A comparative analysis of early child health and development services and outcomes in countries with different redistributive policies

Country selection

Navarro et al. have previously described a conceptual framework to identify and study the complex interactions between politics, policy, and public health [4, 6, 7]. Navarro et al.’s method includes identifying countries by political tradition, so that associations between political tradition (as a proxy for policy) and population health outcomes can be made [4, 6]. Navarro et al. classify governance by political traditions into 4 party types for the period 1950–2000: 1) social democratic parties, 2) Christian democratic or conservative parties in the Judeo-Christian tradition, 3) liberal parties or conservative parties of a liberal persuasion, and 4) conservative dictatorships [4]. Traditionally, social democratic parties have been most committed to redistributive policies. The social policies of these parties have included policies designed to encourage a high proportion of adult men and women to gain employment, generous social transfers and social services, including family-oriented services [4]. Examples of countries with a tradition of social democratic parties include Sweden, Denmark, Finland, and Norway [4]. Christian democratic parties or conservative parties in the Judeo-Christian tradition have been less committed to redistributive policies than the social democrats. They provide social transfers funded mainly by payroll taxes through social security systems. They do not tend to emphasise family-oriented services such as child care [4]. Examples of countries with Christian democratic or conservative Judeo-Christian political traditions include Italy, the Netherlands, west Germany and France [4]. Liberal or conservative parties of a liberal persuasion have not traditionally had a strong commitment to redistributive policies. They do not provide universal social services. Most social services benefits in these countries are means tested, and public social expenditures are much lower than in the countries governed by social democratic and Christian democratic parties [4]. Examples of countries in this tradition include the United Kingdom, Canada, Ireland, and the United States [4]. Lastly, the conservative dictatorships can be characterized by ultra-conservative or authoritarian (fascist) regimes, which can be generally characterized by low social system support and high income inequality. Although not currently dictatorships, examples of historic conservative dictatorships include Spain, Portugal, and Greece [4].

Using the method of Navarro et al., [4] we selected five countries representing a cross-section of the political traditions during the time period of 1950 to 2000, including countries governed primarily by: 1) social democratic parties (Sweden), 2) Christian democratic parties or conservative parties in the Judeo-Christian tradition (the Netherlands), 3) liberal parties or conservative parties of a liberal persuasion (Canada, the United States), and 4) conservative dictatorships (Cuba). Although Cuba is not an “ultra-conservative” state and is constitutionally identified as a socialist state, [8] the country is governed an authoritarian regime and is generally recognized as a communist state led for many years by a dictator [9]. These countries were chosen for several reasons. Firstly, Organization for Economic Co-operation and Development (OECD) countries were desired for availability of data. The OECD compiles data and metadata from member countries to allow for member country comparisons. Secondly, in spite of different political traditions and policies, all of these countries have been recognized as global leaders in different aspects of early childhood development (e.g., delivery of prenatal and child health care through polyclinics in Cuba, measurement of school readiness in Canada). Thirdly, trends in early childhood outcomes in countries with different political traditions have been observed in international reports, such as UNICEF’s report on early childhood services [10], suggesting that one need not be exhaustive of all countries to observe trends in early childhood outcomes. Lastly, authors have personal experience working in early child health and development in all of the countries, except Cuba, which allows for a more thorough understanding of contextual factors, which is particularly relevant for analysis of indicators which fall outside those typically collected on international surveys.

Data sources and indicators

We searched international databases and reports (e.g., OECD, World Bank, and UNICEF) to obtain information on the policies, services, and outcomes of interest. If the information was not available in international databases, we used national or local data sources, as described below.

Demographic, economic, inequality, and social support

Data pertaining to countries’ demographics and economics (population, population density, immigrants, GDP, tax revenue, and expenditures) were obtained through the OECD’s and World Bank’s databases (OECD.Stat and World Data Bank, respectively) [11, 12]. OECD data are obtained from regional- (e.g., Eurostat) or country-level statistical organizations (e.g., Statistics Canada, Statistics Netherlands, Statistics Sweden, National Center for Health Statistics in the United States). Similar to OECD.Stat, the World Data Bank compiles country-level statistical data using information from the statistical systems of member countries. Both databases have made attempts to improve the quality and comparability of data by providing guidance around methodology, sources, and indicator definitions. Data on Cuba are not available in OECD.Stat or the World Data Bank and Cuba does not publicly release statistics for many of the measures of interest. Data on Cuba were obtained from sources in other countries, primarily the United States, which track and monitor indicators of other countries according to standard definitions. For country demographic data, information for Cuba was obtained from the United States Central Intelligence Agency [9].

The Gini coefficient is a measure of income equality with a score of 0 representing perfect equality and 1 perfect inequality [13]. Data for all countries except Cuba were obtained from OECD.Stat [11]. An extensive search for data on Cuba was conducted. No official government source was found, although an article in “The Economist” provided an estimate [14]. This has been included for interest, but should be interpreted with caution as the source, methodology, and definition were not described and may not be comparable to OECD sources.

