Chile was failing its poorest kids, so it closed the gaps between services

Coordination has improved childhood development outcomes

When Michelle Bachelet swept to power as Chile’s first female president in 2006, she showcased her commitment to equality by appointing a cabinet with equal numbers of men and women and making healthcare free for pensioners. But another, less glamorous commitment was also high on the agenda: childhood development.

A national quality of life survey in 2005 had found that 30% of young children were not reaching their expected developmental milestones, with the risk higher among the poorest.

Chile Crece Contigo, the flagship early childhood program developed to improve those outcomes, is committed to coordinating the doctors, teachers, social workers and other government employees in contact with at-risk children.

Creating this kind of comprehensive system is a challenge, particularly at the local level where most services are delivered, but it’s quickly becoming a model for countries across the region.

Growing with you

Chile’s new approach to early childhood development emerged from a presidential advisory council of experts, set up by Bachelet in 2006.

“They came up with this idea of creating an intersectoral policy that could support children and their families, from gestation to their entry into preschool,” said Andrea Torres, national coordinator of Chile Crece Contigo.

The program’s name, which translates to “Chile Grows With You”, reflects that commitment to following children throughout their development.

The main entry point for support is through the public health system, which serves more than 80% of Chilean children, according to Rafael Pérez-Escamilla, professor at the Yale School of Public Health.

“They’re the ones that see them first,” he said, meaning medical employees can flag potential issues even before a child is born.

The first antenatal nurse who sees a pregnant mother, for example, can flag her if she lives in extreme poverty or a household with substance abuse problems. That can lead to home visits from social support workers, free childcare or preferential access to housing and mental healthcare.

Many of those services were already available, but not widely accessed or well-integrated.

Chile Crece Contigo’s budget, which has now expanded to around US$80 million per year, is managed by a coordinating department, the Ministry for Social Development, which transfers funds to the health, education and other ministries for two purposes.

One is to enable sharing of detailed information between different services for children and parents.

“At the local level we have the biggest challenges”

The other is to fund “top-ups” to existing services, where research on early development suggests they’re particularly important. The program funds the health ministry’s effort to incorporate a broader social evaluation into checkups with pregnant women. It also gives cash to the education ministry to deliver classes for parents on how to look after their children, Torres said.

Local differences

The greatest challenge for Chile Crece Contigo, according to Pérez-Escamilla, is making sure those best practices are implemented in each of the hundreds of local communes responsible for delivering most services.

The program was scaled up very rapidly, from 159 local government districts at its launch in 2007 to all 346 the following year. But there are major differences between the prosperous Santiago area, the desert regions of the country’s north and indigenous communities in the south.

“At the local level, I would say, we have the biggest challenges,” Torres said. High turnover of workers means there is a constant need for retraining, she explained, because the program requires people to work across disciplines in a way that is often unfamiliar.

Local mayors also have their own priorities for service delivery, Pérez-Escamilla added. “There are many, many programs involved,” he said. “So for them it’s very difficult to actually think about Chile Crece Contigo as a whole.”

The challenge of local variation isn’t insurmountable, though, because Chile’s government is highly centralised. Local government is granted some flexibility in delivering programs, according to Torres, but when a national ministry issues minimum standards they do work to ensure consistent good practice.

Making sure those standards are well-designed and suitable for local service providers is a major focus for those designing the program nationally. “I’m very convinced that all our efforts have to go towards making that local level do their best,” Torres said, “because it’s there where Chile Crece Contigo is being delivered.”

Evidence and evaluation

As the program has grown, maintaining an ongoing process of evaluation and reform has been a challenge.

There have been more than 35 studies of different aspects of the policy’s implementation since its launch. Money for evaluations, however, is not always forthcoming. It often takes partnerships with universities or international organisations like UNICEF to get studies done. And when papers are completed, the money to put updated interventions into practice is even harder to come by.

“We have been looking into whether the ministry of health should increase their number of home visits to pregnant women who are at risk,” said Torres. “But we haven’t been able to do it yet, because there’s not enough money — even though all the studies are telling us that we should.”

There have, though, been success stories. After evaluations suggested children’s mental health outcomes were particularly poor, an evidence review led to the introduction of targeted home visits and work in schools to improve them.

Pérez-Escamilla pointed to a recent change to standard procedures around umbilical cord clamping, introduced in response to new clinical evidence about anaemia.

So far, Chile Crece Contigo has not had a large-scale assessment of its overall impact. The regular evaluations, however, show that the program is ensuring consistent implementation of interventions best supported by international evidence.

According to Pérez-Escamilla, that should be enough — particularly because outcomes for children in Chile are steadily moving in the right direction.

“Chile is way, way ahead of the curve in the Latin American practice. For all practical purposes, it is now classified as a high-income country,” he said. “Chile Crece Contigo is not perfect, but it is a very important model for the world.” — Fergus Peace

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