Annals NY Academy of Science - 2018 - Nores - Building Capacity in Health and Education Systems To Deliver Interventions

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Ann. N.Y. Acad. Sci. ISSN 0077-8923
A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Special Issue: Implementation Research and Practice for Early Childhood Development
ORIGINAL ARTICLE
Building capacity in health and education systems to

deliver interventions that strengthen early child
development
1
Milagros Nores and Camila Fernandez2
1
National Institute for Early Education Research, New Brunswick, New Jersey. 2 Mathematica Policy Research, Princeton, New
Jersey
Address for correspondence: Milagros Nores, National Institute for Early Education Research, 73 Easton Ave, New Brunswick,
NJ 08901. mnores@nieer.org
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.
Keywords: governance; early child development; systems; capacity; health and education; interventions
Introduction (e.g., home visitors, teachers, and health workers),

among others. Further, high-quality early child-
Decades of research shows that early childhood
hood services require attention to the setting (e.g.,
interventions matter for children’s life-long chance
physical environment) for delivery and to cultural
to succeed,1–4 and specifically that the early years
nuances that influence uptake of services.9 Building
are a period of rapid development where children
capacity in health and education systems in low-
are sensitive and highly responsive to interven-
and middle-income countries (LMICs) to deliver
tions that may ameliorate the influence of exter-
high-quality early childhood services requires coor-
nal risk factors.5–7 We have also learned that for
dinated efforts across sectors; effective governance;
interventions to make a difference in children’s
sufficient financing; an adequate workforce; part-
life quality matters8,9 and that comprehensive or
nerships with the private sector, community, and
combined interventions are more effective than
parents; reliable data systems; and continuous mon-
nutrition interventions alone in supporting child
itoring, evaluation, and improvement cycles. Also,
development1,11,12 Increased access to early child-
context matters in translating descriptive research
hood services, in and of itself, does not fulfill the
to policy.13 Developmental sciences have shown
promise of improved developmental outcomes for
that context makes a difference and renders find-
children.2,10 High-quality services are necessary and
ings from one context invalid in other contexts13
achieved through a combination of adequate con-
and flexibility may be central for local adaptations
tent (e.g., the curriculum in a preschool program
to occur and be sustainable given country-specific
and the content of the home-visits), frequency,
and local-specific constraints and characteristics.14
intensity, and the capacity of direct agents of change
doi: 10.1111/nyas.13682
Ann. N.Y. Acad. Sci. 1419 (2018) 57–73 C 2018 The Authors. Annals of the New York Academy of Sciences 57
published by Wiley Periodicals Inc. on behalf of The New York Academy of Sciences.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in
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Building capacity to deliver ECD interventions Nores & Fernandez
Therefore, a prescriptive approach to early child-

hood health and education systems would be inade-
quate. Successful population-level impacts are more
likely to occur in contexts that support key princi-
ples of effective early childhood care and education
(ECCE), understanding that context influences inte-
gration, programing, governance, and partnerships,
among other things. In this article, we focus on iden-
tifying critical aspects of enabling systemic strength
and support for early childhood services.
Given that services in early childhood are usually
fragmented between health and education systems,
and that both health and education are integral Figure 1. Critical aspects: systems, quality, and partnerships.
components of a child’s early development, we
tackle the concept of capacity building in early 2 map how these draw from key research and
child development (ECD) as an intersectoral highlight important aspects to date.
problem. We follow the article by Black et al. in
understanding that the education sector in ECD has Critical aspect 1: establishing strong
traditionally focused its attention on preprimary collaboration arrangements and/or
education and the transition to primary, while the centralized leadership
health sector has focused on health and nutrition, Leadership and political will are critical for pro-
in particular starting at birth/prenatally.5 Program gram sustainability.5,17,18 Leadership may show in
characteristics and delivery models have bearing on the form of a strong collaborative arrangement
the degree to which a given program is more closely across sectors or as a centralized leadership facil-
aligned with the health or the education delivery itating such collaboration. Central leaders need to
systems, and that may vary from country to country. provide the overall vision for the ECD service model,
