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Integrated and Coordinated Programs in Hong Kong and Chile
In the opening session of the forum, two keynote speakers looked at the issues of coordination and integration of existing platforms by examining experiences within Hong Kong and Chile. Together, their presentations demonstrated a key observation made in the previous chapter: approaches to early childhood development can differ from place to place, but similar issues arise in different contexts.
A COLLABORATIVE MULTIPLIER APPROACH TO EARLY CHILDHOOD DEVELOPMENT
In the first keynote address, Chow Chun Bong, honorary clinical professor in the Department of Pediatrics and the Department of Community Medicine at the University of Hong Kong, emphasized the importance of taking a “collaborative multiplier approach” to early childhood development, while discussant Sophia Chan, Undersecretary for Food and Health of the government of Hong Kong Special Administrative Region, outlined the need for a comprehensive strategy for childhood development and resource allocation.
Hong Kong is densely populated, noted Bong, but building is restricted in the “countrified” areas that constitute 75 percent of the region. Another characterizing feature is that 50 percent of Hong Kong’s 7.2 million people live in public housing, with the figure projected eventually to reach 60 percent. Thus, Hong Kong has small areas of high population density, marked by numerous high-rise residences, while the rest of the region
remains relatively rural. As Chan noted, it is a fast-paced urban region, with many working women and Filipino maids who look after children.
The infant mortality rate in Hong Kong is 1.6 per 1,000 live births, and the under-5 mortality rate is 2.3 per 1,000 live births, which are some of the best figures in the world, said Bong. Life expectancy in Hong Kong is among the longest in the world—80.9 for males and 86.6 for females. The unintentional injury mortality rate in Hong Kong is lowest in the world, at 1.68 deaths per 100,000 people, but the intentional injury mortality rate, at 2.68 per 100,000 people, is closer to the world average.
According to the Economist, Hong Kong ranks 19th in the world in early childhood education, which is the best in Asia, Bong said. On various measures of international educational achievement, Hong Kong students typically rank among the top three in the world, although students in other parts of Asia, such as the city of Shanghai and South Korea, have been catching up in recent years.
As with other countries, Hong Kong has been experiencing an increasing divide between the rich and the poor economic classes. Gross domestic product (GDP) per capita is US$40,000, which is 14th in the world. But the Gini coefficient measuring income inequality is high—the 12th worst out of 141 countries. The child poverty rate in 2013 was 18.6 percent, reflecting a government intervention that reduced the rate from 23.7 percent, and 30.5 percent among people ages 65 and up.
The under-5 child mortality rate is correlated with the economic status of the places where people live. In the most deprived quintile, the rate is almost twice what it is in the other 80 percent of populated areas. Disparities also exist between working-class and middle-class children and encompass other areas of life, including education, injury, and child development, said Bong. There is a particularly large drop in preacademic learning between middle-class and working-class families (Rao et al., 2013).
The fertility rate in Hong Kong is low, which is causing the average age of the population to increase. In 2014 about 15.5 percent of the population was age 65 or above, while by 2041 this number is projected to be 32 percent. “We don’t have enough children,” said Bong. “That is why we need to invest in children.”
SERVICES AFFECTING EARLY CHILDHOOD DEVELOPMENT
Access to services is “quite comprehensive,” said Bong, but the question remains whether it is “equitable in terms of access to quality service.” Hospital services are virtually free and provide more than 90 percent coverage. In social welfare, a good safety net exists through statutory services provided by government and other services provided by nongovernmen-
tal organizations. Education, which is mostly provided by independent schools, is free for 12 years.
However, information and 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. 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, said Bong.
In her remarks, Chan, too, noted that Hong Kong does not have a fully integrated policy for early childhood development. However, various governmental bureaus are focused on children, including the bureaus of education, health and food safety, and labor and welfare. The government also has a commission on poverty, which has found that most poor families have children. “The quickest way to help these vulnerable people is to provide financial resources,” said Chan. In addition, the government has organized commissions and councils on youth, women, the elderly, and families, which are high-level committees above the bureaus. However, no commission on child development exists, though the Family Council looks at issues affecting childhood development.
The emphasis of the forum on coordination and integration is especially relevant in Hong Kong, Bong noted. Hong Kong has access to evidence-based effective interventions, but the problem is providing infrastructure support for the implementers of these interventions. This support would include studies on implementation, dissemination, and quality improvement and the development of the necessary technological and statistical infrastructure. Building a strong implementation strategy would provide needed support for evidence-based interventions by creating linkages across sectors, Bong said.
