3. Scaling up
How can we scale up effective investments in young children?
The Forum on Investing in Young Children Globally (iYCG) focused on:
- moving from pilots to public policies,
- implementation innovation, and
- using existing platforms.
- How do you think this experience will affect Mirta and her family?
- Did you experience an ECD program when you were a child? How do you think it may have affected you?
The evidence from neuroscience, from epigenetics and from several interventions such as the Jamaica Home Visiting Program, Care for Child Development (WHO/UNICEF) and others is clear - quality early childhood interventions have long term positive outcomes. Scaling up such programs is vital to supporting the developmental health of all human beings. The complexities of how to scale successfully and economically, building on existing systems is the dominant discourse in the global early childhood sector and was also within the iYCG Forum.
The Educa a tu Hijo program, attended by the child MIrta in the example above, is a remarkable example of a scaled up, high quality early childhood program. It not only encompasses the entire early childhood period (from conception to age 6), but also reaches close to 96% of the children and families in Cuba. Watch the following video to learn more about Educa a tu Hijo.
Educa a tu Hijo
Narration: The Republic of Cuba, known for its vibrant culture and complex history has also faced great economic challenges for many years. Yet Cuba also has the highest literacy and health outcomes in Latin America.
Dr. Fraser Mustard: Cuba is a demonstration about the power of early stimulation and nutrition on development in the later stages of life.
If you want to really get high quality early human development you have to begin early.
Narration: Early in the Cuban revolution, maternal and child health and literacy were identified as key social priorities. Considerable investments have been made in both the health and education systems, with a particular focus on early child development.
Dr. Isabel Rios Leonard: Cuba's economic conditions, on the contrary, are detrimental to the aspirations of achieving a good education and a good health for the people. From the very beginning of this phase we presently live in, a decision to benefit the people has existed, specifically in these two principal areas of primary achievement - health and education. And investments of our human capital, our main resource, have been made. In reality, we haven't improved or changed much in these fifty years from an economical standpoint, but we have increased our human potential exponentially.
Narration: Cuba made steady progress in improving population health and education outcomes – then, in the early 1990’s, with the fall of the Soviet Union, everything changed. It was at this time that a visionary new program, Educate your Child, was developed. This program is based on research in rural areas in the 70's & 80's. The evidence was clear that when families were directly involved in stimulating their children's development, results were better.
Narration: Educate your Child is an integrated program that supports children and families from pregnancy to age 6. It is a low-cost, highly effective alternative to centre-based programmes.
Narration: Each family’s introduction to Educate your Child begins early – usually soon after they learn that they are expecting a baby. The program begins with services from polyclinics – the community based clinics that are the backbone of Cuba’s highly regarded primary health care system.
Visits to the doctor that is the health care system is very good. There are visits to the doctor every 15 days. I have the card there, I should have brought it. They keep track of everything on the card. They measure you, the height of the belly to see if it has grown, they weigh you every 15 days. Take your blood pressure, and they are constantly there for you.
During prenatal care, the mom-to-be also receives training of the Educate Your Child Program. It's not just after the baby is born – it starts when the baby is inside her belly, with a series of orientations and education at the practice so the moms are prepared. The Educate Your Child activities are not just taught to the mom but to the whole family.
Narration: Cuba also has a system of Maternity Homes for women who are experiencing challenges or risks during pregnancy. The service is preventative and many Cuban women come for short periods of rest and care at some point during their pregnancy.
I'm here because I'm 34 weeks pregnant, and I was having changes of the cervix, that is the cervical collar, so I should say here, resting, and taking care of myself so I can have a healthy future baby.
It's quite good here. There's no stress or tension, you don't need to worry about a lot of things, only about you and the health of the baby.
Narration: Once a child is born, families continue to visit the polyclinics regularly. The focus is not only on physical health but on development as a whole. Health practitioners, including physicians, play a key role in encouraging parents to stimulate and interact with their babies.
Narration: As children grow, the focus of the Educate your Child Program changes from individual support to group activities. When children are 2 to 5 years old the families gather in groups of 15 - 20 for a program specifically planned for this age group.
Dr. Ana Maria Siverio: This structure is an activity which is a three-stage pedagogic structure. The first stage is of orientation, in which the families are asked what they did at home. How they felt performing the activities, what they learned, how the children responded, did they like it or not, if it was difficult to carry out certain activities... and they are asked how it went.
Narration: During the second part of the program, the family learns a new activity which they try out with their children.
Narration: In the 3rd part families reflect on the activities they have just done with their children and discuss any questions they may have.
I urge and encourage everyone who can to come see the program, so they can so how gratifying it is. Through play, a very easy activity for the child, he's able to do things by himself, things that will be useful to him in the future, and that's very wholesome, very good. I recommend it.
As part of Educate Your Child, home visits enhance the activities of the group program and support families in a more individual basis.
She knows the colours, the sizes of things, the shapes of things... Let's see... what shape is the door to the house?
Girl: Let's see... rectangular!
Narration: Educate your Child was started as a way to support families in rural and remote areas but now reaches over more than 75% of Cuba’s families with young children. Together with the Circulos Infantiles programmes, virtually all children in Cuba have access to early childhood services.
Narration: The early childhood programmes in Cuba are rigorously studied and adapted, based on evidence.
We are aware that in these [programs] rests the future of our country. Therefore we are meticulous, extremely particular to avoid taking any wrong steps that could endanger the future of this country.
Narration: The Educate your Child program is a powerful example of how when resources are targeted to the very youngest members of a society, there are great returns in developmental health outcomes.
We always say, everything that we do around us, be it at the institution or at the home, the child is fundamental. The care for childhood in Cuba is a priority.
- How do you think this program impacts children? Their parents?
- Why are the strong links between the program and families so important?
- Educa a Tu Hijo includes multiple inputs from ministries – from health and education to sports and culture. How does its integrated nature contribute to its strengths?
- Do you think this kind of program could exist in your context? Why or why not?
- Can you think of some key factors that made it happen in Cuba?
3.1 Moving from Pilots to Public Policies
Research studies are valuable and point to reliable evidence but the pipeline to impact public policy is long. Building public support for investment in young children is one strategy. Local channels for program delivery are essential to successful execution of policies.