However, intersectoral integration is central to the and from that vision set rigorous research-based
effectiveness of programs and services to support program standards, as well as define the type and age
child development, care, and education.12 Building span for interventions, target populations, work-
capacity for an effective delivery of early childhood force, and financing. In addition, leadership is evi-
services in health, education, and social protection denced in effective leveraging of resources across
sectors, among others, requires convergence of sectors, implementation of system efficiencies, and
goals and a shared understanding of child develop- reduction of competition for resources among pro-
ment holistically (attending to the child’s physical, grams or service providers. When supported by
cognitive, emotional, and social development, as legislative mandates and resources, leaders have a
defined in the Black et al.).5 It also requires lead- stronger capacity to fulfill a national vision of a
ership, innovation of strategies that fit into existing continuum of ECD services that may better com-
structures, evidence-based intervention models, plement each other. Key indicators of national (or
adequate workforces, and effective partnerships that local) leadership include a sustainable allocation
help make interventions more culturally relevant, of funding, legislation, quality standards, and the
help finance them, and help create institutional existence of a high-level ECCE council or technical
long-term support and sustainability for them. committee.5,18,19
Figure 1 illustrates the critical aspects we put One such example is the national strategy for early
forward that are developed in more detail below. childhood in Colombia, known as De Cero a Siem-
The critical aspects identified draw from the pre.a Leadership from the office of the presidency
various work and case studies done on capacity,
governance, and intersectoral collaboration in
the field of early childhood development. Similar
studies on health alone have also identified some a
http://www.deceroasiempre.gov.co/Paginas/deCeroaSie
of the aspects highlighted below.15,16 Tables 1 and mpre.aspx
58 Ann. N.Y. Acad. Sci. 1419 (2018) 57–73 C 2018 The Authors. Annals of the New York Academy of Sciences
Nores & Fernandez Building capacity to deliver ECD interventions
Table 1. Critical aspects mapped to key research in systems and capacity in ECD
Yoshikawa and
Critical aspect Vargas-Barón23 Vargas-Barón18 Britto et al.26 Kabay24 Britto et al.9 Richter et al.17
1. Strong Ensure ECD programs Integrated ECCE Central issues for Quality based on an Political prioritization
collaboration are designed services unite scalability: ECD program or of early childhood
arrangements holistically resources and policy alignment development and
and/or (baseline studies, personnel from with, or emergence financing
centralized supervisory several sectors into from, the values
leadership systems, staff a single program and principles of a
training, standards, community or
and society.
communication)
Appropriate and Needs for high-level a. Comprehensiveness Quality of resource Creation of a policy
flexible program ECCE policy and durations of levels and their environment that
objectives advocacy services distribution. supports nurturing
care of young
children
Establish quality National-level b. Scale and reaching Quality of leadership Delivery systems for
assurance systems integrated/ remote or the most and management scaling up of
and program multisectoral disadvantaged evidence-based
standards planning and populations interventions for
governance early childhood
development
Public sector support Roles and c. Cultural Governance of
responsibilities at perspectives in multisectoral
each level ECCE coordination and
programming and monitoring to
evaluation deliver quality
services equitably
Develop formal Policy instruments Affordability
interagency that support
agreements to integration
achieve integrated
or intersectoral
programming
Participatory policy Create standards,
development guidelines, and
regulations for
ECCE services and
personnel
Develop a strong and
enduring legal basis
for ECD programs
Prepare a policy
advocacy and social
communications
plan and system for
the program
2. Vertical alignment Community-level Horizontal and
ECCE development vertical dimensions
of governance:
implications for
integrated ECD
Roles and Local governance
responsibilities at structures as key
each level lever for improving
integrated ECD
provision
3. Horizontal Develop intersectoral Multisectoral Horizontal and
alignment collaboration coordination: build vertical dimensions
strong cooperative of governance:
and formal implications for
relationships integrated ECD
between ministries
Seek support from the
Ministry of
Planning and
Finance
4. Evidence-based Cultural perspectives Delivery systems for
programs and in ECCE scaling up of
policies programming and evidence-based
evaluation interventions for
early childhood
development
Continued
Table 1. Continued
Yoshikawa and
Critical aspect Vargas-Barón23 Vargas-Barón18 Britto et al.26 Kabay24 Britto et al.9 Richter et al.17
5. Linking programs Link ECD programs Governance of

