The strategies employed when investing in young children are almost as important as the investments themselves. For example, several individual workshop speakers stated that investing only in education or nutrition at the exclusion of social protection and health will not maximize those investments (IOM and NRC, 2014, 2015a). Collaboration and coordination of efforts to increase the outcome and impact of investments were discussed as a key consideration across the forum’s workshops. Other important strategies that were discussed include coordination of financial investments across ministries; integration of programming across different platforms to address social protection, health, nutrition, and education; and targeting investments across the life course. Individual workshop speakers addressed coordinating programs and policies between the public and private sectors; being strategic when scaling; incorporating measurement tools for determining the who, what, why, and how of investing; and communicating findings to stakeholders.
Coordination and Integration
Two challenges in financing investments in young children are fragmentation of the public sector and lack of coordination among stakeholders (IOM and NRC, 2015a; NASEM, 2015). According to Enakshi Ganguly from HAQ: Centre for Child Rights, in India the budgets for programs for young children are spread across multiple ministries, causing problems for budgeting analysis. Coordination among stakeholders is critical to combat this problem (IOM and NRC, 2015a). Another need for coordination was noted by Subrat Das and Protiva Kundu from the Centre for Budget and Governance Accountability who said that policies in India disaggregate children into different age categories, resulting in unequal coverage across groups of children (IOM and NRC, 2015a). In Brazil, Ana Elisabeth de Andrade Lima from the State Health Secretariat of Pernambuco, recommended that the early childhood community assemble partners and stakeholders to work together to see the picture as a whole, as well as to encourage participation at all levels for effective governance (IOM and NRC, 2015b). As stated by Sumit Bose, the former Finance Secretary of India, financing large-scale early child development programs and policies can be extremely difficult given the pressures from other sectors to create short-term solutions. In his experience, expenditures on short-term programs and services do not lead to sustainable solutions (IOM and NRC, 2015a).
Some workshop speakers discussed coordinated and integrated solutions toward sustainable investments in early childhood, with benefits and drawbacks presented for each approach. According to Jan van Ravens from the Yale School of Medicine, there is little evidence that supporting integrated programs leads to more positive child outcomes than coordinated ones, citing a flawed research approach (NASEM, 2015). He pointed out that when considering the argument that children will learn more if a nutrition service is
integrated into a preschool, he stated that study designs typically consider only four groups: (1) children who only have access to the preschool program, (2) children who only have access to a nutrition program, (3) children who do not have access to either intervention, and (4) children who have access to the integrated program. A critical fifth group is missing from this evaluation, said van Ravens—children who have access to a preschool program from one provider and a nutrition program from another provider (NASEM, 2015). Emily Vargas-Baron from the RISE Institute (NASEM, 2015) noted that at the national level, early childhood development policies and programs are multisectoral; however, very few of them are integrated. It is at the local level that she typically sees services integrated around the child. She added that few intersectoral ministries can be found around the world. In general, Vargas-Baron stated that many of the integrated child development ministries have been short lived and have tended to lack power, citing Venezuela’s Ministry of Intelligence; Sri Lanka’s Ministry of Child Development and Women’s Affairs; and Tanzania’s Ministry of Community Development, Gender, and Children. Current intersectoral ministries exist in Georgia, Lesotho, and Bhutan (NASEM, 2015).
An example of a well-coordinated system of policies was described by Molina (IOM and NRC, 2015b). She described a system that was developed in Chile to support early childhood development, Chile Crece Contigo, or Chile Grows with You. Implemented in 2007, the system took a multidisciplinary approach and was planned across sectors by multiple ministries to serve as a comprehensive protection system for early childhood with a child-centered and rights-based framework. Chile Crece Contigo is part of a larger public policy of social protection for workers and those in poverty, with a focus on mothers, children, and families. The policy includes all sectors, including health, education, public health, culture, housing, and other areas of government, because children are affected by all of these aspects of poverty. Molina 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. According to Molina, what began in a hundred municipalities was eventually scaled to incorporate the entire country.
Generating Public and Political Will to Scale Successful Programs
Many programs struggle when scaling. Several individual workshop speakers stated that some problems include generating the will to scale the program, maintaining quality and integration, and making sure that investments are appropriately leveraged for impact (NASEM, 2016b). Jeremy Shiffman from American University pointed out opportunities for scaling include political leadership, engaging the media, partnering with the private sector, and building on existing infrastructure to scale (NASEM, 2016b).
