Former Yugoslav Republic of Macedonia SABER Country Report EARLY CHILDHOOD DEVELOPMENT 2015 Policy Goals Status 1. Establishing an Enabling Environment Preprimary attendance is not mandatory, and the preprimary enrollment rate is low. Given the importance of early childhood education for the country’s economic growth and social wellbeing, the government should prioritize increasing enrollment in quality preschool programs. The legal framework mandates a number of free essential health services for pregnant women and young children. Intersectoral coordination mechanisms may not be adequate to provide integrated and efficient services for children. Finance systems do not allow for tracking spending on ECD services. New preprimary education financing mechanisms will need to be developed to fund increased enrollment. 2. Implementing Widely Macedonia has established many essential health, education, child protection, and social protection programs. The scope of nutrition programs could be expanded. Coverage rates for ECD interventions are fairly high, with the notable exception of preprimary enrollment. There is generally equity in access to health services, but in the education sector, poorer children attend preprimary school at far lower rates than wealthier children. Few children in rural areas and Roma settlements attend preschool. Efforts to increase enrollment among marginalized populations could reduce economic and social inequality. 3. Monitoring and Assuring Quality Macedonia collects a number of important administrative and survey data. It has established professional requirements for ECCE personnel, as well as service delivery and infrastructure standards. It could consider augmenting a few of its standards to bring them in line with international best practice. There is a high level of compliance with existing standards. MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 This report presents an analysis of the Early Childhood High quality preprimary education plays a key role in Development (ECD) programs and policies that affect developing a country’s human capital at the most rapid young children in Macedonia and recommendations and crucial phase of human development, when to move forward. This report is part of a series of reports investments yield the highest returns. It is particularly prepared by the World Bank using the SABER-ECD important for the social and economic wellbeing of framework 1 and includes analysis of early learning, children from poor and marginalized families. A study of health, nutrition and social and child protection policies early childhood interventions among extremely and interventions in Macedonia, along with regional and disadvantaged Jamaican children found that children who international comparisons. participated earned 25% more as adults than other disadvantaged children who did not participate, putting their earnings on par with advantaged children. Given the Macedonia and Early Childhood importance of preprimary education for a country’s Development economic growth and social well-being, the GoM could consider ways to increase preprimary attendance in the The Former Yugoslav Republic of Macedonia is a country country. Both demand side and supply side interventions of 2.1 million people in the Balkan peninsula of Europe. It may be necessary to increase preprimary attendance. is an upper middle income country, with a gross national income per capita, Atlas method, of $4870 in 2013. The ECD environment in Macedonia is strong in the health According to World Bank World Development Indicators, sector, with free basic services reaching much of the in 2010 the poverty headcount ratio was 27.1%, meaning population. One way to further strengthen health and 27.1% of the population lived below national poverty nutrition would be to increase the rate of exclusive lines. Macedonia ranked 84th out of 187 countries in the breastfeeding, which is fairly low. Child protection and 2013 Human Development Index, and UNDP considers it social protection services are generally well established. in the high human development category. Population Intersectoral coordination may not provide the integrated growth is flat. services that children need, and the country lacks a strong The country has established many elements of a strong finance tracking system for ECD. Data collection is preprimary education system, including professional generally good. When an ECD policy is put in place in requirements for educators, and service delivery and Macedonia, it is generally implemented well. infrastructure standards. However, less than one-fourth of children in Macedonia are enrolled in preprimary school. Among Roma children, the enrollment rate is only 4%. A mere .4% of children from the poorest quintile are enrolled in a preprimary program. Rates in neighboring countries are substantially higher. Low preschool enrollment is deleterious for Macedonia’s long-term economic development. 1SABER-ECD is one domain within the World Bank initiative, Systems Approach for Better Education Results (SABER), which is designed to provide comparable and comprehensive assessments of country policies. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 1 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Table 1: Snapshot of ECD indicators in Macedonia with regional comparison Macedonia Albania Bulgaria Croatia Montenegro Serbia Under-5 mortality rate (U5MR) 7 17 12 5 6 7 Infant mortality rate (under 1) 7 15 11 4 6 6 Exclusive breastfeeding <6 months (%), 23 38.6 No data No data 19 13.7 2008-2012* Stunting (%) 2008-2012*, moderate & 4.9 19 No data No data 7 6.6 severe Immunization coverage (%) DPT3 96 99 95 96 94 91 Birth registration (%) 2005-2012 99.7 98.6 No data No data 99 98.9 Attendance in early childhood education 21.8 39.8 79 No data 29.1 43.8 (%) 2005-2012 Source: UNICEF, 2013 Systems Approach for Better Education to address all three goals. As described in Figure 1, for Results – Early Childhood Development each policy goal, a series of policy levers are identified, through which decision-makers can strengthen ECD. (SABER-ECD) Strengthening ECD policies can be viewed as a SABER – ECD collects, analyzes and disseminates continuum; as described in Table 2 on the following comprehensive information on ECD policies around the page, countries can range from a latent to advanced level world. In each participating country, extensive of development within the different policy levers and multisectoral information is collected on ECD policies goals. and programs through a desk review of available government documents, data and literature, and Box 1: A checklist to consider how well ECD is interviews with a range of ECD stakeholders, including promoted at the country level government officials, service providers, civil society, What should be in place at the country level to promote development partners and scholars. The SABER-ECD coordinated and integrated ECD interventions for young framework presents a holistic and integrated assessment children and their families? of how the overall policy environment in a country Health care affects young children’s development. This assessment x Standard health screenings for pregnant women can be used to identify how countries address the same x Skilled attendants at delivery policy challenges related to ECD, with the ultimate goal x Childhood immunizations of designing effective policies for young children and x Well-child visits their families. Nutrition x Breastfeeding promotion Box 1 presents an abbreviated list of interventions and x Salt iodization policies that the SABER-ECD approach looks for in x Iron fortification countries when assessing the level of ECD policy Early Learning development. This list is not exhaustive, but is meant to x Parenting programs (during pregnancy, after delivery and throughout early childhood) provide an initial checklist for countries to consider the x High quality childcare for working parents key policies and interventions needed across sectors. x Free preprimary school (preferably at least two years with developmentally appropriate curriculum and Three Key Policy Goals for Early Childhood classrooms, and quality assurance mechanisms) Development Social Protection SABER-ECD identifies three core policy goals that x Services for orphans and vulnerable children countries should address to ensure optimal ECD x Policies to protect rights of children with special needs outcomes: Establishing an Enabling Environment, and promote their participation/ access to ECD services Implementing Widely and Monitoring and Assuring x Financial transfer mechanisms or income supports to Quality. Improving ECD requires an integrated approach reach the most vulnerable families (could include cash transfers, social welfare, etc.) SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 2 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Child Protection Figure 1: Three core ECD policy goals x Mandated birth registration x Job protection and breastfeeding breaks for new mothers x Specific provisions in judicial system for young children x Guaranteed paid parental leave of least six months x Domestic violence laws and enforcement x Tracking of child abuse (especially for young children) x Training for law enforcement officers in regards to the particular needs of young children Table 2: ECD policy goals and levels of development Level of Development ECD Policy Goal Minimal legal Regulations in some Developed legal Non-existent legal Establishing framework; some sectors; functioning framework; robust inter- framework; ad-hoc an Enabling programs with sustained inter-sectoral institutional financing; low inter- Environment financing; some inter- coordination; sustained coordination; sustained sectoral coordination. sectoral coordination. financing. financing. Universal coverage; Coverage expanding but Near-universal coverage Low coverage; pilot comprehensive gaps remain; programs in some sectors; Implementing programs in some strategies across sectors; established in a few established programs in Widely sectors; high inequality integrated services for sectors; inequality in most sectors; low in access and outcomes. all, some tailored and access and outcomes. inequality in access. targeted. Information on Information on Information on outcomes at national, Minimal survey data outcomes from national outcomes at national regional and local levels; Monitoring available; limited to individual levels; level; standards for standards for services and Assuring standards for provision standards exist for all services exist in some exist for most sectors; Quality of ECD services; no sectors; system in place sectors; no system to system in place to enforcement. to regularly monitor and monitor compliance. regularly monitor enforce compliance. compliance. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 3 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 immunized. For the poorest quintile, 92.7% of children Policy Goal 1: Establishing an Enabling were fully immunized. The rate is 89.2% for children in Environment Box 2: Brazil’s Campaign to Promote Breastfeeding ¾Policy Levers: Legal Framework • Intersectoral Brazil’s campaign to promote breastfeeding is an example of Coordination • Finance successful effort to change public perceptions and An Enabling Environment is the foundation for the design healthcare practices, resulting in significant increase in and implementation of effective ECD policies 2 . An breastfeeding. The campaign was initiated in 1980 by the enabling environment consists of the following: the National Food and Nutrition Institute. UNICEF and the Pan- American Health Organization helped to develop public existence of an adequate legal and regulatory framework awareness materials that addressed the lack of informational to support ECD; coordination within sectors and across materials on breastfeeding in Portuguese. Instructional institutions to deliver services effectively; and, sufficient brochures were widely distributed to mothers. A media fiscal resources with transparent and efficient allocation campaign featured radio, television, and print media spots; mechanisms. and endorsements by well-known personalities. The WHO and UNICEF held training courses on breastfeeding for Policy Lever 1.1: healthcare workers and managers, and the Baby Friendly Hospital Initiative was widely implemented to initiate early Legal Framework feeding. A coalition of numerous actors helped make the The legal framework comprises all of the laws and campaign a success. The Catholic Church, mothers groups, regulations which can affect the development of young associations of medical professionals, community leaders, children in a country. The laws and regulations which politicians, and the media were all engaged in the effort. The impact ECD are diverse due to the array of sectors which exclusive breastfeeding rate rose from 3.6% in 1986 to 40% influence ECD and because of the different constituencies in 2006. that ECD policy can and should target, including pregnant Key recommendations for Macedonia: women, young children, parents, and caregivers. 9 Develop and disseminate Macedonian and Albanian National policies and services promote healthcare for language materials on the benefits of breastfeeding for pregnant women and young children, but aspects could a variety of audiences. These could include training be strengthened. National health insurance covers materials for healthcare workers, awareness pamphlets primary care services, including prenatal care. Guidelines for community leaders and NGOs, and instructional adopted by the Ministry of Health (MoH) recommend ten brochures for mothers. antenatal visits for first pregnancies, and seven visits for 9 Train healthcare workers to educate mothers on the benefits of breastfeeding, and to support them to subsequent pregnancies. These visits are free if they are initiate and maintain the practice provided by primary health care providers. Women are 9 Engage the support of the media, NGOs, women’s also guaranteed free hospital deliveries. Pregnant associations, health workers, etc. women are not routinely screened for HIV and STDs. (Source: Implementation of Breastfeeding Practices in Brazil: Standard screenings and referrals to treatment could http://www1.paho.org/English/DD/PUB/NutritionActiveLife help prevent mother-to-child transmission of these -ENG.pdf ) diseases. Policies and services promote healthcare for young children. A comprehensive vaccination program and Roma settlements. regular well-child visits are important components of healthcare for young children, and both are established The Program of Health and Protection of Mothers and in Macedonia. Young children are required to receive a Children covers regular well-child visits. Visits are full course of immunizations. The Ministry of Health scheduled for children at ages three, six and nine Immunization Program provides free immunizations for months; and two and four years. children age 0-18, with most of the immunizations given in the first two years of life. Immunization guidelines are The GoM could do more to improve the nutritional updated annually. According to MICS, 100% of children status of pregnant women and young children. Good age 18-29 months from the wealthiest quintile were fully nutrition is critical for child health and brain 2 Brinkerhoff, 2009; Britto, Yoshikawa & Boller, 2011; Vargas-Baron, 2005 SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 4 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 development. The National Breastfeeding Committee is can be an effective way to increase consumption of key established within the MoH, and officially the nutrients. government promotes breastfeeding. According to the International Baby Food Action Network, in 2006 few Several policies protect pregnant women and provide provisions of the International Code of Marketing of mothers opportunities for adequate caregiving. Breastmilk Substitutes were law in Macedonia. The Code According to the International Labor Organization is an international health policy framework adopted by database, pregnant women in Macedonia cannot WHO. According the UNICEF, the rate of exclusive perform overtime work. The Labor Relations Act breastfeeding up to six months from 2008-2012 was prohibits the dismissal of pregnant women. The Labor 23%. The rate is higher in Roma settlements, at 32.1%. Relations Act, Article 165 mandates at least 270 days of Given the many benefits of breastfeeding, the GoM paid maternity leave for women working in both the could consider taking additional steps to promote the public and private sectors. Mothers of twins can take one practice given the relatively low rate of exclusive year of leave. There is no paid or unpaid paternity leave, breastfeeding in the country. See Box 2 for an example but mothers who do not use their full leave can transfer Table 3: Regional comparison of maternity and paternity leave policies Macedonia Albania Greece Serbia 270 paid days of maternity leave 1 year maternity leave at 80% 119 days maternity leave at 1 year maternity leave at 100% at 100% wage. No paid or wage up to 150 days, 50% 100% wage, paid by social wage for first and second unpaid paternity leave. wage thereafter, paid by social security and state. Two days children, paid by social security. No paid paternity paid paternity leave. security. Fathers can use 7 leave. paid days of family leave per year. Source: ILO, 2012; World Bank Women, Business and the Law database of a successful campaign to increase breastfeeding rates their leave time to the father. in Brazil. Employers must provide nursing breaks for Both stunting and obesity are health issues confronting breastfeeding mothers with a child below age one, but Macedonian children. According to UNICEF, 16.5% of they are not required to provide facilities for children in Roma settlements are moderately or severely breastfeeding. Pregnant women and new mothers are stunted, while 4.9% of the country’s children are stunted. protected from employment discrimination, but there is Twelve percent of children under age five in Macedonia no law requiring employers to give women returning are overweight. from maternity leave equivalent positions to what they held when they went on leave. Parents of handicapped Salt iodization is mandatory as of 1999. This is an children are entitled to three additional days of annual inexpensive and effective way to improve public health. leave. There is no national policy to encourage fortification of staples such as wheat and rice. According to the WHO Preprimary education is not mandated, and enrollment Database on Anemia 1999-2005, 25.8% of preschool age is low. According to the Primary Education Law, primary children and 31.8% of pregnant women in Macedonia education is compulsory and free at public schools. have anemia. This constitutes a moderate public health Primary school begins at approximately age six. There is problem according to WHO definitions. While the figure no guarantee of any free public education services for is somewhat outdated, this level of prevalence warrants children age five and below. attention from the government. Anemia can have adverse health effects: mild anemia may impair work According to UNESCO, the gross preprimary enrollment productivity, and severe cases can increase risk of child rate in Macedonia in 2012 was 28.6%. In 2007 the gross and maternal mortality. Encouraging or mandating iron enrollment rate was 38.5%, but the year after it dropped fortification of staples with iron and other micronutrients down to 22.3%, when a new policy required children to enroll in primary school at age six. The enrollment rate SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 5 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 has not yet risen to the levels it reached in the mid- multisectoral national body within the MoLSP with 2000s. MICS 2011 data show vast differences in support from WHO. Teachers, health workers, social enrollment rates for children from the wealthiest workers, and police are trained in identifying abuse and families and those from the poorest and most neglect. A taskforce for domestic violence prevention is marginalized. The enrollment rate is more than six times established, as are child abuse tracking and reporting higher in urban areas (37.2%) than rural areas (5.9%). activities. Only 2.6% of four year olds in Roma settlements attend preschool programs. Absence of preprimary institutions, Macedonia’s judicial systems has several measures in fees that are unaffordable, and traditional gender norms place to protect children. The Academy for Judges and may account for these low enrollment rates. Public Prosecutors conducts continuous professional training for legal professionals. UNICEF supports the The regional average gross enrollment rate in preprimary Academy to build the capacity of judges, prosecutors and education in Central and Eastern Europe was 74% in lawyers on issues related to family violence. The country 2012—far higher than the rate in Macedonia. Even has a list of lawyers who are trained to work with minors. among its neighbors, Macedonia’s rate is low. (See Table A specialized court for children does not exist. 