The Poor State of Childcare Centers in the Nairobi Slums: A major Threat to Children’s Health and Development

The Health and Economic Value of Quality Childcare

Investing in quality child care has significant benefits for child health and development and long term impacts on the human capital that is critical for society. Research evidence shows that children who are exposed to safe, nurturing and developmentally stimulating childcare environments are healthier and achieve better growth and development, and the good start in life has lasting benefits on their success as adults, who will also be economically productive (Richter et al., 2017; Britto et al., 2017). 

From a global perspective, quality childcare has the potential to provide multiple benefits to children, families and societies (World Bank, 2019; WHO, 2018).  This is currently driving global priorities in investing in nurturing care for optimum early childhood health and development within multiple Sustainable Development Goals which include targets relevant to young children’s health, safety and development (UN, 2015). This drive is anchored on the Nurturing Care Framework for Early Childhood Development (WHO, 2018) that provides a broad framework to support the development of children from pregnancy up to age three, and is premised on the evidence that investment in the early years has the potential to reduce health inequities and boost individual, social and economic development (Black et al., 2017; Richter et al., 2017; Britto et al., 2017; Shonkoff et al., 2012;). Quality day-care provision’s  social and economic benefits go beyond children to increasing women’s participation in the labor force (Gelbach 2002; Esping-Andersen 2009, Dang et al. 2019) which also indirectly benefits child health (Leroy, 2009).

The Hurdles Facing Childcare

Despite the evidence on the importance of quality childcare, 350 million children worldwide particularly in the Low and Middle Income Countries (LMICs) continue to be exposed to poor quality, informal day care especially in the urban informal settlements. This puts them at risk of disease, growth and  developmental challenges prevalent in 250 million children under 5 years old worldwide.

Informal childcare centers are mushrooming in the cities to meet the rapidly growing populations and the increasing demand for day care emanating from more women engaging in employment outside of the home amidst changing social norms, particularly the diminishing kinship to support with child care. Siblings caring for younger siblings is also an issue of concern that robs children of their childhood and  further endangers the children under the care of older siblings through avoidable accidents. Childcare centers in many poor urban neighborhoods, including in Nairobi slums, are substandard, unregulated, informal, often run by women in their own homes with no training in child health, early childhood development or child safety. Our previous research (Community of Practice (CoP) study) found that only 12 of 129 childcare centers (9%) had received any support or training. Nairobi is one of the few counties in Kenya with a Day Care Act and process for regulating childcare centers. However, this is yet to be operationalized. 

Poor quality of childcare is often associated with frequent infections e.g. diarrheal related diseases, malnutrition, accidents and developmental delays. For the woman, this means that they will often be away from work to take care of the sick child. The economic consequences of using substandard childcare may be equally inhibiting or even worse than absence of paid childcare. At the same time, health systems are struggling to reach children in these communities. Community health volunteers (CHVs) routinely support child health and nutrition programmes in these communities through household visits. However, they do not currently visit childcare centers and are not trained to support Early Childhood Development (ECD). 

Call for Government Action

It is critical that the government and other key players in childcare commit a substantial investment to supporting approaches for improving the quality of childcare centers particularly in the disadvantaged communities. This can be done through leveraging existing structures and working closely with the different players to support and regulate child care.  Our recently completed CoP research demonstrated that a low cost model of skilling and support supervising of center providers by CHVs was feasible and demonstrated a great potential to improve the quality of informal childcare centers.

CHVs play a vital role in visiting households during child health campaigns; however, they do not currently visit childcare centers. In addition, they are not trained to support these center managers to provide an environment for healthy early childhood development. Despite the importance of CHVs, traditionally, they have not received regular remuneration. Nairobi County has recently passed a bill to provide a monthly stipend of KES 2000 (approx. GBP 14) for each CHV. Non-financial incentives such as improved skills and recognition are also needed to optimize community health worker and volunteer programmes (Abuya et al., 2021; WHO, 2018).

Within this context, our team worked with CHVs, parents, childcare providers, County health teams and Kidogo to co-design an intervention where CHVs are trained to support childcare providers through ‘communities of practice’ (CoP) group meetings (Mercieca, 2017). In addition, CHVs regularly visit childcare centers to improve quality and access to routine child health programmes (Oloo et al.).  We tested CoP feasibility with 66 small informal childcare centers in two informal settlements. We found significant improvements in the knowledge and practice of childcare providers and quality of childcare centers after the intervention. Improvements included a better knowledge of a child’s immunization status, provision of healthy foods, toys and encouragement of play (Nampijja et al., under review). The implementation manual, detailing the topics and delivery, is a valuable product that can be used to support wider implementation in Kenya and could be adopted or adapted to other low income settings.  The CoP intervention therefore provides a ready, low cost and sustainable option for strengthening the capacity of center caregiver skills and improving the quality of childcare centers for resource limited settings.