The Toronto meeting in 2016 focused on ‘Moving from Evidence to Implementation’. Jeremy Shiffman, American University, presented on the challenges of achieving widespread focused attention of policy makers that is necessary to move from evidence to action.
Begin by reading a summary of his presentation, below.
In the full presentation, Shiffman identifies strategic challenges, discusses several examples from health that have successfully built political support and moved into the public agenda (such as HIV/AIDS, DOTS treatment of tuberculosis). He then looks at challenges and opportunities specific to ECD within this framework.
Shiffman – Generating Global Political Priority for Early Childhood Development: Challenges and Opportunities
DR. SHIFFMAN: Thank you Dominique. It’s a real privilege to have an opportunity to address this forum and to have an opportunity to speak with you about this subject. I’d like to share with you findings from research we’ve conducted on generating global political priority for early childhood development.
This research was led by Dr. Yusra Shawar, and I joined in on the research as well. What we’d like to do is share with you four common strategic challenges that communities involved in global development often face as they seek to generate attention and resources for the issues that concern them. And then to speak to this with reference to a study we conducted on early childhood development specifically and getting global priority for this issue.
First, what do we mean by global political priority? This refers to the degree to which political leaders both at the global level and at national levels are paying attention to an issue and providing resources commensurate with the problem’s severity. The backdrop to this is the observation that there are hundreds and hundreds of development issues that need to be addressed and that are serious, and there are limited resources, and therefore there is competition for these scarce resources. Another point of backdrop that is important to take note of is an interesting phenomenon in the world of global development that has really occurred over the past two to three decades, and that is that there has been a proliferation of what we would call global development networks.
And what we mean by this are webs of individuals and organizations linked by a shared concern for a particular development issue that is global in scope. This community constitutes one kind. Some of these are formal, they have formal governing structures at the global level. Others are characterized by largely informal ties. I’m going to be illustrating my points with many examples from the health sector because I’m a political scientist but I study global health, so that’s where my knowledge base is.
But to give an example, tuberculosis has a Stop TB Partnership based in Geneva connected to the World Health Organization. It’s a formal governing structure that helps to coordinate global TB efforts. By contrast there’s a global network of surgeons trying to promote surgical delivery services in low income countries. That is more informal kinds of ties that govern this, there’s no central global organizing body.
A third piece of backdrop is the observation that these global development networks influence the level of political priorities their issues receive. They’re not the only influence to be sure, but they’re one among several influences. The efficacy of the way in which they go about promoting the issue matters. Now of course this has to be put in context, there are many other factors that shape priorities.
We have a framework of about 10 factors in these three categories which I won’t go over, but two other broad categories concern the broad policy or political environment. For instance, to give an obvious example, what made it to the SDGs and what did not, what was on the MDGs and what was not. If you made it on it was easier to generate tension and resources, if you didn’t make it on, more difficult.
A third category of factors that shapes political attention are what we call issue characteristics. The idea here is that some issues by their very nature are inherently harder or easier to address than others. And this shapes political attention and resources. I’ll give an example from the education sector. Historically it seems to be the case that access, getting children in schools, has been easier to measure and to achieve than learning, promoting learning. And this arguably is one reason why during the MDG era, whose indicators were predominantly access, not learning, there was greater traction for access than learning. It’s a characteristic of the issue that shapes political attention. Just one example.
We’ve in our research and other research on collective action, and this comes from the fields I’m most engaged with, political science, sociology, to some extent anthropology. We discovered that global development communities, which one might consider this community as one, an example, commonly face at least four strategic challenges in terms of network development. And these are the problem definition, the positioning, the coalition building, and the governance challenges, governance being at the center of this.
And I want to speak to you what I mean by each of these four concepts and these strategic challenges. The problem definition of challenge pertains to how the community itself internally understands what the problem is that they’re addressing it, and what are the appropriate solutions, and does it generate internal evidence-based consensus on this, and why does this matter. And again I’m speaking about how it matters not for science but for political support. Well if there’s coherence, if there’s credibility, if there’s consensus, it augments authority and political leverage. By contrast, if a community is fragmented and engaged in internal wars over what is to be done and what exactly the problem is, it hampers its ability to convince political elites whether it’s a global, national, or subnational level to devote attention and resources to the issue. Again, let me give some examples from the global sector I know best, health. Tuberculosis, well there has been contention in the TB community over what is to be done, but generally speaking the TB folk hit upon what’s called Directly Observed Treatment Short Course or DOTS for short as a strategy to address tuberculosis globally.
And through that internal consensus, general internal consensus, some people are suspicious of the strategy, but through that general internal consensus we’re able to convince many political leaders across the globe to prioritize tuberculosis control, and have largely been more effective than most other global health issues in getting that issue on the agenda. Maternal mortality, the maternal survival community is another community I know very well. Historically they have an interesting trajectory. Historically they have faced difficulties in generating internal consensus, especially in the ‘80s and ‘90s there were differences, disagreements over strategy to address maternal death and childbirth. Antenatal care, traditional birth attendance, skilled attendance at birth, emergency obstetric care, and the fissures were one factor hampering global political attention, the fissures in the community surrounding intervention strategy.
Now you see in the 2000s and especially in the MDG era a coming together, a greater generation of consensus, and that, not the only reason, there are many other reasons, but that is one among several reasons that you see maternal health and maternal survival augmented attention for this issue. So they were able to transcend many of these differences to a great extent.
So I’ve talked about internal problem definition, that’s a function internal to the community of development experts. There’s also the question of how the issue gets framed not just understood internally but externally, and this is the positioning challenge. How is the issue publically positioned in a way that inspires external audiences to act, especially the political elites whose resources are crucial for generating priority for the issue?
And why does this matter? Only some public positioning of the issues resonate widely, and different framings of the issue may resonate with different audiences. Here it’s useful to draw on the case of HIV/AIDS, which originally was understood to be an issue that affected only certain marginalized populations. With that public understanding of the issue it was difficult to get political traction.
