Scaling up an early childhood development programme through a national multisectoral approach to social protection: lessons from Chile Crece Contigo
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MAKING MULTISECTORAL COLLABORATION WORK
Scaling up an early childhood development
BMJ: first published as 10.1136/bmj.k4513 on 7 December 2018. Downloaded from http://www.bmj.com/ on 17 March 2021 by guest. Protected by copyright.
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
A
n estimated 250 million children Chile, a high income country with a made child development a priority for her
aged under 5 (about 43%) in low population of 17.6 million, has made government in 2006.11
and middle income countries are substantial progress in reducing infant, The resulting initiative, Chile Grows
at risk of not reaching their devel- child, and maternal mortality in the past with You (Chile Crece Contigo, ChCC), is
opmental potential. 1 Poverty, 40 years through considerable investments a comprehensive protection system for
undernutrition, lack of effective medical in public health, the development of a children from the prenatal period to 4
care, and adverse childhood experiences highly functional health system, and years, taking advantage of every encounter
can all have long term effects on brain various social policies.2-5 However, these between children and health services and
development and cognition. Many of these overall improvements mask high levels of providing coordinated services across
adverse consequences can be avoided by inequality linked to socioeconomic status different public sectors.12
interventions to prevent or manage devel- and education. 6 7 The second national Although existing evidence identifies
opmental problems at an early age.1 quality of life survey in 2005 found that interventions that can improve early
30% of Chilean children under 5 did childhood development, much less
KEY MESSAGES not reach their expected development is known about how to translate this
milestones, with the poorest quintile knowledge into sustainable large scale
• C hile Grows with You (Chile Crece at highest risk of developmental delay programmes requiring collaboration and
Contigo, ChCC) introduced a new (box 1). 9 Drawing on these findings coordination across sectors.13 We aimed
model of practice and fostered emer- and recognising the increasing global to identify the factors that facilitated a
gent behaviour in child develop- evidence of the importance of childhood national scale-up of ChCC, 10 years after
ment through political will, evidence development to economic and social implementation began. Evaluation was
informed advocacy, consensus based progress, Michelle Bachelet, a paediatrician led and coordinated by a working group
policy development, and use of exist- and the first woman president of Chile, with representation from the Ministry of
ing functional systems
• Health, social, and education teams
Box 1: Tracking early childhood development in Chile—the importance of equity
coordinated by the municipality are
responsible for monitoring the devel- • National quality of life survey assesses early childhood development using standard
opment of children and coordinating measures on a sample of mothers and children aged 7 to 59 months
the provision of services targeted to • A validated development assessment tool is used to measure cognitive, motor, language,
each child and their family social, and emotional progress compared with expected milestones for the child’s age8
• Formation of a non-sectoral coordi- • Chile uses the terms developmental lag and delay to describe the degree of developmental
nating body—the Ministry of Social risk:
Development—improved manage- •Developmental lag is defined as children who achieve a normal overall developmental
ment of social networks and promo- test score based on expected milestones for their age but are behind in a developmental
tion of social development policies, sub-area
while direct transfer funding agree- •Developmental delay is defined as children who do not achieve a normal overall
ments promoted local accountability developmental test score for their age and are therefore behind expected developmental
and quality milestones in more than one area (reflecting a more serious developmental gap)
• Institutionalisation of ChCC by Law • In 2006, 16.4% of all children under 5 had a developmental lag and 13.5% had a
20 379 in 2009, guaranteed consist- developmental delay, with a total of 30% having either a lag or a delay. Children in the poorest
ent and increasing budget allocations, quintile were 12.8% more likely to have a developmental lag or delay. Other disparities were
systematic collection and use of data found by sex and area of residence9
for programme management, and • Longitudinal studies show that children from lower income families have poorer development
coordination of health, education, of cognitive skills than those from wealthier groups, a disparity which emerges early in life
and social services and continues after the age of 610
the bmj | BMJ 2018;363:k4513 | doi: 10.1136/bmj.k4513 1MAKING MULTISECTORAL COLLABORATION WORK
Social Development and the University Box 2: Timeline of programme and policy inputs for the introduction and scale-up of ChCC
of Santiago, Chile, using a modified
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multistakeholder dialogue approach 2005-06
(supplementary file 1 on bmj.com). Our • Pre-investment studies
primary objective was to summarise the • Presidential Advisory Council for the Reform of Child Policies formed
progress towards implementation of • Recommendations for early childhood development programme developed after
ChCC, investigating how cross sectoral consultations
collaboration and coordination were • Creation of Chile Grows with You (ChCC)
managed to provide integrated child 2007-08
development care on a national scale. • ChCC implemented in 159 municipalities
• ChCC extended to all communes in 345 municipalities
ChCC: policy development • Development of training and communication materials begins
ChCC aims to help all children reach their
full potential for development, regardless 2009-10
of their socioeconomic status. It seeks to • Law 20 379 institutionalising ChCC for the protection of children is approved, with a
support children and families through- designated budget line
out early development, from conception • Implementation of the newborn support programme parental skills workshops, Nobody is
to entry into preschool at age 4, through Perfect
universal and targeted support services.14 • Implementation and refinement of the ChCC electronic database and tracking system
The programme is based on rights and sex 2011-13
equity approaches, building on the scien- • New postnatal parental leave (up to 6 months)
tific evidence regarding the importance of • Workshops for promotion of motor and language development started
the first years of life, including gestation,
2014-17
for comprehensive human development.
