Editor’s Note: This blog is one of a series on early childhood development, featuring experts from Brookings and elsewhere that have been discussing the topic as part of work being conducted by the Center for Universal Education.
A child’s physical and cognitive development is highly influenced by the quality of the care and nurture that he or she receives. This makes it important to both provide for children’s nutritional needs and also enhance their stimulation. One way to address both these needs is through bundling the services in a single intervention. In bundling, the goal is to maintain or even enhance the benefits of existing services and gain some benefit from the new program.
For example, it may be feasible to integrate stimulation with primary care home visits or to promote caregiving during visits to clinics for mild illnesses. There is some evidence that suggests that there are additive benefits from combined interventions. Moreover, in most cases studied, a service can be added without having a negative impact on an existing service.
Whether or not linking nutrition services to efforts to stimulate cognitive and socio-emotional development enhances the impacts of each intervention, there may be program delivery synergies if the total cost of delivering both services is less when the two are administered jointly. In addition, combining services can be a way of persuading policymakers of the feasibility of providing new early childhood development (ECD) interventions at relatively low cost.
Home Delivery of Bundled Nutrition and Stimulation in Jamaica
One approach to bundled services is based on the findings of a longitudinal study in Jamaica, in which stunted children aged 9 to 24 months were provided either 1 kilogram of milk weekly for 2 years, or stimulation was promoted by weekly home visits of community workers, or both. While initial observations found additive impacts of stimulation and supplementation on cognitive development, the impact of supplementation was no longer apparent by the time the individuals reached adolescence. Twenty years later, program participants benefited from a 25 percent increase in earnings that was attributed to the stimulation interventions. The stimulation narrowed the gap in cognitive development between children who were malnourished and those that were not; in contrast, the nutritional supplement did not.
But the intervention was relatively expensive, in part due to the need for regular household visits over an extensive period. Also the intervention was targeted to children who were initially malnourished. Such targeting can yield higher economic returns relative to less-focused interventions. Even if the costs per beneficiary increase, it is an open question whether the benefits increase as fast or faster. But the overall cost may limit full-scale rollout where malnutrition is widespread. Thus, the approach is not necessarily feasible for populations in which a large share of the children is stunted or when a climate or financial emergency puts a substantial portion of the population at risk.
The programs that are well-studied, such as the Jamaica example, have shown improvements among children who receive frequent home visits over several months. Although such interventions likely yield attractive benefit-to-cost ratios especially over the longer term, this approach may be more manageable in terms of capacity when the number of at risk children, and therefore overall program costs, is relatively small. More evidence is needed on the effectiveness of other delivery models that can reach a larger number of children at risk using existing infrastructure and services where possible. Pakistan’s “Lady Health Worker” program conducted a recent experiment that may provide such a model. In the experiment, the program delivered nutrition and stimulation interventions through monthly (rather than weekly) home visits supplemented by monthly groups. Even with the lower frequency of the home visits, recent research evidence shows that the program helped prevent cognitive delays in children. And while both interventions benefited children’s development, there were larger and more comprehensive benefits from stimulation. Indeed, children who received both nutrition and stimulation through the program had somewhat lower benefits than those who received the stimulation component alone.
Offering Bundled Services at Caribbean Health Centers
Another approach involves integrating parenting with routine visits to primary health centers. This intervention does not require extra clinic staff and does not increase the number of visits that families make to health centers. In a pilot program in three Caribbean countries (Jamaica, Antigua, and St. Lucia) films were produced showing mothers practicing parenting skills, and community health workers were trained to demonstrate activities and help mothers practice parenting. In addition, clinic nurses distributed message cards and play materials. There were no adverse effects of adding the parenting intervention on children’s nutrition or immunization status. The effect size of the program was comparable to some home-visiting programs but less than the Jamaica weekly home visiting program. The annual cost per child of the integrated ECD trial was substantially less than the home visiting program, mainly because the program was spared the expense of wages for home visitors.
The impact of showing these videos to parents already visiting health centers demonstrates the potential of technology in providing critically beneficial information at scale, particularly given the large number of children that will be born in low and middle-income countries over the next 30 years. It is important to keep in mind though that the videos were not delivered in isolation, and were coupled with training.
So What is the Effect of Bundling?
Given that different programs have different impacts based on timing of interventions and type of delivery, it is important to understand how programs interact in order to know whether bundling services increases or reduces costs. For example, delivering de-worming and nutrition interventions at the same time would not increase overall labor costs, making bundling appear efficient; however, this is less likely in the case of bundling ECD and nutrition where staffing costs predominate. There are also obvious coordination costs between the different ministries involved in delivering these services, costs that could lower efficiency. Moreover, while it is generally the case that bundling does not create interference between the different components, this is not always the case. Sometimes, combining different services may lead to negative impacts because of “information overload.” This has been observed, for example, in a trial of responsive feeding in India.
There are some key considerations for bundling services. It is critical to think about the services being bundled and to whom the services are being delivered in order to determine whether a universal approach to delivery or an approach designed for specific subpopulations is more appropriate. Before bundling services, it is important to consider whether infrastructure and resources will be overstretched in order to prevent a negative impact for existing services. The program described in the Caribbean was successful partly because there is robust primary health infrastructure in the country that may not be present in other places. At the same time, any new service should be considered the responsibility of the existing service and not merely an add-on.
There exist a number of promising approaches to promoting child growth and comprehensive, integrated care. Since ECD programs have long-term benefits, future research should focus on better understanding both the costs and benefits of different programs, so governments can find strategies that they can take to scale.
Homi Kharas delivered the keynote address at IFPRI’s annual staff retreat on September 12, 2018. He explored the evolving development agenda and its implications for policy research.