Eventually over time globally it became reframed and understood as a security issue, a rights issue, a development issue, ultimately an existential threat to humanity. And it was in the process of this reframing that this issue rises to get global attention. Of course there are other factors that mattered, the drop in prices of ARV, the coalition, the social mobilization, but these reframing processes were crucial to the acquisition of political support for AIDS. So problem definitions, positioning. The third crucial strategic challenge is the challenge of coalition building, the question of building alliances. In global health and social development this becomes a crucial issue, and why, because usually these sectors are politically weak, they’re not politically strong compared to other sectors, finance, security, and others. The political actors, there are some exceptions, but for the most part comparatively weak. And yet often these sectors are insular, they build allies from within, when they need to expand outward and build coalitions that are broader and engage finance and other sectors that are crucial for the acquisition of political support.
And also the need for bottom-up civil society pressure on states and international institutions. In the health sector obviously AIDS is an example of an effective global coalition building. Tobacco control represents another comparatively, there are many difficulties, but comparatively tobacco control is a relative success in building broad global, and in some countries national political coalitions that expand beyond the traditional health actors.
You get the 2003 framework convention on tobacco control, the WHO led treaty that ultimately is itself a coalition building exercise but it sparks a broader coalition building process. The fourth is the question of governance, the fourth strategic challenge that these communities face. And these are establishing structures for effective collective action. There are many kinds of structures that work, but the structure needs to be tailored to the kind of issue and the level of development of issue.
But having these kinds of structures help guide the community to steer itself to achieve its collective goal. And in health again one of the prime examples of effectiveness that many point to in health is the taskforce for child survival and development, in the ‘80s led by former UNICEF James Grant, which most observers consider to have been a rather effective institution in mobilizing global political support for a child’s survival most especially.
So Dr. Shawar and I conducted a study. We examined some of the internal dynamics of the ECD community concerning generating global political priority. The intent was not to provide recommendations but to rather understand the state of the field, any strategic challenges, with the hope of sparking deliberation among community members themselves, because it’s only through that process of discussion rather than through externally imposed recommendations that these issues advance. Now I want to say of course it’s the national level that’s most critical, generating priority at national and subnational level. And I’ve read several interesting studies about these national level dynamics. This particular study limited itself to dynamics among global actors. So it’s not a claim to be all encompassing of this field. We used qualitative process tracing methodology grounded in a public policy framework that I developed several years ago with respect to maternal mortality and was published in the Lancet in 2007.
And we conducted semi-structured interviews with 19 members of the community, observers of the community, individuals from low and high income settings, reviewed many documents to try to piece together what are the issues, what are the issues pertaining to global political priority, including both identified explicitly by members of the community as well as dimensions we saw that maybe weren’t quite as apparent to members of the community.
And we found much evidence for great strengths and considerable progress in this community, but also challenges in each of these four areas. And I’d like to highlight some of these challenges for purposes of strategic deliberation. The problem definition most people in this community think is not result. There are differences on what are the contours of the field, is violence a core pillar for instance, people disagree.
What’s the time period constituted by early childhood? This differs by sector, and there’s disagreement over exactly who you’re talking about. Consequently, different interventions and different strategies. Should it be an overall integrative type approach to addressing this, or a sectoral strategy? Especially many people identified tensions about the prominence of child survival in this space, and people from outside the child survival space were concerned about that, so it’s a core tension.
This is a quote. We don’t have a unified problem statement, we desperately need to articulate one, which illustrates how people in this community may be seeing some of these issues. The second is the positioning. And here positioning remains a difficulty if unclear. Perception in many countries that there may be no immediate payoff to the ECD, of course this is inaccurate empirically, but I’m not talking about empirical, I’m talking about perception. Weak data hamper informed advocacy. And fundamentally policy makers may be in many places quite confused as to why they should do this. Amidst scarce resources and many competing priorities, they don’t understand why. Furthermore, they don’t understand what it is exactly they’re being asked to do. They get many different requests. So the cohesion there. This is a quote illustrating. ECD is too nebulous a concept. This is one respondent.
The coalition-building. I was even talking this morning and I learned about additional allies outside this sector, but still the coalition building processes are limited outside these traditional sectors, and even within internally across sectors how well has the coalition building process unfolded.
The governance. Respondents and our findings indicate it’s rather fragmented. And part of this, this is really issue characteristics, it’s inherently an intersectorial issue, which makes it much harder than say TB, which is not as much. It is kind of intersectorial, but it’s mostly health.
This is intersectorial, you have to merge multiple sectors, it makes it more difficult. Respondents said there were many talented advocates and champions, many of whom are in this room, but they weren’t able to point to a single James Grant type figure, a unifying leader. Lack of institutional leadership, especially from within the UN system where respondents said well we have UNICEF, WHO, UNESCO, other entities, but they’re involved with their sectoral priorities, where does this all come together?
Fragmentation at the national level too. The intersectorial nature of this means that it’s divided across multiple ministries. What kinds of national governing institutions are needed to bring this together? This was a quote pertaining to this issue area. Competition and silos dominate. People are jockeying for money and trying to get credit for what they are doing.
Now these challenges are interrelated, because the governance, with effective governance that creates the possibility for a generating effective problem definition public positioning and coalition building. Likewise as these get resolved you get more advanced, you get more trust in governance, and the governing institutions come together. Now I’ve highlighted the challenges because I think it’s useful to highlight those. But one shouldn’t lose sight of or be overwhelmed by that aspect. There are many strong opportunities and developments. The growth in the number of actors in the 2000s, the high profile global resolutions to the fact that there are indicators in the SDGs. New national initiatives, growing evidence on interventions, and the momentum on metrics. So many opportunities. And I’ll just conclude with this slide because ultimately this was meant to spark productive deliberation, not to offer a set of prescriptions, which is our role as outsiders who aren’t part of the ECD space. But how do these leverages, how does one leverage these strengths to meet these four challenges that most development communities face, namely the problem definition, the positioning, the coalition building and governance challenges. And I’ll just leave this chart up here in the hope that it might spark some discussion. Thank you.
Following Shiffman’s presentation, Zulfiqar Bhutta questioned whether it is best to work together or separately in terms of bringing government attention to key issues.
