The advantages and disadvantages of coordination and integration

The integration and coordination of health, education, nutrition, social protection, and other services have the potential to improve the lives of children and their caregivers around the world. However, integration and coordination of policies and programs affecting early childhood development can create both risks and benefits. Careful planning and implementation of policies and programs can help ensure that these investments are optimized, as demonstrated by the programs described by a number of workshop presenters.

Early childhood development programs and policies can be coordinated with each other, integrated into a single service provider or agency, or juxtaposed with no special effort made to coordinate or integrate separate services. As stated by Emily Vargas-Barón, director of the RISE Institute, the government agencies usually involved in early childhood development policies and programs include education, health, nutrition, sanitation, protection, justice, planning, finance, gender, rural development, and interior, though these agencies may combine or overlap in different ways in countries. Agencies usually maintain managerial and fiscal control of their programs, she added, although they may coordinate their services, sometimes closely. For example, they often have formal or informal interagency agreements; may conduct mutual referrals and create a common database and tracking system; and may conduct joint planning, monitoring, and evaluation, though this is usually the weakest area of program implementation in most countries.

Using existing platforms to integrate services on the ground

Efforts by governments or nongovernmental organizations (NGOs) to coordinate or integrate services for children and their caregivers generally are built on existing platforms in the areas of health, education, nutrition, social protection, and other domains. One session at the workshop examined several such efforts to explore the advantages of coordination and the interplay of public- and private-sector organizations as programs are scaled up.

In Bangladesh, the NGO BRAC has developed an integrated childhood development intervention through its Maternal, Neonatal, and Child Health Program that delivers a wide range of services in a cost-effective way. As BRAC's vice chair Mushtaque Chowdhury explained, the program combines workforce development, community empowerment, community-level service delivery, timely referral of emergency cases, and linkage with public and private health facilities. Furthermore, the program informs women about health, nutrition, and early child education, and it aims to increase children's holistic development by creating stimulating environments at home, in designated centers, in schools, and in the community. From conception until age 3, the program offers home-based care and learning services, informing caregivers about nutrition, breastfeeding, monitoring of child development, and referral of sick children. For children ages 3 to 5, the program offers center-based care and integrates education, focusing on play, community involvement, parenting education, and tracking of children. In a pilot phase through 2015, the intervention reached about 45,000 children, with a scaled-up effort projected to reach 200,000 children by the end of 2016. The annual costs have been about $40 for children through the age of 3, when the program is coordinated with nutrition and health services, and $120 from ages 3 through 5, when the program is coordinated with education services, and costs have fallen below that as the program has expanded due to economies of scale.

In Pakistan, the Lady Health Workers Program, which was begun by the public sector in 1994 to serve the health needs of largely rural populations, has implemented integrated interventions in early childhood development and nutrition services. A study of the combined interventions in about 1,200 children through 24 months of age revealed that both the nutrition intervention and the early childhood development intervention significantly improved children's development, though the combined interventions did not have an additive effect, said Zulfiqar Bhutta, Robert Harding Inaugural Chair in Global Child Health at the Hospital for Sick Children in Toronto, founding director of the Centre of Excellence in Women and Child Health at Aga Khan University, and co-chair of the forum. Bhutta also observed that on-the-job coaching, supportive supervision, and master trainers for the lady health workers all improved the quality of the interventions and helped the lady health workers cope with the additional demands on their time.

In New York City, the Mount Sinai Adolescent Health Center provides integrated services to a particularly vulnerable population: adolescents who do not have health insurance and have a variety of health and social needs. Angela Diaz, the Jean C. and James W. Crystal Professor in Adolescent Health and professor of pediatrics and preventive medicine at the Icahn School of Medicine, pointed out that the program provides primary health care, reproductive health care, mental health care and psychosocial support, dental care, optical care, special services, and medical-legal services, with a new initiative encompassing education, jobs, and housing, to more than 11,000 young people annually. Though the program costs less than $1,000 per youth per year, it has reduced teen pregnancy rates, sexually transmitted infections, emergency room visits, and school dropouts.

