INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES
Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean—Workshop in Brief
On November 11, 2014, the Forum on Investing in Young Children Globally of the Institute of Medicine and National Research Council, in partnership with Fundação Maria Cecilia Souto Vidigal (FMCSV) in São Paulo, Brazil, held a 1-day workshop. The purpose of this interactive public workshop was to highlight efforts made to scale program investments across health, education, nutrition, and social protection that aim to improve children's developmental potential. Invited speakers and public participants explored four topics on scaling up program investments: evidence of impact for effective investments in young children; scalability of investments; sustainability of investments; and governance.
Presenters highlighted evidence on effective investments in programs and interventions in Latin America, including an account of their strengths and challenges. Speakers addressed scalability and sustainability of program investments and how to maintain quality at scale, with a focus on approaches in culturally and ethnically diverse contexts and issues of decentralization, local capacity, and information systems for monitoring and evaluation. Presentations and discussions included policy perspectives on scaling up programs.
This brief summary of the workshop highlights the topics raised by panelists, moderators, and public participants, while also including possible directions for further discussion. It represents the viewpoints of individual session participants and should not be viewed as consensus conclusion or recommendations of the workshop as a whole. A full summary of the workshop will be available in summer 2015.
Introduction
Keynote
During her keynote presentation, Claudia Costin of the World Bank discussed the importance of integrating health, education, and social protection in order to promote healthy childhood development. She stated that children should be at the center of policy making and that investing in young children is one of the smartest investments a country can make. However, Costin noted that too few children benefit from early childhood investments, as policy makers may not fully recognize the importance of early childhood. Additionally, teachers and caregivers are often poorly prepared to deliver high-quality attention and education. Costin stated that early childhood programs must be affordable and of high quality, as poor-quality programs have been shown to have detrimental effects. Costin described the Bolsa Familia program in Brazil, in which the federal government maintains a registry of the families below the poverty line and coordinates the cash transfers delivered to them. This program is complemented by the municipality of Rio de Janeiro, which provides additional support to the families based on children's preschool
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For more information about the Forum on Investing in Young Children Globally, please visit http://www.iom.edu/activities/children/investingyoungchildrenglobally.aspx.
attendance and parental education. The keynote was followed by presentations from grant-making organizations on incentives to invest in young children through a lens of grand challenges.
Grand Challenges
Grand Challenges, at The Bill & Melinda Gates Foundation, encompasses numerous initiatives that promote innovative collaborations and solutions to global health issues. Gary Darmstadt of the foundation explained that the purpose of Grand Challenges is to create an outlet for people from all over the world to form a community that works together to address major global health challenges in creative ways.
Claude Pirmez, of the Instituto Oswaldo Cruz, discussed approaches used in Grand Challenges Brazil that focus on seeking innovative strategies for the prevention and management of preterm labor to reduce the burden of preterm births. Pirmez said these complex challenges require an integrated and systematic approach that fosters a sustainable way to provide affordable and universal access to services.
Dominique McMahon, of Grand Challenges Canada, said children who live in poverty face multiple adversities. Therefore, Grand Challenges Canada focuses on integrated approaches that promote health, nutrition, social protection, and a nurturing environment. McMahon acknowledged that a solution requires partnerships among organizations with varying skill sets, including regional partners who understand the local context, implementation partners who can help move initiatives to scale, and corporate partners who can support scaling of specific strategies.
Eduardo Marino, of FMCSV, described the early childhood programs of FMCSV. They aim to improve services and public policies from pregnancy through the first 1,000 days of life. In 2014, FMCSV partnered with Grand Challenges Canada to support three Brazilian projects targeting early childhood development issues in Brazil. Marino stated that a goal of this effort is to create a Brazilian Saving Brains platform.