In his presentation, Shiffman argued that decision makers create policy agendas by establishing priorities. For him, four areas require coherence for generating global political priorities and an increase in resources: (1) problem definition, (2) positioning, (3) coalition building, and (4) governance (NASEM, 2016b) (see Figure 4-1). Problem definition is an internal consensus on both the problem and the solution and is important because it creates credibility, leverage, and community coherence, the formation of a tight network that acts as one body to put pressure on governments to take action. Positioning refers to the framing of an issue that inspires external audiences to act, and different frames resonate with different audiences.
Coalition building (forging alliances) fosters broader political support and strengthens social development sectors. Lastly, according to Shiffman, governance refers to effective structures to guide collective action that is necessary for enabling communities to effectively target goals (NASEM, 2016b). Shiffman stated that these components can be leveraged to increase the number of stakeholders and investments in early childhood development programs.
Several individual workshop speakers stated that it is critical to mobilize the will to go to scale not just within any given system, but outside the system as well, to add leverage (NASEM, 2016b). This can be achieved by engaging actors not typically involved in a space according to Watson (NASEM, 2016b). In the case of early childhood, this means going beyond health and education to engaging nontraditional sectors such as transportation and agriculture. For instance, Sonia Sharma of Mobile Creches explained that in India, Mobile Creches established early childhood centers for migrant construction workers’ children (NASEM, 2016b). By using a holistic model of early childhood services and engaging health, nutrition, education, and safety sectors as well as construction workers to create the infrastructure for the facilities, the intervention was able create 25 centers that provided care and protection to 2,413 children and 1,500 families (NASEM, 2016b).
ReadyNation, an international, nonprofit business membership organization, leverages the experience, influence, and expertise of more than 1,600 executives to promote public policies and programs that build a stronger workforce and economy. As presented by Sara Watson of ReadyNation, these unexpected champions, who are active in countries ranging from Romania to Uganda to Australia, are powerful advocates for early childhood policies and programs (NASEM, 2016b). In the United States alone they helped attract more than $3 billion to early child development between 2014 and 2016. Watson noted that business leaders are compelling backers of early childhood development because of their interest in a strong economy and workforce (Watson, 2015).
Mobilization of the media can be leveraged as another important strategy to generate the will to scale, according to Janine Zacharia of Stanford University (NASEM, 2016a). She stated that the media plays a critical role in mobilizing the will to scale up and can be used to leverage support through effective, clear messaging. One example presented by Sirin was the photo of a toddler’s lifeless body, washed up on shore as a symbol of the tragic loss of innocent life in the Syrian conflict (NASEM, 2016a).
Media can be used to raise awareness about the importance of the first years of a child’s life as well. Eduardo Queiroz from Fundação Maria Cecília Souto Vidigal presented the The Beginning of Life film, which articulates the importance of investing in early childhood development and is geared toward a global audience (NASEM, 2016b). Also, children’s television and virtual reality are useful media tools to show conditions of children in conflict situations to produce empathy and move people to action reported by Nada Elattar of Sesame Workshop and Zacharia (NASEM, 2016a).
Engaging youth in using social media to generate public and social will was highlighted as a successful approach in Amman, Jordan. Thinking across generations to solve problems and promote investments in young children regionally was illustrated by the Web-based dashboard from JEEL 962 (NASEM, 2016a). Ayyam Fouad Al Asaad, vice president of JEEL 962 and a student at the University of Jordan, presented the crowdsourcing platform, which engages youth as sensors in the community to report on problems and solutions to challenges facing young children, youth, and their families.
Bose pointed out that because of the pressure to create short-term solutions, there is sometimes a failure to develop sustainable institutions, which negatively effects child development (IOM and NRC, 2015a). Individual speakers stated that therefore it is not enough to provide services; campaigns to raise awareness and generate behavior changes are necessary, along with coordination among the various stakeholders (IOM and NRC, 2015a; NASEM, 2016a,b). Michelle Gagnon of the Palix Foundation provided an example of the Alberta Family Wellness Initiative, which disseminates research to instigate political action and is an example of how research can be compiled and used to facilitate systemic change (NASEM, 2016b). She added that the media can also be used to engage additional stakeholders that may not be typically involved in early childhood development.
Maintaining Quality When Scaling
Once the will to go to scale has been generated, individual participants noted that the next challenge is maintaining the quality of the program when scaling up (IOM and NRC, 2015b; NASEM, 2016b). These participants discussed the struggles of transitioning from a single project to a national policy, which often results in a loss of quality (IOM and NRC, 2015b). Susan Walker from the University of the West Indies explained that the Jamaica Home Visit Intervention represents a model strategy for maintaining the quality of programs. This program helped foster positive mother–child relationships, improved home environments, and was easy to replicate in settings with low resources (IOM and NRC, 2015b). Walker affirmed that the intervention succeeded in maintaining quality and effectiveness by building human resource capacity, training local community members, and ultimately reaching more families (IOM and NRC, 2015b). By engaging local members and supporting their training, workforce capacity is increased and the community is invested in the program, according to Walker.