Using platforms to reach and invest in vulnerable populations

Vulnerable populations are especially likely to have children and caregivers with needs that early childhood development services can help meet. The question then becomes how best to reach these populations with the kinds of services they need.

One way to reach vulnerable populations is through targeted programs, as opposed to making a program universally available. However, targeting involves tradeoffs between equity and efficiency and is more or less politically acceptable in different places, observed Nicholas Burnett, managing director at Results for Development. Successful targeting builds on robust data concerning households' characteristics and on transparency and accountability throughout the targeting process. It also requires local validation to include eligible households and resolve disputed cases.

As an example of a targeted program, Claire Runciman, a consultant with the Australian Nurse–Family Partnership Program, described the program's outreach to women who are pregnant with an Aboriginal or islander child. The program is run out of community-controlled Aboriginal health service organizations, which means that the program is run by organizations that are trusted by the community and have very strong links with the community. The program also makes use of indigenous family partnership workers who introduce the nurses to clients and ensure that the relationship is strong.

Another targeted program has been working to improve the growth and development of about 4,000 children under the age of five in 77 communities of Sri Lanka affected by the recent armed conflict. Early childhood development interventions that involved midwives, parents, and entire communities helped reduce the percentage of underweight children from 64 to 28 percent, said Kalana Peiris, public health advisor at Plan International. Low birthweight and underweight in preschoolers decreased substantially, and growth failure in the first 2 years went from 18 percent to virtually nothing.

Developing, implementing, and sustaining coordinated and integrated programs

The development, implementation, and sustainability of coordinated or integrated programs depend on many factors, including their costs, financing, political support, and impacts. One session at the workshop explored these factors and their differences across locales, with a particular focus on how programs geared for local needs can be extended to serve more broadly based populations.

In the Southeast Asia-Pacific Region, increased investments in young children's development have decreased infant and maternal mortality and boosted pre-primary enrollments, and the establishment and development of key regional bodies have increased the knowledge of early childhood care and education and the dissemination of that knowledge, observed Emma Pearson, senior lecturer in the Department of Psychological and Human Development Studies at the University of Brunei, Darussalam. Yet in some areas malnutrition remains high, especially in vulnerable and isolated communities. A new focus on what works well at the local level is helping to inform national and international policies so that successes can be replicated. For example, a program in Vietnam called Mother Tongue-based Education serves children from ethnic minority groups who have struggled in the mainstream education system because they do not speak the national language. The program instructs children in preschool and the first few years of primary education in their mother tongue. They learn the standard curriculum in their native language as well as the national language as a second language, and later transition to the mainstream curriculum with other children in the national language.

In Los Angeles's Chinatown and Koreatown, small businesses that provide services, including supplementary education, to particular ethnic groups could be expanded to serve out-group members, observed Min Zhou, Tan Lark Sye Chair Professor of Sociology at Nanyang Technological University in Singapore. To highlight pathways to connect vulnerable populations to each other and to mainstream society, she noted that although ethnic resources can be exclusive, nonprofit community-based organizations can help break down ethnic barriers. For example, churches are nonexclusive, and business owners are both members of churches and can work with those churches to deliver services to the members of multiple groups.

In South Africa, the NGO Kheth'Impilo supports the South African government in providing HIV and tuberculosis treatment, care, and support to individuals in communities where the government's infrastructure, staffing, and delivery of services are inadequate, with the services transitioning fully to the state as governmental capabilities increase. As epidemiologists Najma Shaikh and Ashraf Grimwood of Kheth'Impilo pointed out, a major feature of the program's approach with respect to the delivery of home-based early childhood development services is the use of trained and paid community workers. These social auxiliary workers can form linkages between the members of a household and service providers, acting as a source of coordination not just in clinics but in communities and households.

Coordinating investments in children across sectors from a policy perspective

Many governance, finance, and accountability issues can facilitate or impede coordinated or integrated services for children and their caregivers at the national, subnational, or local levels. Three speakers at the workshop provided examples of programs and initiatives that have confronted these issues in productive and informative ways.