Evidence of Impact for Effective Program Investments
Susan Walker, of the University of West Indies Child Development Research Group, presented a pilot parenting intervention using a minimalistic approach to integrate parent activities into existing health services. This approach required no additional clinic staff and no increase in the length or frequency of patient visits. The intervention used nine films featuring Jamaican mothers practicing positive behaviors, such as praising, reading books, and talking with their baby. The parenting videos were delivered to caregivers during routine child health visits in waiting rooms. Evaluation of the program demonstrated benefits to children's cognition and parents' knowledge of child development. Walker suggested that an advantage to this program in the Caribbean and Latin America could be attributed to the high coverage and compliance with child health care visits.
Walker said the design of the intervention led to various challenges, particularly by limiting the number of opportunities to interact with and engage parents. Specifically, she pointed out that there are only five clinical contacts between the ages of 3 to 18 months, in comparison to the weekly home visits of the original Jamaican home visiting program. Walker noted that an additional challenge emerged from the clinic infrastructure, with waiting rooms that are often crowded and noisy. She stressed the need for evaluation and monitoring to ensure that integrating a new program into the existing clinical infrastructure does not negatively impact the services already being provided.
Marta Rubio-Codina, of the Institute for Fiscal Studies and Inter-American Development Bank, discussed the evaluation of a medium-scale parenting program in Colombia. The program introduced psychosocial stimulation and micronutrient supplementation through weekly home visits. The program was adapted from the Jamaica home visiting program, and aims to strengthen mother–child interactions and promote healthy child development. The intervention used local human capacity through the existing infrastructure of Familias en Accion. Rubio-Codina stated that using local resources is important in creating a cost-efficient intervention, but also in maximizing community ownership and cultural behavioral change. An evaluation demonstrated positive effects, albeit smaller than those in the original Jamaica pilot. However, Rubio-Codina noted the effect could
still be sustained as parenting practices were significantly improved, which indicates a fundamental change within the community.
Rubio-Codina noted three distinct categories of challenges associated with scaling up this project: first, in terms of design, the intervention must be adjusted to meet the education level of the local human resources and adapted to the local context. Second, to ensure successful implementation, staff should receive adequate training and monitoring and have an opportunity for career development. Third, evaluation must include a representative sample that reaches children at the appropriate age and uses adequately adapted measurement tools.
Mauricio Barreto, of the Collective Health Institute of the Federal University of Bahia, described two Brazilian programs, Sanitation in Salvador and The Family Health Program (FHP), which highlight areas for successful large-scale programs to be effective. Sanitation in Salvador aimed to improve the sewage coverage and evaluate the effect of the city-wide sanitation program on diarrhea morbidity in young children. Evaluation indicated that the prevalence of diarrhea fell by 21 percent. The goal of FHP is to emphasize the importance of primary health care and to work toward a comprehensive health system. Evaluation of service provided by FHP showed a significant reduction in infant mortality between 1996 and 2004.
Barreto described lessons learned in these programs. He stated that large-scale interventions are implemented due to political decision and cost-effectiveness; however, the implementation of programs can transcend political decisions based on a large demand within the population. Barreto noted that challenges in evaluation include the fact that child health outcomes have multiple causes, and often several interventions act on a child simultaneously. He pointed out that it is important to develop a clear framework of design and analysis to aid in evaluation.
Scalability and Sustainability of Program Investments
Paulo Bonilha, from the Ministry of Health in Brazil, stated that Brazil has been advancing on a number of social indicators, particularly Millennium Development Goal 4 on infant and child mortality, which he attributed to the public policies adopted by the national system of health. For example, Bonilha described the Bolsa Familia program in Brazil, which is the largest conditional cash transfer program in the world and was a contributing factor to the reduction in infant mortality, especially among vulnerable families. Evaluation of poverty-related deaths found that as Bolsa Familia coverage increased, mortality rates for children under age 5 decreased. Bonilha stated that Brazil's focus going forward is to provide more proactive support for the most vulnerable families within the Bolsa Familia program. The vulnerable families include those with infants who are born prematurely with a low birthweight, who have chronic diseases, or who are born to mothers who have mental health concerns or are drug users.
