Yoshikawa - Integration Policy Challenge

As Ann said, the mission and one of the guiding principles for this Forum is to be practical and yet be grounded in the science of early childhood development. One of the critical challenges for governments is to think of the combination of policy supports that will support the multiple domains of early childhood development.

We know from the science that physical, cognitive, social, emotional, executive function, self-regulation -- these skills are intertwined across the life course and especially during the first years of life. But that creates quite a complicated policy challenge in every country that invests in early childhood. That is because typically, the services that we think of as associated with some of these areas of development have their own disciplinary perspectives, their own organizational and institutional structures and their own ministries, most often. So, whether they are ministries of health, education, social protection, women and children's issues, child protection, there is often a way in which the structure of governments is sliced up and arranged at the national, sub-national and local levels for which the intertwining of these skills and the support of these skills is quite a challenge.

We know that the family is certainly important, community contexts are important, early care and learning environments are important, and economic security kinds of supports are all important. And yet, they are often within these different ministries.

The challenges of conceptualizing and implementing policies have come up repeatedly in our workshops so far.

I think for all of us in the early childhood field the words coordination and integration come up very often, whether they are in the rationales for investing in early childhood, the actual legislation for early childhood development, of which there has been a growing number of low and middle-income countries with national legislation across all these different sectors or areas, and then, most particularly, in the national action planning and the ways that the strategic plans are actually implemented across sectors.

This is not an easy topic.

Aber - National Policy

National policy is both a help and a hindrance. So, the, everywhere in the world families and communities are children’s first circle of support and defence. So families and communities we can never forget is the important basis for all support for children, especially young children. So the question is how national policy helps families and communities support children. It’s always an indirect enterprise. We don’t want national policy reaching right down to the infant. They’re too clumsy and stupid to take care of babies right. But what they can do to support families and communities to do that is very very significant. What I’ve learned in low income and conflict affected countries and what I’ve learned in advanced wealthy democracies like Canada and the United States is that the first responsibility of families and communities is to provide a safe, supportive environment for young children. Safety and basic support is job number one and there are many children who we haven’t provided basic safety and support for. Basic safety and support is necessary but not sufficient to help children thrive. Especially help children who have faced adversities already thrive. So, for me, the question of national government is, what can they do to help provide, help families and communities provide the safety and support that kids need and, if they are able to do that, what else can they do to help families and communities stimulate, nurture, enrich their children’s lives such that they thrive, not just survive.

Samms-Vaughan - Structuring National Early Childhood Programming in Jamaica

DR. SAMMS-VAUGHAN: -- There were three stages to the process of how we got to where we got to. The first was obtaining comprehensive information on the status of the early childhood sector. This happened in Jamaica in the late 1990s. The second was the establishment of a cross-sectoral state institution to develop and take responsibility for the early childhood sector. Jamaica’s Early Childhood Commission Act established the Early Childhood Commission as a government entity responsible for early childhood development in 2003. The third stage was developing and implementing a comprehensive cross-sectorial national strategic plan for ECD. This first occurred in 2008 to 2013, we’re now in the second strategic plan, 2013 to 2018.

I will now provide you with a little bit of detail as to how this works in practice. First, the information gathering process. The information gathering process required not only information on the current status of all aspects of ECD – health, social sector, education – but it also required an understanding of the history of the process of early childhood development in Jamaica. In short, it was important for us to understand where we were, and how we got there. For example, 95 percent of children are in pre-school in Jamaica by the age of three years. This is not something that was instituted by the government or directed by the government, this was part of our history and our culture where every child needs to be in school by three. It was a community demand and not government intervention. So if we’re going to change things we have to know about this, because that’s going to impact our change process.

We also found in our information gathering process that less than a third of parents reported receiving parent support, and parents of children with disabilities were practically challenged. Now although we had so many kids attending preschool we found problems of quality and inequity. So clearly for us access was not a problem, but quality and inequity were. Parent support and the management of children with disabilities was also important. The research also showed that existing early childhood activities were poorly coordinated and would benefit from the establishment of a single coordinating body. This led to the second process.

So the Early Childhood Commissioner, the ECC for short was established within a legal framework to take responsibility for the early childhood sector, and to coordinate activities. The legal framework was particularly important. It ensured sustainability of the organization, it established the structure of the organization and ensured that it was cross-sectoral, and it also clearly defined the organization’s responsibilities in law. The responsibilities of the ECC are to guide policy development, develop early childhood programs, monitor their implementation, regulate the schools to ensure quality, consult stakeholders, coordinate early childhood activities, seek additional financing, conduct research, and ensure public education and information on ECD.

The third phase, which was then done by the ECC, was the development of the cross-sectorial strategic plan. The ECC used all available information internationally and locally as well as public consultation to develop the strategic plan. Public consultation was hugely important because of the huge community input into ECD. The strategy was a lifecycle approach with the first of five strategic objectives addressing parenting. The ECC then went on to lead the development of Jamaica’s national parenting policy, national parenting strategy through the development of parents places, and national parenting standards.

The second and third strategies focused on the needs of children zero to three primarily, and were improving quality of well child care at clinics, which included improving the ability to screen children, and also improving stimulation. And also early identification and intervention for children with disabilities. The fourth and fifth objectives addressed primarily the children in the age group three to six years. So this is about regulating pre-schools, setting up an inspection and a regulatory system, and developing and supporting programs to improve the training of pre-school staff and developing a child centered curriculum. These five key objectives were then underpinned by two working processes. First, there had to be a cooperative framework with each agency or entity of government having its role to play and its own targets to be met. Second was a dependence on evidence, data, and information to guide decisions and for monitoring and evaluation processes.

The cross-sectorial approach is implemented in various ways throughout the ECC. First, the ECC is governed by a board which is cross-sectorial in nature. So represented on our board are representatives from the Ministry of Health, Education, Labor and Social Security, Finance, the Child Protection Agency, the CD, and the government’s national planning agency, the Planning Institute of Jamaica, as well as independent actors, the private sector persons in child psychology. So they’re independent actors as well as government.

A specific senior position in the organization for cross-sectoral work, the Director of Cross-Sectoral Coordination. The strategic plan is also cross-sectorial. For example, quality well child care is a function of the MOH, teacher training is a function of teacher training colleges. So the agencies signed memorandums of understanding with the ECC each year when we have our annual strategic planning meetings. The timing of the meeting is important, because the agencies then put their plans in the budget for the next year.