• Expansion of ChCC to children up to age 9 with the Integrated Learning Support Programme
It also recognises that inequities between
• Pilot of the Children’s Mental Health Programme
the poorest and wealthiest quintiles of chil-
dren influence development considerably
and need to be tackled to improve develop- Law 20 379 was enacted, institutionalising and education through resource transfer
mental outcomes.10 15 ChCC and providing a permanent line agreements, and to municipalities through
In 2006, President Bachelet established for it in the national public budget. 16 direct transfer agreements. Ministries
the Presidential Advisory Council for Child
Development of the newborn support and implement services as part of the ChCC
Policy Reform. The council consisted of
parenting skills programmes began in portfolio through existing networks and
external experts from different fields and
2008, with full implementation in 2009. systems. Direct transfer agreements with
holding different political views. Experts
The development, testing, and introduction municipalities support activities such as
reviewed international evidence and local
of the electronic monitoring database hiring and training staff and providing
data11 and conducted 46 hearings with
began in 2009 and 2010 (box 2). supplies for services. Transfer agreements
national and international experts in the
also specify technical standards that
field, civil society, multilateral and bilateral
Structure, management, and financing must be met by institutions, which make
organisations, academic institutions, and
The ministries of health, education, and fund transfer agreements an important
other relevant organisations, both public
social development are responsible for mechanism for managing the quality of
and private. Members of the council held
hearings in the 13 regional capitals with administration and management of ChCC services.
local organisations and individuals to (box 3). The Ministry of Social Develop- Institutions receiving funds are required
discuss child health, education, and ment is responsible for coordinating and to report monthly expenditures and to
development. Issues discussed included managing the system at national, regional, specify how resources were allocated
resources needed for childbirth, improving and communal levels; it is represented in within the framework of the agreements
housing and social services, access to each region through the regional secretar- signed. Hence a system of continuous
education, and services for indigenous ies of social development. Coordination accountability and feedback is established,
groups. Over 7000 comments were solicited takes place across ministries and services linked with funding availability. Use of
from children, using a website which at the same level (horizontal coordination) the electronic ChCC database allows the
encouraged expression of opinions about and across different levels of government progress of children along the continuum
how to improve community resources from national to commune level (vertical of care to be tracked using key indicators;
for learning and development, such coordination). problem areas can then be identified
as the availability of green space and ChCC is financed entirely by the public and managed (see the monitoring and
educational and health services. Its final sector, with agreements governing the evaluation section below). Routine national
recommendations were reviewed by an transfer of funds to sectoral ministries, and regional supervision to municipalities
interagency technical team in June 2006 local governments (municipalities), and allows feedback in both directions.
and developed into ChCC.11 private stakeholders. A ChCC budget Strengths can be identified and built on;
C h C C w a s i m p l e m e n te d i n 1 5 9 line was established for the Ministry of weaknesses can be identified and managed
municipalities in Chile in 2007; the next Social Development in the budget law collaboratively.
