Municipalities’ experiences scaling up Brazil's Criança Feliz early childhood development program: Comparative case studies analysis

• In Event: A Deeper Dive: Examining implementation of early childhood interventions across three countries

Abstract

Background: To address inequities preventing children from reaching their full developmental potential, Brazil implemented the largest worldwide early childhood development (ECD) program, Programa Criança Feliz (PCF). PCF aims to (1) provide evidence-based home visits and (2) coordinate multi-sectoral actions to reduce families’ vulnerabilities, and ultimately benefit parenting and ECD outcomes. PCF has been scaled up to 2,934 of 5,570 Brazilian rural and urban municipalities. However, after five years of implementation, the pathways required to achieve PCF's intended goals remain unclear. We conducted a comparative case study analysis to examine implementation barriers and facilitators across five Brazilian municipalities.
Methods: Municipalities were selected based on population size, location, and time of implementing PCF. Qualitative case study analysis included: Brasília, Campo Grande, Cuité, Fortaleza, and São Paulo. In-depth interviews were conducted with PCF staff (managers, supervisors, home visitors), families, and intersectoral stakeholders implementing PCF for at least 6 months. Interview guides were designed following the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance) to document implementation barriers and facilitators. A rapid qualitative analysis was used to inductively identify themes across RE-AIM.
Results: 244 interviews were conducted (132 PCF staff, 95 families, and 17 intersectoral stakeholders). Municipalities began PCF implementation in 2017/18, but Brasilia in 2021. Common barriers across RE-AIM: Adoption. Questions about whether PCF should belong to the social assistance sector and the technical capacity to deliver a home visit intervention, a model widely implemented in the health sector in Brazil, have been a challenge for integration with existing social services; Reach. Challenges in enrolling families due to limited knowledge and trust in PCF goals, and lack of integration with social assistance programs (e.g. not linked to cash transfer) led to the need for non-traditional outreach activities (e.g. flyers, word of mouth) to increase reach. Implementation. Lack of intersectoral referral and continuity of care systems is aggravated within catchment areas with long distances and high vulnerabilities. Supportive supervision of home visitors is not prioritized due to the high volume of administrative work and lack of a smart electronic monitoring system. Sub-financing of PCF may contribute to low salaries, temporary contracts, and high turnover, which turns into a barrier to training and fidelity; Effectiveness. Families and PCF staff perceived improvements in ECD and responsive parenting; however, the lack of intersectoral actions to address complex social needs (food insecurity, violence, etc.) may reduce the effectiveness of early stimulation; Maintenance. Lack of an institutionalized municipality policy and a functioning intersectoral committee are major barriers to sustainability. While federal funding enabled PCF implementation, scale-up to different regions within the municipality may not be possible. Table 1 summarizes key lessons learned.
Conclusion: PCF is not fully adopted nor integrated into the social assistance sector. Home visit component is a strength, however, the intersectoriality component is weak lacking clarity on how to operationalize it. PCF sustainability is unclear due to the lack of institutionalization and sustainable funding. These implementation barriers may reduce the potential impact of PCF on parenting and ECD among vulnerable families.

Authors

• Gabriela Buccini, University of Nevada Las Vegas
  Presenting Author

• Muriel Gubert

• Poliana de Araújo Palmeira

• Lidia Godoi

• Georgiana Esteves