Will this work for every country? Probably not, especially details. But the structure and the process may be useful. Has it been easy? Not by a long stretch. Cross-sectorial work is inherently challenging. People enjoy working in their own space, however there have been tremendous successes. Thank you.

Alarcon Policy Framework

DR. ALARCON: (She speaks in Spanish, being translated into English simultaneously)

Good afternoon to you all. I was tasked as I said in my initial comments to share with you an experience that is not like the other presentations we have heard because this is from the side of the government. I am going to explain how a country makes decisions when there is political will to implement early childhood development policies. This is a process that has been under way for three years. The idea behind it was to base ourselves on the national convention on the rights of the child and early childhood development.

I have three different parts to the presentation. At the beginning, I will just quickly say what the country’s approach is; secondly, the elements of two studies that the country has conducted to do with investment; and then thirdly I will provide some conclusions and general ideas for the dialogue on implementation of public policy.

In the first part, in the country, initially, this is what we have been working on. This is something we have seen in many Latin-American countries. It has to do with traditional ways of working as we manage public policy. We found that there are different sectors with different priorities and different development plans and specific investments. They look to important goals for the population, but they don’t talk amongst themselves. They don’t coordinate in practical terms.

In the specific case of Colombia, we had all of the local authorities, the education sector, the healthcare sector, society in general, the private sector as well, which is extremely important in the country. They each had objectives that were targeting a certain part of the population.

The strategy basically looked to reorganize the entire system, the entire institutional framework. It shapes this paradigm where we have a single entity in charge of early childhood. It decided to create an institutional framework from the bottom up. It creates an institutional architecture. We have this inter-sectoral Early Childhood Commission that includes all of the sectors from National Planning, Finance Ministry, the different ministries, and different entities. It created a single work plan.

As an ethical framework, they needed it for protection for children. This is important because Colombia, unlike other countries, is not working from a risk perspective. This is a public policy for the 5 million children who live in the country under different conditions. Colombia is one of the countries with the greatest degree of social inequity in Latin-America and globally.

One of its approaches it makes the central objective integrated care. That is the how and not the why. It means not losing sight of the child at any time, not in budgets, indicators or programs. They often get lost when we are managing programs. This was important. It basically says that we have to have comprehensive development. Very quickly, based on this exercise, it is a management tool that Colombia is using now which is an integrated care pathway. This is where we bring together much of what has been discussed during this workshop.

First, to understand differences in development if we look at the life course looking at different ages from the pre-conception through six years of age and look at the particular circumstances and how those impact public policy interventions. It is not a program. It is a policy framework that brings together about 18 programs, all of which are moving towards inter-sector approaches. It is public policies for developing actions in the home, in healthcare centers and the communities and in public. It can’t be moving in a single direction or in a single environment. It has got to be something comprehensive.

Finally, we have the structural basis for the different actions and activities engaged in an exercise as to what every child and mother needs for healthy development throughout the entire life course. This is a complex exercise and the pathway is 170 different types of activities. There are eight indicators in the country development where we begin to implement the policy.

First, this is integrated development that went from services to more comprehensive actions. This is the focus that the policy has now. As you can see there, we have many different sectors involved. This is around a single child. This is something that is very complex in public policy because it is a matter of inter-sectoral management. With five lines of action, I am going to focus on the second.

The first is national management, a development of knowledge, coverage and quality, monitoring and evaluation of the policy and social movement. Several studies have been conducted. I will just focus on a few of the specific aspects. The first has to do with developing a baseline to determine quality services and matters of quality in healthcare services and in child development centers.

I have two or three key slides I want to show you. The first is to understand that in a public policy framework, when we talk about quality and outreach to the population that is key. What we did for some different types of attention we have quality criteria to create a national database. This is where we believed we had to take action. If we don’t invest in quality, this can be counterproductive for the very community we are trying to help. It is very important to ensure the quality of the investments and to qualify the services and the different activities.

I am not going to spend too much time here, but I wanted to talk to you because it is relevant to what we have been discussing. With great rigor there have been findings and evidence about the prenatal period intended for pregnant mothers and early infancy. There are public policies. We are saying where should we begin? What you are seeing here are the results of a study that show the determination of quality in healthcare services that have to do with notification.

All of what you see in red shows what is not recorded in the medical histories of the pregnant mothers or the child. That means when we start to do follow-up on children, the physician, the obstetrician has no medical records in order to be able to do any monitoring. We have seen the importance of knowing what the medical history is or what the health and nutrition conditions of the pregnant mother are. In public policies, these are variables that can make any progress impossible in this direction.

The other study has to do with the matter of cost. Here what we basically identified was the following. We defined certain types of interventions of what you can find here. I know that it is very hard to read this table up here, but on the left, we have the different ages. What we did was we started to determine cost for services, starting from preconception from pregnancy until birth, from birth until the first month, 2 to 5 months, 6 to 11 months, 1 year, 2 years, et cetera.

At each age, we started to identify what the fundamental services and care were. It was parenting, feeding, nutrition, vaccines, access to culture, physical and recreational activities, learning, schooling, development, screenings, and transitional periods, prevention, recovery, especially when rights have been violated and specific healthcare related issues. Looking at the simple straight-forward costs, we started to make comparisons between the different types of services and care.

In Colombia, we have what we call kindergartens or daycare centers. I wanted to show you where this arrow is. This is when we are taking care of a 1-year-old. That can cost 5 million pesos. In dollars that would be about 2600.00 per year. In another type under those same conditions, it could be costing the country 1700.00 or 1800.00. Other community-based services, it could be 800.00.

When we conducted the exercise, the planners and policy makers were looking at what the cheapest was. What is the cheapest is not necessarily the best for the country. It depends on the conditions. In a large city like Bogota, a big metropolis, that has a significant population. To have community-based centers doesn’t have impact compared to what is available in rural areas or with indigenous communities because we have that in the country or those who are victims of the armed conflict. This is something that we also wanted to show here.

When you are doing evaluations or researching programs or different types of care looking at rules that can be applied from one context to another, you have to take great care in doing that. Bear in mind the context. Within a single country, the conditions can significantly vary. If you say this is a good program or a bad program, you can say that scientific rigor, and you may not like to hear this, but it depends. It depends for what community and what context and what conditions. This would warrant perhaps other approaches in evaluating the programs and not just talk in general terms, which is what often happens.

In some of the conclusions of the studies, it is important in terms of the exercise that we who work in planning and do policy development take into account. It is important to exante and expost studies that help us to look at the context in those evaluations or studies that try to just look at a single program. They don’t help us who work in public policy development or planning very much.

