The conundrum of a global tool for early childhood development to monitor SDG indicator 4.2.1
Authors: Bolajoko O Olusanya, Mijna Hadders-Algra, Cecilia Breinbauer, Andrew N Williams, Charles R J Newton, Adrian C Davis
Journal: The Lancet Global Health (2021)

The UN's Sustainable Development Goals (SDGs) agenda, by contrast to the Millennium Development Goals, provides a global policy framework to address the quality of life of beneficiaries of the remarkable reduction in mortality in those younger than 5 years since the child survival revolution began in 1982.1UNTake action for the Sustainable Development Goals.https://www.un.org/sustainabledevelopment/sustainable-development-goals/Date: 2015Date accessed: December 28, 2020Google Scholar The SDGs explicitly commit all governments and the global health community to actions that will "ensure that all girls and boys have access to quality early childhood development, care and pre-primary education so that they are ready for primary education".1UNTake action for the Sustainable Development Goals.https://www.un.org/sustainabledevelopment/sustainable-development-goals/Date: 2015Date accessed: December 28, 2020Google Scholar To monitor progress towards achieving this target, "the proportion of children under 5 years of age who are developmentally on track in health, learning and psychosocial well-being, by sex" was chosen as the sole indicator (SDG 4.2.1).1UNTake action for the Sustainable Development Goals.https://www.un.org/sustainabledevelopment/sustainable-development-goals/Date: 2015Date accessed: December 28, 2020Google Scholar The choice of this age group is consistent with other SDG targets for young children, including undernutrition, poverty, and mortality (panel).2UNSDG indicators. Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development.https://unstats.un.org/sdgs/indicators/indicators-list/Date accessed: December 28, 2020Google Scholar The extensive scientific literature on human brain development reflects the importance of early detection and intervention, especially for children with, or at risk of, developmental disabilities.3UNICEFThe state of the world's children 2013: children with disabilities.https://www.unicef.org.uk/publications/sowc-report-2013-children-with-disabilities/#:~:text=The%20State%20of%20the%20World's%20Children%202013%3A%20Children%20with%20disabilities,-Home%20%3E%20Publications%20%3E%20The&text=Children%20with%20disabilities%20are%20the,link%20between%20disability%20and%20malnutritionDate: 2013Date accessed: December 28, 2020Google ScholarPanelProvisions for children younger than 5 years under the Sustainable Development Goals framework2UNSDG indicators. Global indicator framework for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development.https://unstats.un.org/sdgs/indicators/indicators-list/Date accessed: December 28, 2020Google ScholarGoal 2: end hunger, achieve food security, and improve nutrition and promote sustainable agricultureTarget 2.1By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious, and sufficient food all year roundIndicators•2.1.1: prevalence of undernourishmentTarget 2.2By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children younger than 5 years, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older peopleIndicators•2.2.1: prevalence of stunting (height for age more than two SDs lower than the median of WHO's Child Growth Standards) among children younger than 5 years•2.2.2: prevalence of malnutrition (weight for height more than two SDs higher or lower than the median of WHO's Child Growth Standards) among children younger than 5 years, by type (wasting and overweight)Goal 3: ensure healthy lives and promote wellbeing for all at all agesTarget 3.2By 2030, end preventable deaths of neonates and children younger than 5 years, with all countries aiming to reduce neonatal mortality to 12 deaths per 1000 livebirths or fewer, and mortality in children younger than 5 years to 25 deaths per 1000 livebirths or fewerIndicators•3.2.1: under-5 mortality rate•3.2.2: neonatal mortality rateGoal 4: ensure inclusive and equitable quality education and promote lifelong learning opportunities for allTarget 4.2By 2030, ensure that all girls and boys have access to quality early childhood development, care, and pre-primary education so that they are ready for primary educationIndicators•4.2.1: proportion of children younger than 5 years who are developmentally on track in health, learning, and psychosocial wellbeing, by sexThe portion of this indicator that measured progress for children aged 0–23 months was deleted in principle in March, 2020, subject to final approval by the UN Statistical Commission•Revised 