PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS Ana-Maria Arriagada, Jonathan Perry, Laura Rawlings, Julieta Trias, and Melissa Zumaeta Financial  support for this work was provided by the Government of Japan through the Japan Trust Fund for Scaling Up Nutrition. Why promote early childhood development? The first 1,000 days of a child’s life are a window of opportunity to lay a strong foundation for later achievements. This timeframe is a period of enormous change characterized by a high degree of plasticity in the child’s neurological development. An early disadvantage can permanently and profoundly impact a child’s development, making remediation more costly and difficult later in life, whereas early investments have been shown to have very high rates of return (figure 1). Investments in the early years of life are the foundation of human capital, and human capital is a key driver of eco- nomic development in the 21st century globalized economy. The Lancet Series estimates that over 250 million children under 5 years old in the developing world risk not reaching their full potential (Britto et al. 2017) because of deficient investments in nutrition, early stimulation, early learning, and nurturing care, as well as due to exposure to stress. Investing in young children can be a cost-effective strategy not only to promote a healthier and more productive population, but also as powerful promoter of opportunity for disadvantaged children. FIGURE 1: Rate of Return to Human Capital Investments: Return to an extra dollar at various ages Source: Heckman, J. (2008). “School, Skills, and Synapses” Economic Inquiry. 43(3): 289-324. Do cash transfer programs promote child development? This note and the accompanying full technical paper examine the existing evidence and the potential for bringing together cash transfer programs and parenting interventions to improve child development outcomes, notably cog- nitive performance. This work builds on an established body of literature that examines the nexus between cash transfer programs and nutrition and health outcomes (Black et al. 2015, Galasso et al. 2016, Leroy et al. 2009, Bastagli et al. 2016) as well as on existing operational guidance on how to combine cash transfers with nutrition interventions (World Bank, 2013). Cash transfer programs are in a privileged position among public sector programs in that they are targeted to the poorest and most vulnerable families where deprivations such as chronic malnutrition and other indicators of poor child development are concentrated. They also benefit from a rich legacy of focusing on behavioral practices, particu- larly concerning parents’ investments in children. 2 PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS Cash transfer programs can protect households against chronic poverty and financial risks, while also providing a way to leverage critical human capital investments, notably in young children. Poverty and human capital deficits are strongly correlated. Pro-poor cash transfer programs can help to mitigate the detrimental and long-lasting effects that poverty and its associated risks have on child development, supporting human capital accumulation and reducing inequality from early in life. Evidence from cash transfer programs reveal a range of early years impacts showing that these programs can (Bastagli et al. 2016, de Walque et al. 2017): • Reduce poverty • Mitigate negative impacts of early life shocks (Adhvaryu et al. 2017) • Improve food consumption and, in some cases, nutritional outcomes (stunting, wasting) • Improve children's cognitive and language skills (see Figure 2) • Increase the use of health services by pregnant women and young children • Reduce morbidity and, in some cases, infant mortality • Reduce maternal depression and stress, enhancing household environment for child development FIGURE 2: Impact of Cash Transfers During Early Years on Cognitive and Language Skills .25 .23 .20 .18 .18 .18 .15 .15 .15 .15 .13 Cognitive .11 Language .10 .05 .00 Paxson et Fernald et Lopez Boo et Marcours et Barham et Fernald et al. 2010 al. 2011 al. 2018 al. 2012 al. 2012 al. 2008 ECUADOR HONDURAS NICARAGUA MEXICO Source: Arriagada, Ana-Maria et al. 2018.Note: Size effects measured in standard deviations. Cash transfer programs are often specifically designed to address not only present poverty, but also the intergener- ational transmission of poverty by fostering human capital investments in children. This is done by attaching “accom- panying measures” to the cash transfer. Traditionally, these have taken the form of “conditions” or “co-responsibilities” expected from households as recipients of the cash transfer. The most common of these “co-responsibilities” are related to building the human capital of the children by requiring parents to attend and take their babies to health clinics for pre- and post-natal care and growth promotion sessions, and to ensure that their children go to school regularly. These requirements are an essential element of conditional cash transfer programs. Increasingly, cash transfer programs are also