Andrea Torres, of Chile Crece Contigo, began her presentation by stating that Chile Crece Contigo is a system and not a program, thus requiring multisectoral collaboration with investments at the ministry level and at the local level. The goal of Chile Crece Contigo is to articulate, organize, and integrate early childhood care from pregnancy to age 5 by providing public services and monitoring the developmental trajectories of young children. Torres explained that the system uses the existing medical infrastructure to deliver services because 80 to 90 percent of children participate in the public health system. Chile Crece Contigo uses an information technology system for monitoring and referrals, which are linked to the national public health system. Torres said local facilities are the point of contact between families and public policies, and therefore need ongoing support to serve families.
Torres identified a number of challenges. She noted that creating culturally appropriate indicators to monitor community achievements is a challenge. Moreover, she stated that this system is considered a challenge because people do not always understand the value of collecting the data. Torres declared that without data, it is impossible to make decisions at the local level regarding follow-up and to track the trajectories of the development of children.
Liese Gomes Serpa, of the Primeira Infancia Melhor (PIM) program, discussed PIM in Brazil. PIM aims to establish a strong parent–child bond and to help families feel comfortable and at ease with the child development process. A program representative conducts weekly home visits to encourage families to play with their children and to provide opportunities to connect with other facets of the intersectoral care network. Gomes Serpa stressed the importance of establishing appropriate targets and understanding cultural contexts because populations in each region vary significantly. Home visitors are from within the community, and are therefore more adept at maintaining cultural traditions while fostering the relationship between the parent and child.
One challenge Gomes Serpa described was in gathering data. The country introduced a database to monitor child development, but ensuring that the municipalities collect the necessary data is difficult. The data are important because they provide home visitors with the tools needed to track the achievements of each child, and data reports guide municipalities on how to improve performance.
Perspectives on Governance
Maureen Samms-Vaughan, of the National Commission for Early Childhood Development in Jamaica, outlined the process of scaling up a small pilot program into a national program in Jamaica. Samms-Vaughan said the first stage consisted of obtaining comprehensive information on the status of children and programs for early childhood development. One finding was that approximately 95 percent of children attended preschool in Jamaica due to community demand and not a government intervention; however, there is an issue with quality and inequity of preschool programs. Second, a cross-sectoral state institution, the Early Childhood Commissioner (ECC), was created to take responsibility for the early childhood sector and coordinate activities to ensure a sustainable cross-sectoral approach. Finally, ECC developed a cross-sectoral strategic plan using international and local research as well as public input. The strategic plan included program development, monitoring and evaluation, and ensuring public awareness. Samms-Vaughan concluded by stating that while the structure and process of the cross-sectoral work of the ECC may be instructional, cross-sectoral work is inherently difficult, and thus this system may not work for every country.
Ana Elisabeth de Andrade Lima, of the Government of Pernambuco in the Secretary of Health, Brazil, discussed the Mãe Coruia (Mother Owl) program in Pernambuco. Mãe Coruia was developed to reduce infant mortality by providing care to pregnant women and their children through age 5. Andrade Lima explained the significance of the name. The owl is the only bird able to see 360 degrees, which parallels the program's philosophy of ensuring that the various contextual components of a situation are seen as a whole. Andrade Lima stated that program data are accessible online to allow for real-time monitoring and intervention. She indicated that Brazil has had an overall reduction in infant mortality; however, the rate of reduction in Pernambuco was the greatest, especially in municipalities where Mãe Coruia was present.
Cristina Lustemberg, coordinator for Uruguay Crece Contigo, discussed an assessment in 2012 that pointed out important gaps in early childhood and early adolescence. Based on these results, Uruguay Crece Contigo (modeled after Crece Contigo in Chile) was developed to target vulnerable populations, pregnant women, and children through age 4. Uruguay Crece Contigo provides comprehensive care to households with pregnant women and children. Lustemberg said that implementing Uruguay Crece Contigo addresses three main challenges: (1) fragmentation of early childhood policies across sectors, (2) lack of coverage of services for children under age 3, and (3) inability to reach the most vulnerable populations.
