Integration of Early Learning and Responsive Care into a Health-Care System in India: Results from an Evaluation Spanning Multiple Levels 

• In Event: Roundtable Session (Monday II)
  In Refereed Round-Table Session: Nurturing care: building evidence for program implementation and effectiveness_session II

Proposal

The global ECD community has strongly recommended utilizing existing platforms, such as at-scale health systems, to support parents in providing early learning and responsive care for children from birth to three years (Britto et al., 2017). This paper examines the implementation of an intervention that integrated early learning and responsive care content into a state-wide health-system in Central India, which was primarily focussed on health and nutrition.

The intervention included: 1) the development of an integrated home-visiting manual and 2) a cascaded training and supportive supervision program across five administrative levels of the health system’s hierarchy. This study examined: 1) the extent of integration of early learning and responsive care content across 5 administrative levels and 2) the factors fostering and inhibiting this integration.
The sample for the study spanned respondents from state to hamlet level and included 132 community health workers (CHW’s) at the hamlet level, 44 CHW Trainers at the cluster level, 22 Block Coordinators at the block level, 7 District Coordinators at the district level, 3 Program Associates, and 5 Program Coordinators at the state level.
Semi-structured interviews were used to collect data on knowledge, beliefs, and perceived impact of the integration across respondents from each administrative level. They were also used to collect data on factors fostering and inhibiting the integration. Semi-structured observation instruments were used to collect data on the quality of home-visits conducted by the CHW’s. Data were analysed qualitatively using inductive thematic analysis. Frequencies of the themes were calculated using percentages when meaningful.
As to the extent of integration, the study revealed a system-wide shift towards a holistic view of child development, which included health, nutrition and early learning. This was evidenced in changes in organizational routines, beliefs about child development, and home-visits. While the motivation for and adoption of early learning messages seems to have been achieved, mastery and depth of the content and communication skills for effective delivery were not fully achieved, especially at the frontline worker level.
As to the factors fostering and inhibiting this integration, the top-leadership commitment to the agenda of holistic development emerged as a critical enabler. It brought the new content into the mainstream narrative of the organization, by seamlessly integrating it into their home-visiting manuals, trainings, and supportive supervision practices. A central inhibiting factor was the overburdening of functionaries across hierarchy which affected the quality of ongoing coaching and monitoring. The results provide potent insights into the nature of changes needed in home-visit manual, training and implementation processes to strengthen this integration.

This study addresses the ambivalence amongst health policy-makers on integrating early learning content into their mandate. It illustrates that not only is this inclusion viable, but that the workforce readily appreciates the relevance of the new content. It recommends that such integration can be achieved through leadership commitment and by investing in decentralized training and coaching systems. The research design and methods adopted in this study contribute to the nascent body of literature that looks at systemic interventions in early childhood development.

Authors

• Anaga Ramachandran, NYU

• Aparna Chakravorty, Centre for Learning Resources

• Harini Raval, Centre for Learning Resources

• Chittaranjan Kaul, Centre for Learning Resources

• Hirokazu Yoshikawa, New York University