to program to international multisectoral
outputs and policies and coordination and
outcomes instruments for monitoring to
children deliver quality
services equitably
6. Investing in the Create standards, Quality of physical
early childhood guidelines, and and spatial
work force and regulations for characteristics of an
meeting ECCE services and ECD program
standards of care personnel
Quality of leadership
and management
Quality of interactions
and
communications
7. Continuous Establish quality Conduct research Cultural perspectives
improvement assurance systems in ECCE
cycles and program programming and
standards evaluation
Measuring and
monitoring
-Child assessments
-Program quality and
implementation
8. Partnerships Create public–private Quality of interactions
partnerships and
communications
created the national strategy in 2011 and set it for- grow and remain when they have strong leadership,
ward as a decree.20 The strategy put forth policies, influential support, and are part of a national ECD
programs, projects, and actions in support of ECD, policy or framework.23
with the goal of guaranteeing comprehensive ser- Centralized leadership does not, however, imply
vices for almost 3 million low-income children ages centralized management or provision on early child-
0–5. It also brought together all sectors involved in hood services; but it is necessary to overcome issues
early childhood intervention and opened opportu- that arise from national-level fragmentation.3,17
nities for partnerships with the private sector; and There are various approaches to integration of ser-
it was sustained across several years and culminated vices. Although India, for example, has integrated
with a national ECD law, approved in August of services from health, education, and child protec-
2016,b which defined early education as a Right tion into a single program with unified standards of
for all children under 6 and set implementation of care, other countries have opted to coordinate ser-
the policies in the strategy.21 This process has been vices offered by different agencies under the juris-
closely supported by Primero Lo Primero (PLP),c diction of separate Ministries through a national
a private sector alliance established to enhance ECD policy of coresponsibility.24 While no single
ECD programs and infrastructure in Colombia by approach to inter sectoral integration or coordina-
combining technical, administrative, and financial tion is superior, clear national leadership regarding
efforts of De Cero a Siempre. In the period between child development goals is critical to deliver com-
2011 and 2015, this initiative increased access to prehensive early childhood development and care
ECD services from 1 to 1.9 million children.22 This services.
example illustrates how programs are more likely to Specific actions within this critical aspect (see
Table 3) are, among others, securing political com-
mitment through partnerships and intersectorial
b
http://es.presidencia.gov.co/normativa/normativa/LEY arrangements in participatory processes, creating
%201804%20DEL%2002%20DE%20AGOSTO%20DE% intersectoral collaboration arrangements (with
202016.pdf written agreements, responsibilities, etc.), securing/
c
http://www.primeroloprimero.co/about/
Table 2. Critical aspects mapped to additional key research in systems and capacity in ECD
SABER-ECD 2007 EFA Global
Framework, World OECD Quality Essential Elements Monitoring Report on ISSA Quality
Critical Aspect Bank69 Toolbox for ECEC70 Framework, NIEER71 ECD72 Framework73 Scaling Up Nutrition74
The SABER 15 “essential
framework addresses elements” found to
3 policy goals & Identifies policy levers characterize Focus on children
relevant policy for implementing high-quality public under 3
levers for advanced quality ECEC preschool reviewed
EDC policy for US states &
development localities
1. Strong Goal 1: Enabling Policy lever 1: Setting Enabling environment Involve stakeholders Policy Area 5: Have nutrition plans,
collaboration Environment out quality goals & from a range of Governance and endorsed at the highest
arrangements regulations sectors Funding (an level, with national
and/or approach that nutrition targets and
centralized promotes the costed actions that guide
leadership seamless collective implementation
integration and/or and resource allocation
alignment of
services in order to
best serve the child
under 3 & their
family)
-Adequate legal & Challenge 1 : Building 1. Political will, Efforts led by a strong Regularly and transparently
regulatory consensus on the including from agency with track budget allocations
framework goals political leadership decision-making against plans and
and, more rarely, power demonstrate better use of
judicial mandates finance data through
improved advocacy,
planning, and impact
-Coordination within Challenge 2 : Aligning 2. A compelling vision Responsibilities for Increase resources for
sectors & across goals to stimulate & strong leadership ECD clearly nutrition from both
institutions quality provision from early learning delineated domestic and external
leaders sources
-Adequate fiscal Policy lever 2: Design Strong Program Systems for Mobilize, advocate, and
resources/finance & implementation Practices accountability put communicate for impact
systems of curriculum or in place
standards
Goal 2: Wide Challenge 1: Defining 15. Integrated systems Regulations Have aligned policies,
Implementation goals & content of standards, legislation, and
curriculum, regulations in support of
assessment, nutrition
professional
development (PD)
& evaluation
-Address children’s Challenge 2: Ensure consistent and
development Curriculum sufficient investment in
holistically, alignment for capacity strengthening by
targeting all continuous child governments and
relevant groups development partners
Challenge 3: Ensure equity, equality, and
Dissemination & non-discrimination for
communication all, with women and girls
about the at the center of efforts
framework
Have nutrition plans,
endorsed at the highest
level, with national
nutrition targets and
costed actions that guide
collective implementation
and resource allocation
2. Vertical alignment Support local capacity Have all key stakeholders,
including communities,
making measurable
contributions to scaling
up nutrition
Continued
Table 2. Continued
relevant policy levers for implementing high-quality public under 3
for advanced quality ECEC preschool reviewed
3. Horizontal Have multi-stakeholder