encouraging or requiring parents and caregivers to participate in parenting programs (see Figure 3). PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS 3 FIGURE 3: Parenting Programs WHAT IS A PARENTING PROGRAM? WHAT TOPICS DOES IT COVER? HOW IS IT DELIVERED? Interventions or services aimed at enhanc- • Nutrition • Child • Home visits ing parent-child interactions, parenting • Health stimulation • Community-based group meetings knowledge, beliefs, attitudes, behaviors • Positive • Hygiene • Primary health care facility or health care center and parenting practices through training, parenting support, and coaching • Combination How can cash transfer and parenting programs work together to promote child development? Parents and caregivers are the architects of their children’s development. They are crucial to the healthy development of infants, acting as agents responsible for investments in their nutrition, health and safety. They shape the environment in which the child develops and help ensure a safe supportive home as well as access to key services. Beyond this, parents also actively shape children’s skills and socio-emotional development by talking to them, playing with them, reading or telling stories to them and interactively responding to their cues. FIGURE 4: Cash Transfers and Accompanying Measures for Child Development PROGRAM PARENTAL BEHAVIORS/OUTPUTS CHILD OUTCOMES INTERVENTIONS Cash transfers: Increased parental Improved ability to purchase Increased financial investments in children basic needs (food, shelter), resources for increased investment in child’s Decreased emotional future (e.g. purchase of toys, households stress/depression support of early learning) Children 0-5 Cash Transfer Improved child outcomes: Program • Birthweight Accompanying Increased access to More nurturing, responsive • Morbidity/mortality (CT) targeted measures: supply side and/or CT to poor, parenting, due to lower • Nutrition & growth Incentivize use of services (medical care, constraints and reduced stress • Cognition vulnerable health, nutrition & nutrition, vaccinations, households • Language education services growth monitoring, • Motor skills childcare, pre-school) • Socio-emotional skills Provide information, Early stimulation and learning goods and services opportunities received by on nutrition, hygiene, children from providers Increased health, child outside the household parent/caregiver access stimulation, positive parenting to skills, training for child development Increased knowledge, beliefs, attitudes, behaviors, practices on appropriate child rearing Source: Arriagada, Ana-Maria et al. 2018. The combination of the cash transfer and the accompanying measures designed to improve parents’ own practices and support to children can be a powerful tool to improve child development during the early years. The theoretical framework for combining cash transfers with parenting interventions is presented in Figure 4, where the top half displays 4 PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS the income effect of cash transfers on children’s outcomes. The bottom half (in orange) displays the information, goods and services that parents access through cash transfer programs' accompanying measures, with results on access to services and changes in young children's physical health, cognitive and socio-emotional development. This model illustrates the following: • Cash transfer programs operate at the household level, enabling poor parents to relax their household’s budget con- straints and thus improve their home environment, spend more time engaging with their children and invest in their children's health, nutrition and education. • Cash transfers improve the psychological well-being of household members by reducing the effects of financial strain and deprivation. In turn, this allows parents to engage more positively with their children to promote child development. • Accompanying measures can directly provide child focused goods and services as well as encourage parents to access available services, to acquire knowledge and adopt behaviors that promote their young children’s physical health and their cognitive and non-cognitive skills, and to provide them with a safe and stimulating environment for early learning and development. What are some possible models of cash transfer programs combined with parenting interventions? We identify four main models for combining cash transfer and parenting programs: integrated, convergence, alignment and piggy-backing. The full technical report reviews 10 cash transfer programs in lower- and middle-income countries that included accompanying measures aimed at promoting positive parenting behaviors for child development in the early years. Country cases include Bangladesh, Colombia, Indonesia, Madagascar, Mexico, Niger, Peru, Rwanda, Senegal, and Burkina Faso, while recognizing that other interesting cases exist such as Brazil's Crianza Feliz program. The report includes detailed information for the cash transfer program and the parenting intervention related to the design, financing, human