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Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
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5

Maintaining Quality at Scale

This session was framed around five questions posed by the moderator, Florencia Lopez Boo from the Inter-American Development Bank (IDB):

  • What challenges were present in the scaling up of programs, and what lessons were learned to overcome these challenges?
  • What processes to set and monitor quality standards during implementation were successful in maintaining quality at scale?
  • What has been your experience in using data information systems for monitoring and evaluation, and what successful feedback loops or continuous quality improvement systems have been used?
  • How have issues in centralization and local capacity been addressed, in both the short and long term? How are gaps between local needs and infrastructure and resources being addressed?
  • What are some best practices in approaching culturally and ethnically diverse populations, and adapting programs to meet their needs?

Panelists responded to these questions from their own perspectives in designing and implementing national and state-level policies and programs.

Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×

DEVELOPING A NATIONAL CHILD POLICY IN BRAZIL1

Paolo Bonilha of the Ministry of Health of Brazil explained that Brazil has been advancing on a number of social indicators, particularly Millennium Development Goal four on infant and child mortality. Brazil had a significant reduction in infant mortality, as a result of public policies adopted by the national system of health. This includes universal health care, with a focus on primary care and family health, a comprehensive immunization program, and the prioritization of breastfeeding. Additionally, he discussed the effectiveness of the Bolsa Familia conditional cash transfer (CCT) program and its impact on infant mortality. Bonilha remarked that this program provides families and children with better prenatal and vaccination coverage, and has also been shown to decrease infant mortality, particularly in the most vulnerable families.

The improvement in child survival in Brazil, Bonilha noted, has created momentum for the development of a national policy for children’s health to build a foundation for healthy development throughout the lifespan. Bonilha explained that the government of Brazil created a national program called Brazil Carinhoso, which was inspired by Chile Crece Contigo, de Cero a Siempre2 in Colombia, and Educo a tu Hijo3 in Cuba. This program guaranteed that Bolsa Familia would offer CCTs with attention on early childhood. The program is also expanding quality daycare centers, micronutrient supplementation, and school-based health care. It also includes a special focus on vulnerable families, including those with children with disabilities or chronic disease, or mothers with mental illness or substance use disorders. Bonilha cautioned, however, that to expand this program, community health agents would require additional training to be properly qualified to work with pregnant women and young children. He explained that some pilots have been initiated to assess the possible strategies that could be integrated into the national policy, home visitation in particular.

An additional project that is being developed, Bonilha explained, is focused on reducing malnutrition inequities in indigenous populations in the Amazon region and in the countryside of São Paulo. Malnutrition and mortality rates are high among these populations, and comprehensive

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1 This section summarizes information from Paulo Bonilha, National Coordinator, Children’s Health and Breastfeeding, Ministry of Health, Brazil.

2 De Cero a Siempre is the National Strategy for Comprehensive Early Childhood Care implemented in Colombia by the Presidency of the Republic (http://www.deceroasiempre.gov.co/QuienesSomos/Paginas/QuienesSomos.aspx) (accessed June 23, 2015). Constanza Alarcón discusses components of this strategy in Chapter 6.

3 Educo a tu Hijo is a research-based and intersectoral early childhood development program for children birth through age 6 and their families (Organizacion de Estados Iberoamericanos, n.d.). Components of this program were not discussed at the workshop.

Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×

programs are being developed in these regions to educate health agents to visit homes and work with mothers on issues of malnutrition, breastfeeding, and healthy food provisions. These health agents will also focus on fostering the link between mother and child and encourage healthy early childhood development.

CHILE CRECE CONTIGO4

Andrea Torres noted that Chile Crece Contigo is a system, not a program, which requires complex coordination of multiple strategies. This system was initiated in 2007 with strong support from President Bachelet to work in half of the municipalities in Chile, and in 2008, it was implemented throughout the entire country. In discussing how to scale up the system across all of Chile, Torres emphasized the importance of multisectoral collaboration, with investment not only at the ministry level but also the local level, and drawing upon existing local and international successes and experiences, including Chile Solidario and Bolsa Familia in Brazil. Torres also highlighted the goal not of creating new structures within the government but rather taking advantage of what already existed, starting with the public health system, because 80 to 90 percent of children between 0 and 4 years of age receive care under that system.