Mariavittoria Ballotta of UNICEF asserted that, particularly in postconflict countries, there is often a lack of experts with backgrounds in early childhood development, as there are competing priorities for governments and resources (IOM and NRC, 2015a). Some participants discussed ways in which investing in local capacity building can ensure quality and sustainability and facilitate scalability. Participants also
mentioned that integrating services horizontally instead of vertically can also facilitate scalability (IOM and NRC, 2015b).
Considerations When Scaling
Constanza Alarcon from the Office of the Presidency of Colombia mentioned that one strategy to ensure quality when scaling up policies and programs is to build on existing infrastructures and available human resources to avoid a decrease in quality encountered when creating something new and unknown (IOM and NRC, 2015b). Models from pilot projects need to be adapted to various contexts, Alarcon said, modifying variables according to the local reality in order to maintain quality and cost-effectiveness (IOM and NRC, 2015b). As for how to sustain quality as programs are scaled up, Alarcon urged participants to identify specific program goals and criteria as well as to encourage staff to support high quality through training, coaching, compensation, and shared experiences. She drew these lessons learned from the Colombian government’s policy, De Cero a Siempre (From Zero to Forever), which succeeded in engaging local stakeholders and used an integrated approach to improve early childhood development (IOM and NRC, 2015b). Alarcon added that cross-sectoral follow-up assessment is a key component to identifying effectiveness and encouraging public commitment to create and implement sustainable and effective public policy using the quality information gathered (IOM and NRC, 2015b; NASEM, 2016d). Costin suggested that through impact evaluations we can find out what works as a guide for future investments (IOM and NRC, 2015b).
According to Andrea Torres of Chile Crece Contigo, when scaling up, it is also important to 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 (IOM and NRC, 2015b). Runciman added that an integral factor in scalability is maintaining the integrity of the model while adapting to local circumstances (Hill and Olds, 2013; IOM and NASEM, 2015).
Another consideration when investing in young children is an awareness of who bears the burden of the costs. Families and communities make disproportionate investments in children compared to governments, industry, and other stakeholders, asserted Larry Aber of New York University (NASEM, 2016d). According to Alex Coutinho, the former director of Uganda’s Infectious Diseases Institute, families require the government’s commitment to invest in children. Heymann noted that paid parental leave, and leave to meet children’s health needs, are both essential to the ability of parents to care for children while working and earning income to support their families (NASEM, 2016d).
Coutinho added that governments should educate caregivers about child development and empower them to take action to optimize the well-being of their young children (NASEM, 2016d). Therefore, according to Coutinho, parents must be included in the policy planning processes. Vargas-Baron was also supportive of parental involvement in the policy planning process (NASEM, 2015). She discussed that empowerment of the parent is central in helping them improve their lives and the development of their child (NASEM, 2015). One way to engage parents is through community-led collective action, which can be an effective path toward change, especially in collective communities where others have a great
influence on what happens in the household, suggested Kalana Peiris from Plan International (NASEM, 2015). He added, that programs are owned by the community and embedded in their daily routine, rather than prescribed to them, thus incentivizing greater engagement.
Financing Scaled Programs
Several speakers at forum workshops discussed strategies for financing programs. Sherri Le Mottee described her work with Ilifa Labantwana, a program in South Africa providing children and their caregivers with an essential package of services from conception to entry to formal education (IOM and NRC, 2015a). The program is supported by a donor collaboration that works in tandem with the government and civil society to develop sustainable programs with community input and catalyze additional government funding. As a cautionary note, she pointed out that politics can often serve as an obstacle and that while having resources opens doors, navigating both individual and systemic politics can cause delays (IOM and NRC, 2015).
Cash transfer programs are another option for investment in caregivers, according to several speakers (IOM and NRC, 2014, 2015a). These programs involve providing a cash supplement to caregivers—with or without conditions—in order to increase access to programs and services and improve child outcomes (Fernald and Hidrobo, 2011). As Lia Fernald from the University of California, Berkeley, outlined, the added income can help caregivers purchase basic needs, invest in children’s schooling, or forego outside employment to focus on caregiving (IOM and NRC, 2014). She and her colleagues found that comprehensive approaches—which include combinations of cash transfers and the direct promotion of child development through parenting support, parenting education, and childhood stimulation rather than single investments—were the most effective in improving outcomes.
