Commentary Smart investment in global childcare requires local solutions and a coordinated research agenda Alex Aliga ,1,2 Tefera Darge Delbiso 3 , Patricia Kitsao-W ekulo ,4 Monica Lambon- Quayefio ,5 Rachel Moussié,6 Amber Peterman ,7 Natan Tilahun8 To cite: Aliga A, Delbiso TD, INTRODUCTION Kitsao-W ekulo P, et al. Smart Childcare is a smart investment and key for SUMMARY BOX investment in global childcare requires local solutions advancing gender equity. An emerging body ⇒ The COVID-1 9 pandemic has re- emphasised the of evidence demonstrates that providing critical role of accessible, affordable and quality and a coordinated research childcare to reduce and redistribute the gender un- agenda. BMJ Glob Health childcare services contributes to improved equal distribution of unpaid care work as an invest- 2023;8:e012827. doi:10.1136/ health, well-b eing and economic oppor- bmjgh-2023-012827 ment towards the well-b eing of children, women, tunities for children, women, families and families and society. communities with potential for intergener- Handling editor ⇒ Smart investment in childcare and care systems Seye Abimbola ational impacts.1–4 For these reasons, invest- in Africa requires context-s pecific and cultural- Received 11 May 2023 ment in care systems is said to result in a ‘triple ly appropriate local solutions driven by national Accepted 19 July 2023 dividend’: facilitating women’s entry into the stakeholders—including commitment by national labour market, promoting child development governments to resource and build systems of pub- and boosting employment in the care sector, lic provision. a predominantly female workforce.3 Nonethe- ⇒ These investments must be guided and matched by less, attention to and investment in accessible, nationally led evidence generation to fill research affordable, context-s pecific and high-q uality gaps and contribute to a coordinated agenda on childcare. care services still lag behind other forms ⇒ We propose four themes to build the foundation of of social protection. For example, despite a regional research agenda: (1) understanding the an unprecedented global response to the landscape of childcare coverage and demand; (2) pandemic, out of 3099 social protection and unpacking ‘what works’ for whom over time; (3) labour market measures enacted or planned building knowledge on implementation of scalable by governments through July 2021, less than and locally adapted solutions and (4) answering 20% took gender into account, and only 7% macro-q uestions on policy, financing, systems and supported unpaid care.5 Support of unpaid sustainability. care was particularly low in sub-S aharan ⇒ Coordinated national-l ed investment in childcare is Africa, representing only 2% of all measures. needed in the Africa region and beyond—however, Recognising the critical role of robust care this alone is not a silver bullet and must be part of a larger effort to address structural barriers and ca- systems in catalysing changes in gender norms talyse systematic change across sectors to promote around women’s participation in economic women’s social and economic empowerment. activities (and men’s role in care work), child- care is high on the post- pandemic agenda.4 6–8 The Generation Equality Forum in Paris in systems-b uilding and evidence- generation by © Author(s) (or their 2021 galvanised commitment to address the national scholars. Without these efforts, the employer(s)) 2023. Re- use care crisis, launching the Childcare Incentive agenda on childcare risks misalignment with permitted under CC BY- NC. No commercial re- use. See rights Fund. The fund mobilises $180 million in new local realities and national policy priorities. and permissions. Published by investment to support the design and imple- In this commentary, we highlight the value BMJ. mentation of childcare programmes, and of a coordinated research agenda taking an For numbered affiliations see to improve evidence generation and policy African regional perspective. In discussion end of article. designs in low/middle- income countries.9 with childcare implementers and researchers Correspondence to While this is a welcome step, efforts are needed involved in the Growth and Economic Dr Amber Peterman; to ensure an approach that prioritises locally Opportunities for Women (GrOW) cross- a mberpeterman@g mail.c om led and culturally adapted implementation, country childcare research and programming Aliga A, et al. BMJ Glob Health 2023;8:e012827. doi:10.1136/bmjgh-2023-012827 1 BMJ Glob Health: first published as 10.1136/bmjgh-2023-012827 on 4 September 2023. Downloaded from http://gh.bmj.com/ on September 26, 2023 by guest. Protected by copyright. BMJ Global Health portfolio, we propose four key areas and corresponding these questions provide a starting point to think about questions which could serve as a starting point for such a commonalities and priorities for future research. research agenda. We highlight innovative local solutions Theme 1 relates to better understanding the basics: to the childcare crisis as examples and inspiration for