DR. BHUTTA: Jeremy, I appreciate this is work in progress. What did your assessments so far say in terms of the types of coalitions that need to be built on existing coalitions? So what is your assessment? Is ECD better off layering on top of existing coalitions around for example newborn child survival, or is it better for it to create its own coalition? I mean what is the best buy here? Because there are many overlapping Venn diagrams here, particularly given for example in nutrition. So if you take the big risks of ECD, poverty stunting, there has to be some commonality of mission, which could be beneficial for ECD, or could require a separate initiative.
DR. SHIFFMAN: That’s a fantastic question, and you’re much better qualified to answer that than I am, so I’m looking forward to hearing your answer. I’m going to make a couple comments, and please excuse me for not directly answering your question because what I want to do is spark discussion. Three comments. Yes, there is a considerable amount of fragmentation and difference over this issue within this space. ECD, maternal nutrition, newborn education, how do you put that together, what’s the right way? This is a crucial issue that these communities need to resolve and they haven’t resolved and they disagree. The second observation is this is not an uncommon problem, you can go into any development space and there’s a perpetual tension between integration versus specificity. And in some ways it parallels the verticality versus horizontality debates in global health. There’s probably not an ideal resolution. It’s a perpetual tension that never gets resolved, but it has to somehow be advanced in this space.
The third point I would make, and this is one that helps people, I think neglect, and I’m thinking about our research on health, not in other spaces. Those coalitions that do best go beyond their usual allies. They build political coalitions beyond the health space. They involve finance parliamentarians, other unusual suspects. The ones that do the worst are insular. They think it’s just about the science, it’s just about my buddies, it’s just about getting the evidence. Of course necessary, but never sufficient.
The following comment from the Lancet Review discusses the various elements that need to come together to generate effective investment and scale up of early childhood programs.
- Why do you think they assert that community-level knowledge is equally important as the evidence of science?
- Can you think of some examples of early childhood resource allocation, successful or not, to support your reasoning?
The following article from the 2016 Lancet series provides an excellent overview of critical importance of scaling up investments in young children and families as the key pathway to human potential and equity embodied in the Sustainable Development Goals.
Notice that on Panel 1, page 106 of this article there is a list of investments in ECD that are known to be effective. How many of these exist in your context?
3.2 Implementation Innovation
The debate is shifting from ‘why’ to invest to ‘how’ to invest. Innovative demonstrations can be part of, or in close coordination with existing systems and human resources. NGOs and philanthropic groups can work with governments to test-drive new policies and program approaches.
In the next two clips, iYCG Forum members Sarah Klaus, Open Society Foundation, and Larry Aber, New York University, discuss the keen interest of the forum in implementation science.
Klaus - Implementation Science
I think the biggest themes of the forum; I mean largely I think one of the themes is about implementation science in a way. How do you take policies or how do you take, sorry, research and bring it together with policy and take it beyond policy into practice and into implementation science and exploring different corners of that in a sense. What’s it like to work in a de-centralized way in a country if that’s the challenge of making something work is making it work at the local level. Or what’s it like working with the most vulnerable groups. So I think there’s been a bigger focus perhaps on implementation in policy then on research per se, you know. So I think the forum has taken things much more in a direction of implementation, implementation science. Quality is an issue that comes up a lot in the forum discussions; equity, I think those are all themes as well.
But when we talk about scaling up and what I see in practice or what I see in my own work is that we’re usually dealing with a policy with a government that has, you know capacity to do a limited amount and the children with disabilities are the and, if and later or we’ll try this first and that’s too difficult. And I think that we shouldn’t be working like that at all and it should always, you know we should be; that shouldn’t be an optional extra you know. And I think the forum; there are a number of members of the forum who’ve written papers on the issue of disabilities in young children and I think a kind of focus on it now because of the awareness at the forum in each one of the themes; a sort of sub theme around that group.
Aber - Implementation Science
As critical as the science is, the bigger challenges are implementation and policy challenges. So, I’m a card-carrying union member, I’m a developmental scientist, I deeply believe in the positive role science can play in revealing what children’s development is all about, what’s most influential, and guiding us to good intervention strategies, but identifying an intervention that works is light years different from figuring out how to scale those interventions with sufficient quality to have population based impact. And so, I think, this forum has shed a very bright light that in almost every country in the world, the gap between science and reality for an entire population of kids on the ground is a very big gap.
The second insight, though, is that we don’t have to despair in the face of that gap. There are many things we are learning how to do, so through implementation science, we’re learning how to deliver programs more efficaciously, with higher fidelity at lower cost, and if we don’t learn how to do these with equal power for lower cost, the economics of the situation will not allow us to have population based impact. We’re also learning that some policies can really enable that kind of activity, and some policies actually discourage or throw up severe barriers to that kind of policy, and we’re learning that advocacy with policy makers can help us strengthen some of the enabling factors and reduce some of the barriers. But it’s pick and axe work, there’s nothing fancy or glorious about it. You go in and you develop relationships and you hope that reason and sense will out over time.
- Aber remarks that 'identifying an intervention that works is light years different from figuring out how to scale those interventions with sufficient quality to have population based impact.' What does this mean?
- Why was the forum so eager to shine a light on implementation?
The inclusion of children with disabilities mentioned by Klaus will be discussed in more depth on Page 6 of this module.
Investments in early childhood encompass many different kinds of delivery systems and programs. In the next presentation from the Toronto workshop, Sonia Sharma, Mobile Creches, describes a highly innovative program in India that has been operating for 47 years, providing childcare and health services for mothers who are migrant labourers on construction sites.
Sharma - Mobile Creches India: Scaling-up early childhood centres for migrant construction workers’ children in India
DR. SHARMA: Good afternoon everyone. I’m Sonia Sharma and I’m representing my organization, Mobile Crèches from India, it’s a 47 year old organization, and we are working on the rights to ECD for the children for marginalized children in construction sites and urban slums, and I’ll be talking more on the experiences of scaling up early childhood centers for migrant construction worker children in India.