This gap that exists in scientific findings and the development of policy is very serious for many countries. In the case of Colombia, when we were looking at the study that showed quality data in terms of healthcare services, the country that doesn’t have data, that doesn’t have the medical history of a child or doesn’t have any of that information it is very difficult and very complicated to develop actions that are going to have an impact on childhood development programs to support families, provide nutritional support or look at the nutritional situation of the pregnant mother.

If there is no ability to access data, it is very difficult to make significant decisions in terms of education. In the case of Colombia, what we have discovered was discovered in many countries too. We know that it is not just the case of Columbia, for early childhood education now there are a lot of opportunities. We are seeing a significant number of people who can provide those services. That is not just because a law was passed or because quality standards were developed. You have to generate skills and strengthen institutions and make sure that there are quality services so in the medium term we can have positive outcomes. It is not just shifting to different approaches.

These approaches have to be worked on. You have to make an investment. One of the major costs that ultimately has to be paid is to be paying for very costly services that are not having an impact on the children. If we don’t have a quality action the services will not have the impact we want and we will be losing the investment. It will be an investment with a much lower impact than what we would like.

Another element that we hope to see included in evaluation agendas has to do with having multiple factors, obviously cost-effectiveness, but also integrated approach to services. In Colombia it doesn’t matter what the environment is. In the health environment, you can provide integrated services, provided that they understand that the child is a whole being with many variables.

It is not helpful to us in policy implementation to have the very specific programs or visions because the child is lost. If you talk about nutrition that has to do with emotional care, access to other services, bonding, or connection with other services. If you don’t see it as part of a whole, the exercise can be pointless. The big challenge in Colombia is to look at all of the things that are provided, nutritional recovery programs, reading rooms for families, early childhood education, early childhood health programs.

Now it is moving towards a more integrated system. A doctor isn’t going to become a teacher, but the doctor needs to understand that he is talking to a child who has feelings, who reads, who has a teacher, who has different sides to him. It doesn’t cost more to have that vision, but the cost of not having that vision can be very high. You can have the nicest doctor’s offices and highly trained people, but if the basics are lost at the early childhood level then the costs are going to be higher to pay down the road and our actions will have a higher impact.

There are two comments that I absolutely need to share with you before I wrap-up. First of all, we cost the direct care for the child and the services they receive. We also have to cost the policy implementation side. This involves social mobilization, communications, training, supports, and institutional architectures. Those can be invisible costs often times. It can be a risk if attention is not paid to those aspects.

Then lastly with the differentiated approach it is essential to understanding different needs of different populations. For instance in Colombia, we have different ethnic groups. We have afro-descendant groups, indigenous groups, aboriginal groups, and so actions have to be differentiated. Work has to be done to identify differential costs, different service modalities. Even within a country you cannot have just one package of programs. We need to factor that in, in the short, medium and long-term as we move from our policies.

Yesterday, someone said it was fundamental to have political will. Yes, you need that support and investment and decisiveness, but the big thing is to move from the policy of an administration to making it truly a government state policy that will last for the long-term. Thank you.

Molina – Chile Grows With You

DR. MOLINA (through interpreter): Good afternoon to all of you. I am very grateful to the organizers for having given me this opportunity to share with you some of the experiences in Chile in the area of childhood. I will be speaking in Spanish which is, of course, easier for me, but my slides are written in English, which will probably make it easier for you to understand.

I shall briefly describe the context and we will look at the implementation stages of a program, which is not really a program; it is a public policy in Chile on childhood and social protection of childhood. This is an intersectoral policy which we have been developing in Chile since 2007 and which was one of the main pillars of the first government of President Bachelet. We will explain briefly what governance has been in our country, how we were able to administer this whole thing in our country; namely, this intersectoral system which has been operating from the local level to the national level. And finally, I will be talking about some of the lessons we have learned and which have also become challenges. Now just a brief explanation, not quite as detailed as the previous speaker, but I would just like to say that Chile is a rather small country. It has a population of 17 million inhabitants. It is a centralized country although it is divided into 15 regions. The central government is administratively decentralized but it is not a federation of states; it is one single country.

The GDP per capita is now at $22,416, which means we are still a developing country, with a median average income. Although the index of poverty has been dropping considerably over the last 20 or 30 years, there is still a major gap between the highest incomes and the lowest incomes. We have a Gini index of 0.50, which has been improving over time but rather slowly, too slowly we feel when we compare it to the improvement of the economy of the country.

Our child mortality is higher than here, but within the context of Latin America and the Caribbean, we are among the three countries with the lowest infant mortality -- 7.4. We are in a period where the birth rate is dropping; 100 percent of births are attended institutionally and maternal mortality is the lowest in Chile and of all those in Latin America. Although for many years we were a low-income country, infant mortality and maternal mortality as well as education did improve over the years, in fact, I would say independently of economic growth.

And this I think is linked to something which I think deserves to be highlighted, and that is that public policy in the health area is that -- our idea is not to always start with zero, but always make use of what already exists in the country, which is important resources. Very often there is duplication of effort, repetition of initiatives without integrating what has already been done before.

I would like to stress that, in Chile, perhaps the most important factor in the improvement of our indicators is because we had policies that last for a long time -- primary healthcare policy, important primary healthcare centers and services with well-trained staff at the centers. For instance, malnutrition or dis-nutrition does not exist in Chile. Malnutrition for lack of food does not exist. There is a very small percentage, less than 1 percent, of secondary malnutrition caused by chronic diseases. Chile has also been facing the issue of obesity and overweight, and we are now facing an epidemic in that area.

The strength of the public health system in Chile from 1952 when the national healthcare system was adopted has been improving. We started out with a multidisciplinary team which is a fundamental factor for what came later. We have followed this new policy of infant health, but as part of a system where the biomedical aspect of infant health was already well implemented.

What has been done with the policy, which I will describe to you, is to incorporate a more holistic view, a vision of childhood -- the development of children, the rights of children, include those also, and the necessary intersectorality to be able to work on human development from the start, understanding what we already have. There is a lot of evidence of the importance of the very first days in the spiritual, cultural, cognitive, sociological and motor development of children, and also in the cost-efficiency of actions that are done in those very first years of life of the children. Those are the pillars on which our policy is based.

In 2006, Dr. Bachelet assumed the presidency of the country. She is a pediatrician, a doctor; therefore, we have had a lot of support in working on childhood issues. She set up a Committee on Early Childhood, of which I was a member, and we worked 4 months full time to draft a document which was known as The Future of Children is Always Today, which is of course a sentence from Gabriela Mistral, the literary Nobel Prize winner of Chile. We set up there the conceptual framework of the national policy which I will be describing.

