The enormous concentration of economic power in young children: Time to tap it

Bridgethegap1-0134The JC Coetzee Memorial Lecture delivered by DGMT CEO, Dr. David Harrison,  at the 19th Annual Family Practitioners’s Conference on 13 August 2016 

Introduction

It really is an honour to be invited to give the JC Coetzee Memorial Lecture today. I trust the organisers of the conference have not strayed too far from his wishes in inviting me to speak – not even a practising doctor, let alone an OBGYN.  To add insult to injury, I’m going to be speaking about the topic of money – who has it and who doesn’t – because that is at the very heart of the theme of this year’s Conference (One Country, Two Worlds:  Innovating Quality Health Care). We live in two worlds in one country precisely because some people are wealthy and most continue to live in poverty.

Our common mission – as doctors, lawyers, business owners, office clerks, you name it – must be to work towards greater equality of income and wealth, not just to treat people as equals. We must, because rising levels of inequality will – in fact already do – threaten our nation’s stability.

I will be talking about money, but I’m not an economist – and I hope that I reflect accurately the work done by the genuine economists to which I will refer. There are many criticisms of attempts to reduce health and health care to their economic role in nurturing human capital. Even the very language equating humanity with capital as a factor of production is anathema to some. Those criticisms hold some water, but we must be pragmatic. If we cannot speak the language of business and economics, we will struggle to secure the public resources that are needed to invest in the public goods of health, social well-being and early education. We will lack the common language that is required to mobilise coalitions of civil society, the corporate sector and government. We will underrepresent those constituencies that struggle to find the platforms to speak for themselves – not least of all, children.

For these reasons, ideological leanings aside, I’m going to speak the language of capitalism.

A rude assertion

The rather abrupt entrée to this address is a rude assertion – ‘rude’ because it questions, or at least seeks to qualify, the assumptions underlying the theme of this year’s conference, namely One Country, Two Worlds: Innovating Quality Care for All.  The rude assertion is that quality health care beyond the client’s age of about two years – no matter how innovative –  will not contribute fundamentally to making one world out of two in this country.  Health care for older children and adults has many vital roles, but redistribution of resources across populations is not one of them.  We will come back to the role of health care for people over two years of age a bit later.

The economic role of health care is to nurture human capital, which is most narrowly defined as the skills and knowledge which enable an individual to produce outputs that earn money. The more money they earn, the greater their human capital. There are expanded definitions of human capital, but let’s stick with that narrow one. The term ‘health capital’ was coined to describe the stock of health intrinsic to each individual at the time of birth.  Health capital can be viewed as the ‘fertiliser’ for human capital – providing the physical competence that enables an individual to participate in the economy.  It was originally regarded as a set genetic endowment that depreciated over time, and did not explicitly recognize that the size of health endowments have changed over centuries or can be shaped by external factors[1]. The term ‘psychological capital’ came into vogue early this century, describing the characteristics of hope, optimism and resilience that enable individuals to optimally mobilise the human capital at their disposal.[2]   Around the same time, the economist Robert Fogel coined the phrase ‘physiological capital’ which recognized that health stocks can accumulate differentially, depending on extrinsic factors, both before and after birth.  It is physiological capital – malleable to accrual during pregnancy and beyond birth – that holds redistributive potential.

A stock of good nutrition is the most fundamental currency of physiological capital. Fogel estimates that, from the Elizabethan era to the end of the 19th Century, about 20% of Englishmen and women lacked the energy for regular work. Not only that, but their bodies made physiological adjustments (that we would today call epigenetic effects) that enabled them to survive, but not to thrive. The average height of men who reached maturity in Europe was unchanged from 1750 to the late 19th century. Since then, mean height in European men has increased by about 10cm, and similar findings have been noted in Japanese men.

