During the IDB Group’s Knowledge Week on October 23–27, academics, regional and international experts, and IDB specialists met to share experiences on topics that are critical to the planet’s future.
At the event, I had the chance to talk with Sally Grantham-McGregor, Emeritus Professor of Child Health and Nutrition at University College London (UCL), and Sebastián Martínez, Director of Evaluation at 3ie. We explored the question, “Is there a way to scale up social investments and poverty alleviation programs while maintaining quality?”
Quality and scalability in the sphere of early childhood
We know that children from vulnerable families start off elementary school at a strong disadvantage. Data from Ecuador or Mexico, for example, show that at age five, the language development of children of mothers with basic-level education lags behind that of their peers whose mothers have a college degree by nearly 1.5 years. This exemplifies the “intergenerational transmission of poverty,” a cycle we need to break through interventions that offer opportunities for play and learning.
With this aim, in Jamaica in the mid-1980s, three community health workers were trained as facilitators of a play-based intervention, now known as “Reach up.” For 24 months, they made weekly, hour-long home visits to chronically malnourished children ages one to two years old from vulnerable families in the city of Kingston. During these visits, they showed mothers how to engage in play and language activities with their children.
An experimental evaluation of the program found substantial increases in the children’s cognitive, language and motor development as a result of the visits. What’s more, over time these children performed better in school than a comparable group of children who did not receive the visits. And, by age 31, they still had higher IQs, higher educational attainment, better mental health, less involvement in risky behaviors, and !
This program improved the lives of 64 children in Jamaica. Would it be possible to achieve a similar impact on a larger scale?
More recently, Peru’s National “Cuna Más” Program applied a version of Jamaica’s home visits model for families of children under age three and pregnant women in rural and vulnerable areas. The content of the visits was adapted to the country’s diversity, with specific materials for the Andean and Amazon regions, as well as local songs and games. Cuna Más currently serves over 117,000 families.
When we analyze the results, we see a significant disparity related to the difficulty of maintaining quality at scale: in Jamaica, the impact was 8 times greater than in Peru. Moreover, in Jamaica this impact was lasting, while in Peru the long-term impact has yet to be analyzed.
Striking a balance between quality and scale
According to Sally Grantham-McGregor, who led the Jamaica project and later worked on the Peru project, it is possible to achieve high-quality programs that change children’s lives, but we have not yet been able to maintain that quality when we scale them up. Difficulties such as changes in administration and lack of policy continuity; play-based programs that are yoked to broader agendas, like health, that often have other priorities; the precarious employment arrangements of facilitators; or shorter training times can all jeopardize a program’s quality.
Meanwhile, Sebastián Martínez argued that successful examples of scaling up do exist, though reaching this balance is not easy. In Mexico, for example, the replaced dirt floors with cement floors to improve families’ health and living conditions. found positive impacts like fewer cases of anemia, diarrhea and parasites, so the incoming administration decided to scale up the program in several parts of the country.
It’s true that building infrastructure is not the same as building relationships, which is a must in child development programs. The best strategy for scaling up an intervention varies according to the context and nature of the intervention itself. But previous experiences provide useful insights about how to move forward.
Keys to scaling up with quality
To scale up programs effectively, we need research and documentation that show us how: not just how the project can benefit a certain group, but how it should be adapted and implemented. Flawed implementation can erase any impact, as Sally argued during our conversation.
That is why it isessential to document errors as well. Little is said about what doesn’t work, what goes wrong, but this information can be extremely useful for other teams, which can incorporate these lessons early on.
Flexibility is also critical: scaled-up interventions must consider local needs, be familiar with the community, and include relevant adaptations and innovations.
And if decision-makers are to get behind a scale-up initiative, the evidence must be reliable and accessible, meaning that it is written succinctly and in plain language, as Sebastian explained.
Finally, having allies is key: for a program to truly work and have an impact, its implementers need to interact not only with regional and national leaders and technical teams, but also with communities and local media.
The work must be constant but part of a learning cycle: as long as improving people’s lives is the goal, the question will be how to do so effectively.
Watch the full conversation (which could easily have gone on for a few more hours!) here. And tell us: what do you think are the keys to scaling up while maintaining quality?