Like the Gini coefficient, the Inequality-adjusted Human Development Index (IHDI) also measures inequality at the country-level. While the Gini coefficient measures only income inequality, the IHDI measures the level of human development of people in a society while accounting for inequality [15]. It is made up of 3 dimensions, including health, education, and income [15]. A score of 0 represents perfect inequality and a score of 1 perfect equality. IHDI data were obtained from United Nations Human Development reports which use standardized methodologies to draw information from country-level statistical sources for the index calculation [15]. No data were available for Cuba.

Information on health insurance funding was provided by the authors who have personal experience with the included countries.

Social determinants of early child development

Four social determinants of ECD were selected to provide a cross-section of key time periods in a child’s life from prenatal to kindergarten [1]. They included: 1) prenatal care, 2) maternal leave, 3) child health care, and 4) child care and ECE. For each determinant, relevant policies and services were identified which could influence early child health and development outcomes. Further information on the services and policies of each social determinant and the corresponding outcomes are described below.

Prenatal care

Prenatal care can provide an effective intervention to improve maternal and child health by supporting positive behaviour changes (e.g., smoking cessation) and connecting parents to prenatal and parenting programs [16, 17]. During the intra-partum period, health care providers also have the ability to impact on maternal and infant morbidity and mortality, and promote positive practices, such as breastfeeding. Evidence shows that midwife-led care is associated with an increase in spontaneous vaginal birth and the initiation of breastfeeding [18]. As a policy of interest, we compared the prenatal care services in each country. As outcomes of interest for prenatal care, we identified maternal smoking rate, caesarean-section (c-section) rate, infant mortality rate, and low birth weight rate.

Data for policies and outcomes of prenatal care were generally taken from national statistical databases [19–22]. The c-section rate for Cuba was obtained from the World Health Organization, [20] and data for all countries on infant mortality rate and low birth weight rate (<2500 g) were obtained from the OECD and World Bank [11, 12]. Based on standard definitions, data on c-section rate, infant mortality rate, and low birth weight rate have good comparability. Country comparisons for maternal smoking rate and c-section rate were limited by data availability as data were not always available for the same year [23–26]. Where years of data collection differ, this has been noted in the corresponding tables.

Maternal leave

Maternal leave is recognized as an important component of child health and enabler of breastfeeding and attachment [10]. Breast milk promotes sensory and cognitive development, and protects the infant against infectious and chronic diseases [27, 28]. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhea or pneumonia, and helps for a quicker recovery during illness [27]. These effects can be measured in low and to some extent high income countries [29]. International experts recommend exclusive breastfeeding up to 6 months of age with continued breastfeeding up to 2 years and beyond [30, 31]. For policies related to maternal leave, we included maternal leave allowance, maternal leave pay, and parental leave. As a maternal leave outcome, we identified maternal breastfeeding rates (initiation and sustained).

Data for policies on maternal leave (i.e., maternal leave allowance, maternal leave, and parental leave) were obtained primarily from country-level government sources, with the exception of Cuba’s data which were obtained from an academic source [32–36]. Data for maternal leave outcomes were generally taken from statistical databases [11, 37]. Information on breastfeeding for Cuba was obtained from UNICEF [38]. Although most countries obtained information on initiation of breastfeeding through routine collection, information on exclusive breastfeeding at 6 months was more difficult to obtain and was taken from a variety of sources, including one-time surveys (Canadian maternity experiences survey, breastfeeding report card in the United States), [19, 39] population statistics (Sweden, the Netherlands), [23, 37] and UNICEF (Cuba) [38]. Although definitions for exclusive breastfeeding are similar, challenges to comparability arise from different time periods of data collection and methods of sampling populations.

Child health care

Child health care includes acute and preventive care. Beyond moral and professional obligations, the health sector has a unique opportunity to promote healthy child development because of the high levels of interaction with children and their parents during early childhood [40]. In each country, we compared the acute and preventive child health care services and the number of recommended preventive care visits and approximate cost per child per year [United States dollars (USD)]. Outcomes of interest for child health care and services included coverage of preventive visits, childhood immunization coverage rates, and the under 5 years mortality rate.

Data on policies for child health care were obtained through knowledge of the authors working in their respective countries, and through academic sources for Cuba [41]. Outcome data for service coverage was only available for 2 countries (Sweden and the Netherlands) [42, 43]. However, under 5 years mortality and vaccination coverage data were available for all countries through UNICEF [44].

Child care and early childhood education

Today’s generation of children is the first in which a majority are spending a large part of early childhood in some form of out-of-home child care [45]. Neuroscientific research demonstrates that loving, stable, secure and stimulating relationships with caregivers in the earliest months and years of life are critical for every aspect of a child’s development [45]. We compared the ECE and education services and policies in each country. We focused on the organization of child care, pre-school, and kindergarten and looked specifically at age of enrollment, hours of operation, and contribution from parents and government. As outcomes of ECE and education, we included the Child Development Index (CDI), the Early Development Instrument (EDI), and the educational achievement of 15 year-olds.