service coverage, what drives demand and how to reduce how investment can be nationally led and lay the ground- barriers to childcare uptake. This is important as large- work for systems-b uilding. In closing, we discuss broader scale population-b ased surveys currently do not capture issues linked to unpaid care work, as well as policy and information on comparable indicators on childcare structural barriers which must be addressed to advance service availability or use, nor do they include informa- the childcare agenda and women’s social and economic tion on informal or kinship- based care arrangements, empowerment in Africa and beyond. obscuring understanding of coverage of different types of care models, over time and across contexts. In addi- tion, studies on access to new forms of childcare services A REGIONALLY LED RESEARCH AGENDA in the region suggest uptake rates are far from universal, Recent years have seen an increase in rigorous studies varying from 25% to 73%, indicating a need for a better examining dynamics around unpaid care, including child- understanding of what drives demand and preference care, as well as ‘what works’ to reduce and redistribute across contexts vis-à-vis existing traditional childcare it. Studies increasingly answer more complex questions models.10 12 For example, family or kinship- based models and examine impacts beyond the health and well-b eing of childcare, which women and families may prefer to of children, to include impacts on women’s engagement low- quality centre- based services, are widely used across in the labour market, social and economic empowerment the continent, particularly in rural areas.15 16 Nonethe- and growth of economies, among others. For example, less, as family structures change due to rapid urbanisa- a systematic review of childcare and mothers’ labour tion, research should address these trade-o ffs to better market outcomes published in 2023 found 22 rigorous understand targeting of services and how to close gaps studies—virtually all of which found at least some impact in access due to cost, gender norms and other factors. on women’s work or earnings.2 Nonetheless, only one Answering these questions lays the groundwork for more study, which examined the impacts of subsidised child- complex questions around programming and policy. In care on women’s economic empowerment in Nairobi, addition, experimentation with survey modules could Kenya was from the African region.1 Thus, large regional lead to the development of standardised measures to gaps exist, which means, among others, the under- harmonise childcare indicators and serve as a starting standing of impacts and dynamics around local solutions point for integration into routine national and regional remains limited. data collection efforts. Since the aforementioned systematic review was Theme 2 unpacks ‘what works’ in terms of different compiled, several other working papers have emerged, service models for different populations across a broad examining the impacts of community-b ased daycare in range of outcomes, particularly beyond the child level. rural Democratic Republic of Congo, ‘mobile creches’ We highlight the need to continue demonstrating impact in Burkina Faso and childcare vouchers alongside cash on women’s economic outcomes, but also to measure transfers in Uganda.10–12 Despite producing promising under-e xamined outcomes, including intra-h ousehold results underscoring the value of childcare in rural power measures, spillover effects on other household settings, author teams are nearly exclusively based outside members (including siblings), potential adverse effects the region, reinforcing inequalities in knowledge genera- and mechanisms attached to these impacts. Further, we tion and missing opportunities to decolonise research on emphasise the importance of understanding how impacts unpaid care.13 14 The GrOW portfolio of mixed- methods may vary for families who are less able to traditionally take impact evaluations underway on childcare and women’s advantage of childcare, including for carers of children economic empowerment in Ethiopia, Kenya and Uganda with disabilities or for teenage mothers. Again, to better seeks to reverse this trend, with nationally led evalua- understand impacts in relation to the myriad of cultural tion teams. With a growing momentum on childcare settings across the continent, these impacts should be evidence generation, there is value in gaining consensus understood in relation to diverse forms of informal, and coordinating key research questions and building ‘distributive’ and kinship-b ased caregiving, which may synergies on measurement and methodology. We reflect confer benefits to children and caregivers via socialisation, on four themes we believe are critical for the future development and safety, among others.15–17 While impact research agenda on childcare services and systems: (1) evaluation evidence lends itself to answering these ques- understanding the landscape of childcare coverage and tions, equally important is rigorous qualitative evaluation