resources, and monitoring and evaluation. Typologies for the institutional architecture of combined programs are defined based on the way in which the cash transfer and the parenting interventions are arranged and delivered, see Table 1. TABLE 1: Institutional Architecture Typology for Combining Cash Transfer and Parenting Programs INSTITUTIONAL ARCHITECTURE DESCRIPTION Integrated The parenting intervention is managed by the cash transfer program. Examples: Jawtno (Bangladesh), Familias en Acción (Colombia), Burkin-Na- ong-Sa ya (Burkina Faso), and Niger Safety Nets (Niger). Convergence Different agencies explicitly combine efforts to bring the separate cash transfer and parenting programs to the same populations. Examples: Program Keluarga Harapan (PKH) (Indonesia), Prospera and Edu- cación Inicial (Mexico), Human Development Cash Transfer program (Mada- gascar), and Family Strengthening Intervention (Rwanda). Alignment The cash transfer and the parenting programs do not explicitly coordinate with one another but deliver interventions to similar if not the same populations. Example: Juntos and Cuna Más (Peru). Piggybacking The cash transfer is delivered through a separate established platform such as the primary health care network that is already delivering a parenting program. Example: Rapid response child-focused social cash transfer (Senegal). Source: Arriagada, Ana-Maria et al. 2018. Note: See the full technical report for details on each program PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS 5 Study Weight (%) Pollitt et al. 2000 1.3 Castillo-Duran et al. 2001 1.9 Hamadani et al. 2001 3.3 Black et al. 2004a 2.7 Black et al. 2004b (1) 1.5 Black et al. 2004b (2) 1.3 Lind et al. 2004 (1) 5.5 Lind et al. 2004 (2) 5.5 Do parenting interventions improve child development outcomes? Lind et al. 2004 (3) Gardner et al. 2005 5.5 1.9 Taneja et al. 2005 9.7 While the evidence from developing and developed Aboud & Akhter countries 2011 3.1 is mixed, many evaluations find that parenting inter- Rosado et al. 2011 2.0 ventions can improve child development outcomes, notably 2.8 Siegel et al. 2011 (1) cognition and language. However, the studies were mostly Siegel et al. 2011 (2) 2.8 Therefore, small efficacy studies of home visiting programs.Siegel et al. 2011 (3) it is 2.8 an open question as to whether large-scale interventions would produce similar effects. In the USA, evidence-based Gurnida et al. 2012 Manno et al. 2012 large-scale 1.0 5.7 evaluations of parenting interventions such as the Nurse Family Partnership Program have found that Naharthese et al. 2012 programs 2.3 had a positive impact on children’s development. Phuka et al. 2012 1.8 Surkan et al. 2013 (1) 9.0 Another aspect to consider is that parenting interventions Surkan et al. 2013 (2) Vazir et al. 2013 seem 9.0 6.1 to be more effective in improving child cognitive devel- opment than nutrition interventions and conversely,Yousafzai et al. 2014parenting that 11.5 interventions are less effective in improving nutri- Overall e ect size 100.0 tional outcomes. A recent review of 21 parenting interventions in developing –1.0 countries –0.5 at enhancing aimed0.0 0.5 early child 1.0 development found medium-sized effects from parenting interventions on cognitive and language development cognitive while the development of children (95% CI) 18 nutrition interventions were less effective in these domains (see Figure 5). FIGURE 5: Impact of parenting and nutrition interventions on child cognitive development Study Weight (%) Eickmann et al. 2003 2.9 PANEL A - PARENTING Gardner et al. 2003 3.0 Powell et al. 2004 2.7 INTERVENTIONS FOR Walker et al. 2004 2.9 CHILD STIMULATION: Gardner et al. 2005 2.5 Hamadani et al. 2006 4.3 Average effect on cognitive Jin et al. 2007 1.9 development: 0.42 standard Peairson et al. 2008 Nahar et al. 2009 2.3 1.5 deviations Nair et al. 2009 16.6 Lozo et al.2010 IDA 1.7 Lozo et al.2010 ND 2.1 Potterton et al. 2010 2.1 Nahar et al. 2012 2.7 Aboud et al. 2013 9.6 Boivin et al. 2013 2.7 Carlo et al. 2013 R 2.7 Carlo et al. 2013 NR 3.8 Tofail et al. 2013 IDA 4.9 Tofail et al. 2013 ND 4.4 Vazir et al. 2013 7.4 Yousafzai et al. 2014 15.3 Overall e ect size 100.0 –1 0 1 2 cognitive development of children (95% CI) Study Weight (%) Pollitt et al. 2000 1.3 PANEL B - NUTRITION Castillo-Duran et al. 2001 1.9 INTERVENTIONS: Hamadani et al. 2001 Black et al. 2004a 3.3 2.7 Average effect on cognitive Black et al. 2004b (1) 1.5 Black et al. 2004b (2) 1.3 development: 0.09 standard Lind et al. 2004 (1) 5.5 Lind et al. 2004 (2) 5.5 deviations Lind et al. 2004 (3) 5.5 Gardner et al. 2005 1.9 Taneja et al. 2005 9.7 Aboud & Akhter 2011 3.1 Rosado et al. 2011 2.0 Siegel et al. 2011 (1) 2.8 Source: Aboud and Yousafzai 2015 Siegel et al. 2011 (2) 2.8 Siegel et al. 2011 (3) 2.8 Gurnida et al. 2012 1.0 Note: Effect sizes (standard mean difference) are represented Manno et al. 2012 5.7 in a square and 95% confidence interval (CI) represented as Nahar et al. 2012 2.3 lines. Panel A reports effects sizes for promoting play and Phuka et al. 2012 1.8 Surkan et al. 2013 (1) 9.0 parent-child