If income differentials were the outcome of a “race between education and technology”, as Thomas Piketty describes it[3], with education favouring returns to labour and technology favouring returns to capital, then better nutrition was the key to higher wages.  Children could learn more and workers could work better with sufficient food to meet both baseline maintenance and the energy requirements of labour. Physiological capital, in the form of stored energy and adequate micronutrients, thus accumulated over time across a wider swathe of the population than ever before. These characteristics of the Industrial Revolution were replicated in developing countries in the 20th Century. For instance, the economist Paul Schultz found that every centimetre increase in in height among Ghanaian and Brazilian workers between 1940 and 1970 led to 8-10% increase in wages.[4]  Later studies tempered the magnitude of the wage gains, but substantial statistical effects remained. A study published in the Lancet in 2008 followed cohorts of children into adulthood in five different countries (including South Africa). It found that children’s height at two years of age was the best predictor of adult human capital. Stunted children performed worse at school and were less economically productive as adults.

According to the World Bank, a 1% decrease in adult height results in a 1.4% decrease in labour productivity and stunting knocks off about 2-3 % of gross domestic product (GDP) in the most severely affected countries[5]. Maternal undernutrition (as represented by low birth weight babies) accounts for about 20% of stunting[6]. With a low-birth-weight rate of 13% and a fifth to a quarter of children stunted, [7] a conservative estimate would be that early malnutrition accounts for at least 1% of GDP lost to South Africa.  That’s about R40 billion a year.

Obviously the best option would be to prevent nutritional stunting in the first place, but the good news is that catch-up growth is possible within the first two years of life. Encouragingly, if stunted children receive extra food and intellectual stimulation, their life-time earnings potential can increase by 25-40%.[8]  But the remedial value of interventions to combat stunting is limited after two years of age.[9]

The formative power of the ‘first thousand days’ is not restricted to a determination of height (and hence wage-earning potential).  Medical research over the past two decades has shown that many life-long patterns of illness and health are calibrated in the first years of life. Children who experience malnutrition and other forms of toxic stress are at higher risk for adolescent delinquency, drug and alcohol use and risky sexual behaviours.[10] As adults, they experience higher rates of cardiovascular, metabolic, neuro-endocrine disorders, neuro-psychological problems and obesity as adults.[11] Major health differentials are established early on and are, subject to wide individual variability,  outcomes that are sustained through the course of life.

If we return to the economic role of health care, the basis for the rude assertion made above is hopefully far clearer. In economic terms, the role of health care for people older than two or three years of age is to limit the depreciation of health capital. It is health care in the first thousand days that has the potential to be truly redistributive if it enables poorer people to accumulate the physiological capital associated with good antenatal care and better nutrition.

But we must not over-reach ourselves.  Physiological capital accumulation is only the starting point for reducing inequality.  It must be followed up with other redistributive strategies that enable better access to quality education and reduce economic marginalization. To understand what is really possible, we need to understand the basis for inequality of income and wealth – what’s driving it to diverge further and what can reasonably be done to cause convergence.

What drives inequality, and what can be done to reduce it?

In this regard, I draw on the magnum opus of the French economist Thomas Piketty, who first published Capital in the Twenty-First Century in 2013 (translated into English in 2014).[12] His work demonstrated that Simon Kuznets was wrong, over the long term. Kuznets had argued that increasing inequality was a temporary feature of an evolving capitalist economy, and that countries returned to a more egalitarian state as they became richer. He described an inverted parabola that became known as Kuznets’ Curve.[13] If Kuznets were right, then inequality would slowly dissipate if left to its own devices – and in fact, inequality could be regarded as catalyzing a necessary but transitory set of incentives for economic progress.  Through long-term analysis – stretching back to the 18th Century (and with the benefit of fifty years of observation since Kuznets’ seminal publication), Piketty was able to demonstrate that there is no ‘natural’ economic reason why high levels of inequality in countries would gradually dissipate.  In fact, the past three decades have seen a concentration of wealth among the top percentile not dissimilar to that seen in Victorian times.  (The one significant difference has been the growth of the middle class, which has tempered the extremes of income inequality, though not the recent intense concentration of wealth among the richest 1% in Anglo-Saxon countries).  Similarly, countries such as South Africa, India and China have seen a growth in the top percentiles’ share of total income, with one fifth (19.2% in 2012) of national income now accruing to the richest 1% of South African wage earners.[14]

The implication is that countries may experience increasing concentrations of wealth until their societies become inherently unstable, leading to social conflict and new revolutions.  For that reason, we must understand what causes divergence and what factors promote convergence (i.e. less inequality).

Piketty’s starting point is the quantitative relationship between ‘capital and income’, expressed as the capital/income ratio where ‘capital’ reflects the total wealth (public and private) owned by a country at a point in time and ‘income’ reflects the quantity of goods produced and distributed in a given year.  Put another way, the capital/income ratio is the number of years it would take to accumulate the country’s current wealth. This ratio is not a direct measure of inequality in a country, but indicates the relative role that capital plays in that society. For example, the capital/income ratio ratio in Great Britain and France reached nearly 700% in the late 19th century, then plummeted as a consequence of the two world wars to between 200 and 300%.  By 2010, the ratio had risen again to 500%.  It stands to reason that when the returns to the corpus of wealth exceed the combined returns to labour (income) that accrue from economic growth, then inequality will increase.  Piketty describes this as r > g.  Conditions that give rise to r > g include the mobility of capital (enabling wealthier people to seek higher rates of return in other geographies) and low economic productivity.

When the reverse is true, income differentials decrease and there is a net decline in country inequality. This situation arises when economic productivity is high, leading to higher growth rates.[1]  The real rate of return to capital can also be reduced by redistributive wealth taxes, but these are difficult to implement when countries are competing for foreign investment.

The robustness of Piketty’s thesis for a developing country like South Africa has been tested by Anna Orthofer, who concludes that while the wealth/income ratio has been much lower (200 – 300% in South Africa over the past 45 years), there has been a significant recovery in private wealth since the late 1990’s, suggesting that this country may be starting to follow the trends of more developed countries.[15]

If that is the case, then the potential for reducing inequality in South Africa rests primarily in greater economic productivity. There is evidence over the long-term that there is scope for considerable economic growth in developing countries, with an apparent convergence of economic output per capita between Europe-America and Africa-Asia since 1950.  Sub-Saharan Africa still lags far behind in terms of per capita economic output – suggesting that there is still significant potential for both economic catch-up and greater redistribution of wealth.  However, the question is whether South Africa and other sub-Saharan African countries can fully exploit the potential dividends of the demographic bulge of young people who have vast potential to learn and acquire new skills. In order to answer this question, we need to look at the specific dynamics of each country.

The prospects for South Africa

Earlier, I described the fact that the richest 1% of South Africans are getting steadily wealthier relative to the rest of us, but we need to understand what is happening across the entire income distribution.  Since 1994, the SA wage gap has compressed in the bottom half and fanned out in the top half of the income distribution[16].  In other words, wage earners at the 10th percentile earn a little more than they did in 1994 – 30% of the median wage in 2010 compared to 23% in 1994.  Not a massive difference.  At the other end, wage earners at the 90th percentile earned 430% the median in 2010, compared to 270% the median in 1994.  For the highest decile of wage earners, the divergence is likely to be even greater. That, coupled with the tremendous return on investments in equities on the Johannesburg Stock Exchange between 1994 and 2014 (8.6% p.a. real return)[17], has led to a greater concentration of wealth – despite the redistributive policies of a democratic government.[18]  Truth be told, some of the ostensibly redistributive policies of post-apartheid government may have been less so in practice. For example, the heavy financial emphasis of black economic empowerment policies has concentrated extreme wealth in the hands of relatively few beneficiaries. More successful have been social security policies (old age pensions and the child care grant in particular) that have increased the size of the ‘social wage’ for the poorest income quintile of the population.[19]

Further working against the concentration of wealth has been an increase in labour productivity since 1994. However, sectoral trends in productivity have not changed much since 1994: those sectors that performed poorly in terms of productivity have continued to do so, while those that fared better then have shown greatest productivity gains over the two decades. These differentials probably reflect the underlying inequalities in skills that have not changed significantly in the past twenty years.  According to Statistics South Africa, the percentage of black African workers classified as ‘skilled’ increased by only 2.8 percentage points between 1994 and 2014.  Still fewer than one in five black African workers is skilled, while the minority population groups have become a lot more skilled over the past twenty years.[20] Over half the adult workforce is either unemployed (35%, expanded definition) or employed in unskilled categories of work (18%).[21]  Only 15% of workers are categorized as skilled, indicative of a failing educational system.

While fingers are typically pointed at the quality of schooling and the vocational training system, Van den Berg has demonstrated that the damage is already done by Grade 4: the divergence in learning outcomes between the bottom two school quintiles and the top two school quintiles happens between Grade 1 and Grade 4, where-after the gaps are sustained at pretty much the same magnitude.[22]  In fact, the poorest 40% of children already enter school at a disadvantage – scoring about 20% less on average for maths and home language than children in wealthier quintile schools. These findings point to the fact that deficits in language and cognitive ability have already accrued by the age of five. The net result is that, by Grade 5, it is already clear that there will be insufficient educational throughput to sustain South Africa’s growth as a knowledge economy compared to most countries of similar economic size.[23]

One could argue that South Africa could become a country characterized by largesse by the richest towards the poorest through massive redistributive taxation.  However, the capital base is too small to make massive new tax demands on it without crimping incentives for investment and prompting capital flight.[24]  This is illustrated in the health sector by the financing incidence of the South African health system, where the wealthiest 20% derive more-or-less the same benefit from the public health system as other quintiles (taking into account population-level benefits like immunization) and derive the lion’s share of private benefits.  At the same time, they pay for over 80% of total health care funding (through the various forms of taxation and private medical top-ups), leaving little room to further increase their contributions to a health care system that already consumes close to 9% of GDP.[25] Even if there is room to increase marginal rates of taxation, we currently face a ‘trust’ issue in which taxpayers are no longer convinced that their contributions are being used efficiently.  In contexts like this, tax avoidance strategies proliferate.

In terms of securing the future of South Africa and reducing inequality, we are left with no choice but to make strategic investments in human capital. In particular, we need to develop and protect the source of human capital – and that means investing in young children.

The concentrated economic power of young children

Children’s rights activists have shied away from representing children as factors in the economic value chain – and not without good reason.  But this has often meant that the interests of children are not adequately represented when private investments are made by business and when public funds are divided up.  It is time to explicitly recognize the potential economic power that resides in children that could be harnessed if it were factored into economic equations by government and business leaders.

For that reason, we should reframe our narratives about children – seeing economic opportunity where others see social deficit. For example, as described earlier, the eradication of stunting could generate an additional R40 billion a year [26]– enough to fully fund a national early learning programme for 2-4 year olds and make a sizeable dent in the funding shortfall at tertiary institutions. In turn, if a universal early learning programme resulted in a fully literate working population, the country’s GDP could grow by about a quarter as a result.[27] If that and other investments in children ensured that the dropout rate by Grade 12 were reduced from 50% to near zero, each rand invested would yield between R8 and 18 in return.[28]  Of course, there are overlaps in these strategies such that the projected economic returns may be being double-counted in the short- to medium-term. But skills beget skills, resulting in the long-term in an exponential trajectory of compounding returns to investments in early childhood development.

The source of such economic power in young children rests in nothing other than their normal physical, emotional and cognitive development – when the basic inputs of love, food, safety and stimulation are in place. The ‘first thousand days’ has gained currency as a buzzword for the immense concentration of human potential from conception to two years of life. Of course, the accumulation of physiological and human capital continues beyond that and good schooling and tertiary education must be in place to fully realise this potential, but it is instructive to comprehend just how much power to change the destiny of individuals and of the nation resides in our youngest children. The Harvard Center on the Developing Child has shown that – at least in terms of synapse formation – sensory pathways, language and cognitive development peak within the first year of life.[29] Brain sensitivity for development of language, self-regulation and executive function is greatest in first three years of life. [30] The irony is just how simple the inputs are, that should be non-negotiables for every child.

So how do we harness this untapped potential?

How do we tap it?

The starting point is to identify those targeted strategies that should provide the highest additional returns. As a country, we have made excellent strides in the provision of antenatal and obstetric care. There has been a steady increase in early antenatal bookings (54% before 20 weeks in 2014 compared to 38% in 2010) as well as the percentage of deliveries carried out by health personnel in health facilities (86% in 2014 compared to 66% in 2002).[31] The introduction of antenatal highly active antiretroviral treatment (HAART) has reduced the vertical HIV transmission rate to less than 2% in most parts of the country.  There is more that can be done to improve existing obstetric practices, especially in district hospitals and beyond, but our focus is ‘at the margin’ and on the redistributive potential of new or enhanced interventions.

By now, at least two of the highest return strategies should be clear. The first is zero-tolerance of stunting as part of a national nutrition strategy for children under five years of age. There is a national nutrition roadmap 2013 – 2017 published by the Department of Health.[32]  But it needs to be prioritized and activated by a national agency dedicated to its implementation. The second is to ensure that every child is ready-to-read by the time they go to school – which implies sufficient investment in early learning and the large-scale promotion of story-telling and reading.  The third is less obvious, but just as important. We should not lose sight of the fact that most child vulnerability is found in households, which are economically fragile and socially marginalized. It is these household and family factors – rather than a lack of access of health and social services – which place children at greatest risk from day-to-day and which result in cumulative deficits. The majority of children live in single-parent households, mainly with their mothers. Roughly a million babies are born in South Africa annually, of whom half may be regarded as socially and economically vulnerable.  Encouragingly, the proportion of women who were recorded as having follow-up postnatal care rocketed to 74% in 2014 from 5% in 2009.[33]  But it is often what happens at home between 6 weeks and two years after birth that determines child outcomes. Ironically, this is the time that formal support systems (other than the sustained benefits of a monthly child care grant) have least access to the child. For this reason, we need to place far greater attention on mobilizing local networks of care and support for at least the quarter of a million children born annually who are at highest risk. These networks – creating social and psychological capital in the lexicon of economics – build the resilience of children to withstand adversity.  The psychologist Ann Masten calls such simple strategies – parental love, another significant adult in the life of a child and modest connections to opportunity at crucial points in life – ‘ordinary magic.’ [34]

Arguably, these are among the country’s top strategies for achieving new economic growth and redistribution. Undoubtedly, they involve mobilization of additional public resources for therapeutic food supplementation, enhanced household food security and to fund new early learning programmes.  But other role-players are equally central – not least yourselves as family practitioners – who together with nursing practitioners are the professionals with greatest access to children in their first thousand days.

In terms of a national commitment to zero-stunting, your role is critical in preventing stunting by bolstering maternal nutrition, promoting exclusive breastfeeding for the first six months and encouraging diversified weaning diets, micronutrient supplementation, deworming, managing sub-clinical infections and counselling mothers on the risks of drinking alcohol during pregnancy.  Accurate measurement of growth is critical, and every child whose growth starts to cross centiles should have a definite plan of action.  Where needed, therapeutic supplementary feeding should be part of the plan, with appropriate referral and follow-up. It is however a reality that the system of State-supported supplementary feeding for undernutrition is not operating well in most provinces, and referral systems are inadequate. This is part of the challenge that must be taken up through national mobilization for zero stunting of children under five by 2025, through a coalition of civil society, professionals, the business sector and government.[2]

Family practitioners should also be the forefront of cognitive stimulation and promotion of reading. Parents are often unaware of their own power to develop their babies’ language and cognition, starting with the ‘serve and return’ interactions with their infants.  This back-and-forth exchange – a mother’s verbal response to the baby’s gurgle or engagement through facial expression – is vital for early sensorimotor and language development. Furthermore, few parents understand that the basis for reading is being laid down from birth, and all new parents should be encouraged to tell stories and read to their children from Day One.  In the United States, Reach Out and Read is a national network of 20,000 primary care providers and staff who make reading promotion a standard part of their paediatric care, including mini-libraries for children in their waiting rooms.[35] In South Africa, the national reading-for-joy campaign, Nal’ibali, has a growing library of electronic resources that are freely available (www.nalibali.org).

Third, family practitioners should be leaders in developing local networks of care and support for children at risk – tapping into existing public and non-government organisations, but also mobilizing new ‘connectors’ through faith-based and other service organisations.  Cape Town Embrace is an example of such an initiative that is making slow-but-sure strides in linking vulnerable families with other caring connectors (see www.embrace.org.za).  Similar initiatives need to spring up across the country.

