Using Existing Platforms to Integrate and Coordinate Investments for Children: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Centre for Health Education and Health Promotion; and Wu Yee Sun College of the Chinese University of Hong Kong (2015)

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Issues in Program Development, Implementation, and Sustainability

The development, implementation, and sustainability of programs depend on many factors, including their costs, financing, political support, and effects. Furthermore, these factors differ from place to place, so interventions need to be adapted to different circumstances.

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 and Pacific region, programs developed to meet local needs have implications for regional, national, and global initiatives (as described in the first section below). In Los Angeles’s Chinatown and Koreatown, small businesses that provide supplementary education could be expanded to serve groups beyond those that are currently served (in the second section). And in South Africa, the nongovernmental organization Kheth’Impilo provides care and support to individuals in communities where the government’s infrastructure, staffing, and delivery of services are inadequate, with the services transitioning back to the state as governmental capabilities increase (in the third section).

STRENGTHENING PLATFORMS FROM THE GROUND UP IN THE SOUTHEAST ASIA AND PACIFIC REGION

The targets established as part of the Millennium Development Goals and the Education for All movement have led to major advances in early childhood care and education in the Southeast Asia and Pacific region,

said Emma Pearson, senior lecturer in the Department of Psychological and Human Development Studies at the University of Brunei, Darussalam, but much remains to be done.¹ Persistent gaps among groups pose a major challenge to equity, and many of the early childhood care and education programs in the region are still heavily dependent on funding from nongovernmental organizations, which poses issues of sustainability. In addition, the quantitative and globalized nature of the Millennium Development Goal targets has, to some extent, diverted attention away from the complex localized issues of providing early childhood care and education, which is a point that also has been made in the broader human development literature. Finally, the proposed post-2015 Sustainable Development Goals for early childhood care and education pose a challenge, said Pearson. The United Nations (UN) Secretary-General’s recent report, The Road to Dignity, calls for a transformative agenda that is both universal and adaptable to the conditions of each country. This agenda also needs to be adaptable to the conditions of diverse communities within countries and needs to be reflected in post-2015 goals, said Pearson.

Increased investments in young children’s development have decreased infant and maternal mortality and boosted preprimary enrollments in the Southeast Asia and Pacific region. The prevalence of malnutrition and stunting also has dropped. The establishment and development of important regional bodies have increased the knowledge of early childhood care and education and the dissemination of that knowledge. Yet in some areas malnutrition remains high, often because of the difficulties of providing services for children in non-mainstream communities that are hard to access because of their geographic location or marginalization. “We are beginning to focus much more on what is happening at a community level in terms of what works, why, and how, and feeding that information up to the national and regional levels and subsequently to the global level,” said Pearson.

As a concrete example of a localized program with national and international implications, Pearson described a program in Vietnam called Mother Tongue-based Education.² The program serves children from ethnic minority groups who have been struggling in the mainstream education system because they do not speak the national language. During the preschool years and for the first 3 years of primary school, they use their

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¹ More information about the Millennium Development Goals and Education for All is available at http://www.un.org/millenniumgoals and http://www.unesco.org/new/en/education/themes/leading-the-international-agenda/education-for-all (accessed April 15, 2015).

² More information about the program is available at http://vovworld.vn/en-US/News/Mother-tongue-key-role-in-Vietnams-educational-development/313338.vov (accessed April 15, 2015).

mother tongue to learn in the traditional academic areas and also learn the national language as a second language. Then they transition into the mainstream curriculum. This program is now being used at the national level and is “a really nice example of how a successful program that has been very well documented is now informing policy at the national level and above.”

Pearson also cited a program in Vanuatu, which had been hit by a severe hurricane just a few days before the workshop, of early childhood teacher training. With little funding available, the program provides teachers with basic theoretical and pedagogical foundational knowledge over an initial 6-week period. Teachers also learn how to build preschool structures within the community working with community members and how to make their own learning resources out of natural materials.

Finally, Pearson mentioned a program from the Philippines that is informally called ECCD on Horse, in which child care workers travel to remote communities, set up in a community space, and provide a playgroup program. In some locations, community members have become involved in developing learning materials that reflect indigenous values, including songs and stories. In some of the more successful communities, these preschool programs have become entry points for health, welfare, and other services.