year it was extended to the remaining of the Chilean public sector. Resources The basic communal networks of ChCC,
186 municipalities. In September 2009, are allocated to the ministries of health consisting of health and education teams
2 doi: 10.1136/bmj.k4513 | BMJ 2018;363:k4513 | the bmjMAKING MULTISECTORAL COLLABORATION WORK
Box 3: Ensuring that ChCC reaches children at highest risk in Chile: expanding coverage of ChCC was 1 987 755, with the number of
health, education, and social services children under developmental observation
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in the public health system reaching 646
Guaranteed healthcare services for all 692 in 2017.28
• The public health system is used by around 80% of the population and is free for lower By 2017, 94% of women registered in
income groups. Services are provided by the National Health Service System (SNSS) through the public system received the newborn
a national network of hospitals and primary care centres linked with family health community support package at birth and 94% received
centres and rural health posts, based on a family and community health plan17 postnatal counselling, with significant
Free education increases in the number of comprehensive
• Early education from 0 to 4 years is financed by both public and private bodies. ChCC home visits for vulnerable pregnant women
guarantees by law that children from the lowest two wealth quintiles can access education and children; improvements in prenatal,
free of charge, beginning with nursery care. At age 5 years, children attend kindergarten, the delivery, and postnatal practices; and
first mandatory educational level, and have free access to public schools. increasing rates of preschool education
Social protection attendance (table 1). 29 30 In 2017, all
• The social household registry is used to assign vulnerability ratings to households and so registered children diagnosed with a deficit
determine whether they qualify for benefits under the social protection system. By July 2017, in psychomotor development were referred
the registry had ratings data of about 73% of the national population18 to stimulation rooms, with 75% of those
• The social protection system includes psychosocial support for extremely poor families completing treatment discharged without
through the Security and Opportunities programme, preferential access to existing social deficits.28
programmes, and guaranteed access to subsidies or cash transfers provided by the state.19 The targeted ChCC programme is
ChCC is part of the social protection system, therefore allowing all those in need to receive provided for caregivers, families, and
benefits children entering the public health system,
representing about 80% of the population.
and coordinated by the municipality, about the child’s development, activate the The remaining 20% of the population
are responsible for routine provision of necessary services, and make intersectoral obtains health services from private
preventive and curative services. Expanded referrals. The second major component providers through private insurance or
networks include stakeholders from other consists of periodic evaluations to assess occupational coverage. Other mechanisms
municipal departments or local services the effectiveness of programme services are in place to ensure that those in lower
that target children and their families. or activities. To date, more than 30 stud- income groups have access to care without
Communal networks are therefore ies have been undertaken on ChCC, with high cost barriers to care (fig 1, box 3).20 21
responsible for coordinating cross sectoral different methodologies and approaches, The core of the ChCC targeted approach is
services based on local resources available, including both qualitative and quantita- the Biopsychosocial Development Support
geography, and any cultural factors needed tive user satisfaction, impact, and process Programme, which includes health checks
to ensure services meet the needs of studies.6 26 during pregnancy, care during labour and
children and families. birth, child health checks, screening for
Summary of progress and timely treatment of developmental
Implementation Between 2007 and 2017, annual budget- delays, care for hospitalised children, and
ChCC provides a public education pro- ary allocations for ChCC increased progres- child mental health using standardised
gramme on early child development for all sively, rising from $7.8m in 2007 to $13.9m tools (fig 2).22 For example, evidence based
families, caregivers, and providers using in 2008, and reaching $81m in 2017.27 interventions at birth include provision of a
a website, social media platforms, a radio During this period, the number of pregnant birth companion of choice, immediate skin-
show, and print material (fig 1). women admitted to prenatal care under to-skin contact between mother and baby,
Monitoring, accountability, and learning Regions where children and families live
Programme support for administration and management of ChCC implementation:
From the outset, the coordinating ministry • Initiatives for Children fund
• Municipal strengthening programme
developed a monitoring and evaluation
plan for ChCC with two main components.