After having delivered that document which, as I said, President Bachelet requested from this group, it was then worked on by a group of representatives from 10 different ministries in the modulation and articulation of how to implement this policy. The child that was born out of this effort is known as Chile Grows with You, which is a childhood social protection system, an integral system, which started off in 2007 with 100 municipalities and has been scaled up to the whole country in 2008. Now, we have had several years of implementation, the system has been evaluated, and we are now in a process of re-formulating or strengthening all those aspects which the evaluation has shown are not strong enough and trying to achieve better results.

In 2009, we adopted a new law approved unanimously by Congress, which also shows that the issue of childhood, when it is presented and when it is ably advocated for to generate necessarily consciousness among politicians and economists and so forth, that is very important, as well as the people on the whole, the population in general. It is possible to establish and institutionalize and establish by law a health system that gives priority to childhood in all these aspects which I will be describing.

Basically, it is a system of protection where the conceptual framework is the ecological concept of development. There is consensus that child development is based on an ecological model which recognizes the multi-directional influences of the social determinants of health, of the environmental determinants of health, everything that is related to the health system, to the educational system, to the labor system, to the social legislation and so forth. So it is a system which is centered on children but is based on foundations that regard not only the biological aspects but also the social and economic and political aspects of childhood.

Another characteristic which is part of our conceptual framework and which, to a certain extent, explains many of the aspects of implementation is the life cycle focus. When we work on early childhood, from zero to 8 years, according to the UNICEF definition, in Chile Grows with You, we actually based it on zero to 4 years, but after one year we extended it to 8 years. It starts out considering that what is done now for the newborn or prenatal period or in this first or second year of life are important fundamental foundations to be able to build up the system, build up with the necessary bricks and mortar from the time of birth until old age, ensuring adequate human development and a healthy life.

This is the idea of the life cycle approach which is extremely important for us because in the Ministry of Health, when I took over as Minister, the first thing I did was to finish off with the childhood program, the women's program, the adolescents program, the chronic age program, and we set up a Department of Life Cycle where we could work together. All of those aspects which we know are synergies potentially have effects on subsequent ages. This I think is what has established a fundamental element of the childhood policies.

I won't go into all the details but we did believe that we should not be just drafting a nice policy, very handsome policy in terms of implementation and of evaluation and monitoring, but we should also try to see how can we approach this problem to see what are the determinants of the development for a child to achieve optimum development, and to achieve a healthy and happy life. This is what we want for our children, not only during their childhood but also throughout life.

In that context, under the presidency of Bachelet, we developed several fundamental steps which made it possible for us to take charge as a country of the necessity and priority of childhood. That led us to a reform in the taxation system and in the educational system. We insisted on giving priority and resource allocation to these priorities so that we could break the intergenerational aspect of poverty.

We know that when children do not manage to achieve optimum development -- well, in Chile, I did not bring you the figures because the time is too short, but 30 percent of vulnerable children -- that is to say, coming from poor families, indigenous people, rural people -- have some level of delay in their development. Some are small delays, some are more profound. But in the children that are from wealthier families or have more resources, not even 15 percent of them suffer from any kind of developmental retardation.

So, we have to overcome a great gap in quality, and in addition to good quality we need to have policies to reduce the inequalities, policies that allocate more resources to the areas most in need, and always based on a good analysis so as to obtain the best results.

Chile Grows with You is a policy that is part of an overall framework of public policy, of social protection of the workers, social protection of the poor, and it is therefore sort of put on top, added onto the social protection system but with a focus on mothers, children and family, and with a fundamental purpose of achieving the highest possible level of development. What we discovered in Chile when we started to analyze and make studies to try and put forward this policy is that there were many programs, many initiatives, many pilot projects, lots of aspirations here and there which sometimes fell upon the same people. Many things were repeated. So what we did first of all was put together a model which could integrate all those activities and things that were dispersed, which were programs more based on the supply, so as to be able to create an integrated system that is based more on the needs of the children and of families.

Chile Grows with You is a social protection system with the main actors being the family, the various levels -- municipality and so forth -- the health system, the education system, the public health system, which are the fundamental axis. But we also have, of course, the influence of cultural, housing and other areas of the government and other ministries that have made us copy the slogan of the World Health Organization which says Health in All Policies.

In Chile we have said childhood development in all policies because there is practically no policy that leaves children outside. Accidents, urban health, as the previous speakers said, growth and so forth, all of these are influenced by the development of children and, therefore, by the development of people.

So the governance of our social services system, which is a system to accompany families all the way from birth up to 4 years, and now we want to go on to 8 years, is a policy which is centrally planned so it is an up-down policy which is implemented at the local level and provides feedback at the local level so as to be able to re-examine, re-look and re-think. It is a bottom-up policy which nevertheless goes down to the various levels of the region.

The coordination at the ministerial level is in the hands of the social development ministry because we identified it as the most appropriate ministry because the technical ministries compete with it. Education and health usually compete and, also, often don't make full use of the opportunities and resources available. Therefore, there is a ministerial committee which sets the policies, the strategies and the plans and the evaluation model and distribution of resources from a single budget. There is a single budget but several ministries that execute the activities with, of course, sectorial activities.

Below the central level we have the regional level where we find the health services, and 80 percent of the people in Chile have recourse to the public health system, so the mothers and children are practically captives of the health system during the first two or three years of life because of mortality, morbidity, vaccinations and other services needed. So the services exist there, and the policy in the first three years is strongly commandeered, so to speak, by the health sector. After 2 years of age, the educational sector acquires greater importance and there we will work more and more at different levels of intensity but always in an integrated manner.

Finally, in the health services there are special managers for this program. At the central level we have joining of the various sectors and actors because at the local level that is where we intend -- I think it is very similar to what the previous speaker presented. We are trying to find the various actors at the local level to be able to implement public policies.

Let me explain briefly what are the strategies which, from the Ministry of Health, are being worked on in the first years of life. There is universal access for 100 percent of the children born in Chile, so 80 percent of the children receive their care from the public health system, and there is also an important package of intervention for the children of greater vulnerability. More vulnerable children are about 60 percent of those who attend the public health system.