One lesson they learned from this process was the need to incorporate and maintain strong support in local governments, because while policy can be outlined at the national level, the point of contact between families and public policies is at the local level. This support involves financial resources, technical assistance, materials, training, and more, in addition to an assessment model. Torres noted that additional work was still needed to develop quality standards for all of Chile Crece Contigo’s services within the various participating sectors (education, health care, and social protection). While there are quality standards in health, more work is needed in creating quality standards for education and community networks.

Some quality process indicators and standards have been developed to monitor the services of Chile Crece Contigo, such as thorough uniform protocols that can highlight gaps in the service or in reliability of implementation. Some of these indicators relate to the development of a work plan at the local level, performance of health staff, registration and referral, follow-up monitoring, and delivery of educational materials. In terms of community indicators, Torres noted that Chile is more family oriented, and there are still lessons to learn to build community impact.

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4 This section summarizes information presented by Andrea Torres, Director, Chile Crece Contigo.

Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×

Some additional indicators she identified include children’s well-being, parental skills, and reduction in the rates of developmental lags or delays.

To monitor, assess, and follow up on the developmental trajectory of children, Torres noted that Chile Crece Contigo designed and implemented an online registration, referral, and monitoring system, which is linked to the national public health system. Each individual child has a unique identifier that is used to monitor and track development. The data system also focuses on risk factors, including teen pregnancy, maternal depression, lack of family support, racial violence, and others, and creates alerts for areas of vulnerability in order to refer a child as needed. She explained that data are collected and analyzed, and the assessments are used to inform public policy decision making. Torres noted some challenges with using this system, including limited or no Internet connection in certain areas and the fact that, in some local teams, there are still gaps in the management and use of information.

PRIMEIRA INFÂNCIA MELHOR5

Primeira Infância Melhor, as explained by Liése Gomes Serpa, is the early childhood policy implemented in the state of Rio Grande do Sul, Brazil, and is funded and coordinated by the Secretariat of Health alongside the Secretariats of Justice and Human Rights, Policies for Women, Culture, Health, Education, and Labor and Social Development. Gomes Serpa explained that the main objective of Primeira Infância Melhor is to make families feel comfortable and at ease with their children’s development in order to establish strong parent–child bonds. This is done through a weekly home visitation program in which visitors encourage parents to incorporate daily play with their children. The home visitor, local to the community, also links the family into an intersectoral care network.

Gomes Serpa noted that Primeira Infância Melhor is implemented in 268 of the total of 497 municipalities in Rio Grande do Sul. At the municipal level, she described, there is a policy management group that oversees challenges and coordinates across sectors. This group also holds training sessions that help the state identify differences in populations across regions in order to better recognize and address issues for specifics groups and contexts. Targets are established on a local level, and indicators are measured based on data collected during home visits.

To maintain quality at scale, Gomes Serpa mentioned periodic trainings—quarterly, semi-annual, and yearly—where experiences are exchanged and lessons are shared. There is also a database to hold infor-

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5 This section summarizes information presented by Liése Gomes Serpa, Director, Primeira Infância Melhor.

Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×

mation such as descriptions of communities and families, and helps monitor children’s milestones. Using this system, the home visitors can identify and address gaps to focus on, such as language, cognition, motor skills, socio-affective skills or family relationships. She noted that sometimes it is a challenge to convey the importance of collecting such data, but such monitoring is crucial as reports are issued for municipalities to adjust and qualify their performance.

In closing, Gomes Serpa emphasized that the initiative focuses on vulnerable populations such as the African-Brazilian and indigenous communities, as well as women’s prisons, in order to promote the bond between mothers and their children. Women deprived of their freedom, she explained, keep their children with them up to 1 year of age, after which they are cared for through local intersectoral care networks. Primeira Infância Melhor supports bonding between mother and child in that first year, and continues to follow up after the child leaves the prison facility. Furthermore, she stated that home visitors come from Afro-Brazilian and indigenous communities, so they are able to maintain and foster traditions and culture while promoting the bond between mother and child.