demand; (2) unpacking ‘what works’ for whom over time; evidence, facilitating understanding of the mechanisms (3) building knowledge on implementation of scalable and enablers of impact, while allowing cultural nuance and locally adapted solutions and (4) answering macro- to findings. As the research frontier advances, evidence questions on policy, financing, systems and sustainability. around sustainability of impacts (5 years or longer) will Table 1 summarises these themes and provides illustra- be critical to understand the full scope and evolution of tive associated research questions. While not exhaustive, impacts over time. 2 Aliga A, et al. BMJ Glob Health 2023;8:e012827. doi:10.1136/bmjgh-2023-012827 BMJ Glob Health: first published as 10.1136/bmjgh-2023-012827 on 4 September 2023. Downloaded from http://gh.bmj.com/ on September 26, 2023 by guest. Protected by copyright. BMJ Global Health Table 1 Key themes and research questions for a regional research agenda on childcare Theme Why is it important? Illustrative research questions 1 Understanding We still know relatively ► What is the coverage of childcare services and childcare models at the national, regional and the landscape little about basic local levels, including traditional forms of kinship and family-b ased care—and how is this of childcare service coverage, changing over time? coverage and as well as what ► What factors affect market demand for childcare services, including supply-s ide aspects (eg, demand factors matter for service models, quality, accessibility, flexibility, costs, perceived trust in providers) across demand and take-u p diverse target populations (eg, rural vs urban, family structure, socio-e conomic, ethnic of services across diversity, workers in formal vs informal employment)? contexts—which ► What are the main barriers to uptake of childcare, including the role of gender norms or costs, is the first step in and how can these be reduced or equalised via messaging, targeting of subsidies (including stocktaking where, sliding scales), system linkages or location of services, among others? what and how to ► What are the opportunities to develop a standardised module or iterations of context-s pecific make ‘fit for purpose’ modules of childcare model coverage, as well as indicators of demand and barriers, to and locally adapted integrate into routine data collection at the national or regional level? investments 2 Unpacking We have few ► What are the impacts of access to childcare services on children, women and families—in ‘what works’ rigorous studies relation to existing models of traditional kinship or family- based care? Continued measurement for whom over examining what of women’s economic empowerment is needed, including engagement in the labour market, time works for different earnings, quality of work, financial resiliency and other economic status outcomes. In addition, service models and of particular interest are under- researched areas: populations in relation – Are there impacts on children’s safety and development, women’s mental health and to a broad range of emotional well- being, intra- household outcomes including time use trade-o ffs (including for impact outcomes, older siblings) and outcomes for men, including on gender attitudes and norms? particularly beyond – Are there potential negative or adverse effects across different levels, particularly in settings the child- level where children accrue benefits from traditional forms of family- based care? – What are the behavioural underpinnings or mechanisms leading to these impacts, setting the foundations for understanding generalisability across settings? – How do impacts evolve over time, particularly beyond the short term (<12 months)? ► How do impacts vary by target populations which may be less- well placed to benefit from childcare (eg, children with disabilities, refugees or displaced populations) or have greater need (eg, single and/or adolescent mothers, informal workers, families with chronically ill or disabled prime age adults)? ► How do we trade- off impacts across different service models, including but not limited to: institutional vs residential models, part- time vs full time care (flexible), models that incorporate early childhood education or other plus components (gender norm social behaviour change, safe transport, infant and child health)? 3 Building There is high value ► What are promising models to train, support and finance childcare workers, as well as facilitate knowledge on in opening up their visibility and ability to organise to protect their rights? implementation the ‘black box’ of ► What measurement tools can be used to monitor and assess quality of childcare, including of scalable implementation to availability of infrastructure, compliance with regulations, quality of workforce, child solutions understand both development (objective measures) and engagement—as well as collect parent satisfaction how to best support with services (subjective measures)? childcare workers, as ► What are barriers and challenges to quality and successful implementation of childcare well as ensure quality services across contexts, including the tension between quality vs capacity vs accessibility for children and of childcare centres, particularly in high- risk or informal environments (eg, informal settlement families and slum areas, informal work places, post- disaster, displacement settings, pandemics and other health emergencies)? ► What promising strategies and implementation models encourage involvement and engagement of men in childcare? 