So the context, the numbers are huge. There are 400 million migrant workers in India, which the parents come with their children, very young children with their families and many situations, the factories, construction, agriculture, agriculture being the first and construction being the second largest.
So from the 400 million, 40 million get their job in the construction industry. And one out of the five is women. 20 million children are devoid of the basic care, health and health interventions, care, protection and all, and they’re subjected to the physical psychosocial and emotional neglect.
Mobile crèches responded to this about 47 years ago in the form of healthcare and protection just under a small hutment. Just to respond that they need safety and protection first, and eventually it evolved into a very comprehensive program of four key components of health, nutrition, education and community awareness, which is important as a sustainability piece. And the centers do this all four components with the care and protection which is provided by the trained care worker who is a lynchpin for all four.
So apart from the holistic approach, integrating all health, nutrition, early learning, safety, and care, because it’s about place-based intervention, so the crèche is provided right at the site for the worker, for the parent, so they can drop their children, mothers can come and breastfeed their children. And here the role of the employer that is the builder who is building that construction becomes important, it is shared as part of the finance and responsibility should be there. Mobile crèches over the period of time, we have developed systems, protocols for the health interventions, education, a community awareness for all that. And even we tried and tested our training models in internal and external settings. And even we developed the crèche expertise, we developed a framework for doing the work over there, and even gather knowledge, even seek expertise from the pedagogy assessment, what should be the major tools for how to deal with the situation and even gathered the data on the construction industry, how it works, the situation of the migrant and all. And the role of the worker becomes important because we feel that they should be well compensated.
So this is how we evolved, I will just briefly touch upon it. The context was there was no political will, ECCD being low priority there, the industry was noncompliant. And so in the 70s and 80s we just entered into the site. So the builders were just you come and serve the children, I’ll not provide you with anything. So that was the case until the 80s. In the 90s the Act came in place, which was the Building and Other construction Workers Act, 1996, which says that if there are 50 women at the site it’s a legal mandate that the builder should provide a crèche. But there was no abiding to that law, no implementation on the ground. We said it’s a legal mandate we advocate with the government because we feel it’s their responsibility, they should do it for us.
But nothing was fruitful. Even during the Commonwealth Games 2010, the eyes were all on India, we tried to do that. But nothing came, in vain total efforts. So we thought why not, builders should come and they should give something. So we just stopped the 100 person subsidy to the builders. At the time we said you have to contribute a little bit. So it started from there to 10 percent, 20, and some took 70 percent, so there were variations.
So this is how the 2000 models involved. But it was not a long-term sustainable model because we feel that ultimately they came and said it’s not our core expertise, we want MC Mobile Crèches and other such organizations to come forward and do this for us. And there were no players in the market, like no ECD player, mobile crèches were one of the very few organizations working for the very young children. You will still find organization who are working for the six plus and older ones, but very few who are working for the under threes, under sixes and all.
So we said we need to develop other players in the market, construction is happening at the outskirts. MC cannot be everywhere, mobile crèches cannot be everywhere. So this is how we said it’s important that we develop other players, so this is a tripartite kind of arrangement which we feel is a lever to scale.
So mobile crèches provides its expertise on the crèche management, we transfer our knowledge to the NGOs, they take it on and provide child care provision at the sites, we negotiate with the builders for infrastructure facilities, a worker, and a support for the basic facilities at the crèche.
So this is the innovation which rests on the MC basic value proposition, and it draws upon various resources from the workplace based intervention itself, but prevention generation from the builder is very challenging. There are standing contributions from the (indiscernible), we’ll sign them over with us, they’ll commit 20 percent a month, 30 percent a month, but it can go with this thing in their hand, please you owe us money. So that’s the challenge. The key piece is the human, the trained resource, so at least the NGOs are replicating the key activities with the basic value proposition, but it will take time because the training investments are high. Until the training is completed, it’s like learning with them. Inculcating those values towards the young children, the sensitivity towards the young children in the new trainees, it takes time.
So this is briefly our goal, we’re demonstrating the scalability of this workplace based intervention model, and the objectives are we are trying to assess the impact of the services on the young children in a way to see the whole process documentation of the business transfer to the NGOs.
These are just the steps for scaling, it’s important to have the evidence building, and institutional readiness was important to sort of just capitalize on the human resources, people, system, then we connect to our partner, we perform the due diligence, which is really quite stringent, it’s really further restricted us to fewer NGOs on the ground, because these are all the current NGOs, they don’t comply with all financial norms and all so easily, so that’s another key challenge. Even the training investments like transferring the whole (indiscernible) practice to the workers to the supervisors and even to the heads of them.
You can definitely do the paper, there is a whole 54 days training for the NGO supervisor, so the strategy was we strengthened the supervisors. Take on the supervision at the center level. Because it’s important we cannot do the day to day monitoring. So that was the plan there, and even the over-arching goal was that the builders bring it in their policy that wherever they have their project site they have the crèche there. So some of the enabling factors were we went ahead with those NGOs who were our network partners, because we are into advocacy, we have been dealing with a lot of NGOs since decades. So we just brought them together, if you were advocate you should be practitioners too, so that was the aim.
So we could leverage that factor here, even the developers who were our old partners and with who we were running our direct delivery center, so we turned them into the (indiscernible) that also helps them. Even GCC helped us in taking that quantum leap, without them we really couldn’t have taken this bold step. That was another enabler. Even the knowledge which we have really gathered over the 47 years was, and we have staff which are there with us since 30 years, so that really helped. And the coming of the Corporate Social Responsibility Act, 2013, which mandated that there had to be some expenditure on the activities by the companies really helped because we re-leveraged some financial institutes who even gave their CSR funds to us and even helped us in linking to those developers who they were funding, for whom they were funding or giving loans to make, they’re under construction and all.
So just some impact which we have, it’s one and a half years almost, we have developed about eight NGOs, they’re running about 25 centers, one per NGO at about on an average three centers. And in partnership with 17 builders we are in Delhi national capital region and we in other cities, which is Chandigarh, Ahmedabad, and Bangalore. And these are some of the nutrition and health indicators which do say the children who are with us for about four months and above, there was age appropriate immunization, 100 percent could receive supplementary diet, all these things. This is just to code by the supervisor how it helped.