For all children, there are important policies of social communication, interactive networks and all the legislative framework. A lot of laws have been adopted. We have extended a postnatal paid leave for mothers up to 6 months. We have established the law, Chile Goes with You, and there is a project of working day-by-day so as to give more legislative and budgetary support to these activities, always within the framework of this global project called Chile Goes with You. In the health sector is where we have the most important program which is called the Biopsychosocial Development Program which has several things -- a program to support newborns which is very important for parenting. There are different programs, but let me just say that the most vulnerable population not only receives daily visits but is also visited by a health team which manages risk factors which have been screened during the first consultation of the mother immediately before birth. And a mother, if she has any vulnerability or the child is vulnerable, is immediately attended and registered in all the various social systems for housing, for economic support, for health, mental health and so on. Maternal depression is also an issue that we are dealing with. There are also specific programs for children with special needs -- technical support, education and so forth.

Basically, what we want to try to show is that when a child or a woman joins or comes into the system, Chile Grows with You, the biopsychosocial risk factors are identified and, according to those risks, the accompanying work to be done is different, whether they need a specialist or whether she or the child needs economic support, social support or labor support. This policy operates with a system of registers and files that allow us to follow the development of each child and to see levels of warning or things which should have happened. For instance, a child is supposed to go to a consultation but we don't know whether he has gone or not. We have all these filing systems so that we can follow that, both the child and mother. Some of the tools that this system has, as I said, are the biopsychosocial development support program which is provided by the primary healthcare system and maternal system and throughout the whole network of health services, and is administered by the Ministry of Health and the Ministry of Social Development.

The program for support of newborns, which is also handled by those two ministries. The economic support which is not only financial support for the program but also funds are given to municipalities so that social organizations, non-governmental organizations or other local actors can obtain resources to develop local strategies.

There are also specific funds to strengthen human resources at the municipal level because, as we know, when you are working in childhood, it is almost a craftsman work, a person-to-person work. In other words, the people who work, both professional and non-professional, need to have the necessary competence and the necessary tools if interventions -- and all of you here know this and most of you here are experts on this matter -- if interventions are not of the necessary quality and don't have the basic quality required, probably it will have no impact whatsoever.

It is important to say that the catalog of services that are provided as part of Chile Grows with You are always evidence-based interventions. Each intervention is based on literature which has been studied, comparisons which have been made so as not to act merely on intuition but to develop activities that are scientifically based and are based on experiences in similar contexts or in different contexts but have been by studying a program. Nobody is perfect. A Canadian program which we have adapted with the help of Canada to accompany people, the mothers particularly, during the pre-partum and post-partum period. This is a system that makes it possible to follow the trajectory, the whole lifespan, to see what is happening to children.

When the Health Ministry was developing all this in the government of President Bachelet, there was an increase of almost 500 percent in installed capacity in terms of crèche, so to be able to increase the necessary supply for children whose mothers work, for instance, or who are children of adolescent mothers who are still going to school, so there is no child in Chile who requires crèche that does not have it. All get attention.

But, of course, we are in a constant struggle because not only do we ensure that the coverage is available, we also ensure that the equality is there. We also have a model of evaluation. We are evaluating the impacts, the processes, the satisfaction level of the users so as to be clear as to what we are doing right, what we are not doing right, what people like and do not like. We also realize that when we are scaling up to a country level very quickly, as we did, we find that there are different levels of quality in different parts of the country, and this, of course, affects the impact of this program. We are trying to correct those things.

We had a post-evaluation, and after that we introduced several changes because we tried to get feedback very quickly to the various stakeholders so that all those that might have any relationship to the development of this policy could know the results of it, and we were able to strengthen effective actions, focus efforts better on the most effective aspects, evaluate how budget was allocated and the resources were used. We also started to build up a new structure so that during this government with President Bachelet we reach the 8-year level.

Among the post-evaluation activities, we also set up a very strong training program because that is indeed an issue that needs to be constant, and it costs a lot. More technical assistance, development of the profiles of the implementers of this program, develop better technical guidelines or clinical guidelines, better protocols, create virtual communities for teams, improve the monitoring system and evaluation system -- in other words, improve everything that needed to be improved in our opinion.

To conclude, I should say that this was a very quick summary, but what have we learned. We learned that some things are fundamental. First of all, political will. If there isn't political will, in this case of the president of the republic, to establish a public policy and to so quickly implement it throughout the country -- without the political will it would have been extremely difficult. We think that political will, together with a plan of action, is the best combination that will lead to the best results.

It is very important that there is awareness of the society, the community in general, the politicians and the professionals and non-professionals who work on policies of health and education, of the importance of early childhood interventions. Children don't vote, children don't speak before they are 2 or 3 years old, so we, who are part of this movement, need to be activists, need to advocate and bring about awareness because once the technicians and the politicians are aware, then we can also expect them to work for childhood in this wider context of development.

It is also important to identify that early childhood development is also a social determinant, an important determinant of health and development outcomes. What we do will have a strong impact on the rest of the life of each individual but also on the life of society as a whole. It is also important to recognize that social equity needs to start from the beginning. Our Forum of course tries to see how can we translate knowledge into action in an appropriate manner and not just in little isolated projects but through a policy in each country which will have an impact.

This is the last slide. This was mentioned a lot and every time we talk about early childhood development, it is difficult, but an intersectoral approach can be achieved. What are the most important sectors in Chile Grows with You to achieve intersectoral integration, for instance, to share the conceptual framework, to be able to work in the same manner? We all have to believe in the same thing, and believe that we will achieve a goal. We can, of course, be diverse and have diversity in the way we approach the subject, but the conceptual framework needs to be shared.

And we need to have a win-win mentality because the fundamental reason why an intersectoral approach works is because each sector is evaluated by its own indicators and its own achievements and has its own budget. No one sector wants to push water to the middle of the other sectors; we all want to win. If I win, you win, and we have to contribute in that spirit. It is also important to ensure that we share budgets, and we need to have political support for this work so there needs to be a national level management. My country is very hierarchical. Usually, what is decided above then trickles down to the bottom, but there needs to be a certain discipline to achieve that.

We also think that some of the interventions were not as successful as we had hoped because the intensity and duration were not sufficient. For instance, home visits, the frequency of home visits was not as high as we had hoped and that was because of lack of resources or budget resources. They were good but not as good as we had hoped.

We think important for the intersectoral approach is that all stakeholders from all interest groups are constantly informed and receive feedback constantly. We also think that an evaluation must be intersectoral, not that each sector evaluates individually but -- the specific aspects, yes, have to be evaluated individually, but there also has to be an overall joint evaluation, and we don't think it is easy unless there is a good system of registration and filing. Good information needs to be evaluated.