The China Women's Development Foundation, which has served more than 27 million people in China through its programs, has demonstrated how a single organization can provide a wide range of coordinated and integrated services for children and their mothers. For example, the foundation's administrative director, HaiLiang Guo, said that programs to promote entrepreneurship among mothers and to identify and provide support for children with autism can improve the financial prospects for families, which in turn can boost the health and well-being of children.

In Southeast Asia, national policies to include children with special needs in mainstream schools vary from country to country, but progress is widespread, noted Yasmin Hussain, director of the Regional Center for Special Education for the Southeast Asian Ministers of Education Organization. Furthermore, despite their differences, some elements of these approaches extend across countries, including support for children, teachers, parents, and schools. However, commendable efforts toward implementing inclusive education are evident in the countries through various approaches taken by ministries of education and related agencies.

In the Western Pacific region, the Action Plan for Healthy Newborns is reforming and coordinating policies and practices not only among, but within countries. As Howard Sobel, the regional coordinator for reproductive, maternal, newborn, child, and adolescent health in the Western Pacific Regional Office of the World Health Organization, pointed out, many harmful or unnecessary practices are still observed with newborns. The action plan included the development of supportive tools, support for countries to localize the plan, and an evaluation of countries' progress, including steps to protect, promote, and support breastfeeding, and a communication strategy called the First Embrace. Technical working groups, stakeholder groups, and professional associations have helped implement the plan, while the development of a clinical practice protocol pocket guide and associated training documents have helped countries foster new practices at the local level.

Coordinated and integrated programs in Hong Kong and Chile

The two keynote presentations at the workshop, by Chow Chun Bong, honorary clinical professor in the Department of Pediatrics and the Department of Community Medicine at the University of Hong Kong, and Helia Molina, who recently completed her term as Minister of Health in Chile, demonstrated that approaches to early childhood development can differ from place to place, but similar issues arise in different contexts.

Access to services in Hong Kong is “quite comprehensive,” Bong said, but services are seldom linked for planning, service provision, or evaluation at the territorial or local levels, which makes it difficult to assess their combined effect. Services tend to be laissez faire rather than policy-directed and welfare-based versus rights-based. According to Bong, greater equity requires more access to high-quality services and a switch from a welfare-based approach to an interventionist, policy-driven, rights-based approach.

Greater coordination of services requires a stronger technological and statistical infrastructure to implement evidence-based interventions, Bong continued. One example of an integrated evidence-based intervention in Hong Kong is the Comprehensive Child Development Service (CCDS), which was established in 2006 to integrate social welfare, early childhood education, and health, including maternal and childhood health centers. CCDS has operated in seven hospital authority clusters that have loose central coordination, allowing for local innovation and flexibility. A governmental evaluation of the program conducted 1 year after its establishment showed that equity, effectiveness, and efficiency had all improved.

As Sophia Chan, Under Secretary for Food and Health, Government of the Hong Kong Special Administrative Region, noted in her response to the keynote addresses, Hong Kong lacks a comprehensive strategy for early childhood development that would bring together the efforts of different bureaus. A child council, similar to those that exist for youth, women, the elderly, and families, could help provide this coordination.

Since 2007, Chile has been working to implement an intersectoral public policy on childhood and social protection, Molina said. A new policy known as Chile Grows with You took a multidisciplinary approach, was planned across sectors by multiple ministries, and adopted a child-centered and rights-based framework. Chile Grows with You, which began in 100 municipalities and was scaled up in 2008 to incorporate the whole country, is part of an overall public policy of social protection for workers and those in poverty, with a particular focus on mothers, children, and families. It is based on a model that includes all sectors—family, health, education, public health, culture, housing, and other areas of government—because children are involved in all aspects of policy. It is an “up-down policy,” as Molina called it, one that is implemented and evaluated at a local level but overseen on a larger scale. The program has a single budget, but several ministries are involved in the execution of sectoral activities.

Molina cited several lessons drawn from the creation and development of Chile Grows with You. The first is the importance of political will combined with a plan of action. Together, this leads to an awareness among politicians, professionals, and nonprofessionals of how important a child's early years are for individual and population health and human development.

Another takeaway lesson, said Molina, is that early childhood development affects not only the rest of a person's life but society as a whole. Social equity therefore needs to be a priority from the start, which can be accomplished through an intersectoral approach within a shared conceptual framework.

One major problem in implementing interventions was that the intensity and duration of the programs were not sufficient. In addition, feedback to stakeholders needs to be improved, Molina said, with evaluation being conducted on an intersectoral level and allowing for an overall joint perspective.

Balancing advantages and disadvantages

Coordination of policies and programs has both advantages and disadvantages, noted Jan van Ravens, a senior policy maker and consultant affiliated with the Child Study Center at Yale University. Coordinated programs can result in synergy if children served by one program can receive other kinds of services at the same time. Coordination also may attract households that would not have sought out a single kind of service.

However, these advantages often fail to materialize in practice, van Ravens said, and integration of policies and programs at the national level almost always has bad outcomes. The development and implementation of policies and programs can be difficult even within a single setting, and these difficulties can be exacerbated in multisectoral settings. Multisectoral policy and program development also can occur outside of regular planning and budget cycles, so that these efforts occur in a political vacuum, or a multisectoral policy can conflict with the policies of the line agencies.

For these and other reasons, early childhood development policies and programs are generally multisectoral at the national level, observed Vargas-Barón, usually involving three or more ministries. There are virtually no integrated early childhood policies at the national level; rather services are sometimes integrated around children at the local level in order to achieve holistic child development. To ensure effective implementation of these policies and programs, national governments often develop multisectoral structures with the participation of governmental agencies, NGOs, and other civil society and private sector organizations.

At the regional and local levels, in contrast to the national level, early childhood development structures, agencies, services, and activities occur on a continuum from sectoral to multisectoral to integrated, said Vargas-Barón. Lessons drawn from these smaller-scale efforts can have important implications for higher levels of organization and for coordination to support local-level services with young children and their families.

Both van Ravens and Vargas-Barón recommended ways to enhance the coordination of policies and programs. Although most coordination begins with informal collaboration and coordination, formal agreements can help ensure that roles and responsibilities are clearly defined, energetically pursued at each level and become sustainable, Vargas-Barón said. She noted that incentives are often needed to build strong multisectoral coordination, including the establishment of job descriptions that lay out roles and rewards. Van Ravens suggested a different approach—to universalize essential child services while continuing to deliver services through separate sectors, with coordination only as needed. Where spontaneous coordination appears to be insufficient, more formal coordination could be provided through local coordination bodies, sensitization, training, and perhaps an early childhood development coordinator. In this way, services would come together in the child, not necessarily in programs or policies.

Regardless of the approach taken to coordination, Vargas-Barón urged that planning processes be inclusive and participatory, with the involvement of people from all levels of a society, including ethnic minorities and people in both urban and rural areas.

Forum on Investing in Young Children Globally (iYCG)

