Country Study

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

Nov 15, 2018

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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Quality preschool starts with supporting teachers

Nov 8, 2018

World Teachers’ Day poses the opportunity to celebrate teachers and their important role in the lives of young children. Early years educators are a part of children’s lives at a critical time in their development. These professionals — through their day-to-day interactions — have the opportunity to transform a child’s developmental trajectory. Today we revisit a blog post by Vidya Putcha of Results for Development, which shares key insights for decision makers to strengthen the roles of early years teachers.

Preschool — often the first time that children interact with the education system — can be a powerful opportunity to support children’s growth and development at a critical stage in life. In Ukraine, the government has acted on a strong commitment to preschool education by providing families with affordable opportunities through its public system of education. However, like many other countries, the system struggles to keep pace with demand. In 2014, for example, 90,000 children were waiting for places in public preschools, with 15,000 in Kyiv alone. Additionally, more attention is needed to improve the quality of preschool programs.

Finding ways to better position and support preschool teachers, who are at the core of the system, is crucial to addressing these challenges. In an effort to learn more about their role and provide recommendations for how to strengthen this workforce, Results for Development (R4D), the Ukrainian Step by Step Foundation and the Institute for Education Development recently carried out a study on preschool teachers in Ukraine. This research was published in a new report, Supporting the Early Childhood Workforce at Scale: Preschool Education in Ukraine, and surfaced critical insights which may be illuminating for policymakers in other countries looking to strengthen the roles of personnel working with young children and families:

1. Provide ample opportunities for hands-on learning early on in preschool teachers’ training.

While nearly all preschool teachers in Ukraine have completed some higher education in teaching, a number of preschool teachers we spoke with described having limited practical opportunities during their higher education. Higher education programs were described as being heavily lecture-based and focused on outdated approaches, with opportunities for student teaching often coming too late in the program and facilitated by teacher educators with very little teaching experience themselves. We also learned that it is difficult to sustain a healthy pipeline of preschool teacher candidates, as many graduates of teacher training colleges and universities do not go on to work in preschools. This may be a product of higher education institutions not effectively fostering a professional interest in preschool teaching among its students.

Hands-on learning can help prospective teachers understand how to apply new knowledge to their work in preschools. At the same time, these opportunities may allow teachers to reflect on their future careers and help to sustain their interest in the field.

2. Offer a range of in-service trainings and ensure that teachers have opportunities to connect and learn from one another.

Encouragingly, preschool teachers are able to receive in-service training every five years with funding from local budgets. We heard that teachers appreciate these opportunities and particularly enjoy being able to connect with and learn from peers. Teachers we spoke with advocated for more of these opportunities, which suggested to us that practical knowledge from peers may better address their professional needs than training courses. However, while these in-service training courses seem to be beneficial to teachers, there are concerns about the quality and variability of the trainings, in particular, that teachers have limited choice in offerings which often do not reflect varying needs and interests.

Many teachers are already poorly compensated so it is important that they have access to training and professional development opportunities that do not require their own personal financial investment. Since teachers may have varying experience and backgrounds, designing different types of training courses, giving teachers the freedom to choose those that best meet their needs, and facilitating peer learning opportunities, can help in ensuring the relevance of offerings.

3. Provide more targeted support on engaging with parents and identify ways in which feedback from parents can be incorporated in programs.

Teachers and other school personnel frequently noted that communication with parents was their biggest challenge. Teachers felt that parents were not involved enough in their child’s development and ignored recommendations on how to support children at home through activities such as reading. At the same time, although many parents we spoke with lauded preschool teachers in public institutions for the work that they do despite low pay and heavy workloads, we learned that a growing number of families are enrolling their children in private preschools as they are drawn to the modern approaches that teachers in these school employ as well as the flexibility offered by these schools.

Efforts to better understand these dynamics could help in strengthening relationships and ensuring that families’ needs are being met in public institutions. Teachers also need support from senior teachers and leaders to help them better communicate with parents in order to ensure complementary home and school environments.

4. Hire and train auxiliary staff to offset challenging workloads and allow for more targeted support to children with special educational needs.

While teachers were strongly motivated by a desire to work with children, they described heavy workloads often resulting from large class sizes and paperwork. This was often further compounded by insufficient time and experience to provide individualized support to children, particularly those with special educational needs who were more frequently part of classrooms after the recent shift to inclusive education in the country. A new initiative to introduce the role of teacher assistants to support inclusive classrooms has been met with great enthusiasm and has potential to alleviate some of these challenges.

Efforts to deploy and mainstream auxiliary staff roles can help to unburden teachers and improve their ability to provide individualized support to children.

Empowering preschool teachers to thrive in their day-to-day interactions with young children can be challenging, given limited resources and the complexity of working with this population. While the insights above are only a small sample of how we can course correct, they offer ideas for how the early childhood workforce can be supported to make a lasting change in the lives of young children. The Early Childhood Workforce Initiative looks forward to supporting countries with knowledge and evidence as they embark on efforts to support these critical individuals.