An example of an effective evidence-based intervention in Hong Kong is a community-based integrated service model to tackle poverty that was created in 2006. Called the Comprehensive Child Development Service (CCDS), it aims to integrate social welfare, early childhood education, and the health system, including maternal and childhood health centers. The integrated program has four major components. In the first component, mothers are screened 6 weeks after delivery in their homes to assess their well-being and provide assistance with postnatal depression. In the second component, children and families are identified and referred for social service interventions. In the third component, preschool children with physical, mental, behavioral, and family problems are identified and referred. In the fourth component, high-risk families, including those with parents suffering from mental problems and those headed by teenage mothers, are also identified and managed.
Bong cited two major challenges with the integrated program: linking the components of the program, and mobilizing communities. For instance, one way to increase linkage is to have a community pediatrician working inside a maternal and childhood health center, Bong said. Another is to have a clinical psychiatric service at health centers. By focusing many childhood development services in a single center, the system can link the district council, the commercial sectors, and also social welfare.
CCDS has operated in seven Hospital Authority clusters that have loose central coordination, allowing for local innovation and flexibility. Local communities have considerable initiative in identifying partners and creating new measures that suit their populations. For example, particular localities are working with new parents, nongovernmental organizations, and new immigrants to address learning problems in young children. New local initiatives focus on home visitation, disadvantaged families, mentally ill patients, and children with learning problems.
An evaluation of the program showed that equity, effectiveness, and efficiency had all improved (Family Health Service, 2007). CCDS allows for easier and timelier identification of risk factors for child development, including teenage mothers, impoverished mothers, and mothers suffering from postnatal depression or drug abuse. The evaluation also had instruments to examine parent satisfaction, knowledge of child development, parents’ sense of competence, practices related to child safety, practices to promote child development, discipline beliefs and practices, maternal depression, injuries requiring medical attention, language development, and child behavior.
As another example of coordinated programs, Bong cited the combination of data from the Hospital Authority and from the Social Welfare Department to examine child abuse at a district level. Using a geospatial information system (GIS), Hong Kong can be mapped according to the incidence of child abuse, creating a map that central policy units can use to better serve the population (Ip et al., 2013). The incidence of suicide is another health risk that can be mapped geographically (Hsu et al., 2015). Young and middle-aged males living in deprived areas are found to be particularly at risk.
In her remarks, Chan pointed to the Department of Health and the Hospital Authority as an example of coordinated services in Hong Kong. Within maternal and child health clinics, children are assessed, both physically and psychologically, and provided not only with immunizations and vaccinations but with supports for growth and development. The government also has allocated resources to build the first children’s hospital in Hong Kong, which should be completed within a few years.
Despite the existence of coordination, Chan pointed to the need for
a comprehensive strategy for early childhood development that would bring together the efforts of different bureaus. As an example of what could be done, she pointed to steps now being taken to improve the nutrition of young children in Hong Kong. In Hong Kong, 80 to 85 percent of mothers breastfeed after giving birth, but only 2 percent continue to breastfeed exclusively for 6 months, as is recommended by the WHO. To improve this statistic, the Food and Health Bureau has developed a voluntary code to regulate the aggressive marketing of milk formula and children’s food and a framework to regulate nutrition and health claims on prepackaged foods. In addition, a law on the composition and labeling of milk formula has recently been passed, and a high-level committee to promote breastfeeding has been established.
Bong agreed that Hong Kong could be more integrative and interactive in all the services it provides. In addition, the engagement of parents and the public still needs to be improved, he said.
Bong also described some of the work that he has done on childhood injuries in Hong Kong. He and his colleagues have developed a GIS that maps injury data in Hong Kong, identifying areas with a high incidence of falls, playground injuries, and traffic injuries (Chow et al., 2012). For example, after identifying the areas with the highest incidence of traffic injuries, a road engineer examined each of the areas and identified such features as pedestrian crossings and traffic lights that could be changed (Loo et al., 2013). This information was presented to district councils and other government agencies to foster change.
The same system also has identified high-risk playgrounds for injuries. This led to a focus not on rebuilding playgrounds, which in general are very safe, but on risky behaviors in playgrounds, with an emphasis on teaching community workers, children, and others how to use playgrounds safely. Ten risk behaviors were identified, including
- improper dressing,
- improper ways of playing,
- improper supervision,
- access to nearby car parks,
- improper equipment for elderly, and
- improper age.
A program known as Safe Community and Healthy City hopes to establish purposeful community engagement with community safety as a platform. By integrating, collaborating, and coordinating different aspects
of a community, the well-being of residents can improve, Bong said. In addition, by assessing regional data at both an individual and a community level, problems can be identified and addressed. This is especially important in GIS-identified hot spots or high-risk zones, where what Bong called “place-based collaborative multipliers” can create a decision support system based on integrated locational data.
Bong then described other platforms for decreasing child injuries in Hong Kong. These included health-promoting schools and kindergartens, safe schools, and school-based programs for high-risk students in community settings.