Child care centres, or daycares, are places where parents can take children for care while they are otherwise occupied (e.g., while at work). There is generally some cost borne by the parent. Child care centres may be formal institutions or home-based. There are no global databases that collect comprehensive information on child care centres; information was obtained from various reports [42, 46–49].

Pre-school or infant education is a formal environment to stimulate child development in multiple domains. Programs may or may not charge parents a fee. Again, no global database containing this information exists, so data were compiled from various reports [50, 51].

Kindergarten represents the first formal education level in school. Data on kindergarten start age was obtained from national policy sources.

School readiness measures a child’s preparedness to perform in multiple domains (e.g., emotional, behavioural, cognitive) in the school environment. There are no globally accepted measures of school readiness, however several different methods have been developed and are used to differing degrees around the world [52–55]. For example, the EDI is an internationally recognized tool which can be used to assess school readiness on a population-level [56]. The instrument evaluates children in 5 key domains of early development: physical, social, emotional, communication, and language and cognitive skills. Children who fall in the lowest 10^th percentile for a given domain are deemed “vulnerable” in that area [57]. Data in this area are presented for interest, but comparability is limited by differences in source, method of collection/sampling, and validity of the measures. The CDI is a tool used globally to assess countries’ performance on child health, education, and nutrition [58]. Countries are ranked according to their scores based on a child’s risk of dying before his/her fifth birthday, of not enrolling in school, and of being underweight [58]. The CDI is measured on a scale of 0 to 100 with a higher number suggesting children are worse off [58]. To consider longer-term outcomes of child care and ECE, the educational achievement of 15 year-olds in reading, math and scientific literacy were reviewed. The OECD conducted a cross-sectional survey of 250,000 students in 41 countries [45]. Students were given a 2-hour test designed by a group of international experts that measured ability in literacy, numeracy, and science as applied to the management of everyday life [45]. Students were measured on a numerical scale with the OECD average being around 500 [59]. Equivalent data for Cuba were not available.

Comparison of countries and redistributive policies

Prenatal care

The infant mortality rate ranged from 2.4 per 1000 (Sweden) to 6.8 per 1000 (United States) [63, 64]. Sweden’s rate was significantly lower than the next lowest rate of 4.9 per 1000 (the Netherlands) and more than half the rate of Canada, the United States, and Cuba. Low birth weight rates (<2500 g) ranged from 4.2% in Sweden to 8.1% in the United States [20, 65, 66].

Maternal leave

Child health care

Child care and early childhood education

Strengths

We used a previously established method of categorizing countries by redistributive political traditions. This allowed for comparison between multiple countries in all of the categories, while keeping the number of countries manageable to allow for meaningful comparisons. Where data were available, they were generally robust and collected consistently across countries (e.g., immunization rates, infant mortality).

Limitations

Global databases, such as OECD.Stat and World Data Bank rely on data collected by national statistics. Although these large databases have made increasing strides to standardize indicator definitions, data sources, and collection methodology, inherently, there will be differences between some countries that limit comparability. Additionally, not all policies and outcomes of interest were collected through standardized, country-level sources, making comparability more challenging for some indicators. Due to these limitations, we attempted to choose indicators with objective or widely recognized definitions. Additionally, some data points were missing as statistics were either not publicly available or not collected. Although this was most readily apparent for Cuba, we elected to include the data available, with cautionary notes on interpretation, as Cuba’s successes in some areas of early child health and development may serve as case studies for other resource-constrained settings.

Early child health and development is impacted by a web of different social, cultural, economic, genetic, political, and environmental conditions. While redistributive policies and indices, such as the Gini coefficient and IHDI, attempt to capture the complexity of this web, the categorization is inherently incomplete.

Another limitation is that we only included one country from each different political tradition in our analysis. However, if we examine UNICEF’s latest report about early childhood services, the same ranking is observed as in our study with the social democratic countries having the best and the liberal countries the worst early childhood outcomes [10]. UNICEF’s report proposed 10 internationally applicable benchmarks for early childhood care and education [10]. The report card scores ranged from 1–10, a 10 indicated that all suggested standards were met. The social democratic countries (Sweden, Denmark, Finland and Norway) all scored 8 or higher; the Christian democratic countries (the Netherlands, Germany and Belgium) scored between 4 and 6; and the liberal countries (Canada, Ireland, and US) scored the lowest, between 1 and 3. An exception was the United Kingdom which also has a liberal government and scored a 5, this is possibly explained by the “Sure Start Program” which offered full day care for children, good quality teacher input to lead the development of learning within the centre, and child and family health services for disadvantaged groups [2]. This underscores the statement of Navarro et al. that there is a great need for further research to establish the interactions between politics, policy, and health outcomes [4].

As discussed previously, a comparative analysis allowed for correlation, but not causation. In the east Asian welfare states (South Korea, Japan, Taiwan, Singapore, and Hong Kong), child health seems to be as good as in Scandinavia [71]. The east Asian welfare states are characterized by low social, educational, and health expenditures. Thus, the findings in our study might not be generalizable to countries outside the western tradition.

Future directions

In order to better understand and continue to improve early child health and development, policy makers should consider the following: