Early detection and intervention services for children with disabilities in the first 3 years of life are delivered predominantly within the health sector by diverse professionals including community health workers. The responsibility for the 3–5 years pre-school age is shared by both the health and educational sectors to ensure effective transition to school. Active collaboration between the health and educational sectors with support by the social and finance sectors is recognised as essential to promoting school readiness (29, 30).

Many ECD programmes are presented as disability-inclusive, suggesting that all children are provided equal access to all listed services from birth to school entry. However, several cultural, logistical, financial and systemic barriers to equitable access, including discrimination, stereotyping, and stigmatisation are commonly reported (31), making true inclusion for children with disabilities unattainable. Moreover, children with disabilities are not a homogeneous group (6), and many require individualised support to learn and participate on an equal basis with their peers without disabilities (31, 32). Hence, one-size-fits-all ECD programmes often missed or are poorly equipped to serve children with disabilities, particularly those with complex conditions. It also infringes on parental rights and freedom to choose what they consider to be in the child’s best interest.

A twin-track approach has therefore, emerged in several countries like Australia, UK, India and USA, where a disability-inclusive ECD programme is implemented alongside a dedicated disability-focussed ECD programme to optimise access to support services for children with disabilities. Each track is independently managed by a designated department or ministry but coordinated to effectively serve all children with disabilities. For instance, in the USA, disability-inclusive Head Start and Early Head Start programmes under the Department of Health (29), are complemented with disability-focused early intervention programme under the Individuals with Disabilities Education Act (IDEA) coordinated by the Department of Education (30). In the UK, the Early Years Foundation Stage (EYFS) programme for all children under-5 (33), is implemented alongside disability-focused Children with Special Educational Needs and Disabilities (SEND) (34). In India, the Integrated Child Development Services (ICDS) programme which provides early childhood care for all children under-6 (35), is supported with the disability-focused Rashtriya Bal Swasthya Karyakram (RBSK) programme (36).

ECD programmes are supported with guidelines for routine newborn screening, developmental screening and surveillance, diagnosis and timely referrals for children with developmental delays and disabilities. Early parenting support is prioritised to ensure family-centred intervention. In some countries, ECD guidelines are integrated with community-based and facility-based maternal and child health services. However, routine newborn screening for developmental disorders and disabilities that is mandated in several HICs is limited in LMICs (37, 38).

National legislations or executive orders are put in place to support ECD programmes for children with disabilities. These laws outline eligibility criteria, service entry points, family involvement, coordinating agencies, performance indicators, workforce training, enforceable rights of children with disabilities and their families, and statutory provisions for funding. Some legislations designate functions to be carried out by various levels of government: national, state and local authorities. Others make explicit provisions for non-state actors including non-governmental organisations. Engagement with and active participation by organisations for people with disabilities (OPDs), adults with lived experience and parent groups is also mandated in line with the UN Conventions of the Rights of the Child (UN-CRC) and the Rights of Persons with Disabilities (UN-CRPD). These legislations facilitate political support for ECD programmes especially for budgetary allocation, and they also provide tools for advocacy.

Funding schemes for implementing service provisions in the ECD legislations are established predominantly in HICs. Most services are federally funded and grants are made to other levels of government based on agreed protocol and responsibilities. The US-based Head Start Programme and Early Intervention and Preschool Education Programme under the IDEA are perhaps the most established and well-funded multi-racial disability-oriented national programmes globally. Funding for IDEA reached $10.8 billion in 2022, supporting states to implement the Act, with $410 million allocated for preschool grants and $496 million for early intervention services. Disability insurance schemes that provide financial assistance directly to families especially where costly support services and assistive technologies are necessary also exist in some countries like Australia. In many LMICs, the absence of federal funding for ECD services contributes to the failure or ineffectiveness of national ECD programmes, even when disability legislations are in place (39, 40).

Multisectoral coordination, monitoring and a system of accountability at the national and community levels are provided and legislated in many countries. The accountability mechanisms stipulate roles and responsibilities, rewards and incentives for good performance as well as penalties for poor or non-performance. For example, in the USA, at least 10% of enrolled children must have disabilities and be eligible for special education or early intervention services under the Head Start and Early Head Start programmes. Since inception, these programmes have served over 38 million children and families with up to 13% enrolment of children with disabilities. Before 1975, many disabled children in the USA were excluded from public schools, but in the 2020–21 school year, over 7.5 million received special education services, with more than 66% integrated into general education classrooms under IDEA. Since its inception, India’s RBSK has served approximately 1.2 billion children under 18 years, identifying 86 million with selected impairments or disorders through 360 District Early Intervention Centres.

A comprehensive global ECD strategy for young children with disabilities ideally should encompass several key components, including a well-defined disability policy, supportive legislation, operational guidelines, sustainable funding mechanism and a robust monitoring system. The proposed policy should address the needs of children with disabilities from birth up to age 5 years, emphasising the critical role of early intervention from birth as a foundation for pre-school education. Early intervention before age 2–3 years has been demonstrated in longitudinal studies to reduce the need for special education for some children with developmental delays and disabilities at school entry (46, 47). The exclusion of children under 2 years from the current indicator for SDG 4.2 and the UNICEF monitoring tool (ECDI2030) therefore, needs to be resolved as soon as possible (48). The ECDI2030 should be harmonised with the Global Scale for Early Development for children aged 0–3 years recently developed by WHO to produce a single tool for children under-5 for use in all LMICs. The global disability policy should make explicit provisions for the required health and educational services including newborn and developmental screening and surveillance ideally synchronised with well-child visits including routine immunisation, referral pathway for diagnostic evaluation, and links for timely enrolment into family-centred support programmes for children with disabilities (49, 50). The absence of routine newborn screening for developmental disorders and disabilities in the vast majority of many LMICs needs to be addressed to ensure the timely detection of children with disabilities. Early parenting interventions should be emphasised to minimise the emotional burden and sense of helplessness often encountered by parents following diagnosis of disability in their child (51, 52). The policy should also provide clear guidance on how to manage the transition from family-based intervention services in the first 3 years of life to pre-school enrolment starting at age 3 years.

The global ECD policy needs to be supported by appropriate legislations (4, 53–55). All countries included in our review had specific disability laws or general legislations for all children with or without reference to children with disabilities. The UN Conventions of the Rights of the Child and the Rights of Persons with Disabilities already provide a practical framework and guidance for mandating all countries to make specific provisions for children under-5 in their national laws for persons with disabilities and childcare legislations. A template can be developed to assist countries with and without disability legislations to make specific legally binding provisions for services required by children with disabilities in line with SDG 4.2. Such legislations also empower parents to seek their rights to state support for their children.

Comprehensive operational guidelines for service providers across all levels of service delivery are necessary. These guidelines should be adaptable to different populations and should reflect the standard protocol for clinical recommendations and guidelines provided by WHO. The guidelines should address the range of services listed in the framework as a matter of principle and best practice. Even in situations where ideal technologies may not be readily available, these guidelines can serve as a valuable compass, informing service providers about the desired direction and potential avenues for future improvement.

Disability policies and legislations are necessary but not sufficient without funding. The critical role of funding is reinforced in various global reports on disability inclusion (Appendix 1). Many LMICs rely on funding from donor organisations and HICs for maternal and child health programmes (56) and are more likely to require such support for ECD initiatives (57). In our view, the introduction of a global disability-focussed ECD strategy is likely to attract greater attention and funding. At the current levels of developmental assistance to LMICs for childhood disabilities by OECD donors and others, the global ECD agenda is unachievable (58). A dedicated global fund should be considered to support LMICs that have instituted appropriate legislations for children with disabilities and are committed to allocating a proportion of their annual health and educational budgets for ECD services.

Global funding schemes require effective monitoring system for accountability linked to specific performance indicators (16, 41–43, 55). For example, it is important to track the number of children that are screened, identified with disabilities, enrolled for early intervention services, and attending preschool programmes during each reporting period. Ongoing access to global funds should be contingent on these performance indicators.

The key actors with critical roles in ensuring the effectiveness of the global ECD Strategy include donor organisations, relevant government ministries, state and local authorities, accredited providers of services for children with disabilities at community-level, including OPDs and a designated national governance body. Countries may consider establishing an independent but multidisciplinary ECD Commission with specific mandate for inclusive education in line with all the provisions of the SDG 4.2. In line with the efforts to transform the NCF into a global disability-inclusive ECD programme, it will be necessary to designate lead UN agencies for the development and implementation of the global disability-focussed ECD strategy. Additionally, we recommend that in developing a comprehensive global strategy as proposed in this paper, the relevant UN agencies should consider engaging with administrators of established national ECD programmes in different world regions for better insights on the associated operational challenges and how to address them. Lessons and key performance indicators (e.g., school enrolment and participation, school completion rate, programme costs) that have not been published can be garnered from such engagements to inform the introduction of global and national targets. Also, it is important to clarify that the implementation of a global strategy is typically country-led, allowing nations to adapt and prioritise service delivery within a defined operational framework to promote a greater sense of ownership and best possible developmental outcomes across diverse cultures and contexts. We are not unmindful of several cultural, health and social barriers to service delivery and uptake that persist even in countries with well-established and well-funded ECD programmes especially in high-income countries (59–62). A global disability-focussed ECD strategy is unlikely to fully address the stigma and discrimination faced by children with disabilities and their families worldwide as they transition into school education in inclusive settings. However, it provides a pathway for individualised support especially for children with severe or complex disabilities.