4.) This low rate may have negatives consequences for students’ future academic success. On PIRLS 2006, which A number of social protection policies and services are assesses children in the fourth year of formal schooling in place. The Social Protection Law requires the on a range of reading comprehension strategies, fewer government to provide housing for orphans and children children (55%) reached the lowest benchmark in without parental care. This is largely provided through Macedonia than all neighboring and EU countries which two public institutions: Children ages 0-3 years old live in participated. On the TIMSS assessment of grade 8 one facility, and children ages 3-18 live in another facility. mathematics and science, Macedonia did significantly In 2012, a total of 238 children lived in these institutions; worse between 1999 and 2011 e.g. the average 38.6% of those children were age six or below. In mathematics score fell from 447 to 426, with no other addition to housing, orphans receive food, healthcare, European country scoring lower. The proportion of and education until age 18. The National Strategy for Macedonian students who achieve the minimum Deinstitutionalization in the Social System 2008-2018 standard (the ‘low international benchmark’) fell from 70 aims to reduce the number of children in institutional to 61% in mathematics and from 73 to 53% in science. care by increasing the number of foster families and Investment in quality early childhood education can providing continuous support to families. improve returns on investments in primary and secondary education—making it a wise use of a The Child Protection Law protects the rights of children government’s limited resources. with disabilities and promotes their participation in ECD services. The law defines disability as impairments of Table 4: Gross enrollment rates in preprimary vision, hearing, speech, behavior, and physical abilities. education in nearby countries Children with mild disability attend standard educational Macedonia Albania Bulgaria Romania Serbia programs, with an individualized approach. Children with 28.6% 70.6% 85.7% 77.4% 58.4% severe disabilities attend special education programs. Source: UNESCO, 2012 Child protection policies and services are established. By law births must be registered within 15 days after delivery, and birth data are collected by the government statistics office. The policy is effective, with birth registration at 99.7% according to UNICEF. In 2012, the Ministry of Labor and Social Policy (MoLSP) issued the National Strategy for Prevention and Protection from Family Violence for 2012-2015. This built upon the first National Strategy for Family Violence Prevention 2008-2011, which was developed by a SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 6 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Key Laws Governing ECD in Macedonia treatment. Vulnerable children may simultaneously experience health, nutrition, cognitive, emotional and x Standards and Norms for Providing ECCE Services Act, 2014 social issues, requiring an integrated network of services. x Labor Relations Act, 2014 Box 3 provides an example of an effective system in Chile x Social Protection Law, 2013 for identifying and delivering integrated services to all x Professional Development for ECD Center young children. Employees Act, 2013 A department within the Ministry of Labor and Social x Child Protection Law, 2013 Policy leads ECD efforts, but it does not coordinate x Health Protection Law, 2013 closely with other ministries. The Department of Child x Health Insurance Law, 2012 Protection within the Ministry of Labor and Social Policy x Legislation Act for Parental Fees for Public Kindergartens, 2003 was appointed to head government ECD efforts in 2011. x Birth Registration Law, 1995 It has staff dedicated to ECD, and is supposed to set policies related to ECD, monitor quality of ECD services, and coordinate across agencies responsible for ECD services. Aside from housing the ECD coordinating body, : Policy Lever 1.2: the MoLSP develops policies to promote child wellbeing Intersectoral through providing economic security for families and Coordination providing early childhood care and education services. Development in early childhood is a multi-dimensional The MoH delivers many services to young children, process.3 In order to meet children’s diverse needs during including providing health services and inspecting early the early years, government coordination is essential, childhood education centers for safety and sanitation. both horizontally across different sectors as well as Services for children with special needs may exist within vertically from the local to national levels. In many both to MoLSP and the MoH, and mechanisms should countries, non-state actors (either domestic or exist for providers to share information and referrals. In international) participate in ECD service delivery; for this many countries, MoH healthcare providers deliver reason, mechanisms to coordinate with non-state actors developmental messages to parents of very young are also essential. children who are not yet old enough to attend preschool. Macedonia has an ECD strategy, but it does not provide It is not clear that mechanisms are in place to ensure a framework for integrated services. The GoM’s ECD strong coordination between the MoH and MoLSP. In strategy is encompassed in the National Action Plan for contrast with many countries, the Ministry of Education Children’s Rights 2006-2015. The strategy covers the plays no role in preprimary education in Macedonia. At sectors of education, health, nutrition, social protection, the very least, coordination between the MoLSP and the and child protection. The plan includes objectives for MoE should ensure that the preprimary curriculum is each sector. In 2007 the National Committee for coherent with the Grade 1 curriculum to ensure that Children’s Rights (NCCR) was established as a children are prepared to begin primary school. governmental body to monitor implementation of the The GoM could consider if responsibility for various age Plan. There is a costed implementation plan. groups is clearly delineated and lies with the most While these are important elements of an ECD strategy, appropriate governmental body. For example, 0-2 year the Plan does not adequately address the need to olds often are under health and social protection provide integrated services to address children’s holistic systems, whereas 3-5 year olds are more likely to be in development. Children often experience multiple health the formal education system and thus the responsibility and developmental delays and need referrals to more of ministries of education. than one service provider to address their needs. For Policies and services in ECD typically involve multiple example, a young child with recurrent ear infections may ministries, necessitating clear coordination mechanisms be at risk for delayed language development. The child’s and delineation of roles to reduce inefficiencies. Figure 2 healthcare provider should have a mechanism to refer depicts ECD coordination at the central level. Box 3 the child to a speech therapist for evaluation and 3 Naudeau et al., 2011; UNESCO-OREALC, 2004; Neuman, 2007 SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 7 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 provides an example of effective ECD intersectoral Box 3: Multisectoral ECD Coordination and Integrated coordination structures established in Chile. Services in Chile Figure 2: Intersectoral Coordination in Macedonia Chile Crece Contigo (“Chile Grows With You”) is an intersectoral ECD program introduced in 200. The multi- disciplinary approach is designed to achieve high quality ECD by protecting children from conception with relevant and timely services that provide opportunities for early stimulation and development. The creation and implementation of the CCC has been accomplished through a multisectoral, highly synergistic approach at all levels of government. At the central level, the Presidential Council is responsible for the development, planning, and budgeting of the program. At each of the national, regional, provincial, and local levels there are institutional bodies tasked with supervision and support, operative action, as well as development, planning and budgeting for each respective level. One of the program’s key accomplishments is the ability to provide timely, targeted service delivery. A core element that makes this possible is the Biopsychosocial Development Support Program, which tracks the individual development of children. The program commences during the mother’s initial prenatal check-up, at which point an online file is created for the child. All of the primary actors within the Chile Crece Contigo comprehensive service network – including family support unit, public health system, public education system, and other social services – have access to the child’s file and are required to update it as the child progresses through the different ECD services. If there is any kind of vulnerability, such as inadequate nutrition, the system identifies the required service to address this issue. Through the integrated approach to service delivery and information system management, these services are delivered at the right time and in a relevant manner, according to each child’s need. Key considerations for Macedonia: 9 Multisectoral policy that articulates responsibilities for each government entity, from the national level to the service delivery level, and coordination mechanisms between those entities. 9 Allows for identification of children experiencing developmental problems, with procedures in place for referrals to services. Macedonia’s child development portfolio system could be expanded beyond education to encompass health, nutrition, and other sectors, and a referral system established. 9 The program covers all children in Chile, not just those enrolled in preschools. (See Policy Lever 3.1, Data Availability.) This ensures that the most vulnerable children receive the services they need. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 8 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Coordination of ECD service delivery could be lasting intergenerational benefits. 4 Not only do strengthened, although some local education investments in ECD generate high and persistent returns, coordination takes place. The government has not they can also enhance the effectiveness of other social established a menu or list of integrated services that investments and help governments address multiple young children should receive. Each year the MoH sets priorities with single investments. goals for coverage of health services such as The health and education sectors use explicit criteria to immunizations, health screenings, and outreach services determine ECD spending, but other sectors do not. for newborns and young children. The targets are then Education financing and delivery are delegated to distributed to health providers. Similar objectives are set municipalities. The MoLSP sends municipalities per for the education and child and social protection sectors. capita block grants for preprimary education institutions These kinds of targets provide a kind of common action on a monthly basis. In 2013 the preprimary education plan for service providers. budget provided by the MoLSP was $19,496,491 USD. Within each preschool, teachers and caregivers meet on The block grants are based on the number of children a monthly basis for planning and coordination. It is not enrolled; criteria such as the children’s background clear that service providers in other sectors meet on a characteristics, such as socio-economic status or special regular basis. Given the holistic nature of children’s needs status, are not considered when allocating development, coordination between service providers funding. Numerous municipalities have no preprimary can help ensure that children experiencing institutions, and therefore receive no funding. This developmental difficulties receive the support they need funding structure serves to reinforce inequalities from health, education, and social workers. between poorer and wealthier areas. In