Assessing these important programs using currently accepted international standards of quality raises “some real issues,” according to Pearson. For example, the teacher training program in Vanuatu is very brief, though there is follow-up. In the Philippines, the child care workers cannot visit the communities very regularly, so children do not receive a high dose of the intervention. Pearson referred to the proposed Sustainable Development Goal: “All girls and boys to have access to at least 1 year of a high-quality preschool program.” She argued that to ensure the “universality and adaptability” outlined in The Road to Dignity in shaping and determining post-2015 Sustainable Development Goals for early childhood care and education, “what we mean by high quality needs to be very carefully defined.”

Pearson has done a thematic analysis of documents presented at a recent childhood policy forum, and many of the issues she identified were also prominent topics of the workshop. Policy concerns include dealing with diversity, engaging stakeholder groups, education and training, strengthening the evidence base, formalization of early childhood networks, and ensuring the clarity of messages from the national level to the district and local levels. “We have to do more in terms of addressing those issues,” Pearson said, quoting Navi Pilay, the UN High Commissioner for Human Rights: “We have tended to treasure what we measure. It’s time now to measure what we treasure.”

CHALLENGES AND OPPORTUNITIES FOR EDUCATING IMMIGRANT CHILDREN

Education is a critical part of the integration project of any country receiving migrants, said Min Zhou, Tan Lark Sye Chair Professor of Sociology at the Nanyang Technological University in Singapore. Furthermore, the education of immigrant children from poor families poses many challenges, including cultural and language barriers and poverty, economic disinvestment, the social disorganization and isolation of neighborhoods, and high dropout and failure rates of local schools. Zhou, who has been studying the integration and adaptation of immigrant children in the United States, described ways to promote immigrant children’s educational achievement, using Chinatown and Koreatown in Los Angeles to illustrate the role of the community.

Both Chinatown and Koreatown are populated disproportionately by racial and ethnic minorities (see Figure 7-1). These neighborhoods consist largely of immigrants, and the high school dropout rate among residents in these neighborhoods is high—59 percent in Chinatown and 43 percent in Koreatown. The poverty rate is 27 percent in Chinatown

FIGURE 7-1 Racial composition in Chinatown and Koreatown in Los Angeles.
NOTE: Chinatown and Koreatown in Los Angeles have multiple ethnic communities.
SOURCE: U.S. Census Bureau, 2010.

and 31 percent in Koreatown, compared with 12.4 percent for the United States as a whole.

The infrastructure of a given ethnic community within an immigrant neighborhood can be measured by its “institutional completeness,” said Zhou. This completeness is determined by a set of neighborhood-based formal and informal institutions that can satisfy the needs of members of an ethnic community, with the degree of social and economic organization in an ethnic community measured on a continuum. The local infrastructure depends on such neighborhood-based establishments as public facilities, nonprofit organizations, local businesses, ethnic organizations, and religious organizations. Even though the members of a group live in a poor neighborhood, the group itself may have resources to build a community that benefits low-income members of that group.

Zhou highlighted the importance of ethnic businesses in immigrant neighborhoods. Chinese and Korean immigrant communities have a high density and diversity of ethnic businesses, including professional services geared specifically toward children. In addition, nonprofit organizations provide children’s services, such as after-school programs.

In particular, Chinese and Korean immigrants tend to have ethnic systems of supplementary education, Zhou noted. Children are pushed to achieve and have institutions to support them, even in poor working-class communities. After-school tutoring, preview or review of school curricula, college preparatory services, and academic enrichment programs all promote academic achievement. “Some people think that Asians are bookworms,” said Zhou. “They are not. They know that in getting into good universities, you have to look good on your application. To look good on your application, you have to be provided with opportunities to do things beyond books.”

The private educational services available in the neighborhood depend partly on the demand from the immigrant community, but Zhou argued that supply also can stimulate demand. For example, if bridges could be built between the Asian and Latino communities in neighborhoods, Latino families could tap into Asian community resources and supplemental education services owned and run by Asians.

Local businesses can be important sites for interpersonal interactions and also can be sources of entrepreneurship in supplementary education, Zhou observed. These businesses could partner with nonprofit organizations and help break ethnic boundaries by opening up existing local resources to out-group members.