We think that sustainability depends mainly on the institutional aspects, and particularly community empowerment. It is important to integrate the whole life course, the context through the various social determinants, and also integrate the various actors from different sectors in order to achieve effective policies that march towards equity.

Finally, something which is self-evident but which we often find we have raised the argument and they go no, no, in my country we have very high mortality and, therefore, we cannot yet be concerned about development. We first have to make sure that children survive. We think that the best policies for ECD and for survival are the same. They are common strategies. So we need to break that belief that very often leaves without a strategy the countries that most need them.

Let me leave you with the words of Gabriela Mistral, the Nobel Prize winner from Chile, who said, "Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him, we cannot answer, tomorrow, his name is today." This was written by Gabriela Mistral in 1948 when little was known about childhood development. But, as a very good artist, she had a vision of the future which I think is an example for us. Thank you very much.

Marfo - Silos Integration

But for me the thing that it’s probably above all is that I have also been very very concerned about the siloed nature of our work. I mean we all talk about it and so sometimes it becomes almost a cliché. I don’t see anything wrong with working in siloes when we are creating knowledge although I’d rather create knowledge that takes multiple viewpoints into consideration. But I think we are able to understand the world when we focus on phenomena at a very very deep level. But I think when you come to apply things, there is no other choice; there is only one way all applications draw on multiple disciplines.

Right now if you run into a nutrition scientist, and you ask the person, “what does the developing world need most?” they will tell you all nutrition in the first 1000 days. You run into a neuroscientist, and I bet you if you run into Fraser, whom we all love, you know, Fraser would probably talk first about brain development right, and then maybe talk about other things. If you talk to an MNCH person, I mean, they’re going to talk about you know survival, the things we can do to reduce mortality and that. I don’t think we intend to sound that way but actually, the way we’re trained as professionals, as experts, we are nurtured within our own knowledge bases so when we’re looking at recommendations to government, we make recommendations on what we know when in fact, what most children and families and communities need in many parts of the world including the advanced world is that humans are very, very multifaceted and our needs are very, very multifaceted. And so, you want to look at problem-solving from the point of view of, who are the people whose needs we’re trying to meet? What are the multiple dimensions of their needs? You cannot go in and provide, you know, water supply and then think that everything is solved. Or going with hygiene. You really need to go in there with and understand how does whatever I have to offer fit into, you know, other things that are very, very important to the lives of you know, communities. So that’s what I mean.

So we do have wonderful interventions and wonderful research on interventions but actually they each are sitting in almost parallel fashion. How do we bring them together? You know, so these days the language we use is integrated intervention services. When you talk of integrated, you are acknowledging the reality that given our resources, given the structures that we’ve created, you know, through governmental systems, we have actually, we have created artificial boundaries that make it very, very difficult to do the most commonsensical forms of interventions which is just figure out how to put things together.

Now, I don’t know how much money has gone into it, so in my idealism, I feel great if I know that more and more of us are beginning to think across what I call disciplinary boundaries. Because that needs to happen at the academy level for us to get forward movement on some of the practical things that we want to do. To the extent that the people who are seen as the best in case in their fields are still talking in parlour fashion.

Van Ravens – Child Policy in Young Nation States

MR. van RAVENS: Good morning, ladies and gentlemen. Thank you for the introduction, Hiro. I would like to start out by saying my presentation is entirely based on an essay of the same title -- child policy in young nation states. If I go too quickly, if I skip steps in the presentation, it is all there. Children must develop holistically, and this requires services and interventions from multiple disciplines, sectors and governments administered by different ministries. I think this is a consensus at least in this room, and the question is what are the implications of this consensus.

Some of you, perhaps many, maybe even most, will say that multisectorality of ECD requires integrated ECD programs and integrated ECD policies, and this is also following the order of my presentation starting with programs and then to policy. One of the main arguments for integrated programs is what I would like to call the synergy argument. For example, if nutrition is integrated in a preschool program, then you will see that the child benefits more from that program, is more receptive to that program. The evidence for that is typically found in studies that monitor three groups of children, a control group, children who have access to the nutrition or children who follow the preschool program, and a group of children who follow the integrated program. It is usually found that the last group has the best outcomes, and this is then seen as an argument for integrated programs.

However, for that conclusion, we would actually need an additional group. It is not entirely sound logically. You would need also a group of children who have access to the same nutrition program from one provider and the same preschool program from another provider. This is what I would like to call combined programs, for lack of a better term. I think in the field of poverty reduction people call it converging programs.

In any case, it is a situation where children receive multiple programs but they are not integrated. And there is no evidence, to the best of my knowledge, that children in combined programs fare less well than children in integrated programs because it has never been compared in a research setting.

You might argue that combined programs are an unknown phenomenon; we never heard of it, we have not investigated this as thoroughly as integrated programs. Do they even exist? Where are they? Actually, they are everywhere; they are all over the place. They are in this room. To illustrate the point, I would like to briefly speak for myself for just a minute to illustrate this incredibly important point.

I was born in a poor family in a country that was recovering from war, but I was lucky because people were paying taxes. My essay shows that tax morale is the key to child wellbeing. I am not giving you the argument because I only have 15 minutes and not 15 hours. But I was lucky, so for me there was a preschool program at the age of four. There was a medical doctor who charged no fees. There was perinatal care, I was vaccinated. There was no nutrition but there was a child benefit scheme that allowed my parents to buy good food and there was promotion to promote healthy behavior, et cetera. So I benefited from combined programs.

I think we all did. Everybody in this room was born -- millions of people in the world are born to those circumstances with access to multiple programs but they are not integrated. That is what counts. Children services need to come together for the child, and this is where you have the synergy as well.

I admit that these combined programs are predominantly found in rich countries or in the richer groups, the elites of poorer countries, but by the year 2030, the end of the sustainable development goals, I think there is a very good chance that many people, many children, even in developing countries, will have access, will be born to a situation of combined programs if we work on it, if we stay focused on that.

To conclude this point, I would like to say that we, who consider ourselves to be the global research community of ECD, have been looking for synergy and we found it in integrated programs because that is where we looked for it. Had we looked for synergy in combined programs or converging programs, we would probably have found it as well. It is a classic example of research bias.

Another argument for integrated programs -- by this time, you may have noticed that I am not a great fan of integrated programs; I am in favor of coordinated programs -- is the attraction argument. If we integrate two interventions, then one intervention attracts the other. A great example is school meals. You provide meals, and they have a goal in and of themselves, and it will attract children to the school who would not have come otherwise.