So I’ll go to the end of the story. So there were issues in selection and retention of the workers for say how to transfer that, inculcating the sensitivity, commitment towards the childcare issues, and even taking care of the special children, for the workers need time and the new trainees will take time in getting over that, and even supervision capacities. The other challenges are ECD per say is quite comprehensive, it’s not easily amenable to institutionalization as health or education is. I already talked about that there were no service providers for the under-sixes, and transferring that commitment, ownership, accountability does not come in one year or 1.5 years’ time. It takes time and construction industry policy.
So the model of yes it did retain some elements, at least we could prove through the tools we assessed the quality of the centers and we could find out that the majority performed well, at least they could follow the pharmacy guidelines. They scored high on most of the domains and even the healthcare workers, these are those centers who had received six to nine months of our technical support. But some of the compromised elements, or some quality I can say, opportunities for making children and creative thinking, so those kind of things. And even the community interventions were not that aggressive which are there in our center. So that’s just the way forward, we would really go to those locations where the supply and the demand is there. With NGOs, we’ll work on the gap areas. For sustainability purpose we’ll work on the fundraising capacities of NGOs, negotiation capacities with developers, and the training of the trainers is another.
So I think we’ll call out the potential NGOs, and we’ll train them so that they can further train and that will cause a ripple effect for them. But government definitely will go over the evidence building with the research piece which is there embedded in the project itself, networking with the NGOs, community awareness together so that we can motivate the policy makers, decision makers to do that further. But there I would like to end.
- The mobile creches seek to improve the daily life and ultimately outcomes for some of the most disadvantaged children and families. According to Sharma, the initiative has had many successes but also many challenges over the years. Can you outline some of these?
- Who are the key stakeholders? Why is it critical to have them all on board?
- What can we learn about how to scale up from Sharma’s presentation?
- How does it relate to Shiffman’s key points and the Lancet comment in the previous section?
The following website contains of wealth of information about mobile creches.
Once an innovation has been proven successful, a major challenge for decision-makers is how to scale it up. Often the quality of the original intervention is hard to replicate. On the previous page, you learned about the highly successful Jamaica home-visiting program which has been shown to have very positive long term effects. In the next clip, Susan Walker, University of the West Indies, comments on how delivery of the intervention at different intensities had different outcomes.
Walker - Intervention Intensity
Well they, in that particular trial, they were aged between one and two years, and the intervention continued for two years, and was given weekly, so it's pretty intensive. In others work that we've done, we started a bit earlier, around six months, but anytime from around six months, and then the intervention can go up to three or four years, so the curriculum is quite long. And as I said, it's weekly visits, though we've also done work looking at two weekly visits and shown that that can also be effective. Very interesting work that was done some years ago by Christine Powell, showing that where she looked at weekly, fortnightly and monthly visits, and it's probably still the only time it's been done in the literature to really actively compare those, and showed that weekly was the best. But that, you know, if you went fortnightly, you still benefitted children's development, and that by the time you went down to monthly, it really was not sufficient.
An emerging and really interesting field is the application of innovative uses of technology to tackle social challenges. The Innovation Edge is a South African group who are trying to induce catalytic change with new approaches, with and without technology, to improve ECD outcomes.
3.3 Existing Platforms
Education, health, nutrition and social protection can be the essential building blocks for investing in young children. Build community, municipal and regional capacity to monitor implementation of services for young children and families.
In this section we will explore several examples of programs scaled up or researched for potential scale-up in different contexts.
Larry Aber, New York University, has been involved in a project in Ghana designed to make existing widespread preschool programs more play-based, scaling up widespread curriculum change.
Aber - Scale-up in West Africa
An example of positive scale up in West Africa is work we’ve been doing in Ghana with the Ghanaian Education Service. Ghana realized over a decade ago that the very poor outcomes for children very early in elementary school could not be turned around with more effective preschool. So, they were influenced by global and African research that suggested that preschool could improve children’s readiness to learn in school. They weren’t sure how to do that. So, we are involved with them in a randomized trial of preschool teacher training initiatives where we’re trying to help support the Ghanaian government support in service teachers, move away from a rote ‘drill and kill’, kind of traditional approach to early education, and to a more play-based, dynamic, language enriched, including not only academic learning, but social-emotional learning. That was partly influenced by what’s called the learning metrics task force. The Secretary-General created a group to say ‘if we’re going to have millennium development goals or sustainable development goals in education, how are we going to measure progress in learning and what is learning. And the great contribution to that learning metrics task force is that they broaden the notion of learning beyond literacy and numeracy to include social-emotional learning, to include moral and character and aesthetic development. So there’s seven domains of learning. The Ghanaian minister of education was deeply involved in the learning metrics task force, he felt that that was a great thing that social-emotional learning could actually help return Ghana to some of its roots about how you nurture and develop kids. So we’re, but policy is a funny thing. All of that stimulated this trial which we’re in the middle of right now, but policy gallops along. The Ghanaian parliament decided that they liked this so much that they want to train 51,000 untrained preschool teachers before the results of the trial are over. So you don’t put the brakes on progressive policy to wait for the study, you just pray that the study will support the model that the policy makers are galloping along to embrace for you, and they’re embracing it for political and constituency reasons. The second thing I’d say about Ghana is, Ghana is a case study of what’s happening all over Africa where people in rural areas are flooding to urban areas. The urbanization of Africa is stunning. There are now about half a billion people who live in African cities. By 2050, a billion and a half people will live in African cities. The population of African cities will triple between now and 2050. So that draws resources from already poor rural areas and creates need in relatively resourced urban areas. So the whole issue of urbanization is important. And the other thing I’ve learned, partly through the work in Ghana, but it’s been repeated often here in the forum is we are not going to be able to serve the worlds kids if we rely only on public sector resources. The private sector has to become involved in what they would think of as ‘this market’, what we would think of as ‘this sector’. And in African slums, in Accra, Ghana 85% of four and five year olds are in preschool, and 85% of them are in private preschools; Private, entrepreneur schools that have grown up because parents demand that their kids be in some kind of school, so parents pay a big part of their tiny salary to have their kids in private preschools. That tells you something about parents hopes and aspirations about what education can do for their kids, but the government is not subsidizing these schools, those are parent paid schools and another big dimension of work that has to be undertaken is to understand how public and private schools can both serve young kids well.