alignment partnerships for
coordination at
national levels
4. Evidence-based Rigorous, articulated, Policy Area 3:
programs & early learning Curriculum
policies policies
4. Adult–child ratio of
at least 1:11
5. At least a full school
day is provided to
ensure adequate
dosage
6. Two (or more)
adult teaching staff
in each classroom
7. Appropriate early
learning standards
for preschoolers
8. Effective
curriculum that has
systemic support
9. Strong supports for
education of special
needs children in
inclusive settings
10. Strong supports
for dual language
learners
5. Linking programs Policy lever 2: Design Strong Program Monitoring Have systems to analyze
to program & implementation Practices and use quality data
outputs & of curriculum or for decision making,
outcomes standards accountability, and
advocacy
Challenge 5: 15. Integrated systems Implement agreed
Systematic of standards, actions at scale and
evaluation & curriculum, demonstrate impact
assessment assessment, PD &
evaluation
6. Investing in the Policy lever 3: Rigorous, articulated Policy Area 2: Work
early childhood Improving early learning Force
work force & qualifications, policies
meeting training & working
standards of care conditions
Challenge 1: 3. Well-educated (BA
Improving staff & ECE expertise) &
qualifications well-compensated
teachers (K-12 pay
parity)
Challenge 2: Strong Program
Workforce supply Practices
Challenge 3: 11. High-quality
Workforce teaching
retention 14. PD to improve
Challenge 4: individual teacher
Workforce performance
development
Challenge 5: Private
provision
Continued
Table 2. Continued
relevant policy for implementing high-quality public under 3
levers for advanced quality ECEC preschool reviewed
7. Continuous Goal 3: Monitoring & Policy lever 4: 5: Strong Program Policy Area 4:
improvement Assuring quality Advancing data Practices Monitoring &
cycles collection, research Evaluation
& monitoring
-Data availability & Challenge 1: Lack of 13. Data-driven
systems to monitor data on demand & decision making &
ECD outcomes supply of ECEC independent
places evaluation
-Quality standards for Challenge 2: Lack of
ECD data on workforce
quality & working
conditions
-Systems to monitor Challenge 3: Lack of
compliance with data on financing &
standards costs
Challenge 4: Lack of
data on child
development
data & information
on the quality of
ECEC services
feedback cycles
8. Partnerships Policy lever 4:
Engaging families &
communities
awareness &
motivation
Challenge 2:
Communication &
outreach
aligning funding streams with initiatives (whether posed implementation’s strengths and weaknesses,
international, national, local, or private- and that the platform that delivers the program
partnerships), and developing integrated ECD locally is replicated subnationally and in other local
vision, goals, and objectives that build on existing education agencies.
structures and services, and that include access and In essence, the quality of the implementation pro-
quality of, for example, standards, guidelines, and gram will depend on the extent to which the capac-
regulations. ity of the pilot or local initiative is replicated in
other locations and how much national (or subna-
Critical aspect 2: vertical alignment—from tional) support may be needed for this to occur.
national to local capacity building Britto et al.9 define this as “quality at the systems
Many early childhood programs start small and levels”—systems being defined as the organizational
are usually delivered by nongovernment agencies, and institutional structures responsible for an ECD
are sometimes funded by international donors, and service. This “quality to implement” will depend
sometimes include local NGOs, university-based on how much new interventions leverage exist-
teams, or other nongovernmental institutions.17 ing services;5 how much the programs were scal-
Integration of these programs into existing service able to start with;23 how roles and responsibilities
delivery platforms (or the creation of new delivery across levels and sectors are clearly delineated; and
platforms) requires an understanding of the pro- whether, as capacity is strengthened nationally, it
Table 3. Critical aspects and relevant actions
Critical aspect Actions
1. Strong collaboration r Secure political commitment through partnerships and intersectorial arrangements in
arrangements and/or participatory processes
centralized r Create intersectoral collaboration arrangements (with written agreements, responsibilities,
leadership etc.)
r Secure/align funding streams with initiatives (whether international, national, local, and
private-partnerships)
r Develop an integrated ECD vision, goals, and objectives that build on existing structures
and services, and that includes access and quality; includes creating national ECCE
standards
r Develop expectations for research and monitoring aligned with these
r Allocate a budget for the national goals
r Align actions and plans with legislation, if possible
r Promote commitment based on research on ECD and research-based practices
r Create a national communication plan
2. Vertical alignment r Invest in national to local capacity
r Include participation from all levels in the development of the strategy for scalability and
implementation
r Coordinate with services that are strong subnationally and locally
r Define roles and responsibilities clearly
r Establish interinstitutional agreements
r Use partnerships with donors to strengthen alignment
r Aligned communication plan
3. Horizontal alignment r Invest in capacity across sectors
r Align sectors under a ECCE national and subnational strategy
r Coordinate all programs and policies under such ECCE strategy (early childhood as a
continuum)
r Build programs on the strengths of the different sectors, for example, leverage programs
that have reached hard-to-reach populations.
r Align indicators that can be used across all levels of governments and sectors
r Promote commitment with coresponsibility
r Use partnerships with donors to strengthen alignment
r Aligned communication plan
4. Evidence-based r Identify evidence-based programs and practices
programs and r Understand the critical program components, dose, and intensity of services that lead to
policies desirable outcomes
r Assess feasibility of implementation
r Developmentally focused curricula
r Contextually grounded best-practices
r Adequate in-service training
r Sustained professional development
r Increase access without compromising quality
5. Linking programs to r Clearly defined program outputs and outcomes
program outputs and r Implementation fidelity monitoring
outcomes r Reliable measurement of indicators
r Outcome indicators for developmental domains and periods
6. Investing in the early r Adequate pre-service training
childhood work force r Continuous professional development and mentoring
and meeting r Clearly defined competences and standards of practice
standards of care r Fair compensation and proper incentives
r Adequate infrastructure, pedagogical resources, and materials
Continued
Table 3. Continued
Critical aspect Actions
7. Continuous r Determine standards and outcomes/indicators against which interventions will be

