Chile Crece Contigo: Implementation, results, and scaling-up lessons

Whole of government approaches to accelerate adolescent success: efficiency and financing considerations

The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings.

Pathways to scale up early childhood programs: A scoping review of Reach Up and Care for Child Development

Evidence-based early childhood development (ECD) programs that strengthen nurturing parenting skills and promote early stimulation, such as Reach Up (RU) and Care for Child Development (CCD), are critical investments for interrupting cycles of intergenerational poverty; however, the implementation impact of these programs varies greatly globally. Analyzing systematically the evidence on the implementation pathways based on contexts (i.e., external and internal influences on intervention implementation), implementation strategies (i.e., mechanisms used to promote program initiation, design, and delivery with existing systems), and implementation outcomes (i.e., related to the implementation goals) can increase the likelihood of implementation success. Our scoping review aimed to identify implementation pathways of RU and CCD programs in low- and middle-income countries. A search in English, Spanish, and Portuguese of grey literature and five databases of peer reviewed literature; from inception through July 16, 2022, yielded 2,267 publications. Using predetermined eligibility criteria, 75 records yielded implementation details for 33 programs across 23 low- and middle-income countries. Two reviewers independently extracted program data on context, implementation strategies, and implementation outcomes following a program theory. A thematic analysis identified 37 implementation strategies across six "building blocks of implementation": program emergence, intersectoriality, intervention characteristics, workforce, training, and monitoring systems. Implementation pathways across building blocks are highly influenced by contextual factors, such as infrastructure, social norms, and the target population's demand and interest, which may shape different implementation outcomes. Six 'building blocks' shaping implementation pathways of CCD and RU in LMICs were identified. The careful consideration of context and use of intentional evidence-based planning can enable the successful implementation of ECD nurturing care interventions. We recommend the use of the ECD Implementation Checklist for Enabling Program Scale Up to guide decision-making regarding context and implementation strategies to support implementation outcomes and subsequent ECD program success.

Perceptions of professionals about factors affecting the implementation of early childhood support systems: A case study evaluation from an ecological perspective

This evaluation research looked at factors affecting collaboration across the various levels of implementation of early childhood support systems. An ecological conceptual framework was used to examine barriers and facilitators to implementing social and health care services from the perspective of the professionals involved at the national, state, and local level of government. A single case study following a qualitative research strategy was conducted with a total of 29 professionals from social development and health ministries, one municipality and a family health center responsible for implementing the Chile Grows with You system. The results show that at the national level, the main factors include socio-political aspects, funding, and the empathy that professional employees hold for peers who are at lower rungs in the hierarchy. At the state level workplace conditions play a key role. For the local level those factors include information system management and the political support of the local government. The discussion section emphasizes the relevance of considering the interdependence of such factors that influence implementation outcomes and the need to move away from a single program evaluation to a multilevel implementation analysis of public policy.

Prioritizing nurturing care at the municipal and district level with the Brazilian Early Childhood Friendly Municipal Index (IMAPI)

The Brazilian Early Childhood Friendly Municipal Index (IMAPI) is a population‐based approach to monitor the nurturing care environment for early childhood development (ECD) using routine information system data. It is unknown whether IMAPI can be applied to document metropolitan urban territorial differences in nurturing care environments. We used Brasilia, Brazil's capital with a large metropolitan population of 2,881,854 inhabitants divided into 31 districts, as a case study to examine whether disaggregation of nurturing care data can inform a more equitable prioritization for ECD in metropolitan areas. IMAPI scores were estimated at the municipal level (IMAPI‐M, 31 indicators) and at the district level (IMAPI‐D, 29 indicators). We developed a quantitative prioritization process for indicators in each IMAPI analysis, and those selected were jointly mapped in the socioecological model for the role of indicators in relation to the enabling environment for nurturing care. Out of 28 common nurturing care indicators across IMAPI analysis, only four were prioritized in both analyses: one from the Adequate nutrition, two from the Opportunities for early learning, and one from the Responsive caregiving domains. These four indicators were mapped as enabling policies, supportive services, and caregivers’ capabilities (socioecological model) and Effort, Coverage, and Quality (indicator's role). In conclusion, the different levels of nurturing care data disaggregation in the IMAPI can better inform decision‐making than each one individually, especially in metropolitan areas where municipalities and districts within metropolitan areas have relative decision‐making autonomy.

The Brazilian Early Childhood Friendly Municipal Index (IMAPI) is an innovative population‐based approach created to systematically measure nurturing care for early childhood development (ECD) using routine information systems data at the municipal level.

Brasilia was used as a case study to evaluate whether different levels of nurturing care data disaggregation (municipal vs. district level) can inform more equitable prioritization for ECD investments in metropolitan areas.

We developed a quantitative prioritization process of indicators to analyse IMAPI at the municipal and district levels, and the selected indicators were jointly mapped into the socioecological model, specifying the roles of the indicator in the enabling environment for nurturing care.

The two different levels of data disaggregation of the IMAPI can better inform nurturing care‐related decisions than each individual level in metropolitan areas where municipalities and districts within metropolitan areas have relative decision‐making autonomy.

