

uninsured individuals

- Moldovans

living/working abroad are

ineligible for programs

- social insurance

experiencing budget

deficit

LEAVE POLICIES

CASH TRANSFERS

Maternity

18 weeks

100% of earnings


Birthallowance

for all

MDL 3,100 (USD 188)for 1st child

MDL 3,400 (USD 206)for subsequentchildren



Employer

Generalgovernment

revenue

governed by: Ministry of Health, Labour, and Social Protection

Insuredindividuals

Employer

Paternity

14 days

100% of earnings

Paternal for insured

individuals

180 days

60-90% of earnings

Childcareallowance

for insuredfamilies

MDL 1,234 (USD 75)per month (up toage 3)

Childcareallowance

for uninsuredfamilies

MDL 540 (USD 33)per month (up toage 1.5)

Peru 30,973,354

POPULATION

04 05 06 07 08 09 10 11 12 13 140

1

Year

2,981,641 Children

age 0-5

89% GER

89% NER

Ove

rvie

w

Ed

uca

tion


Generalgovernment

funds

CHALLENGES

- Andean students

face language

barriers to fully

participate in school

STRENGTHS

- school enrollment

expanding - compulsory school for age

5-6 - targeting of Andean

communities to promote

inclusion

0

1


ECD Components



governed by: Ministry of Education

Peru has a strong national commitment to improving outcomes for children in low-income and rural communities

Nationalgovernment

Regionalgovernment

Hea

lth

STRENGTHS

- stunting rate halved since 2005 - reduced rural/urban gap

- immunizations prioritized for

low-income and rural

communities - comprehensive healthcare for

low-income populations

CHALLENGES

- problems with

accessing health

programs - no universal healthcare

90%


87%



10%

of public health


39%of population enrolled in

free healthcare


Generalgovernment

revenues governed by: Ministries of Health and of

Development and Social Inclusion

MAIN ECD SERVICES: - Integral Nutrition Program

- Comprehensive Health Insurance - Immunizations

04 05 06 07 08 09 10 11 12 13 140

1

2

3

4

Year

Public Health Expenditures as aPercent of GDP

Hea

lth

Sources include: CIA World Factbook; Social Security Administration; the World Health Organization; the WorldBank's World Development Index, UNESCO; UNICEF; Early Childhood Workforce Initiative; Young Lives; and apaper by Huicho et al. (2016)

Fam

ily-S

up

por

t

governed by: Ministry of Development and Social Inclusion

governed by: Comptroller General of the Republic

STRENGTHS

- paternity leave - Juntos reaches

targeted population - improved health and

education outcomes

CHALLENGES

- no parental leave - no unconditional

transfers

LEAVE POLICIES

CASH TRANSFERS

Maternity

14 weeks

100% of earnings


Juntos poor families, mostly in

rural areas, with childrenand/or pregnant women

PEN 200(USD 62) bi-monthly

0.25% of GDP spent

on family-supportpolicies

Employer

Generalgovernment

revenue

Paternity

4 days

100% of earnings

South Africa 54,146,735

POPULATION

04 05 06 07 08 09 10 11 12 140

1

Year

5,560,135

Childrenage 0-5

80% GER

22% NER

Ove

rvie

w

Ed

uca

tion

EDUCATION FUNDINGSOURCES

Generalgovernment

funds

CHALLENGES

- low NER likely due to

low overall enrollment

and children in the wrong

grades for their age

STRENGTHS

- Grade R required for

all children ages 5-6 - pre-Grade R services

for children age 5

0

1


ECD Components



governed by: Department of Basic Education

*missing datain 2013

Hea

lth

STRENGTHS

- high immunization

rate - use of social

impact bonds

CHALLENGES

- lack of healthcare

professionals - poor households

struggle to access

health services

94%


77%



10%

of public health


77%

of population enrolled ingovernment-provided

insurance


NationalHealth

Insurance

Privateentities

Generalgovernment

revenues

governed by: Department of Health

MAIN ECD SERVICES: - prenatal and postnatal care

- nutrition - immunizations

04 05 06 07 08 09 10 11 12 13 140

1

2

3

4

5

Year


U.S. Centersfor DiseaseControl andPrevention

(CDC)

GlobalFund

Hea

lth

Sources include: CIA World Factbook; Social Security Administration; University of Cape Town Health EconomicsUnit; the World Health Organization; the World Bank's World Development Index, UNESCO; UNICEF; and a paperby Zembe-Mkabile et al. (2015)

Fam

ily-S

up

por

t

governed by: South African Social Security Agency

governed by: Department of Labour

STRENGTHS

- reducedadolescent absencefrom school

-increased likelihoodof child growth

CHALLENGES

- stunting among poor

children persists - 26% of poorest

households report

experiencing hunger

LEAVE POLICIES

CASH TRANSFERS

Maternity

17 weeks

38-60% of earnings


Child SupportGrant

child allowance forlow-income families

ZAR 380 (USD 32)per month untilchild turns 18



Employer

Generalgovernment

revenue

Paternity

10 days

100% of earnings

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