From Little Things, Big Things Grow: The experience of scaling a playful parenting program through government health systems in Bhutan

• In Event: Evidence from integrated ECD-Health interventions in low- and middle-income country contexts

Proposal

Programs that work to improve parenting practices for caregivers of children aged 0-3 have been shown to have positive impacts on early childhood development, which have a broad range of positive knock-on effects for those children as they move through life. While many development partners deliver parenting programs directly to beneficiaries, a more scalable, sustainable, and potentially effective approach is to support governments to integrate these programs within their own service delivery systems. But moving from small, controlled programs into national programs that work through government systems and workforces can be a challenging process. This presentation compares results from two quasi-experimental impact evaluations in Bhutan, showcasing the experience of moving a playful parenting program from a pilot project to a government initiative operated through the health sector.
In 2017-2018, Save the Children and the Bhutan Ministry of Health (MoH) piloted the original playful parenting intervention in two districts in Bhutan. Government frontline health assistants were trained to carry out twelve group sessions and periodic individual sessions (including child development screening) with caregivers of children aged 0-3 to promote responsive care and encourage opportunities for early learning. By the end of the pilot, caregivers in intervention districts had, on average, one more play or reading material at home and practiced one more playful activity with their children compared to caregivers in control areas, leading to a significant increase in child development status.
In order to scale this intervention through government health systems, some design changes were needed; the introduction of a cascade training model, refinement of group and individual session guides, and the transfer of monitoring and supervision systems into MoH structures. Scale up, initially planned for the first five districts in 2020 (Phase 1), was delayed until 2021 due to the COVID-19 pandemic with national-level scale up commencing in late 2022 (Phase 2).
Results from the impact evaluation of scaled up Phase 1 showed that significant changes in caregiver knowledge, practice and home environment were maintained from the pilot, with an interesting new result: increased father’s engagement. The availability of play materials in the home increased by 0.62 items, caregivers engaged in 0.83 more positive interactions with their children, and fathers increased their engagement in caregiving and stimulation by one activity, with further improvement for those participating more regularly.
The impact on child development outcomes, however, was not maintained from pilot to scale. Phase 1 scale-up faced implementation challenges, such as sporadic COVID-19 lockdowns and frontline service provider engagement in emergency vaccine provision. At endline, many Health Assistants had not delivered the full set of sessions and caregiver attendance was lower than anticipated. We reason that these factors, along with the usual growing pains of going to scale, account for why we did not see the same impact on childhood development status.
In this panel we showcase results, learnings and program adaptations made through the process of scaling in Bhutan, in order to contribute to the literature on how to bring ECD programs to scale with quality and impact.

Authors

• Thomas Brown, Save the Children

• Emily Weiss, Save The Children International

• Filipa de Castro, Save the Children

• Sara Dang Dang, Save the Children