addition to block grants, municipalities collect user fees to fund Coordination between state and non-state ECD service preprimary institutions. The municipalities may not have providers could be strengthened. There is no much incentive to provide expanded spaces in mechanism established to ensure collaboration between preprimary classes. government and non-governmental organizations involved in ECD. In Macedonia, there are a few NGOs Funding to primary care health centers is determined by that provide ECD services. Most of them are active in usage, price per service, and ability to raise revenue at education, children’s rights and disability. Although they the service level. More funding is allocated per service are few in number, NGO coordination with government for children below the age of seven than for older policy makers should be ensured. children. This formula applies to all clinics with contracts with the National Health Insurance Fund. Service Non-state actors can have close knowledge of the provider salaries are intended to cover some preventive situation of young children in their communities, and can care, such as well-child exams and nutrition counseling. share this information with policymakers. Coordination can also help ensure children receive all of the services No explicit criteria are used when setting funding for they need, and that service providers understand nutrition, child protection, or social protection. The use standards and regulations. of criteria and formulas promotes both transparency and efficiency, as it can help ensure that funds go to where : Policy Lever 1.3: they are most needed. The GoM could consider Finance establishing funding formulas for the nutrition, child While legal frameworks and intersectoral coordination protection, and social protection sectors. It could also are crucial to establishing an enabling environment for consider adding children’s background characteristics ECD, adequate financial investment is key to ensure that into funding formulas. This could help ensure that resources are available to implement policies and achieve adequate funding targets children who may need more service provision goals. Investments in ECD can yield resources, for example, those from poor families and high public returns, but are often undersupplied without children with special needs. government support. Investments during the early years Ministries do not coordinate when setting their ECD can yield greater returns than equivalent investments budgets. In many countries, the overall budget for ECD made later in a child’s life cycle and can lead to long- 4Valerio & Garcia, 2012; WHO, 2005; Hanushek & Kimko, 2000; Hanushek & Luque, 2003 SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 9 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 comes from multiple ministries, necessitating families, and no payment for those who cannot afford to mechanisms to coordinate budgeting and allocations pay anything. Due to demographic shifts in the country, among key agencies. At present the ministries and fewer children are projected to enroll in primary school, agencies involved in ECD in Macedonia do not have potentially freeing up some funding and classroom space processes for budget coordination. This can lead to for the preprimary level. inefficient use of resources, with the risk of gaps and overlaps in services. The GoM could consider Fees are sometimes charged for health services, and establishing coordination mechanisms for budget always for early childhood education services. For planning. Before this can occur, ministries need to be people with health insurance, no fees are charged for able to identify their level of ECD spending. many essential health services if they are administered at primary health centers. If services are rendered at The government cannot accurately report ECD specialist centers or at hospitals, fees may be charged. expenditure in all sectors. The health sectors has three The cost is based on a service price list issued by the main programs focused on young children, and the total National Health Insurance Fund. According to the WHO 2013 budget for those programs is available. The MoLSP Global Health Expenditure Database, out of pocket has responsibility for preprimary education, and there is expenditure is 31% of total health expenditure. no budget figure available for how much is spent on this Preventive services for young children are always free. level of education. Child protection expenditure is under the MoLSP general budget, and there is no way to know Legislation requires that all parents with children how much of this is spent on services targeting young enrolled in ECCE services in Macedonia must pay fees. children. The government cannot report ECD spending in (ECCE refers to early childhood care and education e.g. the nutrition and social protection sectors. The GoM daycare and preschools, while ECD refers to early could consider setting up systems to allow for childhood development more broadly.) This includes disaggregation of ECD spending within general budgets. both public and private centers. The fees vary according This will improve both transparency and efficiency. to program duration (full day or half day), and if the child eats meals there. These fees likely deter poor families The level of ECD financing is not known, and may not be and Roma from enrolling their children, as evidenced by adequate to meet the country’s needs. A figure is not the very low enrollment rates among those populations. available for the percentage of Macedonia’s GDP that is spent on ECD. In 2013, total government expenditure on ECCE personnel are remunerated at a lower level than education was 4.1% of the country’s GDP. primary teachers. Kindergarten teachers and administrators are paid less than primary schools While funding alone cannot guarantee a strong ECD personnel, even if they have the same level of education system, a minimum level of investment is required to and experience. The MoE sets primary teacher salaries, ensure quality, coverage, and access. OECD governments and the MoLSP sets preprimary teacher salaries. The spend an average of 2.36% of GDP on ECD services for difference in salary for teachers is approximately 2000 young children and their families. Evidence from OECD MKD (roughly 35 USD) per month. Wages are set studies suggest that a public investment of 1% of GDP is through collective bargaining, and are determined by an the minimum required to ensure provision of quality index using educational background, experience, and early childhood care and education services. position in school. Increased preprimary enrollment will require developing Low wages in the ECCE field can deter talented teachers new funding mechanisms. A UNICEF study on financing from working at that level. Compounded by little training early childhood education Macedonia suggests that and inadequate support, staff turnover can be high at the universal access for four and five year olds may be preprimary level. This is both costly and can be possible in half day programs through a combination of detrimental to children’s learning. The GoM could funding mechanisms. In addition to government, private consider ways to professionalize the sector, which may sector, and donor investment, user fees could be include better pay and training. charged on a sliding scale. This would include charging higher fees than those currently in place for wealthy SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 10 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Community health workers are paid by the government, education. Given the benefits that quality preprimary and community-based childcare workers are paid by education yields for both individuals and society as a NGOs or local communities. These healthworkers could whole, the GoM could study the feasibility of a phased deliver a range of ECD services given their direct approach to require children to attend preprimary interaction with children and families, including school, accompanied by increased classroom availability supporting parents to interact with their children in a and equitable financing models. This could include positive and stimulating manner. starting with five year olds and then gradually expanding coverage to younger children. Target subsidy programs Table 5: Regional comparison of select health for the poor will be necessary. As discussed later on in expenditure indicators5 this report, the GoM already has many elements of a FYRoM Albania Bulgaria Greece Serbia strong ECCE system in place, including established Out-of-pocket learning standards, professional training requirements, expenditure as a percentage of all private 100 100 97 87 96 service delivery and infrastructure standards, and health expenditure monitoring mechanisms. This shows a commitment on Out-of-pocket the part of the government to preprimary education. expenditure as a 31 51 40 26 38 percentage of total health expenditures Intersectoral Coordination: Government expenditure ¾ The GoM could review its ECD structures, policies on health as a percentage of 6 6 8 10 11 GDP and services to determine if services are adequately Routine EPI vaccines integrated and coordinated. Given the holistic nature of financed by government, 100% NA 100% NA NA 2010 children’s development, children with developmental delays often need services from multiple sectors. This Source: WHO Global Health Expenditure Database, 2013; UNICEF MICS, 2012 requires a system with a menu of integrated services and Policy Options to Strengthen the Enabling coordination between service providers at the point of delivery. Environment for ECD in Macedonia Legal framework: ¾ The GoM could establish coordination mechanisms with NGOs working on ECD. Given the close knowledge ¾ The GoM could do more to promote age-appropriate of local communities and large role that NGOs often play breastfeeding given the fairly low rate of the practice. as ECD service providers, regular dialogue and Breastmilk provides nutrients and antibodies essential information exchange between the government and civil for babies’ development that are not found in milk. society actors can improve efficiency and quality. Breastfeeding confers a number of near term and long term benefits. Public awareness on the importance of Finance: the practice and support for new mothers may be necessary, in addition to adopting all provisions of the ¾ The GoM could establish ECD budget coordination International Code of Marketing of Breastmilk mechanisms across government bodies, and gradually Substitutes. increase financing for ECD. Lack of coordination in budget planning can result in gaps in services and ¾ To address anemia and improve nutrition, the GoM inefficient use of scarce resources. Additionally, budget could mandate iron fortification of staples. Iron coordination processes can improve intersectoral fortification is an inexpensive way to improve nutritional coordination in general. Both the central government intake across the population, increasing the likelihood and municipal levels should increase the level of ECD the pregnant women and young