• Zulfiqar A. Bhutta (Co-Chair)
  Sick Kids Centre for Global Child Health, Toronto, University of Toronto Center of Excellence for Women and Child Health, Aga Khan University
• Ann Masten (Co-Chair)
  Institute of Child Development, University of Minnesota
• J. Lawrence Aber
  New York University
• Amina Abubakar
  Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
• Lola Adedokun
  African Health Initiative, Doris Duke Charitable Foundation
• Constanza Alarcón
  Intersectoral Commission for Early Childhood, Presidency of the Republic, Colombia
• Raquel Bernal
  Center for Research on Economic Development, Universidad de los Andes
• Pia Rebello Britto
  Early Childhood Development Unit, UNICEF
• Helena Choi
  Global Development and Population Program, The William and Flora Hewlett Foundation
• Pamela Y. Collins
  Office for Research on Disparities & Global Mental Health and Office of Rural Mental Health Research, National Institute of Mental Health, National Institutes of Health
• Tracy Costigan
  Research-Evaluation-Learning Unit, Robert Wood Johnson Foundation
• Gary Darmstadt
  Stanford University School of Medicine
• Angela Diaz
  Mount Sinai School of Medicine
• Rana Hajjeh
  National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
• Jody Heymann
  Fielding School of Public Health, University of California, Los Angeles
• Gillian Huebner
  Lumos
• Venita Kaul
  School of Education Studies and Center for Early Childhood Education and Development, Ambedkar University Delhi
• Sarah Klaus
  Early Childhood Program, London, Open Society Foundations
• Vesna Kutlesic
  Office of Global Health, National Institute of Child Health and Human Development
• Albert Lee
  JC School of Public Health & Primary Care and Centre for Health and Education and Health Promotion, The Chinese University of Hong Kong
• Joan Lombardi
  Bernard van Leer Foundation
• Florencia Lopez Boo
  Inter-American Development Bank
• Stephen Lye
  Fraser Mustard Institute for Human Development
• Robert Mallett
  Accordia Foundation
• Kofi Marfo
  Institute of Human Development, Aga Khan University
• Mark Miller
  Division of International and Population Studies, Fogarty International Center
• Helia Molina Milman
  Past Minister of Health, Chile
• Ariel Pablos-Mendez
  USAID
• Janna Patterson
  The Bill & Melinda Gates Foundation
• Alan Pence
  School of Child and Youth Care, University of Victoria
• Ruth Perou
  Centers for Disease Control and Prevention
• Cheryl Polk
  HighScope Educational Research Foundation
• Eduardo de Campos Queiroz
  Maria Cecilia Souto Vidigal Foundation
• Jose Saavedra
  Nestlé Nutrition
• Lorraine Sherr
  University College London
• Andy Shih
  Autism Speaks
• Karlee Silver
  Grand Challenges Canada
• Simon Sommer
  Jacobs Foundation
• Taha E. Taha
  Bloomberg School of Public Health, Johns Hopkins University
• Pamala Trivedi
  Office of the Assistant Secretary for Planning and Evaluation
• Susan Walker
  Tropical Medicine Research Institute, The University of the West Indies
• Sara Watson
  Ready Nation
• Amalia Waxman
  Consultant
• Quentin Wodon
  Human Development Network, World Bank
• Hirokazu Yoshikawa
  New York University

DISCLAIMER

This Workshop in Brief has been prepared by Steve Olson as a factual summary of what occurred at the meeting. The statements made are those of the authors or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the Academies.

REVIEWERS

To ensure that it meets institutional standards for quality and objectivity, this workshop in brief was reviewed by Cheryl Polk, HighScope Educational Research Foundation, and Eduardo Queiroz, Fundação Maria Cecilia Souto Vidigal. Chelsea Frakes, Institute of Medicine, served as the review coordinator.

This workshop was jointly hosted with the Centre for Health Education and Health Promotion and Wu Yee Sun College of the Chinese University of Hong Kong.

SPONSORS

This workshop was partially supported by the Accordia Global Health Foundation; Autism Speaks; the Bernard van Leer Foundation; The Bill & Melinda Gates Foundation; the Doris Duke Charitable Foundation; the Fraser Mustard Institute for Human Development; Grand Challenges Canada; HighScope Educational Research Foundation; the Inter-American Development Bank; the Jacobs Foundation; Lumos; the Maria Cecilia Souto Vidigal Foundation; the National Institutes of Health—the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Fogarty International Center, and National Institute of Mental Health; Nestlé Nutrition Institute; Office of the Assistant Secretary for Planning and Evaluation; the Open Society Institute–Budapest Foundation; ReadyNation; the Robert Wood Johnson Foundation; the Society for Research in Child Development; UNICEF; U.S. Agency for International Development; U.S. Centers for Disease Control and Prevention; the William and Flora Hewlett Foundation; and the World Bank.

For additional information regarding the meeting, visit http://iom.nationalacademies.edu/activities/children/investingyoungchildrenglobally.aspx.

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Footnotes

1

For more information about the Forum on Investing in Young Children Globally, please visit http://iom​.nationalacademies​.edu/activities​/children/investingyoungchildrenglobally.aspx. Forum activities highlight the science and economics of integrated investments in young children living in low-resourced regions of the world across the areas of health, nutrition, education, and social protection. Moreover, as caregivers of young children are key to children's access to health, education, nutrition and social protection, the Forum takes a life course approach and addresses issues related to reproductive health, economic opportunity, and access to quality child care and education programs for caregivers.

Rapporteur: Steve Olson.