Whole of Society Approach: Addressing early childhood development and the First Thousand Days Initiative

Intersectoral collaboration for health – where the health sector works with other sectors to address social determinants of health – has been advocated since the 1978 Alma Ata Declaration of Primary Health Care and, more recently, by the Sustainable Development Goals. Addressing social determinants of health is particularly crucial between conception and when a child is two years old, during which time development occurs in all domains – sensory, motor and cognitive. Conceived of as the First Thousand Days (FTD) and referred to as ‘nurturing care’, this period therefore presents a window of opportunity for early childhood interventions that ensure a conducive environment for adequate child development. An intersectoral approach to FTD is crucial as evidence shows that integrated health, nutrition and stimulation interventions promote positive outcomes that impact the whole life course.

Launched in 2016 by the Province in the Western Cape, the FTD Initiative has been a focus of research at the School of Public Health (SOPH). This has included examining policy processes from 2016 to 2019 to better understand the real-life possibilities for, and constraints to, intersectoral action for health. As part of the broader FTD study, doctoral candidate Ida Okeyo and professors Helen Schneider and Uta Lehmann have analysed how the FTD Initiative emerged and was formulated within the Saldanha Bay Municipality - an area that was experimenting with approaches to joined-up government referred to as the ‘Whole of Society Approach’ or WoSA.

The Whole of Society Approach

The WoSA was approved by the provincial Cabinet in April 2017 and was framed as a co-created and collaborative endeavour between provincial government sectors and local municipalities. The goals were linked to broader policies and frameworks at all levels - from the global Sustainable Development Goals, the country’s National Development Plan, the Provincial Strategic Plan and the Integrated Development Plans of local government. The WoSA was to be piloted in two rural sub-districts (Saldanha Bay and Drakenstein) and two urban subdistricts (Khayelitsha and Hanover Park/Manenburg). General WoSA plans for each region included the assignment of heads of provincial departments to lead each area and an entry process into each community that would be guided by the local municipalities. The Saldanha Bay WoSA process began at the end of the 2017 and was led by the head of the provincial Health Department along with local municipal players. One of the earliest activities was the establishment of strategic focus areas and accompanying local area teams. The FTD Initiative itself was launched in Saldanha Bay in early 2019.

Figure 1: Life course approach that shaped the

WoSA network [DSD: Department of Social Development; DCAS: Department of Community and Safety; DOH: Department of Health; WCED: Western Cape Education Department]

Saldanha Bay Municipality

During 2019 we conducted qualitative interviews with key informants involved in the Saldanha Bay WoSA team. We also observed five WoSA team meetings for different governance structures and analysed key WoSA documents. Although still in its infancy, early findings of the FTD Initiative have shown how the WoSA team adopted the life-course approach as a central framing idea, with FTD and early childhood development as key focus areas for co-ordinated action. The ‘Carol and Lindi’ story – of a mother and child living in an ideal state with the necessary tools, opportunities and appropriate services to cater for their needs over the life-course – provided a powerful common joint framework which was readily adopted by various stakeholders. They frequently repeated the story, symbolising a new collective mindset focused on communities and citizens rather than an inward looking, sectoral approach.

Figure 2: The Carol and Lindi story

Following the launch of the FTD in Saldanha Bay, a referral pathway was co-created by the departments of Health (across levels of care), Social Development and Home Affairs for pregnancy and early child care, reflecting an early commitment to intersectoral processes in the Social Cluster of the WoSA Saldanha team. In May 2019, the Saldanha Bay Municipality hosted an early childhood development (ECD) conference, bringing together numerous actors and stakeholders interested in addressing challenges related to ECD. This was widely seen as an agenda-setting moment for intersectoral relationships, both within and between local and provincial government spheres. The WoSA pilot in Saldanha Bay demonstrated that creating the necessary institutional capability for intersectoral action can be enabled by an area-based approach. Crucially this has to be underpinned by strong founding principles, facilitative and distributed leadership, multi-level governance systems and processes of implementation that focus on building cross-sector relationships. The WoSA in Saldanha Bay has so far proven to be a successful model of collaborative governance, but has required substantial investments of time by skilled and highly committed senior managers. The next cycle of the Provincial Strategic Plan (20192024) and the recent COVID-19 Recovery Plan show the provincial government’s adoption of the WoSA approach as a way of addressing a number of complex socio-economic problems – including safety, unemployment and poverty.

See the case study report: Okeyo, I, Lehmann, U & Schneider H. (2020) Case study report. The First Thousand Days within the Western Cape Whole of Society Approach: Lessons for the collaborative governance of intersectoral action for health.