For successful scale-up and full integration of the CoP intervention into the routine practice, a balance must be struck in the long run, between reduced or even removal of incentives and increased basic salary for CHVs. At the higher level, decision makers at the national and County level (Ministry of Health, and Education) were continually consulted and their approval to use the sub-county teams to deliver the programme was obtained. Embedding the intervention in the existing system made implementation cheaper and easier and hence contributed to its feasibility. Research has shown that successful community programmes are those that have utilized existing infrastructure (WHO, 2008).  The integrated approach promoted ownership, enabled resource mobilization, minimized costs of delivery, and to some extent provided initial capacity which are altogether critical for the sustainability of the programme in a resource limited health system. Additional approaches to incentivise daycare owners to meet the required standards e.g. wavering licensing fees for  newly set up centers while they are pursuing capacity strengthening and working closely with CHVs for support supervision, would be useful.

Specifically, Government/policy makers should support 

1. Training of CHVs on the CoP model and provide the necessary facilitation 
2. Provision of resources that will be needed for the CHVs to train and support supervise center providers 
3. Integration of the training on the CoP into the CHV curriculum  
4. Mainstreaming of reporting on childcare centers within the routine monthly reporting
5. Facilitation for CHVs with a monthly allowance for their support in community health programs
6. Offer leadership by setting up a model childcare facility housed within the government-run ECD centers that can be used for training and demonstration of what quality looks like 
7. Implementation of policy framework including passing pending childcare related bills and operationalizing the acts

Leveraging these teams and integration of the intervention into the health system is likely to enable scale-up and sustainability in Nairobi County and countrywide. The CHV system, the well-articulated implementation manual and community buy-in together with the established relationship between the health system and private childcare centers through this intervention, provide a great opportunity that can be leveraged to support the implementation of the approach and its integration of the model and its scaling up across Nairobi County. 

The vision: Expected impact

Government’s support and investment in this child care program through the Ministry of Health will significantly improve childcare quality and give Kenyan children a chance to be healthier, and grow normally and achieve their developmental potential. Improved childcare will provide a good foundation for optimum development for children in the low income settings ultimately contributing to the development of human capital that is critical to Kenya and the African continent.

References

Abuya, T., Mwanga, D., Obadha, M., Ndwiga, C., Odwe, G., Kavoo, D., Wanyugu, J., Warren, C., & Agarwal, S. (2021). Incentive preferences for community health volunteers in Kenya: findings from a discrete choice experiment. BMJ Open, 11(7), e048059. https://doi.org/10.1136/BMJOPEN-2020-048059

Black MM, Walker SP, Fernald LCH, Andersen CT, DiGirolamo AM, Lu C, et al. Early childhood development coming of age: science through the life course. Lancet. 2017;

Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood development. The Lancet. 2017.

Dang H-AH, Hiraga M, Nguyen CV. Childcare and Maternal Employment: Evidence from Vietnam, GLO 

Discussion Paper, No. 349, Global Labor Organization (GLO) [Internet]. 2019 . 

Available from: http://hdl.handle.net/10419/196844www.econstor.eu

Esping-Andersen G. After the golden age? Welfare state dilemmas in a global economy. In: The Global 

Social Policy Reader. 2009.

Gelbach JB. Public schooling for young children and maternal labor supply. Am Econ Rev. 2002;

Leroy JL, Gadsden P, Guijarro M. The impact of daycare programmes on child health, nutrition and development in developing countries: A systematic review. J Dev Eff. 2012

Mercieca, B. (2017). What Is a Community of Practice? In J. McDonald & A. Cater-Steel (Eds.), Communities of Practice (pp. 3–25). Springer, Singapore. https://doi.org/10.1007/978-981-10-2879-3_1

Shonkoff JP GA, Committee on Psychosocial Aspects of, Child Family, Health et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–46.

Richter LM, Daelmans B, Lombardi J, Heymann J, Boo FL, Behrman JR, et al. Investing in the foundation of sustainable development: pathways to scale up for early childhood development. The Lancet. 2017.

UN (2015) Transforming our world: the 2030 Agenda for Sustainable Development. Resolution 

adopted by the General Assembly on 25 September 2015 A/RES/70/1. 

WHO/UNICEF/WB. Nurturing care for early childhood development: A framework for helping children survive and thrive to transform health and human potential. Medico e Bambino. 2018.

World Health Organisation. Integrated health services-what and why? Technical Brief No. 1. Geneva, Switz WHO. 2008;