A closing tribute to JC Coetzee

Science has eventually caught up with the instinctive wisdom of JC Coetzee.  He was dedicated to ensuring good obstetric and post-natal care for all – I am sure because he was a good doctor. Little could he know that within two decades of his death in 1987, high quality care in the first thousand days of life would be recognized as the very thread that weaves together our social fabric,[36] the foundation of life-long health[37] , the scaffold for later learning and education[38], a key driver of the national economy[39],  and a powerful redistributive force that can reduce income wealth inequality.[40]  JC Coetzee may not have been an economist, but his convictions were right on the money.

Thank you for listening to me today.

 

List of References: 

[1] Higher population growth rates also lead to a higher total growth rate as economic participation expands

[2] Zero stunting of children under five by 2025 recognises that the current cohort of 0-5 year olds already have a high prevalence of stunting which will continue to be a factor in prevalence calculations for the next five years.

[1] Fogel R (2003).  Secular trends in physiological capital: implications for equity in health care. Perspect Biol Med. 46(3 Suppl):S24-38

[2] Luthans F., & Youssef, C.M. (2004). Human, social, and now positive psychological capital management: Investing in people for competitive advantage, Organizational Dynamics, 33(2), 143-160

[3] Piketty T (2014).  Capital in the Twenty-First Century.  Harvard University Press, Cambridge MA

[4] Schultz TP (2002). Wage gains associated with height as a form of human health capital.  The American Economic Review 92(2):     349-353

[5] Repositioning nutrition as central to development: a strategy for largescale action. Washington DC: The World Bank; 2006 (http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf, accessed 12 August 2016).

[6] Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al.; the Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;371:243–60. doi:10.1016/S0140-6736(13)60937-X.

[7] Children’s Institute (University of Cape Town), Dept of Planning, Monitoring & Evaluation of the Republic of South Africa, and Ilifa Labantwana (2016).  South African Early Childhood Review, 2016. http://ilifalabantwana.co.za/south-african-early-childhood-review-2016/, accessed 12 August 2016

[8] Hoddinott J, Maluccio J, Behrman J, Flores R, Martorell R (2008). Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. The Lancet 371(9610): 411-416

[9] Victora, CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev LS, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. The Lancet 371:340-357

[10] Anderson L, Shinn C, Fullilove M, Scrimshaw S, Fielding J, Normand J, Carande-Kulis V, and the Task Force on Community Preventive Services (2003). The effectiveness of early childhood development programmes. American Journal of Preventive Medicine 24(3S): 32-46

[11] Engle P, Fernald L, Alderman H, Behrman J, O’Gara C, Yousafazi A, de Mello M, Hidrobo M, Ulkuer N, Ertem I, and the Global Child Development Steering Group (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet 378:1339-1359

[12] Piketty T (2014).  Capital in the Twenty-First Century.  Harvard University Press, Cambridge MA

[13] Kuznets, S (1955). Economic Growth and Income Inequality. American Economic Review 45 (March): 1–28.

[14] World Weath and Income database. http://www.wid.world/#Country:22, accessed 12 August 2016

[15] Orthofer A (2015).  Private wealth in a developing country: A South African perspective on Piketty. Draft 20 November 2015,  Dept of Economics, University of Stellenbosch. http://www.econrsa.org/system/files/publications/working_papers/working_paper_564.pdf, accessed 12 August 2016

[16] Wittenberg M (2014). Analysis of employment, real wage, productivity trends in South Africa since 1994. DataFirst & Dept of Economics, University of Cape Town

[17] Luüs C (2016). Long term real investment returns. SA Financial Markets Journal May 2016. http://financialmarketsjournal.co.za/long-term-real-investment-returns/, accessed 12 August 2016

[18] Orthofer A (2015).  Private wealth in a developing country: A South African perspective on Piketty. Draft 20 November 2015,  Dept of Economics, University of Stellenbosch. http://www.econrsa.org/system/files/publications/working_papers/working_paper_564.pdf, accessed 12 August 2016