Local businesses are often not taken into account in early childhood development policies, but some of these businesses respond to specific community needs, Zhou observed. Education “is an urgent need in immigrant families regardless of ethnicity.”

Immigrant neighborhoods are not necessarily single ethnic communities, Zhou noted. As previously mentioned, bridges between different ethnic communities can make cultural and educational institutions available to multiple ethnic groups. Opportunities within neighborhoods exist, but a major problem is finding ways to help different ethnic groups tap into each other’s resources. Zhou said the current conceptual model for understanding contextual factors influencing immigrant education uses educational achievement to measure integration. The promotion of children’s education occurs in three contexts: family, school, and community. The middle class uses all three of these contexts to promote educational achievement, but working-class communities need to focus more on the development of the community context, according to Zhou.

In response to a question, Zhou acknowledged that ethnic resources can be exclusive, but 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.

A COMMUNITY-BASED EARLY CHILDHOOD DEVELOPMENT PROGRAM IN SOUTH AFRICA

Of the 19 million children who live in South Africa, 60 percent live below the poverty line, and more than 70 percent of children under the age of 4 do not have access to center-based early childhood development services (Giese et al., 2011). The South African government, since the end of apartheid, has recognized the importance of such programs and has consequently developed an integrated early childhood development policy combined with increased funding of these services through earmarked subsidies, observed epidemiologist Najma Shaikh and public health doctor Ashraf Grimwood of Kheth’Impilo (National Planning Commission, 2011). However, these subsidies have failed to optimally target marginalized children living in poverty, young children under the age of 2 years, children in rural areas, and those living with a disability (UNICEF, 2011). The percentage of poor children covered by the state subsidies remains low, with a national average of 16 percent that ranges from 8 percent to 40 percent at the provincial level, and the average subsidy offered by the state is equivalent to about US$1.50 per child per day, Shaikh noted.

A key research and policy question is to understand what factors may be driving this inequitable distribution of early childhood development services, which in turn generates poor delivery. Although the subsidy is meant to be pro-poor, the current fiscal streams do not lead to equitable distribution given that there is no obligation on the state to establish facilities in poor and underresourced communities. State subsidies are

only granted to early childhood development facilities that are registered, and these facilities overwhelmingly are privately owned in communities that can afford to establish such services and bear the cost of the physical infrastructure, human resources, and operational expenses required. Only through a complex bureaucratic process of submitting an application and review by the local municipality can a service be registered and access to the subsidy provided. Furthermore, early childhood development services are of low standards or are absent in the poorest and remote communities in South Africa. National funding for early childhood development is channeled through the provincial governments, and because the funding is not ring-fenced by the Department of Social Development the provincial or district departments are not obligated to channel the funding for these services but often allocate the funds to other statutory requirements, such as domestic violence or child safety, Shaikh observed. Government is also largely ineffective in the delivery of such services, Shaikh added, despite a progressive policy and accompanying regulatory and constitutional provisions. Ultimately, the levels of financing are simply not sufficient to respond to the national and early childhood development policy goals, Shaikh and Grimwood have argued. Current funding is at about ZAR 1.6 billion, but an estimated ZAR 5.2 billion would be needed to cover all children who need care (Viviers et al., 2013).

Kheth’Impilo, which means “Choose Life,” is a nongovernmental organization that supports the South African government in the provision of HIV treatment, care, and support where government is unable to meet the needs of HIV and tuberculosis health care. Kheth’Impilo has been providing support for more than a decade and over this period has developed innovative models of delivering these services in a manner that links health services, individuals, and their households. Over time, these services are transitioned to the state, with Kheth’Impilo providing technical support, Shaikh said.

To date Kheth’Impilo has provided large-scale HIV and tuberculosis treatment, care, and support to more than 250,000 patients, which represents 10 percent of the cohort receiving antiretroviral therapy in South Africa. One such innovative program evolved when Kheth’Impilo realized that the children from HIV-affected households were not able to access early childhood development services easily, Shaikh reported. In response, Kheth’Impilo initiated a home-based program to provide services to children under age 5 in such households to improve health, educational, and psychosocial outcomes. Children and their caregivers are recruited through referrals from clinics and community workers, including Kheth’Impilo patient advocates who provide adherence counseling and support to those on HIV treatment.