improvement cycles monitored and evaluated
r Create/support capacity understanding and measuring these standards and
outcomes/indicators
r Invest in evaluation, data monitoring, and data production
r Invest in interpretation and use of data for continuous improvement
r Invest in capacities at all levels of governments and intersectorial
r Create mechanisms of technical assistance and/or professional development that will
respond to the information produced
r Use information to inform policies and standards
r Link to international standards, measures on children
8. Partnerships r Create national strategies for engagements with partners (in, for example, provision,
procurement, communication, data, and information)
r External partnerships with international growing cadre of researchers, multilateral banks,
and donors that supports ECD
r External and internal partnerships with donor organizations
r Internal partnerships with research organizations (even if capacity needs to be built)
r Internal partnerships with private sector to sustain coalitions for ECD over time
r Partnerships with families and communities to create a long-term demand and increase
local relevance of a program/intervention
is also done locally in/with community organiza- of government and participation from all levels in
tion and local networks on ECD. Vertical alignment the development of the strategy which would sup-
includes not only the coordination, participation, port scalability and implementation, coordination
and partnership across levels, but also building on with interinstitutional agreements, and a commu-
and investing in capacity at all levels.25,26 Where nication plan common across levels.
policies may be decentralized, subnational ECCE
systems with locally articulated governance struc- Critical aspect 3: horizontal
tures and coordinated strategies will play a central alignment—coordination of services
role, together with their alignment with the national Systems quality also includes the coordination and
leadership.18,26 integration of systems that deliver an ECD service
Britto et al.26 provide examples of strong local with other services provided for the target popu-
governance aligned vertically, albeit recognizing this lation. For example, a home visiting program that
alignment has intermediate levels sometimes miss- focuses on educational stimulation may fail if the
ing. In Cambodia, the authors highlight the direct target population is experiencing low prenatal care
funding of communes where ECD services are inte- and high indices of malnutrition. Similarly, a child
grated into local budget priorities, under national care or preschool program, even with a research-
guidelines. A strong vertical alignment (as well as based curriculum and strong physical environment,
horizontal) is present in Chile Crece Contigo, where may also fail if children are not attending because
the program is coordinated by the Ministry of Social they are sick. Health and education may be natural
Development which also has local representation in partners in addressing early childhood risk factors,
regional secretaries of social development.27 In Peru, but other sectors that may be important (depend-
the program Cuna Más operates under a voluntary ing on the government structures) include social
partnership between the government and commu- protection, sanitation, and justice, and of course,
nities, with the local communities monitoring local planning and finance.23
operations and administering program resources.28 Collaboration across sectors is important not
Actions that would fall under this critical aspect only to align support and facilitate implementa-
include (Table 3) investment in capacity at all levels tion of one particular program, but also to facilitate
coordination across different policies, programs, developmentally stimulating interactions with adult
and actions that the different sectors may be caregivers.1,12
undertaking.29 The more integrated services are, Many of the programs that have demonstrated
the stronger the intersectoral collaboration will be effects on child outcomes encompass aspects of
required.26 Vargas-Barón23 argues for such collab- nurturing care, including parenting support and
oration to include coresponsibility for integrated social protection, care for the caregiver, and early
program work. Shawar and Shiffman3 identify how learning opportunities provided in or out of the
a lack of well-understood and delineated respon- home environment.12 For example, interventions
sibilities for advancing different aspects of ECD targeting the period from before conception until
across government institutions lead to duplication birth often include maternal nutrition, micronu-
and inefficiencies. Examples of coresponsibility, or trients, and iodine supplementation before or
intersectorial arrangements, that have been effec- during pregnancy. These interventions seem to be
tive can be found for Chile, Cameroon, Cambodia, particularly beneficial for expectant mothers at risk
Colombia, India, Lesotho, Nicaragua, Rwanda, and of deficiencies by reducing the risk of small-for-
South Africa, among others.17,18,24,29 gestational-age births and stillbirths, and neural
India’s Integrated Child Development Services tube defects, and by increasing children’s cognitive
(ICDS) is a cross-sectoral program that exhibits development.12 Early childhood interventions tar-
strong horizontal coordination at the national and geting children from birth to 5 years of age focus on
local level.17 It includes nutrition, health, early stim- three types of services: (1) supporting child nutri-
ulation, and community education. Main responsi- tion, (2) improving parenting skills and practices,
bility is under the Ministry of Women and Children, (3) providing child care services, and (4) pro-
which leads a steering group comprising other rel- moting learning through preschool or preprimary
evant sectors. District collectors are responsible for education. Parenting interventions have shown
horizontal coordination locally. positive effects on children’s cognitive and language
Actions that are relevant for horizontal coordi- development across diverse geographic, social, and
nation include aligning different sectors under a service delivery contexts.30–32 Breastfeeding, child
comprehensive national and subnational strategy, nutrition, and micronutrient supplementation
building programs on the strengths of the different programs are also essential in contexts with high
sectors (that is, leverage programs that have proven prevalence of child stunting and wasting. For exam-
capacity to reach hard-to-reach populations), align- ple, micronutrient supplementation for children
ment of indicators, coresponsibility, and, if donor at risk of deficiencies has been shown to improve
funding is of significance at the country level, lever- academic performance.12 Similarly, educationally
aging funding to reinforce alignment. focused child care and both formal and informal
preschool programs have been shown to improve
children’s cognitive and psychosocial development.1
Critical aspect 4: evidence-based
Adverse environments present cumulative risk
programs and policies
factors for children’s health, cognitive, and social
Health and education systems need to imple- development. For instance, severe food short-
ment evidence-based programs that have shown age and insufficient care and stimulation are
robust effectiveness, beneficiary uptake, and fea- present in contexts of severe socioeconomic vul-
sible delivery models. To date, evidence on early nerability. Such cumulative risk factors, that