Several other cash transfer programs were presented throughout the forum workshops. For example, Lucie Cluver from Oxford University also discussed the importance of a comprehensive approach to cash transfer programs (IOM and NRC, 2015a). She and her colleagues found that cash transfers accompanied with care—defined as positive parenting, school counseling, teacher support, or other components—was most effective at reducing youths’ risk of contracting HIV, pregnancies, school dropout rates, and criminal behavior in South Africa (Cluver et al., 2014). In the nationwide conditional cash transfer program in Brazil, Bolsa Familia, an impact evaluation showed decreased infant mortality and hospitalization (Rasella et al., 2013). Similarly, Oumar Barry from the Université Cheikh Anta Diop de Dakar in Senegal found greater results in combining cash transfers to female heads of households in Niger with behavioral components to change parent behavior (NASEM, 2017). This led to improvements in immunization rates, use of mosquito nets, handwashing, child stimulation, food security, and decreases in negative discipline practices (NASEM, 2017). One question raised by some workshop participants is the sustainability of these programs once they are found effective.
Van Ravens reinforced the need for funding of programs to be sustainable and that private funds are useful for establishing services and programs, but that it is crucial for funding to be combined with sustainable, domestic public sources (IOM and NRC, 2015a). Ganguly seconded this point, stating that the entry of the
private sector into provision of basic services must not lead to the state’s abdication of its responsibility (IOM and NRC, 2015a). She advocated for private donors to contribute to a pool of funds administered by the government without replacing the public funding.
Her Royal Highness Princess Sarah Zeid of Jordan stated that identified priority areas will not become actionable until financial mechanisms change toward predictable long-term flexible funding that reaches the needs on the ground where different actors such as community organizers, women’s groups, and religious leaders are most adept at reaching individuals and families (NASEM, 2016a). Moreover, Theresa Betancourt of the Harvard T.H. Chan School of Public Health asserted that there is a need for collaboration between local governments actors and other stakeholders to ensure sustainability and integration of childhood development programs (NASEM, 2016d). Molina added that a collaborative approach ensures increased sustainability, community empowerment, and increased equity as seen with the Jamaica Home Visit Intervention (NASEM, 2015).
Other financing considerations discussed by several workshop attendees included the importance of establishing rules of engagement for multisectoral coordination and collaboration (NASEM, 2016a,d). Individual speakers noted that no one sector can comprehensively address all the challenges in early childhood. Rather, making successful, sustainable investments in young children globally will require respect, transparency, and openness to communication across sectors.
The Role of Measurement
The importance of measuring child development outcomes and program quality as well as the appropriate role of assessments was discussed in several forum workshops. Appendix D shows many of the measurement instruments discussed at forum workshops, while Appendix E provides descriptions of some of the programs highlighted at workshops. Individual speakers pointed out that measurement tools can help with the conception, design, and evaluation of an intervention as well as track developmental outcomes over time to help guide policy (IOM and NRC, 2014; NASEM, 2016c).
Abbie Raikes of UNICEF recommended measurement as a way to create a common language and promote equity, ensuring that all children are counted and acknowledged (NASEM, 2016c). She also stated that measurement leverages available data, further establishing the field of early child development and providing a roadmap for action and change. She championed using a combination of global and national data to inform local policies and programs, ideally having child outcomes measured through culturally relevant tools that also measure context (NASEM, 2016c). Tarun Dua from the World Health Organization stated that measuring child development helps to illuminate the well-being of young children, evaluate the skill level of children, and decide which services promote positive development (IOM and NRC, 2014).
Mark Tomlinson of Stellenbosch University addressed challenges with measurement (NASEM, 2016b). In sum he stated that positive development and “thriving” metrics are more challenging to measure than “survival” metrics. Survival metrics account for preventable deaths, while thriving metrics evaluate health and well-being, he added. Essentially, current measurement tools do not adequately assess the context in
which young children develop, thus making it difficult to create more targeted and effective interventions and promotive programs and policies that support early childhood development. In addition to child-level measures, Heymann addressed the need to measure policies at scale, as well as their implementation and outcomes (NASEM, 2016d). She described the importance of measuring all three longitudinally in order to causally link national actions to outcomes, and learn what works best where and why.
Patricia Kariger from the University of California, Berkeley, asserted that there is a need for a single, comprehensive platform of indicators as well as a core set of metrics to improve coordination and optimize efforts to develop programs and policies to support child development and well-being (IOM and NRC, 2014). Dua added that to implement early childhood development policies at a population level, metrics need to be of the same scope and scale (IOM and NRC, 2014).