4 Answering A policy view will ► What political economy factors influence and facilitate the adoption of childcare policies, macro- facilitate real- time regulatory frameworks and standards and financial commitment by governments? questions advice and advocacy ► What is the ‘return on investment’ of childcare and how can sustainable financing be obtained on policy, towards a systems- to make sufficient investments in quality childcare for all? financing, level approach and ► What by- laws and regulatory frameworks are needed to support local government to regulate systems and coordination for childcare providers—with attention to context- appropriate models considering the living and sustainability sustainable childcare working conditions of informal workplaces? ► How can childcare systems be linked and integrated (or coordinated) with complementary family-f riendly systems and policies, both care- focused (eg, family leave, care for elderly)—as well as other sectors, including early child development and education? ► What is the role of formal sector firms in childcare provision for employees and in building the childcare workforce? Theme 3 focuses on opening up the ‘black box’ of public provision, home and community-b ased, social implementation to understand both how to best support franchising, cooperatives, market-b ased solutions, part- childcare workers, as well as ensure the quality of care nerships, employer- supported and more, each with for children. Childcare models are diverse, including unique implementation challenges.18 19 Yet, all models Aliga A, et al. BMJ Glob Health 2023;8:e012827. doi:10.1136/bmjgh-2023-012827 3 BMJ Glob Health: first published as 10.1136/bmjgh-2023-012827 on 4 September 2023. Downloaded from http://gh.bmj.com/ on September 26, 2023 by guest. Protected by copyright. BMJ Global Health Table 2 Innovative locally led childcare implementation models in the Africa region Model (organisation) Description Community- based ChildFund Ethiopia, with partners Children Believe and Tesfa Berhan Child and Family Development, is piloting a childcare centres in scalable solution for affordable, quality and sustainable community-b ased childcare. Childcare services target mothers Ethiopia of young children in urban centres of Addis Ababa, Adama and Debre Birhan with the objective of encouraging their (ChildFund Ethiopia) engagement in paid work, income generation and overall economic well-b eing. In collaboration with the Addis Ababa University, the project will generate evidence for revising Early Childhood Development (ECD) policies, frameworks and implementation in Ethiopia, showcasing holistic impacts on children, women and families. Each childcare centre, of around 20 children, is managed and run by a facilitator selected from the community and supported by parents on a rotational basis. Facilitators and parents receive intensive training by project field coordinators and ECD specialists from ChildFund Ethiopia, on holistic ECD and management of daily facility activities. Field coordinators conduct regular supportive supervision visits at each childcare centre and provide coaching to community facilitators to ascertain the quality of the childcare centres and improve interaction with the children. The project also includes an economic empowerment component for mothers, through the organisation of self-h elp groups, which include a savings and loans and backstopped by a women economic empowerment specialist from ChildFund Ethiopia. The pilot builds on ChildFund’s experience of establishing childcare centres for the government-r un flagship social protection programme, the rural and urban Productive Safety Net Programme (PSNP) in collaboration with the World Bank and UNICEF, whereby centres provide holistic ECD services to children while parents are engaged in public work activities. Market- based In Accra, Ghana, Women in Informal Employment: Globalising and Organising (WIEGO) established a multi-s takeholder daycare in Ghana forum including the Ministry of Gender, Children and Social Protection, local municipal officials from the Social and South Africa Development Department responsible for ECD regulation and provision, city planners, market trader and street vendors (Women in Informal organisations, and ECD providers to co- create guidelines for childcare provision in and around markets. Street vending Employment: and market trading represents 44% of women’s employment in the Greater Accra area as compared with 11% of men’s Globalising and employment.24 It is a highly feminised sector and women face specific childcare