[19] Bosch A, Rousseau J, Claassens T, Du Plessis B (2010). A Second look at measuring inequality in

South Africa: A modified Gini coefficient. School of Development Studies, University of KwaZulu-Natal. http://sds.ukzn.ac.za/files/WP%2058%20web.pdf, accessed 12 August 2016

[20] Statistics South Africa (2014). Youth employment, unemployment, skills and economic growth, 1994–2014, Report No. 02-11-00.  http://www.statssa.gov.za/presentation/Youth%20employement,%20skills%20and%20economic%20growth%201994-2014.pdf, accessed 12 August 2016

[21] Statistics South Africa. Quarterly Labour Force Survey (QLFS) 2014, www.statssa.gov.za/publications/P0211/P02114thQuarter2014.pdf, accessed 12 August 2016

[22] Van den Berg S (2015). What the Annual National Assessments can tell us about

learning deficits over the education system and the school career year. Stellenbosch Economic Working Papers: 18/15

[23] Gustaffson M et al (2010). The costs of illiteracy. Stellenbosch Economic Working Papers: 14/10. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1727649, accessed 12 August 2016

[24] Jordaan Y, Schoeman N (2015). Measuring the impact of marginal tax rate reform on the revenue base of South Africa using a microsimulation tax model. South African Journal of Economic Management Sciences. [online].  Vol.18 (3): 380-394. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S2222-34362015000300007,

accessed 12 August 2016

[25] Harrison D (2010). An overview of health and health care in South Africa: Priorities, progress and prospects for new gains. http://ftp.bhfglobal.com/files/bhf/overview1994-2010.pdf

[26] Gertler P et al  (2013). Labor Market Returns to Early Childhood Stimulation: a 20-year Follow-up to an Experimental Intervention in Jamaica. National Bureau of Economic Research Working Paper. http://www.nber.org/papers/w19185

[27] Gustaffson M et al (2010). The costs of illiteracy. Stellenbosch Economic Working Papers: 14/10. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1727649, accessed 12 August 2016

[28] Engle P, Fernald L, Alderman H, Behrman J, O’Gara C, Yousafazi A, de Mello M, Hidrobo M, Ulkuer N, Ertem I, and the Global Child Development Steering Group (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet 378:1339-1359

[29] Shonkoff J, Phillips D (2000). From Neurons to Neighborhoods : The Science of Early Childhood Development. Washington, DC, USA: National Academies Press

[30] The Science of Early Childhood Development. (2007). National Scientific Council on the Developing Child. http://www.developingchild.net.

[31] Children’s Institute (University of Cape Town), Dept of Planning, Monitoring & Evaluation of the Republic of South Africa, and Ilifa Labantwana (2016).  South African Early Childhood Review, 2016.

[32] Department of Health, Republic of South Africa (2013). Roadmap for Nutrition in South Africa, 2013-2017. http://www.adsa.org.za/Portals/14/Documents/DOH/Nutrition%20Road%20Map%202013-2017.pdf, accessed 12 August 2016

[33] Children’s Institute (University of Cape Town), Dept of Planning, Monitoring & Evaluation of the Republic of South Africa, and Ilifa Labantwana (2016).  South African Early Childhood Review, 2016.

[34] Masten A (2015). Ordinary Magic: Resilience in Development. The Guildford Press, New York

[35] See Reach Out and Read, http://www.reachoutandread.org/resource-center/medical-providers/, accessed 12 August 2016

[36] Moffitt T, et al (2011). A gradient of childhood self-control predicts health, wealth, and public safety. Proceedings of the National Academy of Sciences of the United States of America. 108(7): 2693 -2698; doi 10.1073/pnas.1010076108

[37] Felitti V, Anda R (2009).   The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare. In:  Lanius R & E. Vermetten (eds). The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease, Cambridge University Press

[38] Engle P, Fernald L, Alderman H, Behrman J, O’Gara C, Yousafazi A, de Mello M, Hidrobo M, Ulkuer N, Ertem I, and the Global Child Development Steering Group (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries  The Lancet 378:1339-1359

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