A major feature of Kheth’Impilo’s approach is the use of trained and

paid community workers (see Figure 7-2). This cadre of workers who were former Kheth’Impilo patient advocates acquired accredited level-4 training to become social auxiliary workers, with further training in early childhood development for 1 year. The community-based model is built around pods in which a social auxiliary worker interacts with the caregivers and their children through circles of support, social workers, and the relevant health and social welfare services. The program has four key components: training of caregivers, facilitation of playgroups and circles of support, home visits, and community mobilization and advocacy. Each circle comprises five caregivers and their children within a neighborhood who meet weekly in the home of one of the members of the circle of support on a rotational basis. These meetings and playgroups are facilitated by the social auxiliary worker, and the caregivers are trained in parenting skills, nutrition, health and safety, and early childhood development activities, including toy making. The social auxiliary workers also form a connection with households so they can address a range of socioeconomic issues. The model dovetails with other service providers, Shaikh noted, with the social worker acting as a point person to refer household members for other needed services.

FIGURE 7-2 The community-based model used by Kheth’Impilo is built around pods in which a social auxiliary worker (SAW) interacts with social workers and social services.
NOTE: HIV = human immunodeficiency virus; ID = identification; ME & R = monitoring, evaluation, and reporting; TB = tuberculosis.
SOURCE: Shaikh et al., 2014.

The evaluation of the program has revealed significant improvements in mother–child interaction through language skills, cognitive elements, and engagement with their children in terms of stimulation, nurturing, and responsivity. For example, children were physically punished fewer times, were held closely more often, and were pedagogically stimulated through learning to count and identifying colors and animal names. Caregivers reported that they felt more empowered in terms of receiving emotional support from others, taking action to better their situation, while also developing their own self-improvement strategies. In addition, household hygiene and safety improved markedly, despite the improvisation that is often required in households without adequate water and sanitation. More mothers learned their HIV and tuberculosis status, which Shaikh and Grimwood highlighted as indicative of the fact that they were accessing particular services for the first time.

Shaikh and Grimwood pointed to several innovations that have emerged from the program. One was to bring multiple sector services of government on site over 2 days in the form of “roving jamborees.” Community members could receive health screenings and tests, immunizations, registration documents, emergency poverty relief, and other social welfare services in one place.

One adaptation of the program to the local context was using indigenous child-rearing practices to inform the program design. For example, an opportunity arose for fathers to be involved in making toys for children using recyclable items. Another was to develop a pathway for mothers and caregivers to become community caregivers.

A key metric that emerged from the program was the importance of tracking anthropometric measures of children given that many resided in HIV-affected and malnourished households and this information was not well recorded otherwise. The program also developed an identification system to track children and families who were accessing intersectoral services.

Continued challenges include a lack of intersectoral coordination in planning, delivering, monitoring, budgeting, and evaluating services. As Shaikh and Grimwood pointed out, no policies, norms, or standards for community-based early childhood development services exist. Moving from innovation to scale-up is challenging because dedicated funds for non-center-based early childhood development services are not funded by the state. The nongovernmental sector has stepped in by providing these services through donor funding. However, the funding cycles in the international nongovernmental sector are short, thus leading to challenges in sustaining, scaling-up, and measuring the long-term effect of these programs,

Providing home-based early childhood development services is pos-

sible and provides many benefits, Shaikh and Grimwood concluded. In particular, benefits to the most marginalized can be maximized through the delivery of a creative, intersectoral, home-based early childhood development model. However, it cannot be a permanent solution with an absent state. As Shaikh and Grimwood observed,

In the short term, home-based services can be supported through such mechanisms as ring-fenced conditional grants, in which governmental funds are specified for a specific purpose. But in the long term, all layers of government are needed to deliver early childhood development services cooperatively within a mandatory framework and set of guidelines, Shaikh and Grimwood observed. The key is providing the funds in a structured manner so they are not used for other needs. Government will need to hold provincial and local authority offices accountable for how funds are spent. This approach has been followed with other interventions in South Africa. The challenge is now to translate the integrated early childhood development policy into action.