4.2.1 (2020): proportion of children aged 24–59 months who are developmentally on track in health, learning, and psychosocial wellbeing, by sex Goal 2: end hunger, achieve food security, and improve nutrition and promote sustainable agriculture Target 2.1 By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious, and sufficient food all year round Indicators •2.1.1: prevalence of undernourishment Target 2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children younger than 5 years, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older people Indicators •2.2.1: prevalence of stunting (height for age more than two SDs lower than the median of WHO's Child Growth Standards) among children younger than 5 years•2.2.2: prevalence of malnutrition (weight for height more than two SDs higher or lower than the median of WHO's Child Growth Standards) among children younger than 5 years, by type (wasting and overweight) Goal 3: ensure healthy lives and promote wellbeing for all at all ages Target 3.2 By 2030, end preventable deaths of neonates and children younger than 5 years, with all countries aiming to reduce neonatal mortality to 12 deaths per 1000 livebirths or fewer, and mortality in children younger than 5 years to 25 deaths per 1000 livebirths or fewer Indicators •3.2.1: under-5 mortality rate•3.2.2: neonatal mortality rate Goal 4: ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Target 4.2 By 2030, ensure that all girls and boys have access to quality early childhood development, care, and pre-primary education so that they are ready for primary education Indicators •4.2.1: proportion of children younger than 5 years who are developmentally on track in health, learning, and psychosocial wellbeing, by sex The portion of this indicator that measured progress for children aged 0–23 months was deleted in principle in March, 2020, subject to final approval by the UN Statistical Commission •Revised 4.2.1 (2020): proportion of children aged 24–59 months who are developmentally on track in health, learning, and psychosocial wellbeing, by sex However, the Inter-Agency and Expert Group on SDG Indicators (IAEG-SDGs), which was established in 2015 by the UN to facilitate the implementation of all indicators, has proposed the exclusion of all children younger than 24 months from SDG 4.2.1, subject to final approval by the UN Statistical Commission in March, 2021 (panel). This proposal is attributable to the inability of UNICEF, as the custodian agency, to provide a suitable population-level measure of functioning and development in children younger than 24 months. The Washington Group on Disability Statistics, which was mandated by the UN in 2001 to develop a composite measure of child functioning, has not yet succeeded in producing a tool that includes all children.4Loeb M Cappa C Crialesi R de Palma E Measuring child functioning: the Unicef/Washington Group Module.Salud Publica Mex. 2017; 59: 485-487Crossref PubMed Scopus (19) Google Scholar Developing the required measure of child functioning for all children younger than 5 years is portrayed as very subjective, culturally dependent, and too complex.4Loeb M Cappa C Crialesi R de Palma E Measuring child functioning: the Unicef/Washington Group Module.Salud Publica Mex. 2017; 59: 485-487Crossref PubMed Scopus (19) Google Scholar This perception has led to the introduction of the Early Childhood Development Index for children aged 24–59 months as the proxy measure for SDG 4.2.1. The proposed exclusion of all children younger than 24 months from the sole global indicator for early childhood development is of great concern for several reasons. First, the proposal is incompatible with the existing goal (SDG 4) and target (SDG 4.2) that embrace all children (panel). Second, exclusion of the youngest children violates non-discrimination provisions of the UN Convention on the Rights of the Child and the Convention on the Rights of Persons with Disabilities, and contradicts the SDGs' core principle of not leaving anyone behind.1UNTake action for the Sustainable Development Goals.https://www.un.org/sustainabledevelopment/sustainable-development-goals/Date: 2015Date accessed: December 28, 2020Google Scholar Third, children younger than 24 months are usually the most disadvantaged cohort and the greatest beneficiaries of early detection and intervention services. Their exclusion is likely to undermine sustainable political support and donor funding commitments towards early childhood development initiatives5WHOUNICEFWorld Bank GroupNurturing care for early childhood development. A framework for helping children survive and thrive to transform health and human potential.http://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf?ua=1Date: 2018Date accessed: December 28, 2020Google Scholar for the estimated 250 million children younger than 5 years at risk of not realising their developmental potential because of stunting and extreme poverty,6Black MM Walker SP Fernald LCH et al.Early childhood development coming of age: science through the life course.Lancet. 