childhood interventions shows that a variety of cross over different domains of child develop-
programs which integrate nurturing, stimulating ment, have prompted the implementation of inte-
care, and protection services from prepregnancy grated early childhood interventions. A well-known
throughout early childhood can have benefits on study in Jamaica showed that 9- to 24-month-
a range of developmental outcomes, from reduc- old stunted children who received food supple-
tions in mortality rates to increased adult earn- ments and stimulation weekly over a two-year
ings. Such interventions may include services that period had higher developmental scores than
support children’s health and nutritional needs, those who received neither intervention nor the
opportunities for early learning, and responsive and nutrition intervention only.33 Like the Jamaican
study, there are substantial examples of successful The nurse–family partnership has defined steps for
integrated early childhood intervention programs implementation to maintain quality that include
targeting families facing multiple risk factors in a adaptation, testing feasibility, acceptability in a pilot,
variety of contexts.11–13,34 A randomized control running a randomized control trial if possible, and
study in postconflict Bosnia of a 5-month group continued refinement and expansion.d The mea-
psychosocial intervention conducted with moth- sure of quality of a program also depends on the
ers affected by armed conflict and their children extent to which it improves the conditions chil-
showed improvements in maternal mental health dren are exposed to, compared with the absence of
and child weight gain.35 In Ethiopia, an emotional such a program or intervention.1 Peréz-Escamilla
stimulation and responsive parenting group inter- et al.41 state that the integrated ECD multisec-
vention integrated into a nutritional support pilot toral programs based on programs implemented in
project showed promising weight gain benefits for Bangladesh, Chile, India, and South Africa owe their
severely or acutely malnourished children attend- success to being based on scientific and economic
ing Therapeutic Feeding Units or Outpatient Ther- evidence, in addition to other factors.
apeutic Programs, as compared to children not
Critical aspect 5: investing in the early
receiving emotional stimulation and only receiving
childhood work force and meeting
nutrition.36
standards of care
In addition, health and education systems often
struggle with trade-offs between access and quality ECD programs and policies, whether focusing on
of services. In the process of scaling up programs to children’s nutrition and health, parenting sup-
improve access and provide universal services for port, or children’s early learning, depend on paid
children, the quality of programs is often compro- and unpaid, governmental and nongovernmen-
mised, and therefore the potential to improve child tal professionals, para-professionals, and commu-
development is diminished if not lost. Maintaining nity agents—this is known as the early childhood
the integrity of quality components during the workforce.28,42,43 The relationship among person-
scale up process is critical. For instance, there is nel, program quality, and child outcomes has been
evidence that high-quality preschool education well established in the United States and other
has consistent and positive short-term effects OECD countries, and there is a growing body of
on early language, literacy, and math skills,4 but evidence emerging in LMICs about the association
consistent and valid definitions of quality have been between early childhood program characteristics
somewhat elusive.37 Thus far, evidence shows and child outcomes.28,44 For instance, the number of
that high-quality preschool instruction requires years of education and specialized training predict
developmentally focused curricula combined the quality of teacher–child interactions and global
with intensive in-service training, coaching, and quality ratings.39,45 Similarly, there is evidence from
sustained professional development for teachers4,37 Colombia that in-service vocational education pro-
that is delivered in classrooms with small class grams in child development and care have a positive
sizes, as well as professionally prepared teachers and significant effect on children’s health, cogni-
who focus on play, one-on-one and small group tive, and socio-emotional development, especially
interactions, and intentional instruction.38,39 for those younger than three years of age.44 To
To deliver interventions that effectively promote date, there is robust evidence that qualifications and
ECD, health and education systems need to care- training of early childhood personnel are associated
fully identify evidence-based programs, maintain with program quality and with children’s cognitive
the critical program components during scale up, outcomes.46
and ensure that in the process of increasing access to Despite such evidence, the early childhood work-
services quality is not compromised. Jamaica’s early force frequently receives inadequate training, lack of
childhood programs, for example, have maximum supervision, poor wages, and suffers other adverse
class sizes set at 20 (3–5 years old), with staff-to-
child ratios of 1:10, child development indicators in d
http://www.ucdenver.edu/academics/colleges/medical
place, structured observations in place, and teach- school/departments/pediatrics/research/programs/prc/
ers and assistant teachers with specialized degrees.40 research/international/Pages/international.aspx
occupational conditions that threaten its motiva- Critical aspect 6: linking program inputs to
tion and capacity to provide high-quality services program outputs and outcomes
to children and families.42 For example, a study of
Health and education systems with clearly defined
the Cuna Más program, a daily child care and home
program outputs and outcomes, and accurate mea-
visiting program in Peru aimed at supporting the
surement processes allow for reliable tracking of
holistic development of 6- to 36-month-old chil-
program outputs and measuring fidelity of program
dren, showed that the heavy workload of commu-
implementation. Outcome measurement is key for
nity volunteers who make weekly hour-long visits
internal program monitoring and evaluation efforts,
to beneficiary families work twice the number of
learning about the extent to which the program is
hours stipulated by the program despite their vol-
reaching its intended goals on child development.
untary status.28 In addition to heavy workloads and
However, without measures of whether the program
inadequate compensation, early childhood workers
components are implemented as intended, it is not
in developing nations also have significant resource
possible to draw conclusions about what was or was
constraints, such as insufficient infrastructure, lack
not effective and, as described below, the precision
of pedagogical materials, inadequate curriculum or
of program improvement efforts is compromised.
activity guides, and lack of training. Such failure
Early childhood programs in LMICs historically
to support the workforce limits the effectiveness of
lacked reliable and systematic outcome measure-
early childhood programs and may diminish the
ment, particularly indicators of cognitive, socio-
potential of other related investments.47
emotional, and early learning indicators. Available
Early childhood workforce investments should
data were limited to small-scale studies, and most