All children in Chile
• Education programme: to inform, educate and raise public awareness about child care,
The first is an electronic database of all respectful parenting and early child development. Resources include website, radio
series (Growing Together), social media networks, stimulation materials, DVDs,
pregnant women and all children enter- pamphlets, and a free child health telephone hotline
ing the health system. This allows track- Children in public health system (81%)
ing of developmental assessments, core
• Biopsychosocial Development Support Programme: development screening,
management and follow-up delivered through routine health system contacts during
health interventions received, and progress pregnancy, childbirth, wellbeing and health child check-ups. Core interventions
included in facility services benefits list
across sectors. Clinic health workers enter • Newborn support programme: supports for hospitalised newborns
• Child mental health support programme
data directly on to the database at each
Vulnerable children (60%)
consultation. Data are managed centrally • Home visits by health teams
by the Ministry of Social Development. Key • Comprehensive care for children with delays through interventions to support child
development programme
performance indicators are used to track • Preferential access for families and children to public and social protection
programmes
completeness of reporting and outcomes • Free nursery and day care centres
• Family allowance
for children classified with developmen- • Technical aids for children with disabilities
tal delays. This system is used by staff in Children in public schools (36%)
health, education, and social protection • Comprehensive learning support programme
sectors to access and update information Fig 1 | Services provided by ChCC. Adapted from the Ministry of Social Development, Chile14
the bmj | BMJ 2018;363:k4513 | doi: 10.1136/bmj.k4513 3MAKING MULTISECTORAL COLLABORATION WORK
Pregnancy Birth 0 to 4 years of age
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1 2 3 4 5
Strengthening Personalised Developmental Strengthening child’s Care for children
prenatal care in care of hospitalised overall in vulnerable
development birth process children development situations
Primary healthcare Hospitals Primary healthcare
• Strengthening • Personalised birth care • Comprehensive • Strengthening of • Strengthening
prenatal care newborn care children’s health interventions for children
• Comprehensive checks for overall in vulnerable situations,
• Development of health care in puerperium • Comprehensive development or with deficits in
plan with family approach care for hospitalised development
children • Educative interventions
• Education for pregnant supporting upbringing
woman and her partner
or companion
Fig 2 | Biopsychosocial support programme: services offered across the life cycle by ChCC Ministry of Social Development, Chile14
and early and exclusive breastfeeding— for vulnerability to be identified at any delay in older children. Evaluations of
all associated with improved outcomes contact with health, education, and social the biopsychosocial programme and the
for both mother and baby.23 The ChCC services and referred across sectors. For Nobody is Perfect parenting education
programme updated facility policies, example, the health sector may identify programme have shown them to be effective
changed work environments, and developmental delays requiring home at improving several measures of child
supported staff training and supervision visits; preschool nurseries may identify development and parenting practice. 32
33
to move towards consistent adoption of developmental problems requiring Services targeting children with
key practices. Screening for developmental screening or a housing problem related developmental delays have been shown
delay is done using a national test applied to poverty that requires support by the to be cost effective.34 Of the beneficiaries,
at each health check. 22 Standardised municipality. 73% describe ChCC as being fundamental
screening also includes assessing Between 2006 and 2016/17, the to their personal experience of pregnancy
maternal and family risk factors, such as proportion of children under 5 with and parenting, suggesting high levels of
low education, substance misuse, and developmental delay declined nationally satisfaction.35
depression. Targeted services are provided from 14% to 10%. Considerable variation Persistent developmental delays in
for children with developmental delays, was noted between age categories, with younger age groups noted in the most recent
including stimulation rooms, home visits, the most dramatic falls in developmental population based survey raised questions
playgroups, and other services (box 4). delay noted in children aged 2 (from 11.6% about the coverage of interventions
Nobody is Perfect is a group education to 6.2%) and aged 3 (from 25.1% to 11.4%) delivered around delivery and very early in
workshop for parents, mothers, and (fig 3).31 In contrast, increasing proportions life, especially for high risk groups. A review
caregivers with children aged 0 to 5.25 It of children aged 7-11 months and 12-23 of these data by wealth quintile and for other
promotes positive parenting skills, mutual months were assessed with developmental higher risk categories is now required to
support by participants, prevention delay. Data are not yet available by wealth determine whether these groups are being
of child abuse and maltreatment, and quintile. These results are consistent with disproportionately missed by the system. In
co-responsibility in parenting using early intervention reducing developmental addition, the quality of early developmental
hands-on practice. Training of primary
care staff for all screening and programme
Box 4: Services provided for children assessed with psychomotor, cognitive, social, or
components of ChCC is done by national communication delay
and municipal facilitators using materials
and job aids based on national standards. • Primary services offered: stimulation rooms, home visiting, and a mobile stimulation
Additional services are provided for service. Stimulation rooms can operate at health centres or community based spaces. One
families with fewer resources or at greater municipality can have one or more of each of the service modalities, depending on demand.