Conditional cash transfers are a very good example. You provide the cash, which has an impact. It reduces poverty and it will attract other people to health checks, parental education. So far so good.

Now, I would like to introduce you to the man on the river. The man on the river is a man I met once in a country somewhere in Latin America. He was the manager of a nutrition program in a jungle area, and he had a wonderful system of reaching each and every child. He had 100 percent coverage, distributing sprinkles in that jungle area by means of narrow boats. It was really fascinating how they managed to do that. The smallest creeks and streams and they were able to find those families. But he got orders from the government, who was inspired by the gospel of integrated programs, that he had to do this through preschools from now on. This was the order. But the problem was that preschool education in that country had a coverage of 70 percent, which is not bad, but in that district it was only 40 percent. Those children were mainly in the capital, and in those creeks and streams, it was zero. There were no preschools there. So had they pursued this measure -- and I am sure they did not, eventually -- then the children who used to have access to nutrition and were not attracted to the preschools because there were none, would have lost the nutrition. I am making this point to point at the importance of coverage. Another example is I was in a country where somebody said, look, we have a nutrition program in this country, we have parental education, and we have preschool. Let's integrate them. We have all three; let's integrate them. But if you look at a map of that country and you draw the places where those three places are, there was no overlap, no place where the three programs overlapped. This is really important.

A last example -- growth monitoring, health checks in kindergarten. Great idea. But if only 20 percent of the children are in kindergarten, those 20 percent are not at risk of wasting and stunting; it is the other 80 percent. So you need to look at coverage if you want to integrate programs.

I still have not done justice to the attraction argument because you might argue that it is not a matter of linking existing programs, but you can integrate the programs from the start. You roll it out as an integrated program. But still you have the same problem. It was not a coincidence in that example of the man on the river that nutrition had 100 percent coverage in preschool and in some places of that jungle area you had zero percent coverage.

Some programs roll faster than others, and programs should not have to wait for one another. My last point about programs is about human resources. In northern Uganda, I once saw a community-based ECD program center where one-half of the staff was illiterate. The teachers were illiterate. They had three days of training by means of a pictorial approach because there was no point in giving them textbooks, and they were performing tasks in the preschool for which you do not need literacy skills -- the singing, dancing, et cetera. I think they were doing a good job. That is not the point. But it is not ideal.

The reason why you would have illiterate caregivers and teachers -- and this is not just northern Uganda and it is an extreme example but it occurs in other countries as well -- is that in that particular area, even today, children hardly complete primary school. So literate people are scarce in that area and they have better options than to be a volunteer or unpaid teacher in a community-based ECD center.

In that same community there was a health post with a similar situation in terms of human resources. Under-staffed, the staff was over-burdened and under-qualified, no doctors, just nurses. In that situation -- again, I admit it is an extreme case -- it would not have been wise to integrate health functions like growth monitoring and health checks in the preschool, or to integrate early learning in the health post. These are extremely fragile human resource systems where the training of people is measured not in years but in days -- 5, 10, 3 days.

All I want to say is that you need to look at that. The problem is that this usually occurs in places where the needs are the highest.

You need to look at educational achievement. You can do it in countries like Chile which has a very good integrated program and policy where most children, most young people, complete high school and secondary education or vocational education but not in the places where the needs are the highest.

At the end, there is one exception which is home visiting where actually integration is imperative, but I don't have time for the explanation so I refer to the essay.

I will now go over to policy, integrated ECD policies. It seems UNICEF is keeping track of the number of countries that are having an integrated ECD policy and the number of countries has grown rapidly. I think more than 60 countries have it. But results on the ground are not seen; there does not seem to be -- except from countries like Chile and maybe a couple other examples, but generally, we don't see the impact that we expect. Why is that?

I think there are three main reasons. Policy-making is never unproblematic, even in monosectoral settings, but if you combine it in an intersectoral setting it gets even more complicated. Even in monsectoral policy-making there are always drawbacks. You get stuck and then you get moving again. The moment you disconnect those cumbersome processes, it will go slower even than in other settings.

Suppose a country has a new curriculum for preschool and it is launched as part of an integrated ECD policy. Fine, great. Everybody says this is a really integrated policy, it is holistic, it is integrated and you really need to accept it as a whole; you cannot take out one element, blah, blah, blah.

Suppose at the same time there is a group of medical doctors who are against all of the health components of that same policy. They are against it; they are stopping it, so the policy does not get endorsed. It also means that the preschool curriculum is not implemented, although nobody is against it. It is these kinds of things that I have seen in a number of countries.

A very important point is that every country has its own set of rules or regulations for planning and budgeting, for parliamentary debate, decision-making in the cabinet. These processes are designed for nonsectoral settings, ministry by ministry. The formulation of integrated ECD policy usually takes place outside the regular planning and budget cycle because it does not fit.

In one country I saw it happening in a conference center away from the capitol in a political vacuum. Some people from ministries were represented but they had no mandate to speak. The result was a fantastic policy but it never got indoors. Why? Because these ECD integrated policies conflict with the standing policies of the line ministries -- the education ministry, health ministry. They have their policies already on the same fields. So, either there is no conflict and it sort of duplicates and in that case the question is what is the point. But the other case is it actually conflicts and they will block it.

There was a country where actually the policy got endorsed but not implemented because people had the idea, perhaps rightly, that donors like to see integrated ECD. So they paid lip service to the idea of integrated ECD policies just to get more money, but then you have problems when faced with the implementation. The last point is that quantitative and financial analysis should be part and parcel of policy development from the start. I have found in many cases, in the case of integrated ECD policies, it comes afterwards. The policy is finalized and then somebody flies me in and says you go and cost it and you make sure -- but that is too late. You cannot change the policy anymore and you end up with significant funding gaps because during the policy formulation nobody had an idea of the costs and of the potentially available funding.

I would like to go to the perspective of the line ministries before I get to my recommendations because they are often seen as the best guys, the ones who resist the integration, and it is good to understand their resistance. If we understand their resistance, this may open up the way to a solution.

The first reason is that line ministries -- education, health, social protection ministries -- have large budgets and they process money, and they want to keep tight control over their operations. Large amounts of state money go down from the center level to the districts and eventually on to service providers and, in some places, families, so there is a big risk of leakage and things that can go wrong. They need to be accountable for that. If these streams of money get intertwined at various levels of the system, then their tools for controlling it are insufficient. They get afraid, they get nervous; they can no longer control the money. They are no longer accountable. Who is accountable in that situation?