include (1) adequate pre-service training with con-
national measurement efforts were directed to track
tinuous professional development and mentoring;
children’s basic health and nutrition indicators
(2) clearly defined competences and standards of
(e.g., height, weight, morbidity and mortality; and
practice; (3) fair compensation and proper incen-
incidence of acute diarrheal disease, acute res-
tives; and (4) adequate infrastructure, pedagogical
piratory disease, and similar high-risk infectious
resources, and materials.43 Health and education
diseases).24 Accurate measurement of developmen-
systems can establish requirements and expectations
tal indicators is particularly challenging due to the
for what early childhood workers should know as
breadth of developmental domains (physical, cogni-
well as standards of practice that can guide their
tive, and socio-emotional) and how these domains
work with young children and their families. Gov-
evolve with children’s age. In recent years, signifi-
ernments at the national, regional, and local levels
cant advances in measurement methods have been
can coordinate and implement processes to make
made with tools for large-scale use, such as the
training paths available and enforce accreditation
Caregiver Reported Early Development Instrument
mechanisms. Overall, the status, pay, and benefits
(CREDI),48 the Early Childhood Development
for the early childhood workforce are poorer than
Index from UNICEF’s Multiple Indicator Cluster
those of primary teachers, leading to low job satis-
Survey,49 the Inter-American Development Bank’s
faction and high turnover.42 On-site mentoring and
Regional Project on Child Development Indica-
coaching has been shown to build teachers’ and care-
tors (PRIDI),50 the Guide for Monitoring Child
givers’ skills and is a promising strategy to improve
Development,51 and the Measuring Early Learning
ECCE services.24 System-wide investments in the
Quality and Outcomes project (MELQO).52 While
early childhood workface should include training
most rigorous impact evaluation studies estimating
pathways and funding streams for continuous in-
program impact rely most often on costly copy-
service training modalities. Finally, to enable work-
righted direct assessments of infant and child devel-
ers to carry out their responsibilities effectively,
opment, the measurement instruments mentioned
early childhood settings need adequate and phys-
above are being used in low-resourced settings glob-
ical infrastructure, pedagogical resources, and age-
ally to monitor progress on child development goals.
appropriate materials.39 Pedagogical resources and
For instance, the CREDI tools have been validated
materials are complementary to the workforce train-
against direct child assessments in LMICs and are
ing and work.
being used in over 17 countries.
Outcome measurement is also necessary for accu- quate use of information and consequential action
rate estimates of cost–benefit, one of the most steps are key components of the improvement cycle.
frequently used tool to gather evidence of eco- The existence of such a continuous improvement
nomic returns to early childhood investment.53,54 cycle may be a defining feature of a highly effective
Therefore, measurement of clearly defined program intervention program, regardless of its scale.8,37,59,60
outcomes is integral to policy change, financing, Improvement cycles are not just about quality
public–private partnerships, and national scale up assurance; rather, they are about setting in place
efforts. For example, cost–benefit estimates based mechanisms to learn what is working and what
on some older pre-K programs in the United States is not, so as to support the system and make
suggest that every dollar invested in prekindergarten course corrections in processes, procedures, and
pays off $3–$17 in individual and societal benefits.55 program components with the goal of achieving
Such estimates, however, rely on accurate calcula- as much progress in children’s development as
tion of the program’s cost relative to the counter- possible. Continuous improvement is cyclical and
factual condition, estimates of the program’s causal data driven, and requires a shift from compliance
impact on outcomes on beneficiary children and with standards imposed externally to creating an
families in the short and long term, and the price organizational culture committed to ongoing qual-
tag (economic value or market price) attached to ity improvement, reflection, and a shared learning
each outcome.55 The economic returns for early environment.61 Nores et al.62 illustrate the use of
childhood stimulation and nutritional programs a quality improvement cycle to inform improve-
have been established for few programs,54 with ments while scaling in the aeioTU program in
estimated benefit–cost ratios of 6–14% estimated Colombia using observations of classroom quality
for increasing preschool enrollment to 25% for one and other instruments to inform their improve-
year of preschool.56 ment processes, policies, and systems. Similarly,
BRAC’s success in scaling up in Bangladesh (which
Critical aspect 7: creating continuous
includes primary and preprimary) was strongly
improvement cycles
supported by monitoring and evaluation feedback
Central to program effectiveness is the idea that loops.63
getting any program or series or initiatives right Table 3 includes a series of actions that can be part
from the very start is hard. A continuous improve- of creating a continuous improvement cycle, such as
ment approach to early childhood services requires defining the standards and outcomes against which
building evidence overtime about what works best interventions will be monitored and evaluated, cre-
for whom, and under what circumstances.57,58 Such ating capacity to understand and measuring these,
evidence might be obtained, for instance, from mea- investing in data measurement and interpretation
suring the impact of changes to program operations (across all system levels), and using data to inform
and services, and testing strategies for improving policies and practices.
participant engagement, implementing different
Critical aspect 8: partnerships
communication and messaging about program
services. Programs need to have feedback loops in Partnerships may be another critical component
place that use monitoring or evaluation practices to of strengthening capacity to deliver ECD interven-
identify program areas for improvement. Establish- tions. Although there is limited rigorous evidence on
ing mechanisms for continuous improvement early the critical elements of ECE partnerships, existing
on can provide timely information about needs for literature defines some features that are supported
program adjustments, professional development, by successful partnerships. There is suggestive
or technical assistance. For example, a continuous evidence that partnerships have the potential to
improvement system may assess whether features of improve quality of care, availability of compre-
early childhood services are aligned with program hensive services for families, staff knowledge and
standards, curricula (when applicable), assess- skills, and staff access to professional develop-
ments, workforce preparation and technical assis- ment supports.64 Stronger partnerships may help
tance, and professional development that operates build programs that are more likely locally relevant,
at local, subnational, and national levels. The ade- politically (through changes in government) and
financially sustainable, and strongly demanded.17 Conclusions

