Sub-Sahara Africa

BLOG: South Africa's Expansion of First 1000 Days Services

Kavita Hatipoglu, Results for Development

 

 

Time and again, we’ve seen that setting policy is often the easier part of reform, with implementing policy being the real nut to crack. And when challenges loom large, sometimes it’s hard to see the progress you have made and determine the way forward. However, the South African government has taken some key early steps towards supporting young children and their families in a more systematic and comprehensive way, including through the recent National Integrated Early Childhood Development Policy (NIECDP; 2015) which laid out goals to be achieved in the coming years. Notably, the NIECDP also set out to strengthen parenting and family support at the community level, identifying Community Health Workers (CHWs) as the key personnel to deliver what are commonly called  First 1000 Days Services.

As part of the Early Childhood Workforce Initiative (ECWI), Results for Development, along with Ilifa Labantwana and researchers from the University of Pretoria, recently studied the NIECDP and its early implementation in two provinces, KwaZulu-Natal and Western Cape, looking particularly at the capacity of CHWs in South Africa to deliver these expanded First 1000 Days services. Reflecting on our work, we’re sharing four key lessons on the implementation process in South Africa.   

1. Clarity, Communication, and Coordination are essential 

While nearly everyone we spoke with responded positively to expanding First 1000 Days Services, it was apparent that not everyone knew about the NIECDP or that those services were likely to be delivered through the existing CHW workforce. Even among those familiar, it was hard to pin down which services we were talking about because as of yet, there is no defined service package. Discussions with the provinces reflected that, without clarity from the top – about the detailed services or how their performance will be measured - implementation often stalls. 

Further challenges arise when there isn’t enough communication between the line department responsible for developing the service package and the department tasked with delivering it.  The Child, Youth, and School Health directorate within the NDoH recently led the overhaul of the Road to Health Booklet (RtHB), and commendably, the tool is organized around the five key pillars of care – Nutrition, Love, Protection, Healthcare, and Early Care, and aligned with the Nurturing Care Framework. However, CHWs are managed by a separate directorate – Primary Health Care – and it is not readily apparent how committed they are to (re)training the CHWs and other health personnel to maximize RtHB’s potential. Communication and coordination will need to be the name of the game to see any services comprehensively delivered and outcomes for young children and families changed.

2. More data is always a good place to start

While you don’t want to collect data for the sake of collecting data, more information about the baseline situation often aids implementation. And despite significant variation in the way services are organized and delivered among the provinces, we consistently heard about the need for more data. There is relatively little understanding, at the provincial or national level, about what the current CHW workforce looks like or what they precisely do. Past estimates suggest up to 72,000 paraprofessionals with differing levels of training and education, experience, and subject-matter expertise -- a vestige of a health system organized around tackling specific diseases.[1] Furthermore, little is known about the exact package of services CHWs currently provide, the visit length different services require, or their relative quality. This type of information could assist provinces to plan for, cost, and evaluate any service changes. Importantly, this would also help ensure that the needs of vulnerable populations are addressed. The need for data is not uncommon, and in fact, is something we heard repeatedly through interviews conducted with stakeholders across the globe, and part of the reason that the ECWI is setting out to develop a tool to help policymakers identify gaps in and strengthen their workforces.

3. Additional Training and Support will be essential if services are to be implemented and sustained

Policymakers in South Africa are aware of the need for enhanced training and are striving to develop it, yet there is simultaneous effort to simplify existing trainings. As CHW Coordinators and NDoH officials noted, there are currently 645 topics within Phase 1 and 2 of the CHW training and a clear need to streamline and update the content, ensuring better alignment with CHWs’ capacity, education, and working conditions. Efforts to simplify training while building out capacity for First 1000 Days Services aren’t necessarily at odds, but it merits close attention and suggests power struggles may be ahead.  Wherever they end up, if providers are to deliver new services, they will need a host of training and upskilling opportunities, as well as continued mentoring and in-service support. However, frontline staff aren’t the only ones in need of training, supervisors and other health professionals do as well, if they are to support, monitor, and reinforce the new services. Current supervisors suggested that supervision was primarily compliance-based and focused on service delivery planning, as opposed to an opportunity to aid, support, or enhance the skills of CHWs. They also noted a lack of training on how to be a manager or provide any type of reflective supervision.  As many First 1000 Days Services also encompass parenting support and coaching on developmental activities, it will be essential for supervisors to also understand the value of these services and be able to provide continuous support to ensure quality delivery.