interaction versus only standard care. Panel B Surkan et al. 2013 (2) 9.0 reports effect sizes for providing extra micronutrients versus a Vazir et al. 2013 6.1 partial set of nutrients or a placebo. In some cases, nutrition Yousafzai et al. 2014 11.5 Overall e ect size 100.0 interventions include parental education on nutrition, with or –1.0 –0.5 0.0 0.5 1.0 without nutrient fortification. All studies are for children 0-24 cognitive months at the time of the intervention. development of children (95% CI) Study Weight (%) 6 PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH Eickmann et al. 2003 2.9 COMBINING CASH TRANSFER AND PARENTING PROGRAMS Gardner et al. 2003 3.0 Powell et al. 2004 2.7 What is the evidence on adding parenting interventions to cash transfer programs? The existing evidence on combined cash transfer and parenting interventions is scarce, but promising. We identified four impact evaluations using rigorous methodologies (randomized control trials or regression discontinuity) carried out in Colom- bia, Mexico, Niger, and Peru. Colombia adapted the successful Jamaican “Reach Up” home visiting program developed by Grantham McGregor and colleagues, introducing it as part of the “Familias en Acción” cash transfer program. Mother leaders elected within their communities by fellow cash transfer recipients were trained to conduct weekly home visits to cash transfer beneficiaries to promote mother-child interactions by engaging families in play activities centered on children’s daily routines. In Niger, the parenting intervention was integrated into the cash transfer program, targeting 5 regions with the highest concen- tration of poverty. The parenting intervention was developed in the country based on the UNICEF “essential family practices” package and delivered by local NGOs as a combination of monthly home visits and group meetings. Peru also adapted the Jamaican "Reach Up" home visiting program to the Peruvian context with trained community members, conducting weekly home visits and fortnightly group meetings for child stimulation. The parenting program “ Cuna Más” was implemented in communities where the cash transfer program “Juntos” was operating but was not targeted exclusively to cash transfer beneficiaries. Finally, in Mexico the cash transfer program PROGRESA coordinated with the National Council for Education Development (CONAFE, which designs implements and evaluates new educational programs targeted to marginalized com- munities such as indigenous populations) to offer cash transfer beneficiaries the parenting program “Educación Inicial”. The parenting program operated on weekly basis in rural areas, where access to early learning programs was very limited. These four interventions from Colombia, Mexico, Niger and Peru had short-term impacts on several measures of child development as well as on changes in parental behavior (Table 2). These programs were implemented at large scale (e.g. Niger) or using a scalable structure (e.g. Colombia). More research is needed to understand the impacts at large scale and whether the effects can be sustained in the long term. TABLE 2: Impact of adding parenting interventions to cash transfer programs COLOMBIA MEXICO NIGER PERU Safety net platform* CCT CCT UCT CCT Delivery modality home visits group meetings home visits and group home visits and meetings group meetings Parenting curriculum Adapted from Educación Inicial Adapted from Adapted from ”Reach ”Reach Up” UNICEF ”Essential Up” Family Practices Package” Impact on Improved parental Not measured Improved nutrition Improved parental parental practices practices (play and stimulation practices: increased and behavior activities and play practices and reduced play activities and material) in the short harsh discipline play material, and term reduced harsh discipline Impact on child None Not reported None Not reported wasting and stunting Impacts on cognitive Improved cognition Positive impact on Improved socio-emo- Positive impact on and non-cognitive and language skills but cognition and language tional skills but no child development, outcomes impacts were not sus- only when the program impact on other child especially cognition tained in the medium included enhanced pro- development domains and language term. No impact on motion of the parenting socio-emotional skills intervention Source: Arriagada, Ana-Maria et al. 2018, based on impact evaluations reports from Colombia (Attanasio et al. 2014 and Andrew et al. 2018), Mexico (Fernald et al. 2017), Niger (Barry et al. 2017 and Premand et al. 2016), and Peru (Araujo et al. 2016). * CCT = Conditional Cash Transfer, UCT= Unconditional Cash Transfer Note: Reported impacts are based on the comparison of cash transfer plus parenting intervention versus cash transfer alone. PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS 7 What are the lessons learned from implementing cash transfer and parenting programs? While combining cash transfer programs with parenting interventions holds the promise of improving early child- hood outcomes, evidence remains limited and there