Then, it is very important that health and education systems have levels and phases. In health it is referral -- you want to refer people; you want to have sound referral protocols from primary healthcare to secondary and, in some places, tertiary healthcare. If you take out one phase or if one of those levels becomes subject to an external policy, then you can no longer control that.

Education is the same thing -- it is called transition. You want good transition from pre-primary to primary to secondary and tertiary education. You take out one phase and the education ministry is no longer able to pursue a longitudinal approach to learning.

Same for social protection. You cannot sever schemes for children from 0 to 6 from families with children from 6 to 18. What about child labor and polices against child trafficking, child abuse? You cannot create boundaries at the age of 6. The last argument is that we are not alone. We are not the only horizontal constituency. By the word horizontal I mean that if you consider line ministries as vertical entities who need to watch over the internal constituency, then we are the horizontal constituency that wants linkages horizontally across the ministries. And this is a conflict; it clashes. We should not get angry about this; we should understand it. It is normal that we have this conflict. If other groups are emphasizing vertical links and we are emphasizing horizontal links, then there is a conflict, but no reason to be angry. Just think rationally about how to resolve it.

But since we are not the only ones -- to give some examples, poverty reduction is typically a field of policy that cuts across not three but maybe six or seven ministries. Urban development, same story. Environmental protection, combatting youth criminality, early school-leaving, policies for elderly people -- they all cut across ministries. I don't think there is any policy field nowadays which is entirely monosectoral. We are not the only ones. If for one moment we take the perspective of the line ministries, suppose we have the ministry of education, then they not only have us knocking at the door and saying wait a minute, we want budget and we want more influence on preschool education, but they have the ministry knocking on the door of vocational education. They will have a number of constituencies that all claim influence and they would disintegrate. The ministry of education or the ministry of health would disintegrate if they would give in to all those wishes. They cannot do that.

So my advice is let's look at the other fields, poverty reduction, environmental care, the other main results of policy fields and learn from how they do it. I have to leave out the argument because of time and I will go right away to the recommendations.

There are five recommendations based on the experience in the other fields but translated to EDC. One is to universalize essential child services. Make sure that all children have access and, as the coverage increases, they will overlap increasingly. More and more children will have access to more and more services, and this is how you will get the synergy. But leave it in the sectors to make sure you have progress. The only thing that counts is that services come together in the child.

However, tie it together at the local level because that is where the child is. This is where you need the coordination and maybe, in some cases, integration. But don't create unnecessary structures. Spontaneous coordination is the best, but when it is not sufficient, if you see it is not sufficient, there are a number of ways to intervene. In teacher training you can integrate components of healthcare and social protection. Coordinating bodies -- There are some great examples from Latin America. Sensitization -- In Kenya we have seen the ECD coordinator playing such a role. And, if possible, use traditional structures as much as possible and local leadership.

The one exception that I already mentioned is home visiting schemes. You really don't want to distribute that. You don't want three or four services all coming to the homes of people. But keep it in the health sector.

Four -- this is where it gets a little bit complicated. If you say tie it together at the local level, link the services at the local level, then the services must be linkable. They must be designed in such a way that you can actually adapt them to local circumstances and link them. This means that you need vertical coordination to make sure. So people at the local level need to have possibilities to send signals up to the central level, or the prevention level, whatever the case is, to say wait a minute, you need to change the conditions of the services because we cannot link them anymore. This is the importance of vertical coordination.

The central office should do also general quality standards but not too specific. They need to be strong but nothing specific, again, to leave room to maneuver at the local level. So you do need coordination at the central level, yes, but not too much.

You need to determine -- and maybe two or three inter-ministry level meetings are enough -- which of the child services are essential -- and this is pretty universal; it is not going to be very different in all countries -- and then to agree on a roadmap for the universalization of those services. Have a monitoring and evaluation process, make sure you can keep track of progress but use the monitoring and evaluation systems of the sectors that already exist and use the councils for stakeholder consultation that already exist as well.

The bottom line is that the essential thing is that to get the synergy, the services must come together in the child and not necessarily in the programs or policies or the national councils. Thank you.

Bhutta - Public Support

Well, you know, especially if you want to scale up coverage of key interventions and support services for early child development, all players are important. Some are more important than others. So clearly government has a big role. Government has a big role because many of the key services available to children and families at critical periods such as early childhood education programs, health programs, programs that look after daycare for small babies and families. Even simple things like regulations in place, support services for promotion of exclusive breastfeeding in young infants which is such a huge developmentally positive intervention. For all of those, government will, policy, resources, legislation, oversight; all of those are important. But at the same time, governments respond to what you and I say and where there is demand from civic society. So I also believe that alongside the role of advocacy to governments and to bilaterals to donor agencies, it’s very important for us to get the message to the communities themselves; to parents, families themselves. Both in terms of best practices; because at the end of the day the government cannot enter your bedroom. I mean, you have to do things within your household. With what you do with young children, how you treat them at home, how you nurture them, how you, you know, provide adequate nutrition support. How you create a drug free environment. All of those things require family participation. And they require also the creation of the demand in terms of awareness, understanding and some of the wherewithal that families need to have. So I think there is a clear role for government, public health policy makers; but there is a very important role for families. And that role needs also to be bridged by interlocutors, by communication, mass media, support, civic society organizations. People like ourselves who are both in the professional domain and the advocacy domain in terms of getting the message out.

Aber - Coordination and Integration

My view is that there are two fundamental things to integrate services for young children. The first is to recognize that no sector can do it alone, so I wouldn’t want education to be thought of as solely responsible for bringing this multiple services of young children together, but in the absence of accountable leadership, nobody does it. So, from my point of view, in most but not all countries, the two systems in government that should be the lead for very early childhood initiatives and integrating them is the health center in most countries, or the social protection sector. And that once children transition to something that’s close to universal education, then the education sector becomes the lead. The health sector can’t do it in the first four or five years alone, but if some group isn’t responsible at population level - ‘we are responsible for everybody in these borders’- then it’s not, integration isn’t going to happen. Similarly with education. If we’re not ‘responsible for everybody in these borders’, so the education system should have the health dashboard, the social protection dashboard for kids from K to twelve, or K to, in low income or conflict affected countries, maybe eight or nine, which is when, the grades where kids normally leave, and earlier than that in some countries. So it’s a governance issue in part and we can’t allow the fragmentation to prevent us from pulling everything together but also having lead sectors that are able to be held accountable.