Saving Brains is a multi-institution, multi-donor partnership led by Grand Challenges Canada which awarded 84 grants to innovation projects across 31 low- and middle-income countries between 2011 and 2017. The overall aim of Saving Brains is to develop sustainable and scalable ways of nurturing healthy brain development in the first 1000 days of life. Through technical support and leadership development, Saving Brains provides an opportunity to demonstrate proof of concept, to ‘transition to scale’ grants, which progress selected interventions towards larger scale and sustainability.
As one of the largest investments in early childhood interventions in low- and middle-income countries (Milner et al., 2016), the Saving Brains portfolio has unique potential to inform understanding of processes towards scaling.
While the portfolio was not designed to explicitly explore all steps from demonstration of intervention effectiveness to policy and programme implementation, it was developed around a portfolio-level theory of change and structured monitoring framework to assess progress along this pathway. Even in ‘seed’ grants, teams were encouraged to consider factors relevant to scaling. As such, Saving Brains provides a unique opportunity to explore questions around implementation of early childhood development interventions in diverse settings with increased focus on scale.
It does so at a critical moment for early child development. Global attention is increasing, from the Sustainable Development Goals (United Nations, 2015), to the Lancet series ‘Advancing Early Childhood Development: from Science to Scale’ (Britto et al., 2017; Daelmans et al., 2017; Richter et al., 2017), to UNICEF’s Early Moments Matter for Every Child report and the launched Nurturing Care Framework for Early Childhood Development, led by UNICEF and the World Health Organization (WHO) and supported by the Partnership for Maternal Newborn and Child Health and Early Childhood Development Action Network (UNICEF, 2017; WHO and UNICEF, 2018).
There is now an opportunity to translate this global attention into large- scale implementation in multiple countries. Analyses of the features of global public health networks which influence their effectiveness in driving action against target challenges have identified the global political context, growth in number of actors and developments in early childhood development metrics, as favourable, but also significant ongoing challenges – notably framing and governance (Shiffman et al., 2016; Shawar and Shiffman, 2017).
In 2016–2017, the London School of Hygiene & Tropical Medicine undertook a participatory mixed-methods impact and process evaluation of 39 interventions across the Saving Brains portfolio. Its primary aim was to understand programming, policy and research lessons learned for scaling interventions across contexts (Milner et al., 2016). Using the UNICEF and WHO Nurturing Care Framework terminology, 84% of interventions in the portfolio focused on responsive caregiving; of them, 63% were delivered through the health system, 25% through early learning facilities and 12% in the community. Among all interventions, 49% focused on nutrition and/or health, and a smaller proportion (9%) on child safety and security (Milner et al., 2016). We suggest three ways in which the Saving Brains portfolio points towards opportunities to strengthen action and overcome challenges related to implementation at scale.
Saving Brains invests in teams in low- and middle-income countries whose members come from diverse professional backgrounds representing a range of sectors, and in proposals which integrate scientific, social and business models (Saving Brains, 2018). While a number of other early childhood development networks are now supported by major funders, Saving Brains is unique in its deliberate drawing-in of new actors, including academics, to explore implementation and transition to scale in diverse settings. Networks in early childhood need to expand to include consumers of information, not just generators, so that evidence can have a greater impact in implementation.
Qualitative feedback through evaluation of the Saving Brains portfolio also highlighted the value of investing in local leadership development for early childhood development. Saving Brains offered teams from low- and middle-income countries a structured leadership development programme during proposal development and the grant cycle. This included webinars and workshops, access to a broad range of technical experts and, to varying degrees, peer-to-peer learning through Saving Brains Community meetings. Moving forward, increased opportunities for peer-to-peer learning and investment in leadership development beyond the time limitations of grant cycles will be important to support scaling.
‘Framing’ or ‘the generation of internal consensus on the definition of the problem and solutions’ has been identified as a challenge to the effectiveness of global early childhood development networks in driving progress (Shawar and Shiffman, 2017). The field has a history of inconsistent nomenclature, variable definitions and arguably artificial dichotomies (such as health ‘vs’ education, development ‘vs’ disability, child survival ‘vs’ development). A key strength of the Saving Brains portfolio, reflected in qualitative feedback, was that it provided a ‘common language’ through training and reporting requirements.
As one manager of early childhood programmes at a leading international NGO put it, ‘Saving Brains really shook the field up … helped us to speak a common language.’ For example, shared knowledge around the ‘human capital’ agenda and rationale for investment in early childhood development was considered by a number of stakeholders as important to advocacy across sectors within their country contexts (Milner et al., 2016).
However, there remained lack of clarity on some issues, with a particular challenge being a disconnect between language used by researchers and those involved in implementation. For example, researchers tend to discuss broad intervention types (for example ‘parenting programmes’) or specific curricula, whereas implementers are keen to talk about specific intervention components (Milner et al., 2016; Britto et al., 2017). As Yousafzai and Aboud have previously suggested (2014), as emphasis in policy and programming shifts there is a need for clearer definition of the ‘what’ and ‘how’ of implementation. Critical intervention components need to be described practically and with greater granularity.
Greater consensus on key definitions of both the challenge and solutions, wrapping these into clearly described ‘packages’ which can be adapted to context, will be important to ensure that the ‘ask’ for policymakers and programmers with primary responsibility for implementation is clear. The Early Moments Matter for Every Child report (UNICEF, 2017) and the Nurturing Care for Early Childhood Development framework (WHO and UNICEF, 2018) are important opportunities towards unifying our voice.
Saving Brains has contributed to recent progress in global child development metrics, including support for development of population-level measures such as the WHO-led Indicators for Infant and Young Child Development and the Caregiver Reported Early Development Index (McCoy et al., 2016). However, measurement across diverse settings remains a major challenge as emphasis shifts to implementation at scale and there is a need to explore, describe and measure the process of implementation (Yousafzai and Aboud, 2014).
Saving Brains developed a monitoring and evaluation framework for grant recipients structured around a portfolio-level ‘theory of change’ which included contextual factors, inputs, outputs and outcomes in intervention implementation, and required grant recipients to track indicators. Qualitative feedback from teams was that this was important and led to consideration of factors (such as policy context) that would not otherwise have been taken into account at an early stage of implementation design. However, many challenges were also identified, including an over-reliance on parental report for measuring outcomes, inconsistent processes for the use of measurement tools across settings, limitations in the range of outcomes measured, and emphasis on short-term cross-section outcomes (Milner et al., 2016). The framework did allow for early signals of potential impact that could be validated with subsequent, larger phases of support (Radner et al., 2018).
Stakeholders within the Saving Brains evaluation also highlighted the importance of communicating child development outcomes in a way that is accurate yet meaningful to stakeholders who are not immersed in the early childhood field. Specifically, interim measures to communicate progress on the pathway towards impact were considered important, given that it takes time to measure long-term outcomes in child development. Measurements need to be both accurate and feasible at scale.
Since the portfolio evaluation outlined in this paper, the Saving Brains partnership has grown (Saving Brains, 2018): with further investments, over 50 additional interventions are now being designed and tested. Saving Brains provides useful learnings, but no silver bullets: to improve scale-up of early childhood development interventions with impact in diverse settings requires engagement beyond traditional networks, including the non-specialist policy and programming community, as well as definition of decision points in programme design and implementation. Evidence to inform decision points is needed to guide common questions raised by those responsible for implementation including cadres, intervention content, costs and how to routinely measure coverage, quality and outcomes for improved accountability in tracking progress towards targets.
References can be found in the PDF version of the article.
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