risk: these include financial support, • Average duration of initial treatment: the average number of initial sessions is 6 with an
free nursery and preschool places, and average duration of 45 minutes. At the end of the initial sessions, further treatment may be
preferential access to public programmes. recommended or a referral made for further assessment and management
Vulnerable families have access to free infant • Staffing: most of the staff working with children are nursery educators or teachers, phono
or toddler care for children under 2, and audiologists, occupational therapists, kinesiologists, or other professionals with formal
preschool places for children aged between 2 qualifications in child development
and 3. Such families represent around 60% of • Technical guidelines: guidelines for staff teams providing services to children been
the population; vulnerability criteria include developed and are used nationally for staff orientation and training24
teen mothers and those with postpartum • Equipment and materials: materials include a wall mirror, rubber mats, tulle or coloured
depression, substance misuse, lack of family gauze handkerchief mobiles, tunnels, balls of different sizes and textures, recorded music,
support, and low levels of education. books for children under 5, didactic toys with stimulation objectives (such as wooden blocks,
The ChCC network should allow rattles, musical instruments, dolls, food, animals), tables suitable for children, access ramps,
children and families with risk factors and other relevant materials tailored to the culture or targeted area of delay
4 doi: 10.1136/bmj.k4513 | BMJ 2018;363:k4513 | the bmjMAKING MULTISECTORAL COLLABORATION WORK
Table 1 | Key ChCC country indicators, 2007-18*
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Indicator 2006-10 2011-14 2015-18
Total public expenditure—ChCC ($m, 2017) 7.809 (2007) 72.715 (2012) 80.989 (2017)
Prenatal care
Home visits: pregnant women with psychosocial risk (total number) 13 310 (2007) 88 103 (2012) 72 547 (2017)
Prenatal care with spouse, family member, or significant other (% of prenatal visits) 18 (2008) 30 (2014) 34 (2017)
Delivery and early postpartum care
Birth companion (% deliveries) — 59 (2012) 67 (2017)
Skin-to-skin contact for at least 30 minutes (% deliveries) — 52 (2010) 76 (2017)
Exclusive breastfeeding for 6 months (% infantsMAKING MULTISECTORAL COLLABORATION WORK
Table 2 | Current strategies and emerging challenges for ChCC
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Aim Current strategies under ChCC Emerging challenges
Improving routine systems to support • Use of existing public health system provides a gateway to • Harmonise registration and monitoring system of ChCC
intersectoral services services with other government data systems to allow data sharing
• Multisectoral coverage by the social protection system • Strengthen efficiency and timeliness of fund transfers for
• Management by the Ministry of Social Development and fund local activities, hiring staff, and meeting goals
transfer agreements for quality and accountability • Close gaps in the social protection system to ensure
• Integrated electronic monitoring and evaluation system families receive housing, employment, mental health, or
substance misuse treatment when required
Adapting to evolving problems • Routine monitoring of biological and psychosocial risks of the Recognise and adapt the developmental approach to demo-
family and child graphic and social changes including:
• Early intervention through the health system based on identified • Child mental health
needs • Children with disabilities
• Intersectoral links to foster appropriate care based on needs • Indigenous people
• Links with social protection services to ensure wider social • Obese and overweight children
problems, such as employment and housing, are tackled • Children and families of new immigrants
• Children raised in lesbian, gay, bisexual, and transgender
families and transgender children
Improving parenting skills • Nobody is Perfect parental education training offered to all • Violence and maltreatment of children is believed to be
mothers and families has been shown to improve general parenting widespread in Chile; more data are needed to allow better
skills management
• Better integrate interventions to promote caring and sensi-
tive care across sectors
Reaching core populations better • Access to care and education through routine prenatal, delivery, • Improve access to services (eg, by changing locations and
and postnatal contacts opening times)
• Home visits to families and children identified as high risk, using • Better use of social media for follow-up and reinforcement
intersectoral links of skills or education
• Many materials and web based links used for communication and • Develop mechanisms to hear children’s views to improve
education services and communication
Expanding the target population • ChCC is focused on the prenatal period and on children aged 0-4 • Local movement to expand ChCC to include children aged
years, the period of highest risk for development 5-9 through the education sector
• Development of a formal policy promoting the rights of all
children from birth to 18 years is under review
allocations guaranteed by law (table 1); data sharing. Some high risk groups do structure allows continuous feedback at
effective coordination both at national not always receive social services such as local level to tackle gaps and problems.