An old Chinese saying is that the first 3 years of life determine the course of a person’s entire life, Bong noted. Knowledge synthesis and translation along with communication to policy makers and the public can improve early childhood development. In addition, Bong cited the relationship between capacity and practice as a critical element of success. All workers must be capable of doing their jobs, and an infrastructure must be developed to help implement evidence-based programs with community engagement, he said. The big question, in Hong Kong and elsewhere, remains how to integrate and translate the data that are available into meaningful information for decisions and actions at national, subnational, and local levels. Many good service models exist, Bong said, but they need to be suited to the local situation. A focus on equity and on coordinated approaches offer the most promise, he concluded.
CREATION AND IMPLEMENTATION OF AN INTEGRATED POLICY IN CHILE
The second keynote speaker, Helia Molina, who recently completed her term as Minister of Health in Chile, described a more integrated system in her country to support early childhood development. Since 2007, Chile has been working to implement an intersectoral public policy on childhood and social protection. This policy has been based on two important elements. The first is making use of the available resources in the country (including a health system that has good primary health care) along with health teams that include general practitioners and other professionals. The second is approaching the issue holistically.
Chile is a small country, with a population of 17 million people, Molina noted. Although it is divided into 15 regions and has decentralized administration, Chile operates as a single country rather than as a federation of states. It is still a developing country, with a per capita GDP of about US$22,500. While the poverty index has declined over the past several decades to 14.4 percent, “There is still a major gap between the highest incomes and the lowest incomes,” Molina said. Chile’s 0.5 Gini
index has been improving but too slowly in relation to the economic growth of the country, she added.
Child mortality rates are higher than in Hong Kong but are among the lowest rates in Latin America and the Caribbean. A 20-year-old complementary food program has helped eliminate malnutrition from the country, and secondary malnutrition from chronic disease is less than 1 percent. In contrast, the overweight and obesity epidemic has been rising. Birth rates are currently dropping, which is a problem for the development of the country.
In 2006, Michelle Bachelet, a former pediatrician with a firm understanding of childhood health and development, became the President of Chile. Molina was a member of the Presidential Advisory Council on Early Childhood Policy Reform created by Bachelet, and she helped to create a document titled The Future of Children Is Always Today. This conceptual framework for a new national policy then was further developed by a group of representatives from 10 different ministries to articulate how to implement the policy.
The resulting policy was known as Chile Crece Contigo, or Chile Grows with You. Implemented in 2007, the policy took a multidisciplinary approach and was planned across sectors by multiple ministries. A common problem in previous initiatives had been a “duplication of efforts, and repetition of initiatives, without integrating what has already been done,” said Molina. Chile Grows with You was a comprehensive protection system for early childhood that adopted a child-centered and rights-based framework (see Figure 3-1). The Ministry of Social Development has been the leader of the effort and the overseer of the program’s budget.
Chile Grows with You began in a hundred municipalities and was scaled up in 2008 to incorporate the whole country. In 2009, a law unanimously passed by the Chilean congress highlighted an institutionalized system that gave priority to childhood, Molina said. In this system, the conceptual framework is based on an ecological model that recognizes both the psychosocial and environmental determinants of health. The framework also incorporates a life-cycle approach (see Figure 3-2), ranging from prenatal health to aging.
Initially, Chile Grows with You focused on children ages 0 to 4, with plans to extend its scope to 8 years in 2016. Chile Grows with You is not only about childhood but also about the linkages between different life stages, said Molina. When she became minister of health, the childhood program, women’s program, adolescent program, and chronic age program were all combined under a life-cycle department because of their intrinsic dependence. The goal was to “achieve optimum development” leading to a “healthy and happy life.”
FIGURE 3-1 Chile has adopted a child-centered and rights-based framework for early childhood development.
SOURCE: Molina, 2015.
FIGURE 3-2 A life-cycle approach to child development extends from conception to adulthood.
SOURCE: Campión et al., 2009.
Accompanying the development of the policy, Chile has taken some fundamental steps to reform the taxation system and the education system to give priority to breaking the intergenerational aspect of poverty. In impoverished children, around 30 percent have some sort of delay in their development. In contrast, not even 15 percent of children from wealthier families suffer from any kind of developmental delay. The only way to reduce this huge inequality is through a sound policy that allocates more resources to those in need, said Molina.
Chile Grows with You is part of an overall public policy of social protection for workers and those in poverty, but with a focus on mothers, children, and family. When the overall policy was first implemented, it was found that many of the projects, programs, and initiatives fell on the same people, Molina said. To reduce this repetition, a model was created to integrate previously dispersed activities to meet the needs of children and families. The resulting program includes all sectors—family, health, education, public health, culture, housing, and other areas of government—because children are affected by all aspects of policy. It is an “up-down policy,” as Molina called it, that is implemented and evaluated at a local level but overseen on a larger scale. The Social Development Ministry coordinates the program, with a ministerial committee setting strategies, plans, and evaluation models. The program has a single budget, but several ministries are involved in the execution of sectoral activities.