2017; 389: 77-90Summary Full Text Full Text PDF PubMed Scopus (990) Google Scholar and for more than 50 million children with developmental disabilities in low-income and middle-income countries.7Global Research on Developmental Disabilities CollaboratorsDevelopmental disabilities among children younger than 5 years in 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Glob Health. 2018; 6: e1100-e1121Summary Full Text Full Text PDF PubMed Scopus (213) Google Scholar Fourth, the suggestion that creating population-level measures for children younger than 24 months is unachievable does not consider all the available survey tools (eg, the Global Scale for Early Development8Richter L Black M Britto P et al.Early childhood development: an imperative for action and measurement at scale.BMJ Glob Health. 2019; 4e001302Crossref PubMed Google Scholar and Caregiver Reported Early Development Instruments9Altafim ERP McCoy DC Brentani A de Ulhôa Escobar AM Grisi SJFE Fink G Measuring early childhood development in Brazil: validation of the Caregiver Reported Early Development Instruments (CREDI).J Pediatr (Rio J). 2020; 96: 66-75Crossref PubMed Scopus (11) Google Scholar). Finally, the proposed exclusion will not facilitate the integrated approach to child survival, development, and wellbeing recommended by the WHO–UNICEF–Lancet Commission on child and adolescent health.10Clark H Coll-Seck AM Banerjee A et al.A future for the world's children? A WHO–UNICEF–Lancet Commission.Lancet. 2020; 395: 605-658Summary Full Text Full Text PDF PubMed Scopus (288) Google Scholar Already, UNICEF is committed to giving priority in everything they do to "the most disadvantaged children and countries in greatest need". Therefore, we have three recommendations. First, the proposed exclusion should not proceed. The IAEG-SDGs should fully disclose the current absence of a single measurable tool for early childhood development for all children younger than 5 years while rapidly harmonising existing survey tools towards a comprehensive Early Childhood Development Index instrument. Second, transparent and active engagements with all relevant stakeholders, particularly those from high-burden regions, should be prioritised. For example, UN conventions require people with disabilities, including children with disabilities, through their representative organisations, to be consulted and actively involved in the development and implementation of policies and programmes that directly affect them. To do otherwise will be unjust and improper. Finally, we should track the proportion of children with disabilities that receive intervention services as a key performance measure for early childhood development. In conclusion, more than 5 years have passed since the SDGs were launched. Every day, the future of many child survivors is being hugely disrupted by life-long impairments. It is time to build trust and deliver services that will directly and positively impact the future wellbeing of all children early enough (<2 years of age) for the best possible developmental outcomes. We declare no competing interests. Setting the record straight on measuring SDG 4.2.1 – Authors' replyWe appreciate the attention of Mark Hereward from UNICEF to the concerns in our Comment published in The Lancet Global Health,1 and wish to clarify some of the alleged omissions and errors. We, and members of the public, are not privy to the internal processes and procedures that have restricted the development of a tool that includes all children younger than 5 years as required by Sustainable Develop Goal (SDG) 4.2.1, and that the component relating to children younger than 24 months is now the sole responsibility of WHO. Full-Text PDF Open AccessSetting the record straight on measuring SDG 4.2.1Although we appreciate the visibility the Comment by Bolajoko Olusanya and colleagues (May, 2021)1 has given to the monitoring of early childhood development, it contains serious errors and omissions about Sustainable Develop Goal (SDG) processes and requirements, including failing to draw distinctions among population-level measures, global monitoring, and child-level assessments. Clarifying the scope and limitations of measurement tools is crucial to strengthening data on early childhood development. Full-Text PDF Open Access