are a wide range of practices. In the 10 cases studied, the “inte- grated model” presented in Table 1, in which the parenting intervention is managed within the cash transfer program, was the most common, but the choice of model needs to be fitted to the program and country context. The implementation of parenting programs both in the developing and developed world has revealed a range of good practices which makes it difficult to develop general lessons. Content and learning approaches based on success- ful experiences; attention to service delivery with respect to program protocols, incentive structures, the intensity and duration of the parenting intervention, and the soundness of the delivery modality; and ensuring the quality of the work- force, including the employer of field staff, the profile of front-line staff and the use of quality assurance mechanisms. Table 3 discusses some of the good practices associated with each of these domains. When considering the incorporation of a parenting intervention into a cash transfer program, policymakers should review available options in light of institutional capacity to manage, coordinate, or align with the cash transfer pro- gram. Policymakers need to carefully consider which organization could serve as the most appropriate implementer for the parenting program and align the duration and frequency of the supervision to the intensity of the program interven- tion and to the qualifications of its front-line workers. In the spirit of continued learning and improvement, monitoring and assessment of program implementation is essential, as well as rigorous evaluation of results, to effectively manage the programs and to draw lessons about program design, institutional arrangements and impacts. TABLE 3: Lessons learned from combining parenting and cash transfer programs BASIC CONTENT DELIVERY WORKFORCE BUILDING BLOCKS • Tailor content to child’s • Invest in strong program • Ensure adequate workforce • Design the intervention developmental stage protocols and materials to training with access to with a solid “logical ensure fidelity necessary material framework” • Take into account cultural relevance and situations of • Strengthen social support • Take into account the pros • Invest in a monitoring and conflict/disaster among participating and cons of paid vs. volun- evaluation system for parents tary work quality assurance and to • Content of parenting identify most effective intervention should target • Build on existing delivery • Consider financial and modalities both parents (mother platforms that the target non-financial incentives and father) and other population is already • Manage performance caregivers using • Take into account pros and against clear standards of cons of using professional quality • Include demonstrations vs. paraprofessional with children and oppor- workers tunities to practice and receive feedback during • Establish a frequent and the training sessions supportive supervision scheme including on-the- job training and coaching for field staff Source: Arriagada, Ana-Maria et al. 2018 8 PROMOTING EARLY CHILDHOOD DEVELOPMENT THROUGH COMBINING CASH TRANSFER AND PARENTING PROGRAMS What are the key issues looking forward? • From an operational standpoint, parenting interventions require significant effort to monitor and supervise. It is crucial to track not only process quality but also structural quality (notably front line staff, often community workers interacting with parents), a core aspect of delivering high quality interventions. The operational question of the opti- mal "dose and response" is also critical and requires more research. Although more frequent interactions can increase the size of the impacts, evidence shows that more contact does not necessary translate into better child outcomes. • The sparse evidence from the small number of programs combining cash transfers and parenting – coupled with the heterogeneity in program design -- makes it difficult to make comparisons across programs and to reach any definitive conclusions about how best to couple these two interventions. However, the four cases that we explored (Colombia, Mexico, Niger, and Peru) did improve parental practices and child development outcomes, with stronger results in certain domains. • Looking forward, process evaluations are required to understand the fidelity of implementation and the quality of the program, particularly the quality of the interaction between community workers and caregivers, the role of contexts and complementary programs, and changes in implementation over time and across partners engaged in service delivery. • Longer term research is also needed on the impact of taking parenting interventions to scale, on dose-response impacts, on the cost-effectiveness of using alternative delivery modalities, and on the sustainability of results. The heterogeneity in the impacts of parenting interventions to date likely reflects the heterogeneity in program design, implementation, what results are measured and how they are measured. 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