- This example is interesting because instead of the trajectory of first finding what works and then expanding, the scaling in Ghana has been led by government vision and policy. It is not always the case that government leads change. What might be some of the pros and cons, specifically in relation to ECD?
In the Sao Paulo workshop, Susan Walker November 2014, University of the West Indies, did an interesting presentation on a project in which researchers worked with health to replicate key elements of the successful Jamaica home-visiting program in clinics. This was an intentional attempt to test the possibility of scaling up the program up at a much lower cost, by creating a less resource-intensive delivery and building on the existing platform of clinic visits.
Walker - Reaching more children and families with evidence based parenting interventions
DR. WALKER: I’m going to be talking about approaches today which involve working through parents, primarily for children zero to three, and really about how we can reach more children and families with evidence-based interventions. I’d like to acknowledge my colleagues at the Child Development Research Group at the university, and also external collaborators who have contributed to this work who are listed.
So the goal of the programs is to improve home environments and ensure that children have interactive caregivers and opportunities to learn. And there are a number of critical needs in moving forward on this, but we’ve really focused on two. One is the need for evidence-based interventions for children, which are feasible for implementation at scale, and to address this as much as Raquel said, I’m going to talk about our pilot in the Caribbean, of delivering parenting through routine child health visits.
The other area that we’ve started to focus on more recently is the need to increase the number of persons in countries and organizations who have the skills to train and to supervise the persons who will implement these programs, and also very importantly the skills to maintain program quality. And so I’m going to talk about some work that we’ve begun more recently on expanding access to our evidence-based Jamaica Home Visit Intervention, which was mentioned earlier, through our web based training package and support.
So the first project was a pilot of parenting interventions in the Caribbean in three countries. And when we designed the approach we wanted to come up with an approach which was in a sense minimalistic in that we didn’t want to have to employ any extra staff at the clinics, and we didn’t want to increase the amount of time or the frequency with which the parents had to come to the clinic. So it is kind of a bare bones approach.
So we produced some films which showed mothers, and these were filmed in Jamaica so these are Jamaican mothers practicing behaviors we wanted to encourage. And there were nine short films, and they covered topics such as talking with your baby, praise, looking at books and so on. And these are shown at each child health visit, from age three months through to 18 months. So this is when the mother or other caregiver is bringing her child anyway to the clinic for her routine visit, and usually immunization.
We train the community health workers to not only show the videos, but then to demonstrate some of the activities that had been seen on the films, and to help the mothers have an opportunity to practice while they were at the clinic. And then the clinic nurses distributed some messages cards which reinforced what had been seen, and on some of the visits gave out a few play materials.
Just to very briefly summarize what we found, we did demonstrate benefits to the children’s cognition and to their parents’ knowledge of child development. The effect sizes are comparable to what’s seen sometimes with more scaled up home visit programs, but we’re less than the Jamaica weekly home visit program, which is not surprising because this is a much smaller less intensive intervention. We didn’t find any adverse effects of adding the ECD activities on children’s nutrition or immunization status, which is important. And so we felt that we demonstrated that it was possible to integrate this intervention.
As I said, requiring no additional clinic staff or mothers’ time, into the routine health services. I was asked to particularly think about some of the challenges that we face, and that wasn’t very hard, because there were many. But I think the key ones come back to the design of the intervention itself, in that there are only five contacts from three to 18 months. So this is not many opportunities to interact and engage the parent, considering we’re coming from a history of weekly home visits. So that’s one of the issues, and most of those contacts are before age 12 months, after 12 months there’s only the 18 month visit. So we do feel that this is a component of a more comprehensive strategy, and likely to need additional complimentary programs for children aged one to three.
The other issue that you won’t be surprised about is the difficulties with infrastructure and resources. The resources were stretched, many of the clinics were very crowded, they were noisy. Some of the staff had not so much time, but this was primarily the nurses, I think the community health workers did actually have the capacity to do this. And so going forward we need to ensure that if we integrate into existing service we don’t have a negative impact on what they’re already delivering. One of the advantages that the Caribbean has, and also much of Latin America, is excellent coverage and compliance with child health visits. But this is obviously something that is going to need to be considered if you’re taking it to places with less comprehensive coverage. So we could reach almost all our children with this approach. So all of these issues will need attention as programs are scaled up, especially where children’s health and nutrition is poorer, and where the capacity of health services is more limited.
We also with the help of Florencia Lopez Boo IBD were able to estimate the annual cost of the intervention, which we estimated to be $14 USD per child if we estimated for all of the children we reached attending the clinics. And so we think this is a promising component of ECD strategies with potential benefits for large numbers of children.
In the early 90’s, Open Society Foundation began working in several countries in Eastern Europe to reform preschool education in state schools. Sarah Klaus describes the process of beginning and scaling up this initiative.
Klaus – Scaling Eastern Europe
Our foundation; our earliest work in early childhood was focused on helping the countries of Central Eastern Europe reform their early childhood education systems and the vision was very big from the beginning but it started with actually very small, not small but I would say much more modest actions. So the strategy of our program was to pick; working very; we had foundations in all of the countries that we were working in and they hired people to work full time on this program for two or three years. And they established relationships and agreements with the ministries of education that over the two years, from the beginning we would all be exploring the results and impacts of the program and if it was; seemed to be a beneficial program, they would change their policy or allow this program to scale up. So we had that built in from the beginning; that would be one principle. And we started fairly small. We started in five to ten pre-schools that were state pre-schools and we worked in two classrooms in each pre-school. We didn’t even work in the whole pre-school. We thought parents shouldn’t have to, you know, put their children in this pre-school program that was experimental in their neighbourhood pre-school. They still had a right to ask for the traditional model. But we worked very intensively on quality. The people in the country who were running the program were mentoring every teacher every month for the first year and I guess what we learned through this process is that when you’re creating a model, you really need to put the time into mentoring and to quality and start; there’s an advantage to starting small because you can work out all the bugs. We could work out things that weren’t going well. We understood what was happening, we could feed back, you know, information quite quickly. And the other thing is really getting the government buy in on this from the beginning because after two years, the program by then had doubled or tripled. But after two years the governments approved this either as a regular or as an official alternative to the regular curriculum and any group could pick this up.