challenges due to their place of work Organising, WIEGO) and commuting time, including obstacles to breastfeeding young children. Markets and city streets also present many hazards for young children. The co- created guidelines are intended to outline these challenges and propose solutions that will be included in the revised national ECD policy to provide a set of principles for childcare provision in markets. Clearer guidelines set the foundation for the expansion of childcare services in markets for street vendors and market traders’ children. In Durban, South Africa, Asiye e Tafuleni is piloting childcare spaces for 6–8 children each in a market and street vending zone following negotiations with street vendors and market traders associations and municipal officials. The childcare centres apply the ECD municipal by- laws and are an innovative approach of creating safe spaces for young children in and around markets. The lack of government subsidies for childcare services is an important obstacle for street vendors and market traders to register their children as they cannot afford the user fees. The pandemic coupled with the cost- of-l iving crisis led to a significant drop in earnings among these workers. However, recent regulatory changes in South Africa are now making it easier for childcare service providers to benefit from the existing ECD subsidy. This can expand uptake of these services among women in informal employment whose earnings tend to be lower than the minimum wage. Across Africa, street vending and market trading represent an important source of employment for women, and many bring their young children to work with them as no viable childcare alternatives exist. Both examples demonstrate how it is possible to extend childcare services in or near informal economy workers’ place of work, including city markets and streets. They emphasise the need for broad consultations with local and national government officials alongside women workers who are the primary users of these services. ‘Mamaprenuers’ Kidogo is a social enterprise operating an innovative ‘Hub and Spoke’ model for low-i ncome communities in Kenya social enterprising in and the Africa region. ECD best- practice hubs are established with trained caregivers using a holistic play-b ased Kenya curriculum, nurturing the growth and development of children—referred to as ‘The Kidogo Way’. In addition, Kidogo (Kidogo) micro-f ranchises ‘mamapreneurs’ or local women running informal childcare centres within the community as ‘spokes’. Mamapreneurs receive a business- in-a - box, including relevant training materials, resources and support. The Kidogo hubs operate as model centres of excellence for the spokes, continually testing and innovating to improve the quality and availability of childcare in the community. Kidogo hubs also offer ongoing training for mamapreneurs. Since 2014, Kidogo has supported over 130 centres serving approximately 2900 children daily in 12 different informal settlements across Nairobi. Preliminary findings from an ongoing quasi- experimental study in Nakuru County, in western Kenya showed that improving the quality of childcare services can improve labour outcomes for women in resource-p oor settings, thereby improving their families’ economic prospects.25 The results also demonstrated that the training and mentorship components of the Kidogo model were transferable, acceptable and feasible. These two aspects could form the basis for the development of a peer- to- peer mentorship model where centre providers, trained as ‘champions’, would support others through a community of practice model to achieve and maintain quality of childcare provision and enhance sustainability of the programme. 4 Aliga A, et al. BMJ Glob Health 2023;8:e012827. doi:10.1136/bmjgh-2023-012827 BMJ Glob Health: first published as 10.1136/bmjgh-2023-012827 on 4 September 2023. Downloaded from http://gh.bmj.com/ on September 26, 2023 by guest. Protected by copyright. BMJ Global Health would benefit from an increased understanding of how in a sustainable way. The Nairobi Childcare Facilities to better recruit, train and support childcare workers, as Act is one example of a promising step by local govern- well as how to better regulate, monitor and ensure quality ment; however, there is a need to have implementation of childcare adapted to caregivers’ and children’s needs. guidelines in place, with funding attached.23 Moreover, In many settings, including in Africa, there is a tension childcare is just one piece of the puzzle and tackling it (trade-o ff) between capacity constraints and quality of alone is insufficient. Changes must be part of a larger service provision, as well as questions about how quality effort to establish comprehensive social protection and should be defined and monitored across contexts. sector- specific policies that enable women’s economic Table 2 includes examples of innovative local models of and social empowerment in Africa and beyond. childcare in Ethiopia, Ghana, Kenya and South Africa, in particular, how unique implementation