DISCUSSION

In the discussion following the presentations, panelists further explored issues and challenges specific to children with special needs and maintaining engagement of staff.

Bonilha explained that there is some confusion in the scientific literature as to the impact of home visitors, particularly because these visitors are not always health professionals, and are not always paid. He pointed out that some research indicates that for high-risk or vulnerable children, such as those with mental illness or developmental difficulties, home visits are not as effective. In Brazil, home visitors are professional health agents, and they have the support of higher-level professionals such as physicians, nurses, and teachers. Torres remarked that the Chile Crece Contigo program identifies the most vulnerable children with disabilities and refers them to special institutions for care. However, there are also efforts to provide special equipment for teachers and caregivers to support the inclusion of children with disabilities in kindergarten classroom settings as well as to support at-home care. Gomes Serpa emphasized that the home visitors with Primeira Infância Melhor work within a network of care. She acknowledged the difficulty of working alone with families, especially families with children with disabilities and special needs, and that it is important to work with a network of professionals in different fields to achieve a system of support.

Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×

In response to a question raised by workshop participant Martin Benavides Abanto regarding efforts to build local capacity in municipalities, Bonilha emphasized the importance of increasing funding to train staff in health care and the home visitation programs, and once the programs expand nationwide, an incentive program can be implemented. Currently, however, funds and resources are limited. Torres observed that Chile Crece Contigo continuously trains staff and encourages the technical assistance of local and national groups. It is crucial to acknowledge the successes, she argued, and it should be recognized that this is important work. She noted, however, that further effort should be made to improve the context in which health agents and home visitors work, in terms of resources, salary, and other areas. Similarly, Gomes Serpa stated that ongoing education is important, as is recognition of, and appreciation for, the work that staff is doing, in addition to providing an appropriate supply of materials and other resources.

Finally, panelists discussed assessment and replicability of programs. First, Bonilha remarked on the assessment of competencies at the family and community levels. Health agents track indicators related to family activities, such as play, reading, nutrition pre- and post-intervention. However, an evaluation of community competencies needs to be explored, and Bonilha stated that health agents can assist with this process. Further, additional questions in such an evaluation could address the involvement of the community on cultural norms to promote healthy childhood. Then, Torres emphasized that an assessment of Chile Crece Contigo’s model would be most useful for other countries, as this model follows the trajectory of development through health, education, and social protection. She explained that the program is coordinated within a small intersectoral ministry focused on social development, because the issue is not under the purview of any one discipline, rather it requires a cross-sectoral approach. Gomes Serpa agreed, noting that early childhood programs cannot take place in an isolated way and emphasized the need and value of an intersectoral network of care.

REFERENCE

Organizacion de Estados Iberoamericanos. n.d. Educacion inicial experiencias no escolarizadas: Programa educa a tu hijo. http://www.oei.es/inicial/cubane.htm (accessed March 17, 2015).

Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×
Page 27
Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×
Page 28
Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×
Page 29
Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×
Page 30
Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×
Page 31
Suggested Citation:"5 Maintaining Quality at Scale." Institute of Medicine and National Research Council. 2015. Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and Fundação Maria Cecilia Souto Vidigal, São Paulo. Washington, DC: The National Academies Press. doi: 10.17226/21749.
×
Page 32
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This report summarizes a joint workshop convened by the Institute of Medicine and National Research Council with Fundacao Maria Cecilia Souto Vidigal in November 2014 in Sao Paulo, Brazil. The workshop presentations and discussions highlighted efforts made to scale program investments across health, education, nutrition, and social protection that aim to improve children's developmental potential. Speakers explored four topics around scaling up program investments: impact, scalability, sustainability, and governance. Participants shared their experiences scaling up programs and implementing early childhood services into a comprehensive national policy. Scaling Program Investments for Young Children Globally synthesizes up-to-date evidence on effective programs and interventions in Latin America and other regions, including an account of their strengths and challenges. This report highlights the presentations and discussions of the event.

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