One issue though, is whether the groups that pilot are always the same groups that can scale up, right, do they have the capacity? So, we started then working with teacher training institutes because they’re turning out people or they’re doing re-training of teachers and they need to offer different types of courses. So I think we see; I think you have to see change as happening in a kind of an eco-system and it has different parts to it and its not just about, its not just about the government providing a policy and then it gets implemented, or the government provides a policy and then you implement in a certain number of places, or you do one training that’s a typical model, cascade training and its done. You need to have a teacher training institute, you need to have NGOs that are still pushing the quality of the model, you need to have parents demanding it, oh my gosh, parents saw these programs, they were so excited, they started to demand it, so the government wanted to provide it or the mayor or the preschool director wanted it in the rest of the, you know, classrooms. So I think you need all of those components and those are all parts of change and I think sometimes we think to narrowly about scale up as just the service being available, but it doesn’t happen without a lot of different pieces being in place.
In our final example, Mauricio Baretto, University of Bahia, discusses three large-scale interventions in Brazil and their effects on health. His talk focuses on the importance and the complexities of monitoring and evaluation.
Baretto - Evaluating Large Scale Interventions on Child Health in Brazil
DR. BARRETO: Thank you very much to be here. What I’d like to talk is on the evaluation of some large scale intervention in Brazil. I will show quickly three examples, and then do some remarks basically on this accumulated experience. I would like to start by saying that I’m an epidemiologist, and we use a lot the concept of evaluation, sometimes different from economists and other groups, but I think you have the same objective.
And then I’d like to start with this remark of Dr. Costin, say the importance of evaluation. And then I start with an example, that you had opportunity to evaluate in Salvador. So there’s it’s a large city in Brazil with 2.5 million inhabitants, and Salvador was during some time there was a huge investment on improving sanitation in Salvador. And this was an important and very interesting challenge to evaluate the impact of this intervention.
And this took a long time, took a lot of a big group of people thinking how to do that, the best way to evaluate and to take experience from that thing because despite that sanitation which starts in the idea that sanitation is good for health comes from the 19th century, yet there are very few evaluations on the effect of sanitation on health. Mainly the Latin American approach that uses sewers, complex sewers in urban environment, and then there are very few examples.
And then after buildup of complex models, very difficult analysis, very complex system of measurement, you arrive at a very simple but very strong result. The sanitation in Salvador was capable to reduce 20 percent diarrhea prevalence, and also more than 50 percent different kind of intestinal ailments. Another example, economic evaluation of this system shows how, using not only cost effectiveness but a more complex approach to economic evaluation show that the population was very keen of this system. They want that, there was a lot of advantage of the sanitation system give to the normal people in the (indiscernable) areas of the city.
Another big program in Brazil is the Family Health Program. This started some years ago, quickly develop in Brazil, now it covers a great part of the country, nearly 66.5 percent of our population is covered by the family health program, and it started also based on the WHO principle of Alma-Ata miti, that stress the importance of primary healthcare. And you have opportunity, you have had opportunity with other groups in Brazil to evaluate the impact of this program on infant mortality, morbidity, and the other outcomes.
Here you see some results on the infant mortality. You see that the TD areas with more consolidated family health program have an important reduction in infant mortality. This reduction is in diarrheal mortality, this impact is higher in areas that have great poverty, then show in some way the success of the program and the effects.
Another thing that you had opportunity to evaluate is the conditional cash transfer program in Brazil, the Bolsa Familia. Bolsa Familia is linked into the health system. Bolsa Familia program through the health conditionalities, now you build up a model that connects these two programs, and you try to evaluate the impact. You see here some of these effects. The Bolsa Familia program had an effect on the decreased infant mortality, also infant hospitalization on infant mortality due to diarrhea, due to pneumonia, and other causes. And you have your independent effect of the Family Healthy program. The two together possibly boost the effect on health, one acted upon health and another acted upon the social determinants of health. From this, I’d like to put some remark for debates. First, the larger scale implementations are implemented by political decision. Well informed and science based interventions have great chances of success than the importance of this kind of discussion. Well designed and well conducted evaluative studies are an important resource aiming to measure and disentangle the effect of different intervention.
Now, in the modern world you have several interventions at the same time that act upon the human beings. Then how do you understand how this work is part of our scientific challenge. Child health outcome has multiple causes and could be the effect of multiple intervention factors. It is a necessary task to develop a clear framework and complex designs and analysis. Why cost effectiveness is important, the public perception of the benefits of the program is crucial. To understand the context where the interventional core is an important part of the evaluative task, and to implement similar intervention in other contexts, to have national information systems and databases that collect and keep good quality routine administrative data on process and outcomes are crucial to the larger scale evaluative efforts.
This is an important thing I think differentiates Latin America from other developing parts of the world. In general in Latin America in the health side there was a lot of improvement in administrative registration of outcomes in the process. It has been very important to this larger scale kind of evaluation. Thank you very much.
- As Shiffman pointed out, ECD is an amorphous concept and not well understood. Why might measuring ECD investment outcomes create a greater challenge than measuring the kind of health outcomes described by Baretto?
Scaling up of small, successful ECD programs, interventions and resources to nationwide, sustainable programs is a global challenge and a global priority. Competing priorities and existing silos are often barriers to building the necessary infrastructure. Re-directing public funding from current health, nutrition, education or social protection programs to more effective ECD program from less effective ones is difficult both politically and logistically.
The Forum on iYCG identified three strategies to move forward:
- Public support beyond the ‘usual suspects’ is essential and builds political will for enabling public policy.
- ECD is a somewhat nebulous concept that is not well understood; in order to increase political traction, ECD needs to be framed more clearly.
- Leveraging existing health, nutrition, education and social protection is a promising strategy to build a sturdier foundation for sustainable ECD programs.