Constanza Alarcon, Presidency of the Republic, Colombia, discussed scaling up early childhood programs in Colombia. Alarcon indicated that the government did not approach expansion with a focus on risks or vulnerabilities, but rather on guaranteeing rights. Alarcon stressed the importance of intersectoral programs, but further explained that there are various ways to address intersectorality. She stated that regardless of the method chosen, each sector will have an agenda, and identifying where all the goals converge is important for successful implementation.
Breakout Groups
Results-Based Financing
Martín Benavides Abanto, of the Group for the Analysis of Development, represented the small discussion group on results-based financing. He noted that the way public resources are managed changes continuously, leading to various opportunities and challenges. One opportunity is the ability to target the budget to address specific concerns within the population. Another opportunity is to empower people through participation in information generation, so that they have more knowledge of the issues.
Abanto noted that an important challenge is that information gathering is very demanding and many countries do not have adequate data systems, so existing systems must be improved. Abanto also said disseminating a results-based methodology could be a challenge because many programs are driven by ideological or political positions instead of data. A final challenge the group discussed was a concern about producing results for impact assessments because most childhood outcomes occur in the medium or long term, not in the short term.
Measurements and Indicators
Mark Miller, of the Fogarty International Center, reported from the small discussion group on measurements and indicators, where participants discussed relevant outcomes to be measured from a population and individual perspectives. A few participants questioned whether an accurate tool could be created to meet specific needs of precision while still remaining cost-effective. Miller stated that the group raised questions about whether early childhood outcomes were accurate predictors of the future; what role environmental factors could play; and how the combination of risk and protective factors should be explored.
Methodology for Measuring Public Investments in Young Children
Javier Curcio, of the Universidad de Buenos Aires, said the small breakout session group discussed six variables used to connect problems of early childhood to state policies: (1) the early childhood age group, up to age 7, including maternal health; (2) incorporation of actions taken by countries at different government levels; (3) registration databases that indicate adherence to public policies; (4) policy mapping of the functions of various sectors, including social services, justice, protection of rights, and documentation of identity; (5) financial strength of types of expenditures and how they impact early childhood; and (6) frequency of investment analysis. Curcio said the group had numerous questions about the process, including how to make comparisons across countries, how to adapt the process to various contexts, how to sustain and institutionalize the process, and how to foster country ownership.
Final Remarks
Alarcon provided highlights she identified from the workshop: (1) the importance of assessments and measurement, including gathering quality data in a timely fashion and following up on the effectiveness of programs; (2) the importance of adapting models for implementation and assessment to account for regional and cultural differences; (3) the knowledge that when scaling up programs, quality may be lost; and (4) the need for cross-sectoral approaches at the national level that address these issues in a holistic way. 
