Beyond the silver bullet: closing the equity gap for children within a generation

Abstract

Over the past decade, inequities in children's health, development and wellbeing have not improved despite great efforts globally.¹ Inequities are unfair and unjust differences caused by preventable social, economic or geographic factors. Inequities generally persist into adulthood, where they carry high costs for individuals and society,² generating substantial costs across health, education and welfare budgets.³ This is an extraordinary system failure for any high income country, including Australia.³ Addressing inequities would generate substantial savings across budgets and raise the productivity of society at large, delivering on greater human capital.^{2, 4}

For the first time in history, this generation will not live longer than the generation before it, worldwide.⁵ The chronic disease epidemic is driving much of this trend, with impacts being disproportionately felt by those experiencing adversity.⁶ Opportunities for thriving are becoming increasingly socially patterned. Evidence shows that strategic investments in early childhood are imperative for averting the onset of health challenges and mitigating their societal impacts.⁷ Yet Australian children on a persistently disadvantaged trajectory over early childhood have a seven-fold increased risk of having poorer outcomes in multiple developmental domains by late childhood, compared with the most advantaged children.⁸

Although it might seem an unachievable goal, with the right political will and resource commitments, Australia could close the child equity gap within a generation. Perhaps more than any other time in the past decade, current federal and state agendas align with this aspiration, with the latest intergenerational report underscoring the need for urgency.⁴ Responding to current policy interests can inform priority areas and the intervention levers that could be considered. Some existing Australian policy interests include: Early Years Strategy,⁹ National Framework for Protecting Australia's Children,¹⁰ Entrenched Disadvantage Package,¹¹ National Children's Mental Health and Wellbeing Strategy,¹² and Early Childhood Education and Care agendas.¹³

This article suggests a path forward that draws on the critical thinking of multidisciplinary leaders (across economics, health, education, social care, legislation and policy) and converges on key themes of “thinking and doing” that can and should inform the early years policy and research agenda for Australia. These collaborations are essential if Australian governments are prepared to deliver on closing the equity gap with the level of urgency required.

Radical pragmatism — “a willingness to try whatever works, guided by an experimental mindset and commitment to empiricism and measuring results”¹⁴ — suggests the need to test and responsively change course as knowledge evolves. The coronavirus disease 2019 (COVID-19) pandemic has shown us that radical change is possible at speed and scale, especially with political will during a time-sensitive period. Australian governments organised the development and distribution of vaccines, distributed payments to people to keep their jobs, doubled the basic income, housed the homeless, and provided access to telehealth across the country.¹⁵ This was possible because political leaders applied bipartisan political will to a crisis, allocated sufficient resourcing to move at pace, listened to community where needed and were prepared to fail and learn from these failings for the greater good of the population.

Researchers and policy makers need to stop focusing on only measuring the problem and start engaging in radically pragmatic approaches to policy and service delivery to address child inequities.¹⁴ Research has identified a range of promising early childhood interventions that are already delivered within existing Australian infrastructure and resourcing. For example, antenatal care, sustained nurse home visiting, early childhood education and care, parenting programs and the early years of school have individually been shown to have a positive impact, when delivered well.^16-18 But their mutual and cumulative benefits are rarely considered in their design or delivery.¹⁷ A commitment to experimenting at speed will help identify new solutions to fill policy and service gaps. Governments need approaches that: (i) can move at speed; (ii) can scale when needed; (iii) are co-designed; and (iv) are driven and monitored or evaluated by data and evidence.

Achieving impact at the scale needed will require a coordinated approach that carefully considers the determinants that children need to thrive, both upstream (social determinants) and downstream (services and strategies),^{17, 19} as well as collaborative efforts to address systemic barriers and mobilise resources (Box 1). This will be challenging to achieve and requires long term commitment, but with an actionable agenda grounded in the ideas of radical pragmatism, anything is possible.

Even excellent single early childhood intervention approaches are insufficient alone to overcome inequities.^{17, 20} Truly closing the equity gap requires moving beyond the silver bullet thinking that remains pervasive in the traditional research and policy paradigm and stepping into complexity. To address the intricacy of inequity, there is a need for similarly complex intervention approaches. Combining or stacking multiple complementary cross-portfolio interventions in the early years, including those addressing the structural determinants of health, that involve federal, state or territory, and local governments, is essential for reducing child inequities and improving outcomes.^{17, 20-23} This should be a relatively straightforward selection of interventions that researchers and policy makers know work, as well as better use of existing education, health and social infrastructure to purposefully redress inequities (Box 2). Grounding this approach in principles of proportionate universalism will ensure the benefits of a universal service base while enabling tailoring to ensure the scale and intensity is proportionate to the level of need, as is required to effectively address inequities.²⁴

The stack must: (i) achieve the greatest impact; (ii) be carefully considered across the life course; (iii) maximise existing resources and expenditure where possible; (iv) use data and indicators to drive system change; (v) enable rapid implementation through well resourced and agile co-design processes; and (vi) stack all the way through the ecological path (ie, from individual through to policy change). There is much to be learned from innovative place-based and community-driven programs that are already putting these principles into practice through integrated service delivery programs with promising results, for example: Sure Start²⁵ and Born in Bradford's Better Start²⁶ (both United Kingdom), Head Start²⁷ (United States), Better Beginnings, Better Futures²⁸ (Canada), and Communities for Children²⁹ (Australia).

Robust data systems and high quality key indicators are paramount to informing more precise and effective approaches to identifying, addressing and monitoring inequities. In Australia, there is increasing interest and investment in linking administrative data across diverse sectors. Linked administrative data assets, such as the Australian Government Personal-Level Integrated Data-Asset (PLIDA),³⁰ the upcoming Life Course Data Initiative³¹ and the National Disability Data Asset,³² provide a time- and cost-efficient opportunity to generate actionable policy-relevant evidence. However, key data gaps (including limited data on the family environment, child outcomes and some priority population groups) as well as limitations surrounding data accuracy, completeness and timeliness can hinder our understanding of where and how to allocate resources to effectively address inequities.

There are opportunities to stack data sources by linking administrative data with well designed epidemiological studies collecting robust information that is not feasible to obtain through administrative data. The Longitudinal Study of Australian Children, which has been following the development of 5107 infants since May 2004,³³ is an example of a population representative cohort that has been enhanced through significant data linkage. A recent example is Generation Victoria (GenV), a prospective whole-of-state multipurpose birth and parent cohort that began in October 2021;³⁴ over 120 000 babies and parents have been recruited to date. GenV is representative of the state of Victoria, and thus, in most respects, Australia. Enhanced through extensive linkage to state and federal administrative data, GenV will have the richness and breadth of information needed to support the evaluation of policy-relevant stacked interventions across the child's entire ecological system.

When combined with innovative causal analytic approaches, these kinds of data can be used to robustly test interventions that may not be timely, ethical, or feasible to test in the real world. It is important to consider how these types of data can be more widely shared to foster intersectoral collaboration and engage political and community leaders, advocates, researchers and service users, who are paramount to the conceptualisation and delivery of the stacked approach.

The agenda for children needs reframing. It is clear that almost anything can be achieved with sufficient resources alongside community and political will. About 72 000 Australian babies are born into adversity every year³⁵ and their chance of a long, healthy and productive life is reduced. Children being born today should have more equitable adult outcomes than their parents, not less. There is a sense of urgency and momentum among researchers and policy makers. But there is also a sense of purpose. The time to act is now.

No relevant disclosures.

Not commissioned; externally peer reviewed.