Partnerships with families and communities may
Building systems’ capacity for the delivery of inter-
create demand and strengthen the local and cultural
ventions to promote ECD is no small task. Establish-
relevance of programs.65 Partnerships with the pri-
ing systems able to deliver strong national programs
vate sector may allow linking public programs to
and interventions requires a coordinated, deliberate
secure long-term support and build on other exist-
effort to build policies and programs for children
ing infrastructure, and partnerships with NGOs can
on infrastructures that are already strong, and/or
provide programs and initiatives face validity to
develop effective multisector coordination efforts
the extent these organizations have long-standing
to deliver integrated services. Children’s develop-
reputations in the country.23 Partnerships with uni-
ment is multidimensional, and the efforts to support
versities, as well as donors, may increase the capac-
their development must be so as well. Creating effec-
ity of the program in terms of data monitoring,
tive systems includes addressing governance, mon-
evaluation, and accountability, but also may give
itoring and evaluation, program content, and work
credibility to its content and research base origins.66
force.
When donor spending surpasses country spending,
While there may be many plausible ways to
the role of donor goes much beyond this.66 Addi-
achieve this, we, in this article, set forward actions
tionally, donors are often influential spokespeople
that have been part of successful experiences in
for the initiative to the public and with elected and
ECCE in Colombia, Peru, India, and Chile, among
appointed officials.67
others. While national integrated leadership is cen-
The resources that come from the partnerships
tral to the advancement of a national coordinated
can be numerous, ranging from support in data
initiative, program, or strategy, subnational and
monitoring and evaluation activities, direct deliv-
local integration and alignment are also central for
ery, materials, facilities, providing information for
any plan or program to reach the targeted popu-
local and cultural adaptations, advocacy, building
lations effectively and be locally and culturally rel-
local support, technical assistance, and professional
evant. Successful large-scale sustainable programs
development, among others. Black et al.5 high-
have been the result of coordination systems highly
light how, in many countries, ECD services are
articulated horizontally and vertically.9,23 Indica-
delivered by disjointed groups of nongovernmen-
tors, outcomes, and measurements toward goals
tal organizations with limited attention to qual-
should be understood and used by all organiza-
ity and little coordination. Finding ways to lever-
tions coresponsible for the initiatives undertaken
age these efforts, to increase their quality and
(whether it be one program or various comple-
their coordination, is central to a coordinated ECD
mentary ones). With the growth of information on
effort.
effectiveness and scalability in the field, programs
In Bangladesh, BRAC and donors worked
and initiatives can draw more and more on rigorous
together to streamline donor support through a
research, increasing the potential for acceptability
donor consortium.68 Bangladesh’s child devel-
and effectiveness. In addition, at the core of any
opment center (Shishu Bikash Kendra) is a
program’s potential is its quality and its content,
public–private partnership focused on early
and attention should be paid to not diluting quality
screening, assessment, intervention, treatment, and
for the sake of access, as this can lead to a waste
management of development disorders or delays.14
of resources and sometimes even harm children’s
In Colombia, aeioTU is a social enterprise that,
development. Quality means investing in the deliv-
through public–private partnerships, currently
ery agents, those who oversee bringing any inter-
provides services in 13 cities to nearly 13,300
vention and program to families or children, and in
children, delivering high-quality early childhood
those in charge of supporting them. It also means
services to children under the age of five. In
investing in efforts to collect information on chil-
addition, it works with other early childhood
dren and on the quality of the program to monitor
providers and professionals and the government,
the program and improve it over time. That infor-
partnering for quality improvements.62
mation will also be used to sustain the program over
time across election cycles.
A program, whether small or scaled, is sustain- 5. Black, M.M., S.P. Walker, L.C.H. Fernald, et al. 2017. Early
able to the extent that there is demand for it, there childhood development coming of age: science through the
life course. Lancet 389: 77–90.
is support for it, and it is cost-effective. Part of this
6. Shonkoff, J. & D. Phillips. 2000. From neurons to neighbor-
involves partnerships with families, communities, hoods: the science of early childhood development. Washing-
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it, and increase its sustainability and effectiveness development and the foundation of a sustainable society. In
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over time. Every action that strengthens any of the
hood Care and Education. P.T.M. Marope & Y. Kaga, Eds.: 55.
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ernance structure,3 to deliver a locally relevant and system of high-quality universal preschool education in
comprehensive ECD strategy that promotes chil- the United States. In Childcare, Early Education and Social
Inequality: An International Perspective. H.P. Blossfeld, J.
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Acknowledgments childhood development programs in global contexts: ratio-
nale for investment, conceptual framework and implications
This paper was invited to be published individu- for equity. Soc. Pol. Rep. 25: 3–23.
ally and as one of several others as a special issue 10. Larson, L.M. & A.K. Yousafzai. 2017. A meta-analysis of
of Ann. N.Y. Acad. Sci. (1419: 1–271, 2018). The nutrition interventions on mental development of children
under-two in low-and middle-income countries. Matern.
special issue was developed and coordinated by Child Nutr. 13. https://doi.org/10.1111/mcn.12229.
Aisha K. Yousafzai, Frances Aboud, Milagros Nores, 11. Aboud, F.E. & A.K. Yousafzai. 2015. Global health and devel-
and Pia Britto with the aim of presenting current opment in early childhood. Annu. Rev. Psychol. 66: 433–457.
evidence and evaluations on implementation pro- 12. Britto, P.R., S.J. Lye, K. Proulx, et al. 2017. Nurturing care:
cesses, and to identify gaps and future research promoting early childhood development. Lancet 389: 91–
102.
directions to advance effectiveness and scale-up of 13. Dodge, K.A. 2011. Context matters in child and family pol-
interventions that promote young children’s devel- icy. Child Dev. 82: 433–442.
opment. A workshop was held on December 4 and 14. Pérez-Escamilla, R., V. Cavallera, M. Tomlinson & T. Dua.
5, 2017 at and sponsored by the New York Academy 2018. Scaling up integrated early childhood development
of Sciences to discuss and develop the content of this programs: lessons from four countries. Child Care Health
Dev. 44: 50–61.
paper and the others of the special issue. Funding for 15. Hanson, K., M.K. Ranson, V. Oliveira-Cruz & A. Mills. 2003.
open access of the special issue is gratefully acknowl- Expanding access to priority health interventions: a frame-
edged from UNICEF and the New Venture Fund. work for understanding the constraints to scaling-up. J. Int.
Dev. 15, 1–14.
16. Mangham, L.J. & K. Hanson. 2010. Scaling up in interna-
Competing interests tional health: what are the key issues? Health Policy Plan. 25,
85–96.
The authors declare no competing interests.
17. Richter, L.M., B. Daelmans, J. Lombardi, et al. 2017. Invest-
ing in the foundation of sustainable development: pathways
to scale up for early childhood development. Lancet 389:
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Annals NY Academy of Science - 2018 - Nores - Building Capacity in Health and Education Systems To Deliver Interventions

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17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13682 by HINARI - ARGENTINA, Wiley Online Library on [31/10/2022].

Building capacity in health and education systems to

Introduction (e.g., home visitors, teachers, and health workers),

Therefore, a prescriptive approach to early child-

5. Linking programs Link ECD programs Governance of

3. Horizontal Have multi-stakeholder

Table 3. Critical aspects and relevant actions

Critical aspect Actions

Critical aspect Actions

7. Continuous r Determine standards and outcomes/indicators against which interventions will be

financially sustainable, and strongly demanded.17 Conclusions

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