Forum on Investing in Young Children Globally (iYCG)
Zulfiqar A. Bhutta (Co-Chair)
Sick Kids Centre for Global Child Health, Toronto, University of Toronto Center of Excellence for Women and Child Health, Aga Khan University
Ann Masten (Co-Chair)
Institute of Child Development, University of Minnesota
J. Lawrence Aber
New York University
Amina Abubakar
Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
Constanza Alarcón
Intersectoral Commission for Early Childhood, Presidency of the Republic, Colombia
Raquel Bernal
Center for Research on Economic Development, Universidad de los Andes
Pia Rebello Britto
Early Childhood Development Unit, UNICEF
Helena Choi
Global Development and Population Program, The William and Flora Hewlett Foundation
Pamela Y. Collins
Office for Research on Disparities & Global Mental Health and Office of Rural Mental Health Research, National Institute of Mental Health, National Institutes of Health
Tracy Costigan
Research-Evaluation-Learning Unit, Robert Wood Johnson Foundation
Alex Coutinho
Institute for Child Wellness in Africa, Accordia Global Health Foundation
Gary Darmstadt
Stanford University School of Medicine
Angela Diaz
Mount Sinai School of Medicine
Rana Hajjeh
National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
Jody Heymann
Fielding School of Public Health, University of California, Los Angeles
Gillian Huebner
Lumos
Venita Kaul
School of Education Studies and Center for Early Childhood Education and Development, Ambedkar University Delhi
Sarah Klaus
Early Childhood Program, London, Open Society Foundations
Vesna Kutlesic
Office of Global Health, National Institute of Child Health and Human Development
Albert Lee
JC School of Public Health & Primary Care and Centre for Health and Education and Health Promotion, The Chinese University of Hong Kong
Joan Lombardi
Bernard van Leer Foundation
Florencia Lopez Boo
Inter-American Development Bank
Stephen Lye
Fraser Mustard Institute for Human Development
Robert Mallett
Accordia Foundation
Kofi Marfo
Institute of Human Development, Aga Khan University
Mark Miller
Division of International and Population Studies, Fogarty International Center
Helia Molina Milman
Past Minister of Health, Chile
Ariel Pablos-Mendez
USAID
Janna Patterson
The Bill & Melinda Gates Foundation
Alan Pence
School of Child and Youth Care, University of Victoria
Ruth Perou
Centers for Disease Control and Prevention
Cheryl Polk
HighScope Educational Research Foundation
Eduardo de Campos Queiroz
Maria Cecilia Souto Vidigal Foundation
Jose Saavedra
Nestlé Nutrition
Lorraine Sherr
University College London
Andy Shih
Autism Speaks
Karlee Silver
Grand Challenges Canada
Simon Sommer
Jacobs Foundation
Taha E. Taha
Bloomberg School of Public Health, Johns Hopkins University
Pamala Trivedi
Office of the Assistant Secretary for Planning and Evaluation
Susan Walker
Tropical Medicine Research Institute, The University of the West Indies
Sara Watson
Ready Nation
Amalia Waxman
Consultant
Quentin Wodon
Human Development Network, World Bank
Hirokazu Yoshikawa
New York University
IOM Staff
Kimber Bogard
Forum Director and Director, Board on Children, Youth, and Families
Sarah Tracey
Research Associate
Charlee Alexander
Research Assistant
Amanda Pascavis
Senior Program Assistant
Patrick Kelley
Director, Board on Global Health
Consultant
Jocelyn Widmer
University of Florida
DISCLAIMER: This workshop in brief has been prepared by Amanda Pascavis, rapporteur, as a factual summary of what occurred at the meeting. The statements made are those of the authors or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the National Academies.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this workshop in brief was reviewed by Amalia Waxman, Maternal and Infant Nutrition at Nestlé, and Stephen Lye, Fraser Mustard Institute for Human Development. Chelsea Frakes, Institute of Medicine, served as review coordinator.
This workshop was jointly hosted by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal.
SPONSORS: This workshop was partially supported by the Accordia Global Health Foundation; the Aga Khan Foundation; Autism Speaks; the Bernard van Leer Foundation; The Bill & Melinda Gates Foundation; Fundação Maria Cecilia Souto Vidigal; the Fraser Mustard Institute for Human Development; Grand Challenges Canada; the William and Flora Hewlett Foundation; the Inter-American Development Bank; the Jacobs Foundation; the National Institutes of Health— the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Fogarty International Center, and National Institute of Mental Health; Nestlé Nutrition Institute; Office of the Assistant Secretary for Planning and Evaluation; Open Society Foundations; Society for Research in Child Development; UNICEF; U.S. Agency for International Development; U.S. Centers for Disease Control and Prevention; U.S. Department of State; and the World Bank.
For additional information regarding the workshop, visit http://www.iom.edu/Activities/Children/InvestingYoungChildrenGlobally/2014-NOV-11.aspx.