Health services occur largely on the regional level. About 80 percent of Chileans are under the public health system, and mothers and children have especially high contact with that system, said Molina. After 2 years of age, the focus shifts to the educational sector, though with a continued integration of services. As in Hong Kong, Chile is working toward finding support at a local level to better implement public policies.
All children in Chile have access to health care. Molina noted that intervention packages target particularly vulnerable children with good-quality free nursery school and kindergarten, home visits by health teams, family subsidies, comprehensive care for children with developmental difficulties, technical help for disabled children, and preferential access to the social protection system. In addition, laws have been adopted to extend the postnatal paid leave for mothers to up to 6 months.
For all children in the public health sector, the Biopsychosocial Development Support Program and Newborn Support Program provide services to meet their needs, Molina noted. These programs include home visits by a health team that assesses risk factors in the most vulnerable populations, including the health of the mother before birth. Vulnerable children are immediately registered to various social systems for housing,
economic support, health, and mental health. Postnatal depression is a focus, as are children with special needs, access to technical support, and educational inclusion. Financial support is provided not only at a regional level but also at a local level so social organizations, nongovernmental organizations, and local actors have the resources to develop their own strategies.
Chile Grows with You incorporates evidence-based interventions derived from the research literature, Molina said. For example, taking a page from the Canadian program Nobody Is Perfect, Chile has adopted a strategy to accompany mothers during the prepartum and postpartum periods. Molina also emphasized, in response to a question, the need to involve fathers and other family members in the psychosocial development of children. For example, health centers remain open after normal working hours so workshops, trainings, and materials are provided to caregivers from the start of the pregnancy. “We try to include in these working groups all those who, in some way, participate in the parenting.”
LESSONS LEARNED AND CHALLENGES OF SCALING UP
After Chile Grows with You was introduced, an evaluation of the program brought about several changes based on feedback from stakeholders. This process sought to strengthen effective actions, focus efforts, evaluate budget and resource allocations, and begin to build a new structure that supports children through an 8-year time frame. During this revision stage, major activities included developing training plans for deficient teams, technical assistance plans for regional teams, performance profiles for technical implementers, new technical guidelines, virtual communities for teams, and improvements in the monitoring and feedback system.
When a policy is rapidly scaled up, as was done with Chile Grows with You, some things do not turn out as well as planned, Molina admitted. But evaluation allows for changes. For example, by evaluating the effects, processes, and satisfaction levels of users, Chile has found that quality differs in different parts of the country, which has led to efforts to correct the problem.
Molina cited several lessons learned 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 as a key stage for individual and population health and human development. As Molina pointed out, “Children don’t vote, children don’t speak before they’re 2 or 3 years old, so we who are part of this movement need to be activists.”
Another lesson 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, according to Molina. “We all want to win,” Molina said, “so if I win, you win.” By sharing a budget and having national-level management, everyone can be on the same team and have the same overall goal.
One major problem in implementing interventions was that the intensity and duration of the programs were not sufficient. For instance, home visits were not as frequent as intended by the policy because of a lack of resources. Molina urged that there is a greater need for more dosage of the intervention in order to achieve effectiveness as “it is not enough to just have one home visit or two.”
On a larger scale, feedback to stakeholders needs to be improved, said Molina, so evaluation is conducted on an intersectoral level and allows for an overall joint perspective. A collaborative approach to improvement can allow for heightened sustainability, community empowerment, and increased equity.
The leaders of some countries might say they need to focus on more basic needs, such as reducing infant mortality, rather than early childhood development. But Molina insisted that the best policies for survival and early childhood development are similar. She closed with the words of Chilean Nobel Prize winner Gabriela Mistral:
Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him, we cannot answer “Tomorrow,” his name is today.
TOWARD GREATER COORDINATION AND INTEGRATION
During the discussion following the keynote addresses, several forum participants pointed to options for increasing coordination and integration in Hong Kong, Chile, and other countries as well. Lillian Wong, a pediatrician and president of the Hong Kong Pediatric Society, lauded Hong Kong’s construction of a children’s hospital but pointed to the continuing needs for a child health policy in Hong Kong and for a children’s commission. “We need a child policy to unite all the actions.”
Bong and Chan discussed what can be done even in the absence of a unified policy. Bong emphasized providing policy makers with information that will lead to constructive action. He has worked to generate “data that will support the government and also the local people, who should work together and have a common goal.” Building capacity is also critical, Bong observed, so that an infrastructure for change exists and professionals have the ability and training to work together.
Chan added that more unified policies require not only political will but political wisdom, to know how to bring the work of different bureaus together. “We should think about what are some of the things that the different bureaus can do and work with our partners collaboratively.”