Scaling up of Brazil's Criança Feliz early childhood development program: an implementation science analysis

To address inequities that prevent socioeconomically vulnerable young children from reaching their full developmental potential, Brazil implemented Programa Criança Feliz (PCF) ("Happy Child" early childhood development program) in 2934 of its 5570 municipalities. A qualitative case study was carried out on the basis of in-depth interviews with 22 key informants, employing purposive sampling, from past or current national and state coordination teams. Thematic analysis followed the RE-AIM framework, and complex adaptive system constructs mapped how barriers and enablers influenced scale-up. One overarching theme related to PCF emergence, and 18 subthemes were identified within the RE-AIM. An enabling national political environment favored PCF emergence through a top-down approach that led to governance challenges. Changes in the enrollment criteria for families facilitated reach, and evidence-based methodology favored the designing of the home visits. However, operationalizing the intersectoral actions remains a barrier for effectiveness, while intrasectoral resistance across levels delayed adoption. WhatsApp facilitated networking, capacity building, and adoption. Rushed scale-up generated barriers for quality delivery and led to different implementation pathways across municipalities. Legal institutionalization is critical to assure permanent funding and maintenance. PCF has enhanced early childhood services in Brazil, but strong negative feedback loops need to be addressed for effective sustainability.

Autism screening and conditional cash transfers in Chile: Using the Quantitative Checklist (Q-CHAT) for early autism detection in a low resource setting

LAY ABSTRACT

Getting a diagnosis of autism can take long, because autism is different across people, but also because it depends on the way it gets diagnosed. This is especially important in poorer countries or in the case of poor people living in wealthier countries that have significant groups of disadvantaged communities. We adapted a 10-item version of the Q-CHAT-25 questionnaire for use in routine health check-ups programme in Chile and recruited 287 participants under the age of three divided into three groups: Controls (125), Developmental Delay (149) and Autism Spectrum Condition (13). Our results show that a short questionnaire for autism screening can be successfully applied in a health-check programme in poor resource settings. Our results show that our questionnaire had good overall performance, not different to its longer version, the Q-CHAT-25. Our questionnaire was autism specific, with good sensitivity and reliability, and is suitable to be used in a screening setting. This study provides evidence that the implementation of Autism Spectrum Condition screening programmes using the Q-CHAT-10 provides value for money and improves diagnosis of Autism Spectrum Condition in those participating in routine health check-up programmes in developing countries or poor areas of wealthy countries.

Under five and infant mortality in Chile (1990-2016): Trends, disparities, and causes of death

Background

Child health has been a health policy priority for more than a century in Chile. Since 2000, new health and intersectoral interventions have been implemented. However, no recent analyses have explored child mortality and equity in Chile, an indispensable input to guide policies towards the achievement of the Sustainable Development Goals, specially, in the context of a deeply unequal country such as many other Latin American countries. Thus, the objectives of this study are to analyze the variations in the risk and the causes of death among Chilean children aged <5 years, to identify the determinants, and to measure inequality of infant mortality from 1990 to 2016.

Materials and methods

An observational study was conducted to analyze the Chilean children's mortality from 1990 to 2016 using under five deaths and live births data from the Vital Statistics System. To describe the variation in the risk of death, a time series analysis was performed for each of the under five mortality rate components. A comparative cause of death analysis was developed for Neonatal and 1–59 months’ age groups. The determinants of infant mortality were studied with a descriptive analysis of yearly rates according to mother’s and child factors and bivariate logistic regression models at the individual level. Finally, simple and complex measures of inequality at individual level were estimated considering three-year periods.

Results

Regarding under 5 mortality: (i) Child survival has improved substantially in the last three decades, with a rapid decline in under five mortality rate between 1990 and 2001, followed by a slower reduction; (ii) early neonatal mortality has become the main component of the under five mortality rate (50.6%); (iii) congenital abnormalities have positioned as the leading cause of death; (iv) an important increase in live births below 1,000 grs. Regarding infant mortality: (i) birth weight and gestational age are the two most relevant risk factors in the neonatal period, while social variables are more significant for post-neonatal mortality and, (ii) the inequality according to mother’s education has shown a steady decline, with persistent inequalities in post-neonatal period.

Conclusions

The Chilean experience illustrates child health achievements and challenges in a country that transitioned from middle-to high-income in recent decades. Although inequity is one of the main challenges for the country, the health sector by granting universal access was able to reduce disparities. However, closing the gap in post-neonatal mortality is still challenging. To overcome stagnation in neonatal mortality, new and specific strategies must address current priorities, emphasizing the access of vulnerable groups.

Building capacity in health and education systems to deliver interventions that strengthen early child development

Building capacity within health and education systems of low- and middle-income countries in order to deliver high-quality early childhood services requires coordinated efforts across sectors, effective governance, sufficient funding, an adequate workforce, reliable data systems, and continuous monitoring, evaluation, and improvement cycles; it also requires partnerships with the private sector, communities, and parents. In addition, building capacity requires leadership, innovation of strategies to fit into existing structures, evidence-based intervention models, and effective partnerships that help make interventions more culturally relevant, help finance them, and help create institutional long-term support and sustainability for them. In this article, we focus on identifying eight critical aspects of enabling systemic support for early childhood services. Every action that strengthens these critical aspects should be seen as necessary, but insufficient, steps toward a national strong governance structure for delivering a locally relevant and comprehensive early child development program that promotes children's developmental potentials.

Scaling up an early childhood development programme through a national multisectoral approach to social protection: lessons from Chile Crece Contigo

Helia Molina Milman and colleagues describe how intersectoral collaboration between health, social protection, and education sectors enabled Chile Grows with You (Chile Crece Contigo) to help all children reach their full developmental potential