challenges Author affiliations 1 have been approached. For example, ChildFund in Ethi- Department of Economics, Muni University, Arua, Uganda2Research Department, Ace Policy Research Institute, Kampala, Uganda opia has developed a set of training manuals and imple- 3Department of Public Health Nutrition and Dietetics, Addis Ababa University School mentation guidelines, audio-v isual social and behaviour of Public Health, Addis Ababa, Ethiopia change communication materials alongside coaching 4Early Childhood Development Unit in the Human Development Theme, African and supportive supervision tools. These have been influ- Population and Health Research Center, Nairobi, Kenya 5 ential in opening discussions with the government and Department of Economics, University of Ghana, Legon, Ghana6Women in Informal Employment: Globalizing and Organizing, Port Louis, Mauritius communities regarding the need for designing quality 7Department of Public Policy, University of North Carolina, Chapel Hill, North services. A unified understanding of key implementation Carolina, USA aspects to test and improve, including barriers and chal- 8Programs Department, ChildFund Ethiopia, Addis Ababa, Ethiopia lenges to engaging men in successful implementation of Twitter Monica Lambon- Quayefio @Monica_Lambon, Rachel Moussié @RMoussie childcare, can help deliver better outcomes for workers and Amber Peterman @a_peterman and families. Acknowledgements We thank Annet Abenakyo Mulema and Martha Melesse for Theme 4 focuses on macro-l evel factors, including poli- helpful discussion and comments at the inception of this commentary. The ideas cies, systems, financing and sustainability. For example, expressed in this commentary benefited from discussions and expertise of broader which political economy factors influence and facilitate research teams at Ace Policy Research Institute, the African Population and Health adoption of childcare policies, adherence to regulatory Research Center, Addis Ababa University, ChildFund Ethiopia, Kidogo, the Institute of Policy Analysis and Research, Women in Informal Employment: Globalizing and frameworks and commitment by governments? What is Organizing and from participants at the GrOW midterm workshop held in Nairobi in the ‘return on investment’ of childcare services and how October 2022. can sustainable financing be obtained to ensure quality Contributors AA, PK- W, AP and NT contributed to conceptualisation. TDD, PK- W, childcare for all?20 Childcare systems must be linked and AP, RM and NT contributed to writing—original draft. All authors contributed to integrated (or coordinated) with complementary care- writing—reviewing and editing. Authors are listed in alphabetical order to denote related and family- friendly systems, as well as sectoral equal contribution. All authors approved the final version. policies—and a better understanding of these synergies Funding No explicit funding was received for this commentary. However, authors thank the GrOW East Africa, a multi- funder initiative, for providing open access fees can facilitate improved outcomes in multiple sectors. associated with the publication of this commentary and for funding the evaluation Coordination with businesses in the formal sector is portfolio on childcare, with which numerous authors are affiliated. also important, as it can be one way to extend childcare Competing interests The views expressed in this commentary are those of the services as an employee benefit.21 Policy and political authors alone and do not represent the views of their affiliated institutions. All analysis will ensure we are taking a macro-v iew with the authors report no conflicts of interest. objective of providing relevant strategic advice to govern- Patient consent for publication Not applicable. ments regarding sustainable growth of a quality childcare Provenance and peer review Not commissioned; externally peer reviewed. sector with dividends for society at large. Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-c ommercially, CONCLUSION and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the Childcare is a smart investment and everyone’s concern— use is non- commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. not a ‘sunk cost’ or a women’s issue.6 The pandemic highlighted the cost of inaction in addressing childcare ORCID iDs Alex Aliga http://orcid.org/0000-0001-6342-5688 and raised the need to advocate for a change in narra- Tefera Darge Delbiso http://orcid.org/0000-0002-7681-1649 tive globally.22 We are encouraged by recent attention to Patricia Kitsao-W ekulo http://orcid.org/0000-0003-4206-9746 childcare infrastructure and investment, but highlight Monica Lambon-Q uayefio http://orcid.org/0000-0003-4126-6430 the necessity of a locally led research and implementa- Amber Peterman http://orcid.org/0000-0002-3921-5936 tion agenda. Without this approach, the movement risks imposition of western ideas and models of care, which may fail to realise the potential triple dividend to chil- dren, women and society. 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