children receive financing. adequate iron. ¾ The GoM could establish systems to allow for ¾ The GoM could develop a phased approach to identification of ECD spending across sectors. Currently transition toward universal and mandatory preprimary it is not possible to determine the level of ECD spending 5 Out of pocket expenditure is any direct outlay by households, including whose primary intent is to contribute to the restoration or enhancement of gratuities and in-kind payments, to health practitioners and suppliers of the health status of individuals or population groups. pharmaceuticals, therapeutic appliances, and other goods and services SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 11 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 in Macedonia. Knowledge of what is being spent in each which ECD programs across key sectors reach all sector is essential for program planning and evaluation, beneficiaries. Figure 3: Essential interventions during different periods of young children's development and is a key component of a strong finance system. Figure presents a summary of the key interventions needed to support young children and their families via Policy Goal 2: Implementing Widely different sectors at different stages in a child’s life. ¾ Policy Levers: Scope of Programs • Coverage ECD programs are established to benefit all relevant •Equity beneficiaries in Macedonia, although more could be Implementing Widely refers to the scope of ECD done to target parents. Interventions are established programs available, the extent of coverage (as a share of that serve pregnant women, young children, and parents the eligible population) and the degree of equity within and caregivers. As shown in Figure 4, programs targeting ECD service provision. By definition, a focus on ECD parents are limited to cash benefits. The GoM could involves (at a minimum) interventions in health, consider expanding programs for parents to include nutrition, education, and social and child protection, and sharing message on young children’s development and should target pregnant women, young children and their positive parenting. Programs to improve the quality of parents and caregivers. A robust ECD policy should parent-child interactions can significantly improve include programs in all essential sectors; provide outcomes for children, both in cognitive and social skills. comparable coverage and equitable access across These kinds of messages can be delivered through home regions and socioeconomic status – especially reaching visits, healthcare workers, or at community centers. the most disadvantaged young children and their While a range of programs is established, coverage rates families. for some are low. : Policy Lever 2.1: Scope of Programs Macedonia has established many essential health Effective ECD systems have programs established in all programs, and could consider adding maternal essential sectors and ensure that every child and depression programs. Important healthcare services are expecting mothers have guaranteed access to the provided to pregnant women and young children. The essential services and interventions they need to live GoM could consider establishing maternal depression healthfully. The scope of programs assesses the extent to screening and treatment. Emerging evidence suggests that maternal depression is common in low and middle SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 12 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 income countries. It can interfere with bonding and attachment, and can have a long-term impact on a child’s cognitive and emotional development. The scope of nutrition programs could be expanded. Currently interventions to improve nutrition are limited to breastfeeding promotion and mandatory salt iodization. These could include fortification of food staples with iron and other nutrients, micronutrient support for pregnant women and young children, food supplements for pregnant women and young children, feeding programs at ECCE centers, and healthy eating and exercise programs to prevent obesity. Several different types of early childhood education programs and child and social programs exist. ECCE program modalities include full and half-day public programs, private programs, and community-based programs. Most children in public preschools attend full day programs, combining care and early learning services. Community-based programs typically target children ages 3-6, and focus mainly on early learning. A range of child and social protection programs support orphans and vulnerable children, children with special needs, and provide cash assistance to some families. Key programs in Macedonia are summarized in Table 6. The table indicates that while a range of ECD interventions exist, coverage is not always universal. Figure 4: Scope of ECD interventions in Macedonia by target population and sector SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 13 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Table 6: ECD programs and coverage in Macedonia ( 9= service exists, X=service does not exist; service may exist but coverage rate may be unknown) Scale ECD Intervention Service is provided Universal coverage Education State-sponsored preprimary/kindergarten education 9 X State-sponsored ECCE 9 X Community-based ECCE 9 X Health Antenatal and newborn care 9 9 Integrated management of childhood illnesses and care for development X Childhood wellness and growth monitoring 9 Not known National immunization program 9 9 Nutrition Micronutrient support for pregnant women X Food supplements for pregnant women X Micronutrient support for young children X Food supplements for young children X Food fortification X Breastfeeding promotion programs X Anti-obesity programs encouraging healthy eating/exercise X Feeding programs in preprimary/kindergarten schools X Parenting Parenting integrated into health/community programs X Home visiting programs to provide parenting messages X Special Needs Programs for OVCs (Boarding schools & children’s homes) 9 Not known Interventions for children with special (emotional and physical) needs 9 Not known Anti-poverty Cash transfers conditional on ECD services or enrollment X Comprehensive A comprehensive system that tracks individual children’s needs X Macedonia occur without a skilled attendant present. It Policy Lever 2.2: : is not known how many women who are HIV positive Coverage receive antiretroviral therapy to prevent mother-to-child transmission. A robust ECD policy should establish programs in all essential sectors, ensure high degrees of coverage and Access to essential health interventions for young reach the entire population equitably–especially the children is generally high, but more data are needed to most disadvantaged young children–so that every child assess fully. Nearly all one year olds in Macedonia are and expecting mother have guaranteed access to immunized for DPT, an indicator of the success of the essential ECD services. national immunization program. Seventy-four percent of children with suspected pneumonia receive antibiotics, Pregnant women have access to essential health suggesting the need for better access to primary interventions. Ninety-four percent of women receive at healthcare services for some families. Two data points least four prenatal care visits. Very few births in used in SABER-ECD to assess health access for young SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 14 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 children are not available for Macedonia: the vitamin A Table 8: Regional comparison of level of access to supplementation coverage rate, and the number of essential nutrition services for young children and children who sleep under an insecticide-treated net pregnant women (which is not applicable in Macedonia given that malaria Macedo Albania Bulgaria Greece Romania nia is generally not found there). Table 7 shows health access Children below 5 with in Macedonia and other regional countries. moderate/severe 4.9% 19% NA NA 13% stunting Table 7: Regional comparison of level of access to Infants exclusively breastfed until 6 23% 38.6% NA NA 16% essential health services for young children and months of age pregnant women Infants with low birth 5.5% 3.6% 8.8% NA 8% Macedo weight Albania Bulgaria Greece Romania nia Prevalence of anemia 1-year-old children 31.8% 34% 29.7% 18.6% 30% in pregnant women immunized against DPT 96% 99% 95% 99% 89% Prevalence of anemia (corresponding vaccines: DPT3ß) in preschool-aged 25.8% 31% 26.7% 12.1% 39.8% Children below 5 with children diarrhea receive oral Source: UNICEF Country Statistics, 2012; WHO Global Database on 62% 54% NA NA NA rehydration/ continued Anemia feeding Children below 5 with suspected pneumonia Coverage of preprimary education is low. As discussed 92.7% 69.6% NA NA NA taken to healthcare in Policy Lever 1.1, Legal Framework, the gross provider enrollment rate in preprimary education is low, at 21.8%. Pregnant women receiving antenatal In 2012 the Statistical Office recorded 26,885 children 93.9% 66.8% NA NA 76% care (at least four enrolled in public ECCE centers. In 2013 there were 179 times) accredited public ECCE centers and five accredited Source: UNICEF Country Statistics, 2012 private for-profit ECCE centers. See Box 4 for a description the ECCE system in France, which has achieved universal attendance through a variety of Access to some nutrition interventions could be heavily subsidized service provisions. improved; other indicators suggest relatively good nutritional status. The rate of exclusive breastfeeding Birth registration is universal. Macedonia’s birth until six months is 23%. As discussed in Policy Lever 1.1, registration policy has been successful at achieving Legal Framework, breastfeeding is a key nutrition universal birth registration. Table 9 shows birth intervention to improve children’s health and registration in Macedonia and other regional countries. development, and efforts should be taken to increase the breastfeeding rate. Rates of low birthweight and stunting Table 9: Regional comparison of level of access to birth are relatively low, but anemia rates among young registration children and pregnant women could be addressed. Table Macedo Albania Bulgaria Greece Romania 8 shows nutrition access in Macedonia and other nia countries in the region. Birth registration 99.7% 98.6% 100% 100% NA Source: UNICEF Country Statistics, 2012 SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 15 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 skilled attendants when delivering (97.2% versus 92.4% Box 4: Universal preprimary enrollment in France: France invests considerably in childcare and education for the poorest quintile). As shown in Figure 5, there are services in the years preceding formal school entry and small differences in access to ECD services in urban and has achieved remarkable success in terms of providing rural areas. The rate of skilled attendants at births in equal opportunities for children. Publicly funded early urban areas is 97.2%, and 95.4% in rural areas. The rate childhood education is well established and has a long of