vary by year, province, and indicators, rendering comparisons difficult. The Early Childhood Development Index (ECDI),<sup>1</sup> the best available measure of child development at scale across provinces, shows substantially lower-than-average scores for children in Pakistan relative to the 75.1 percent average seen across 60 low- and middle-income countries (Lu et al., 2020): 59.4 percent in Punjab (2017–18), 47.5 percent in Sindh (2018–19), and 54.6 percent in Khyber Pakhtunkhwa (2019) (Tomlinson et al. forthcoming). There are no recent ECDI scores from Balochistan, the poorest province in Pakistan, and except for health surveys that provide proxies for ECD, there are no national ECD data sets for children from birth to age 3. Smaller-scale or province-specific studies shed light on patterns and rates of parental distress or depression, psychosocial stimulation, participation in ECE, and similar variables of interest, such as integration of parenting and nutrition interventions in community health settings in Sindh (Yousafzai et al., 2018) and Idara-e-Taleem-o-Aagahi (ITA)-Early Learning Partnership (ELP) studies of ECD during COVID disruptions in Punjab (ITA, 2021). This study aims to broaden the knowledge base by providing nationally representative data.

# Young children in Pakistan are exposed to a host of risk factors that impede development

Child development occurs through a series of biological and psychological processes that are influenced by risk and protective factors that have the potential to alter brain structure and have implications throughout the life course. Common risk factors include social determinants of health, such as poverty, poor water and sanitation, and lack of maternal education, the health of the caregiver and child, including physical and mental health of the caregiver and malnutrition and infections for the child, and caregiver psychosocial health, including parental distress. Exposure to multiple risk factors reduces children’s chances of staying on track developmentally, and the rates of multiple exposure are high in Pakistan. Province-level estimates find that approximately one-quarter of households with young children experience four risk factors—for comparison, the same share of households with young children in the United Kingdom experience just two risk factors (Sabates & Dex, 2012)—and about 10 percent of young children in Pakistan experience six or more risk factors (Tomlinson et al., forthcoming). There is a clear negative association between the number of risks experienced and the likelihood of developing on track in every province. For example, 83.0 percent of young children in Sindh exposed to one or no risk factors are developing on track vs. 44.8 percent of children experiencing three risk factors (See Figure 1, as reported in Tomlinson et al., forthcoming). Reducing the number of risks

> 1 The ECDI is a population-based measure of child development that includes 10 items in four early developmental domains: 3 language/cognitive items, 2 physical items, 3 social-emotional items, and 2 approaches to learning items. Based on parent-report of children’s ability, children are classified as being either on-track or off-track in terms of development.

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