4. Innovation can be sourced from within

In South Africa, policy is set at the national level and the nine provinces have a greater level of autonomy to determine the implementation service model that best fits their needs. For example, Western Cape primarily contracts NGOs to deliver community-based services, whereas KwaZulu-Natal has a well-developed and extensive system of Community Care Givers (CCGs) who have smaller caseloads but larger teams. CCGs are also employed on a contract-basis through the Provincial Department of Health. The Western Cape has also created a branded initiative, The First 1000 Days Initiative, to bring partners together and raise awareness of the importance of these early days for children and families. The variation among provinces presents an excellent chance to learn from the challenges and opportunities these differing workforce models present, and suggests a context ripe for innovation and adaptation. It would be highly beneficial to create more structured learning opportunities between the provinces on the road to full implementation.  

Pushing ahead

The road to implementing integrated ECD policies is almost always messy. It requires bringing people, sectors, and roles, under one house and aligning them in new and different ways. From what we saw, South Africa continues to grapple with many of the same challenges that we often talk about in relation to the global early childhood workforce: they are an underpaid, undervalued, and undertrained system of professionals, para-professionals, and volunteers who, though dedicated to their work, require additional support to more effectively care for young children and their families. However, in South Africa, there are many indications -- like the adoption of the NIECDP and the recent creation of Mother-Child Think Tanks at the Department of Health -- that suggest that the country is up for tackling these challenges and that the momentum around the First 1000 Days will only increase. Their efforts tie into the growing global consensus around the Nurturing Care Framework, and our work at ECWI, where we are eager to continue learning alongside countries and support them with tools and resources as they crack that implementation nut!

Read the Country Study, Supporting the Early Childhood Workforce at Scale: Community Health Workers and the Expansion of First 1000 Days Services in South Africa.

 

[1]An audit of CHWs by the Department of Health in 2011 identified about 72,000 CHWs, the figure still quoted in planning documents for the 2015 ECD policy. Nearly 50,000 of these CHWs were identified as home-based carers (HBC) or community care givers (CCGs) while others include lay and adherence counsellors, DOTS supporters, peer educators, further highlighting the diversity of this workforce (National Department of Health, 2012. Annexure B1. Human resource requirements for re-engineering primary health care in South Africa.)

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Reflections from the AfECN Conference

Denise Bonsu, Results for Development

Last month, I had the pleasure of attending the African Early Childhood Network (AfECN) Conference in Nairobi with my colleague Kavita Hatipoglu. The event was monumental, not just because it was the largest international conference on Early Childhood Development (ECD) to take place in Africa but also because it was my first work related travel with R4D. As someone with a growing interest in ECD, I was ecstatic to find out that I would be setting foot on African soil after a four-year hiatus and attending an event that would provide me with a crash course on ECD.

The beginning of the conference was nerve-wracking. I had just arrived in Nairobi and was extremely jet-lagged following many hours of travel. Upon entering the conference room, I was swallowed up by a crowd of over 800 people including government officials, researchers, funders, and many other experts in ECD from different corners of the world. Although initially intimidated at being surrounded by well-known experts in the field, my fear quickly dissipated as I was sucked into the buzz and excitement of the crowd and began conversing with the other participants.

Conference Highlights

One of the highlights from my first day was witnessing President Uhuru Kenyatta’s speech during the opening ceremony. Kenya’s ECD sector has undergone remarkable transformation in recent years and accessible, comprehensive, and equitable early childhood care and education is slowly become a reality for millions of young children. Recent accomplishments include an increase in the general enrollment in preschool from 69.4% in 2012 to 77.1% in 2017 and a 32.8% increase in the number of teachers trained in early childhood education during that same period. Despite these achievements, the President emphasized the need for more work and highlighted the challenges that Kenya still faces with high adult: child ratios, a lack of teaching resources, and low cross-sectoral collaboration. To tackle some of these issues, his administration plans to develop an integrated early childhood development policy to ensure the coordination of services across ministries for young children and families.

To emphasize this point, the President called on the wives of thirty-one county governors who were attending the conference and urged them to remind their husbands to prioritize ECD. This moment was important because it showed that ECD was a priority for high-ranking officials in the context of a decentralized system.

Following the opening ceremony, we were whisked away to various plenary and parallel sessions on topics that included the following:

Strengthening Systems for Children with Disabilities

As someone with a strong interest in supporting children with disabilities in low and middle-income countries, I was encouraged to find out that the conference featured multiple presentations on this subject area. Although over 53 million children under the age of five worldwide have a developmental disability, this group does not receive much attention in ECD discussions, especially in low and middle income countries. Children with special needs have a higher risk of experiencing marginalization, abuse, and behavioral and emotional problems and are less likely to be enrolled in formal pre-primary education programs due to the stigma that surrounds disabilities in many countries. Pre-primary teachers are often ill equipped to support these children as their pre-and in-service training focuses on traditional teaching methodologies that do not cater to diverse learning styles. This session explored how pre-service early childhood teacher education programs can be strengthened if they include mandatory courses on assisting children with disabilities and stressed the importance of providing members of the workforce who routinely support students with disabilities with in-service training on this topic. Providing the workforce with these trainings will not only reduce the stigma surrounding children with disabilities, but also create a pathway for these children to thrive later on in life. Although these sessions left me feeling disappointed at the extent to which children with disabilities have been ignored in ECD policy discussions, I left the session hopeful that programs could be bolstered to better support these children and their families.

Focus on the Early Learning Workforce

I found this session interesting because it highlighted the importance of putting children at the center of their learning experience and resonated with my work with the Early Childhood Workforce Initiative. Although research increasingly shows the benefits of play-based approaches, many African teachers primarily employ teacher-led approaches and encourage rote learning. To address this challenge, the Open Society Initiative in Southern Africa (OSISA) supported a “materials re-development” process in Lesotho and 10 other African countries from 2011 to 2017. These materials were re-developed using the resources developed and used in Eastern Europe by ISSA, co-host with R4D of the Early Childhood Workforce Initiative. This process involved the piloting of resource kits comprised of content modules, activity modules, facilitator guides, and children’s activity books in select classrooms. The activity books, in particular, were bright and colorful and featured pictures to appeal to young children. At the end of the piloting process, teachers stated that the kits not only fueled their students’ interest in learning, but also encouraged their own collaboration with students. This experience in Lesotho highlights how teachers can effectively use low-cost materials to create a positive environment that places children at the center of the learning process. Although play-based methodologies have not traditionally been employed in certain African pre-school settings, I am excited to see what lessons can be learned and achievements made as this practice becomes more widespread.

Wrapping up the last day

On the last day of the conference, I was both excited to be returning home to loved ones but also sad that the experience was almost over. As I walked out of the conference room to prepare for the long journey back, I paused in front of a showcase of a play area featured by Kidogo, a social enterprise that delivers early childhood care and education to children in East Africa. A little girl was seated in the middle of the showcase and drawing on a sheet of paper while her caregiver smiled and watched on. As I proceeded towards the exit, it dawned on me that by investing in the caregiver and providing her with the opportunity to flourish within the profession, we are ensuring that the little girl in the play area is able to grow into a healthy, productive, and well-rounded citizen of the world.


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