improved sanitation facilities is 97% in urban areas, history in France. Children have a legal right to a place versus 83.1% in rural areas. in a preschool from the age of 3. Although enrollment is not required, nearly all children attend. The gross Figure 5: Access to services by urban and rural location enrollment rate in preprimary education in 2012 was 109.8%, according to UNESCO. The école maternelle is the dominant institutional form of ECE provision for children aged 3 years to school entry age. There are also a number of other forms of services outside the education system, particularly for children under 3 years of age. Publicly subsidized services include: childcare centers, parent co- operatives, kindergartens providing flexible childcare services, family day cares and family crèches. Furthermore, a number of other innovative services have been established with the aim to provide equitable access in rural and urban areas, including mobile services and parent-child drop-in centers. Preschool educators are generally trained at the same level and in the same training institutions as primary teachers. France provides generous family benefits, Young children’s opportunities for learning vary by allowing parents to choose the type of childcare facility economic status. In contrast with access to health they think best for their child and to reduce their services—which are fairly similar across socio-economic professional activities in order to have adequate time to care for their children. status and geographic areas—there are large disparities in home learning environments between the wealthiest Key recommendations for Macedonia: and poorest households. This is made clear in Figure 6. 9 Consider expanding preprimary education More than 80% of young children in the wealthiest through a variety of formal and informal ECCE quintile have at least three children’s books in their modalities to meet families’ and communities’ homes, whereas only 18% of children in the poorest varying needs. quintile have at least that many books. In the top income quintile, 96% of children age 3-5 experience adult support for learning, versus 81% of children in the : Policy Lever 2.3: bottom quintile. Adult support for learning includes Equity activities such as reading books, telling stories, singing, Based on the robust evidence of the positive effects ECD counting, naming objects, playing with the child, and interventions can have for children from disadvantaged taking the child for a walk. backgrounds, every government should pay special attention to equitable provision of ECD services6. One of The starkest difference is in attendance in early the fundamental goals of any ECD policy should be to childhood education. Virtually no children in the poorest provide equitable opportunities to all young children and quintile (only .3%) attend preprimary school, whereas their families. more than half (55.9%) of the wealthiest children do. There are few disparities in access to health services These figures suggest that Macedonia’s poor children between rural and urban areas and by economic status. face multiple disadvantages: they are not enrolled in Women in the top quintile are slightly more likely to have preschool, and their home environments do not facilitate learning as much as wealthier children’s home 6 Engle et al, 2011; Naudeau et al., 2011 SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 16 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 environments do. These children stand to benefit the Policy Options to Implement ECD Widely in most from attending quality early childhood education programs, as inequalities tend to increase over time. Macedonia Investing in early stimulation and education programs for Scope of Programs the most disadvantaged children is an effective and cost- ¾ The GoM could consider establishing programs to efficient strategy to address inequality. identify and treat maternal depression. Maternal depression is common and can be deleterious to Figure 6: Opportunities for learning by economic status children’s development. It is also treatable, sometimes through home visiting and community support programs. Interventions to support mothers with the stresses of caring for young children and programs to identify and treat depression can yield high returns. ¾ The scope of nutrition programs could be expanded. Several additional types of nutrition interventions could be established, such as fortification of food staples with iron and other nutrients, micronutrient support for pregnant women and young children, food supplements for pregnant women and young children, feeding programs at ECCE centers, and healthy eating and exercise programs to prevent obesity. Coverage The Inclusion of Roma Children in Preschool Program is a step towards addressing inequity among marginalized ¾ The GoM could study reasons for relatively low groups. In many European countries, the Roma have enrollment in preschool. Given the substantial benefits substantially lower socio-economic, education, and that quality preprimary education can have for health status than non-Roma citizens. The Ministry of individuals and society over the long term, the GoM Labor and Social Policy established the Inclusion of Roma could study reasons for the low attendance rate in ECCE, Children in Preschool Program in 2006 with support from and come up with strategies to address these. Barriers the Roma Education Fund and UNICEF. Implemented may be both on the demand side and the supply side. with the cooperation of local NGOs, Roma children age Strategies may include public awareness on the 4-6 attend preprimary education with the aim of importance of preprimary education, more preprimary preparing them for successful inclusion in public primary programs, and measures to address financial barriers to schools. The program has trained Roma and non-Roma enrollment. It may be useful to study how other caregivers, and provided materials for classrooms. countries in southeast Europe have managed to achieve fairly high preprimary enrolment. The program reaches only a small number of Roma children (in 2011 only 2.6% of Roma four year olds ¾ The GoM could consider several kinds of ECCE attended preprimary education), but is an important modalities to determine which are appropriate for step towards addressing the disadvantages facing Roma. establishment or expansion. Options to consider Research shows that the benefits to poor children who include public preschools, private preschools that are attend quality preprimary programs include higher subsidized for those who cannot afford them, facilitated educational attainment and completion, improved parent-child playgroups, community-based centers, and attention, and better learning outcomes. These benefits cooperative preschools. can extend beyond these children and into their communities. Equity ¾ The GoM could study reasons for disparities in Girls and boys are enrolled in preschool at roughly the learning opportunities for children in the poorest and same rate. In 2012, the preprimary gross enrollment rate wealthiest households. Consider ways to increase ECCE was 29.1% for girls and 28.1% for boys. enrollment among the poorest families. Children in poor SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 17 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 families have few learning opportunities at home and of information is an essential component of informed almost none of them attend preschool, yet that they policymaking: it can be used to develop new programs stand to benefit the most from quality preprimary and modify existing ones in response to needs identified education. The GoM could consider demand side and by data analysis. supply side interventions to increase preprimary enrollment among poor families. Macedonia collects many important survey data, which are based on sampling a population. Its participation in Policy Goal 3: Monitoring and Assuring UNICEF’s Multiple Indicator Cluster Survey (MICS) is an important part of gathering indicators related to health, Quality nutrition, and education. It also allows for comparisons ¾ Policy Levers: Data Availability • Quality between rural and urban areas and the wealthiest and Standards • Compliance with Standards poorest families, making it an important tool for Monitoring and Assuring Quality refers to the existence assessing equity in the country. of information systems to monitor access to ECD services and outcomes across children, standards for ECD services Table 10: Availability of data to monitor ECD in and systems to monitor and enforce compliance with Macedonia those standards. Ensuring the quality of ECD Administrative Data: interventions is vital because evidence has shown that Indicator Tracked unless programs are of high quality, the impact on ECCE enrollment rates by region X children can be negligible, or even detrimental. Special needs children enrolled in ECCE Policy Lever 3.1: 9 (number of) Data Availability Children attending well-child visits (number of) 9 Accurate, comprehensive and timely data collection can promote more effective policy-making. Well-developed Children benefitting from public nutrition X information systems can improve decision-making. In interventions (number of) particular, data can inform policy choices regarding the Women receiving prenatal nutrition X volume and allocation of public financing, staff interventions (number of) recruitment and training, program quality, adherence to Children enrolled in ECCE by sub-national 9 standards and efforts to target children most in need. region (number of) Average per student-to-teacher ratio in public Many survey data on access to ECD services are X ECCE available, but administrative data collection could be Is ECCE spending in education sector X expanded. Table 10 presents the types of indicators a differentiated within education budget? country can collect to assess access to ECD and Is ECD spending in health sector differentiated 9 outcomes. A few administrative data for Macedonia are within health budget? available; these figures reflect total uptake of services Survey Data and are gathered through a census or at the point of Indicator Tracked service provision. Administrative data gathered include: Population consuming iodized salt (%) 9 the number of children with special needs enrolled in ECCE, the number of children enrolled in ECCE at the Vitamin A Supplementation rate for children 6 X subnational levels, and ECD spending within the health -59 months (%) sector budget. Anemia prevalence amongst pregnant women 9 (%) The GoM could consider expanding the types of data it Children below the age of 5 registered at birth 9 (%) collects relevant to the health of young children and Children immunized against DPT3 at age 12 pregnant women, such as the number of children 9 months (%) benefiting from well-child visits, and the number of Pregnant women who attend four antenatal children and pregnant women receiving nutrition 9 visits (%) interventions. As Discussed in Policy Level 1.3, Finance, Children enrolled in ECCE by socioeconomic differentiating spending on ECCE in the education sector 9 status (%) budget is an important piece of data to gather. This type SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 18 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Data are available to differentiate access and outcomes for special groups. The government statistics office : Policy Lever 3.2: collects information on background characteristics of Quality Standards children enrolled in public Kindergartens, including Ensuring quality ECD service provision is essential. A focus gender, special needs status, municipality, mother on access – without a commensurate focus on ensuring tongue, and ethnicity. There is no indicator on family quality – jeopardizes the very benefits that policymakers income, but information on parental employment status hope children will gain through ECD interventions. The and subsidized fee status are collected. quality of ECD programs is directly related to better cognitive and social development in children7. The number of children with special needs is estimated as the number of children receiving social services. The Macedonia has established standards for what students number of children with special needs may be much should know and learn. In 2009 the Ministry of Labor higher, as only children whose parents have registered and Social Policy adopted the Early Learning and them for social assistance are counted. The ability of a Development Standards (ELDS). The ELDS lay out what system to track the access and outcomes of children children from birth to age 6 should know and be able to based on these types of characteristics will impact a do across a range of developmental domains, and form system’s ability to ensure that all children’s needs are the basis of creating a systematic approach to services met. For this reason, the GoM could consider for young children. After validation, the ELDS were establishing a more comprehensive way to record the implemented starting in 2010. number of children with special needs to ensure that those children are receiving the support that they need. The EDS take a holistic view of child development, and include the domains of physical health and motor Macedonia tracks several domains of individual development; socio-emotional development; children’s development. As of 2014, every child enrolled development of approaches to learning; language in an ECCE center has a child development portfolio. The development, literacy and communication; cognitive portfolio contains tools to track the child’s development development and general knowledge acquisition. based on the Early Learning and Development Standards framework adopted in Macedonia. These cover the A government approved curriculum is available for use physical, cognitive, language, and social development in preprimary classes. In 2014 the MoLSP approved a domains. Checklists and notes in the portfolio document curriculum for use in preschools. The curriculum is based the child’s strengths, abilities and interests. Preschool on the Early Learning and Development Standards and is teachers use this information to adjust the curriculum takes a play-based approach to learning. It covers and teaching. The information conveys children’s school sensorimotor development, healthy behavior and safety, readiness, is used to smooth the transition from social interaction with peers and adults, diversity, preschool to primary school. The tool can help identify emotional development, language development, children experiencing developmental delays, and emergent literacy and math, general knowledge, science teachers may be able to adjust their teaching strategies concepts, and creativity. accordingly. A referral system is not yet in place to refer children with delays to specialist support services. It is not clear that efforts have been taken to ensure that the preprimary curriculum is coherent with the primary It should be noted that less than one-fourth of children curriculum. in Macedonia attend preprimary school, so most children do not have a child development portfolio. There are educational requirements to become an ECCE caregiver or educator. The GoM distinguishes between caregivers (those engaged in child care) and educators (those engaged in learning activities) in preprimary schools. Caregivers must have completed upper secondary school. Educators must hold a bachelor’s 7Taylor & Bennett, 2008; Bryce et al, 2003; Naudeau et al, 2011; Victoria et al, 2003 SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 19 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 degree. The degree does not have to be in child olds; 18-20 children per class for four year olds; and 20- development or education. 25 children per class for five year olds. Five public universities and several private universities in It does not seem that there are established child-to- Macedonia offer training for Kindergarten teachers. The teacher ratios. If there is only one teacher or caregiver in Ministry of Education regulates all of these universities. each classroom, then particularly in the lower age groups Programs of study include diploma courses, and this class size could be detrimental to children’s bachelor’s and master’s degree. wellbeing and safety. Early childhood educators who pursue bachelor’s All ECCE programs are open five days a week. Full day degrees or higher in ECD receive intensive training over programs are open between nine and eleven hours per six to eight semesters. About half of that time is spent day; half day programs run four to six hours per day; and on coursework, including mandatory courses in short programs run up to three hours a day. education and psychology, and other elective courses including science and music. Towards the end of the Infrastructure standards are in place for ECCE centers. course, students complete fieldwork practicums in All ECCE facilities must meet a number of infrastructure Kindergarten classrooms. requirements in order to be registered. Requirements cover the amount of space per child, hygienic facilities, In-service training is provided for ECCE center staff, and potable water, roof, floor, windows, build materials, is mandatory. The Professional Development for ECD structural soundness, heating, and soundproofing. Center Employees Act, 2013, lays out guidelines for training for personnel working in ECCE centers. The The MoLSP is responsible for licensing public and training covers general topics such as communication private ECCE centers. The MoLSP provides skills, group management, and project management; and documentation to centers stating that all standards are topics specific to ECD, including the Early Learning and met. Development Standards, child assessment, early learning strategies, the basis of child development, and Infrastructure standards are established for all health partnership with parents. Training ensures that facilities. Hospitals and health centers must meet longstanding teachers are familiar with the new mandatory facilities requirements covering curriculum and teaching and learning methods. Currently infrastructure, access for people with disabilities, the MoLSP in collaboration with UNICEF and its partners medical equipment, and indoor and outdoor implement this in-service training. environments. Some health workers receive training on delivering ECD : Policy Lever 3.3: messages. The family medicine curriculum trains doctors Compliance with Standards in communication skills to deliver developmental Establishing standards is essential to providing quality messages to parents. Health workers can be effective ECD services and to promoting the healthy development messengers to share information with parents on of children. Once standards have been established, it is developmental milestones, childcare, parenting, and critical that mechanisms are put in place to ensure early stimulation. Midwives, psychologists, and compliance with standards. extension health service workers do not receive any training on this. ECCE educators and caregivers meet professional qualifications standards. Of the 1015 educators in There established service delivery standards for ECCE public ECCE centers, most or possibly all have completed centers. The Child Protection Law establishes limits on the requirement for tertiary degrees. Most of the the number of children allowed in each preprimary class. caregivers in the school seem to meet the current The limit varies by age group: 6-8 children per class for 0- requirements for those positions. 12 months; 8-10 children per class for 12-18 months; 12 children for 18-24 months; 12-15 children per class for Public and private ECCE centers comply with service two year olds; 15-18 children per class for three year delivery and infrastructure requirements. Of the 182 buildings housing ECCE centers in Macedonia, all of them SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 20 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 meet construction standards and infrastructure Without multiple teachers in classrooms, the current requirements. All centers are open for the minimum group size policies may be detrimental to children’s number of operating hours per week. They also seem to development and wellbeing. comply with the limits on group size. Mechanisms are in place to enforce standards. ECCE centers that fail to meet standards do not receive Compliance with Standards accreditation from the MoLSP and do not have permission to operate. Centers that lapse in meeting ¾ It seems that there is a high level of compliance to standards will have their license suspended. The MoLSP ECCE professional requirements and infrastructure and has staff with the mandate of monitoring for adherence service delivery standards. Macedonia did not receive a to standards. Inspectors visit each ECCE center at least score of Advanced on this policy lever because the child- once a year. The MoH monitors centers for proper water to-teacher ratio is not in accordance with best practice and sanitation systems. standards. Policy Options to Monitor and Assure ECD Comparing Official Policies with Outcomes Quality in Macedonia The existence of laws and policies alone do not always guarantee a correlation with desired ECD outcomes. In Data Availability: many countries, policies on paper and the reality of access and service delivery on the ground are not ¾ The GoM could collect several additional pieces of aligned. Table 11 compares ECD policies in Macedonia administrative data. Additional data that it may be with ECD outcomes. The table is encouraging in that it helpful to track include the number of pregnant women suggests when an ECD policy is put in place in receiving nutrition interventions. As mentioned in Policy Macedonia, it is implemented well. Almost all Lever 1.3 on Finance, it is important to know the level of households consume iodized salt; immunization rates spending on preprimary education. are very high; birth registration is universal. Macedonian law does not contain all provision of the International ¾ The GoM could consider using the child development Code of Marketing Breastmilk Substitutes, and portfolio to identify children with developmental breastfeeding rates are fairly low. Preprimary school is delays and refer them to support services. This would not required, and less than one-fourth of the country’s necessitate establishing a referral system in preschools, children are enrolled in preprimary education. as well as ensuring that services staffed by trained professionals are accessible. Table 11: Comparing ECD policies with outcomes in Macedonia Quality Standards ECD Policies Outcomes ¾ The GoM could establish additional training Policy mandates the registration Completeness of birth requirements and professional development of children at birth in Macedonia registration: opportunities for ECCE caregivers. It is not clear that 99% caregivers in ECCE centers must meet any education or Young children are required to Children with DPT (12- certification requirements beyond completion of upper receive a complete course of 23 months): secondary school. To ensure children’s healthy childhood immunizations 96% development, caregivers should have knowledge of child Macedonia has national policy Household iodized salt development, caregiving practices, safety, and hygiene. to encourage the iodization of consumption It may also be beneficial to introduce the ELDS. Consider salt 94% establishing in-service training opportunities for caregivers to provide ongoing professional development. Preprimary school ¾ The GoM could review its policies on group size in Preprimary school is neither free enrollment: ECCE centers. Perhaps more important than standards nor compulsory in Macedonia 28% on group sizes in ECCE centers is child-to-teacher ratios. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 21 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 the nine policy levers and three policy goals. The SABER- ECD classification system does not rank countries according to any overall scoring; rather, it is intended to Few provisions of the Exclusive breastfeeding share information on how different ECD systems address International Code of Marketing rate (> 6 mo): the same policy challenges. of Breast Milk Substitutes are 23% law Table 13 presents the status of ECD policy development in Macedonia alongside a selection of Europe and Central Asia (ECA) countries according to World Bank regional Benchmarking and International categories. Comparison of ECD in Macedonia On the following page, Table 12 presents the classification of ECD policy in Macedonia within each of Table 12: Benchmarking Early Childhood Development Policy in Macedonia Level of Level of ECD Policy Goal Policy Lever Development Development Legal Framework Establishing an Enabling Inter-sectoral Coordination Environment Finance Scope of Programs Implementing Widely Coverage Equity Data Availability Monitoring and Assuring Quality Standards Quality Compliance with Standards Latent Emerging Established Advanced : Table 13: Classification and Comparison of ECD Systems in ECA Level of Development ECD Policy Goal Policy Lever Kyrgyz Russian Macedonia Albania Bulgaria Tajikistan Uzbekistan Republic Federation Legal Establishing an Framework Enabling Coordination Environment Finance Scope of Programs Implementing Widely Coverage Equity Data Monitoring and Availability Assuring Quality Quality Standards SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 22 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Compliance with Standards Latent Emerging Established Advanced Legend: Table 14 summarizes the key policy options identified to Conclusion inform policy dialogue and improve the provision of The SABER-ECD initiative is designed to enable ECD policy essential ECD services in Macedonia. Macedonia has makers and development partners to identify successfully established many elements of a strong ECD opportunities for further development of effective ECD system, including essential healthcare and standards for systems. This Country Report presents a framework to early childhood education. It may need to strengthen its compare Macedonia’s ECD system with other countries intersectoral coordination and finance systems. The in the region and internationally. Each of the nine policy country’s biggest challenge may be how to expand levers are examined in detail and some policy options are preprimary enrollment—especially to children from poor identified to strengthen ECD are offered. families—while maintaining quality. Table 14: Summary of policy options to improve ECD in Macedonia Policy Policy Options and Recommendations Dimension x Promote breastfeeding through public awareness of its importance and support for mothers. x Develop a phased approached to transition toward universal and mandatory Establishing an preprimary education; develop equitable financing models to achieve this. Enabling x Review intersectoral coordination mechanisms—including between government Environment bodies and at the level of service delivery—to ensure integrated services and efficient use of resources. x Establish ECD budget coordination mechanisms across government bodies. x Establish systems to allow for identification of ECD spending across sectors. x Establish programs to identify and treat maternal depression. x Expand nutrition programs to include interventions such as food fortification, Implementing micronutrient support, and healthy eating and exercise programs. Widely x Study reasons for low enrollment in preschool, especially among the country’s poorest families, and develop strategies to address these barriers. x Collect additional administrative data in the health and nutrition sector, and data on ECD spending. Monitoring and x Review policies on group size in ECCE centers to ensure that child-to-teacher ratios are Assuring Quality adequate for children’s development and safety. x Establish training requirements and professional development opportunities for ECCE caregivers. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 23 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 Implications for Equity.” Social Policy Report, 25 Acknowledgements (2):1-31. This Country Report was prepared by Lindsay Adams Engle, P. L., L. C. H. Fernald, H. Alderman, J. Behrman, (Consultant, Education Global Practice, World Bank) with C. O’Gara, A. Yousafzai, M. Cabral de Mello, M. inputs from Amina Denboba (Consultant, Education Hidrobo, N. Ulkuer, and the Global Child Global Practice, World Bank) and Janice Kim (Consultant, Development Steer Group. “Strategies for Education Global Practice), under the direction of reducing inequalities and improving Quentin Wodon (Adviser, Education Global Practice, developmental outcomes for young children in World Bank). The report presents country data collected low-income and middle-income countries.” The using the SABER-ECD policy and program data collection Lancet, Early Online Publication, 23 September instruments and data from external sources. This report 2011. Doi:10.1016/S0140-6736(11) 60889-1. was prepared in consultation with Bojana Naceva and Nadica Janeva and the Government of Macedonia. For Gertler, P., J. Heckman, R. Pinto, A. Zanolini, C. technical questions or comments about this report, Vermeersch, S. Walker, S. Chang, S. Grantham- please contact the SABER-ECD team McGregor. 2014. “Labor market returns to an early (helpdeskecd@worldbank.org). childhood stimulation intervention in Jamaica.” Science 344.6187: 998-1001. Hanushek, E. (2003). "The Failure of Input-Based Acronyms Schooling Policies." The Economic Journal 113; 64- ECD Early Childhood Development 98. Hanushek, E. A. and D. D. Kimko. (2000). “Schooling, ECCE Early Childhood Care and Education (often used Labor-Force Quality, and the Growth of Nations." synonymously with preschool, preprimary education, The American Economic Review, Vol. 90, No. 5, or Kindergarten) 1184-1208. GoM Government of Macedonia Naudeau, S, N. Kataoka, A. Valerio, M. J. Neuman, L. K. Elder. 2011. Investing in Young Children: An Early MICS Multiple Indicator Cluster Survey Childhood Development Guide for Policy Dialogue and Project Preparation. World Bank, Washington, MoE Ministry of Education DC. MoH Ministry of Health Neuman, M. & Devercelli, A. 2013. "What Matters Most for Early Childhood Development: A MoLSP Ministry of Labor and Social Policy Framework Paper." SABER, World Bank, Washington DC NCCR National Committee for Children’s Rights Neuman, M. J. 2007. “Good Governance of Early SABER Systems Assessment for Better Education Results Childhood Care and Education: Lessons from the 2007 Education for All Global Monitoring Report.” WHO World Health Organization UNESCO Policy Briefs on Early Childhood. United Nations Educational, Scientific and Cultural Organization, New York. References OECD (Organisation for Economic Co-operation and Development). 2009. “Doing Better for Children.” SABER-ECD Policy Instrument, Macedonia 2014 OECD Publications, Paris. SABER-ECD Program Instrument, Macedonia 2014 OECD (Organisation for Economic Co-operation and Britto, P., Yoshikawa, H., Boller, K. 2011. “Quality of Development). 2011. “Starting Strong III: A Quality Early Childhood Development Programs: Rationale Toolbox for Early Childhood Education and Care.” for Investment, Conceptual Framework and OECD Publications, Paris. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 24 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 UNESCO-OREALC. 2004. “Intersectoral Co-ordination in Early Childhood Policies and Programmes: A Synthesis of Experiences in Latin America.” Regional Bureau of Education for Latin America and the Caribbean, United National Educational, Scientific and Cultural Organization. Van Ravens, Jan. 2010. “Fair Play: A financially feasible plan for equal access to early childhood programs in the Republic of Macedonia.” UNICEF. Vargas-Barón, E. 2005. “Planning Policies for Early Childhood Development: Guidelines for Action.” Paris: UNESCO/ADEA/UNICEF (United Nations Educational, Scientific and Cultural Organization/ Association for the Development of Education in Africa/United Nations Children’s Fund). Victoria, B. H., L. Adair, C. Fall, P. C. Hallal, R. Martorell, L. Richter, and H. S. Sachdev. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital. “ The Lancet 371 (9609): 340-57. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 25 MACEDONIA ǀ EARLY CHILDHOOD DEVELOPMENT SABER COUNTRY REPORT |2015 www.worldbank.org/education/saber The Systems Approach for Better Education Results (SABER) initiative produces comparative data and knowledge on education policies and institutions, with the aim of helping countries systematically strengthen their education systems. SABER evaluates the quality of education policies against evidence-based global standards, using new diagnostic tools and detailed policy data. The SABER country reports give all parties with a stake in educational results—from administrators, teachers, and parents to policymakers and business people—an accessible, objective snapshot showing how well the policies of their country's education system are oriented toward ensuring that all children and youth learn. This report focuses specifically on policies in the area of Early Childhood Development. This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. SYSTEMS APPROACH FOR BETTER EDUCATION RESULTS 26