level by the Ministry of Social Develop- housing, employment assistance, or men- ChCC instituted a phased transition to a
ment and at local level by motivated tal health services when required, and gaps new model of practice and fostered emer-
health and education teams with experi- need to be closed. Access to public services gent behaviour in this area through strong
ence in implementing maternal and child can be improved in some areas by changing political will, evidence informed advocacy,
health programmes, who have up-skilled the location and opening times of clinics consensus based policy development, and
to gain further developmental skills and and offices and by better promotion of care use of existing functional systems. Inter-
competencies; collection and use of data using social media platforms. Finally, new connectedness within this network allowed
for programme management and intersec- and emerging problems and demographic progressive cultural change, which placed
toral coordination using the programme shifts in the country will require ChCC to value on the principles of equity, coordi-
monitoring system; regular evaluation of adapt the range and type of services pro- nation, and recognition that development
programme components and use of data vided. These include management of child- needed attention. All of these features con-
for improving services; and increasing hood mental health problems, disabilities, tributed to better uptake and effectiveness.
focus on developing and implementing and obesity, and the problems of new immi-
quality standards, which are used for both grants and indigenous populations. In the We thank the key informants who answered in-depth
questions about child development programming,
tracking progress and providing incentives. longer term there is a movement to expand participants in the case study expert review meeting,
Quality standards led to the creation of a ChCC services to older children aged 5-9. and Jeanet Leguas and Vanesa Hernández of ChCC
benefits list for the biopsychosocial support (Ministry of Social Development) for their support in
collating key informant responses to questionnaires.
programme implemented by the Ministry Conclusions
of Health. ChCC has features of a complex adaptive Contributors and sources:HM conceptualised the
system in which positive and negative case study. CC, AT, and PV conducted field interviews
and collected data and reports of the programme.
Limitations feedback loops have a central role in the CC, AT, and PV conducted the data synthesis. HM, JM,
ChCC must evolve in line with Chile’s development and implementation of the CC, AT, and PV drafted the manuscript. All authors
changing health context and adapt to oper- programme.36 Features include communal reviewed and commented on the manuscript before
finalisation. HM is the guarantor.
ational challenges to improve its efficiency networks with multiple formal and infor-
and effectiveness. Several challenges have mal connections between sectors to foster Competing interests: The authors have read and
been identified for the next phase of imple- coordination of services and adaptation understood BMJ policy on declaration of interests
and declare: AT was the national coordinator for ChCC
mentation (table 2). ChCC systems need to local needs. Local budgetary authority during the period the case study was conducted;
strengthening in some areas, including allows resources to be allocated in accord- HM, CC, and PV have previously worked for the ChCC
improving the efficiency and timeliness of ance with local priorities. Feedback loops programme at national level. WHO Partnership for
Maternal, Newborn and Child Health provided support
fund transfers to municipalities and better are used in the research and evaluation for the work for this article. The views expressed are
integration of the monitoring system with system to monitor and improve opera- those of the authors and do not necessarily represent
other government data systems to allow tions. The intersectoral and participatory the views, decisions, or policies of WHO.
6 doi: 10.1136/bmj.k4513 | BMJ 2018;363:k4513 | the bmjMAKING MULTISECTORAL COLLABORATION WORK
Provenance and peer review: Commissioned; 9 Ministry of Health. Chile. Second quality of life and 24 Ministry of Health. Chile. Technical guidelines
externally peer reviewed. health survey. Ministry of Health, 2006. for supporting child development: guidelines
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Partnership for Maternal, Newborn and Child Health disparities for early childhood anthropometrics http://www.crececontigo.gob.cl/wp-content/
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peer reviewed, edited, and made the decision to University of Pennsylvania Population Center working las-modalidades-de-apoyo-al-desarrollo-infantil-
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