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WELCOME
Asia-Pacific Regional ECD Conference 2017
March 3, 2017
Siem Reap, Cambodia
1-3 March 2017Asia-Pacific Regional ECD Conference 2017
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Presented by
M Habibur RahmanSr. Education Advisor, Save the Children, Bangladesh
and Vice Chair of Bangladesh ECD Network (BEN)
Roxana KhanomManager-Early Years Development, Save the Children, Bangladesh
Building the Human Capital of Tomorrow:An Impact Evaluation of the Early Childhood Stimulation Program in
Bangladesh
Asia-Pacific Regional ECD Conference 2017 1-3 March 2017
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Contexts
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Bangladesh context
• Recent success in improving education and health indicators
• Social indicators have improved and accelerated by economic growth.
• ECCD still a challenge
High malnutrition
– 36% are stunted and 33% are underweight*
• Cognitive development
– 21% aged 36 to 59 months reach literacy and numeracy milestones
– Poor and children born to uneducated mothers have a negative developmental trajectory
Asia-Pacific Regional ECD Conference 2017 1-3 March 2017
Source: BDHS 2014*
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Goal of the Program
Promote positive early stimulation practices
among mothers or caregivers of children ages 0–3
years.
Early Childhood Stimulation (ECS) Program in Bangladesh
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Program Development Progression
Early Childhood Stimulation ( ECS) Program in Bangladesh
2011
Mother Focused Early Childhood
Stimulation Program Piloted in Meherpurfollowing community
and institutional model
2012
Father Focused Early Childhood
Stimulation Program Piloted in Meherpurfollowing community
model by using technology
2013-2015
Scale up of Mother Focused Early
Childhood Stimulation Program
Implemented in diverse geographical locations with larger population following institutional model
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Early Childhood Stimulation (ECS) Program in Bangladesh
Implementing Partners:
- Govt. National Nutrition Services & Community Clinic Project (RCHCIB) under the Ministry of Health and Family Welfare (MOHFW)
- Save the Children projects under Health and Education Sector:
i) Tackling Childhood Malnutrition &
ii) Early Childhood Stimulation Program
Evaluation Partner: American Institute for Research (AIR)
Technical Partner for BAILEY: icddr,b
Evaluation Funding Partner: Strategic Impact Evaluation Fund (SIEF), World Bank
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Early Childhood Stimulation (ECS) Program in Bangladesh
• Added an early stimulation component to an existing service infrastructure: Community Clinics and frontline service providers
• Integrated with National Nutrition Services (NNS), by adding additional training on ECS
• Combined messages delivered during routine home visits, Community Clinic visits, and immunization events, and engagement of community groups
• Did not offer additional incentives (monetary or in-kind) to frontline service providers; Did not have supervision power over service providers
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Early Childhood Stimulation Program Delivery Mechanism
Community Clinic
EPI Site Home Visit
Growth Monitoring Promotion
(GMP)
Courtyard Meeting
SCI staff TOT on EarlyStimulation
TOT on Early Stimulation
for Govt. Health
Supervisors (HI, AHI &
FPI)
Basic Training on Early
Stimulation for Govt. Health
Service Providers (CHCP, HA
& FWA)
Refreshers Training for
Govt. Health Service
Providers
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Program AreasKulaura, Maulvibazar
Pop: 360000
Union: 13
Hillocks
Muladi, Barisal
Pop:175000
Union: 7
Prone to river-erosion
Satkania, Chittagong
Pop: 385000
Union: 17
Coastal Belt
Selection Criteria:
1. Implementing
NNS
2. Low presence of
other actors
3. Geographically
distinct to
maximize use of
learning nationally
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Evaluation Design
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Evaluation Design
• Theory-based, mixed-methods, cluster-randomized control trial (RCT)
• Randomized 78 community clinics and their catchment areas to treatment and control conditions; stratified by Union (30 unions)
• Randomly sample 33 children/households from each community clinic’s catchment area, totaling 2574
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Research questions
1. What is the impact of the ECS Program (delivered with the NNS) on children’s cognitive and language development outcomes?
2. What is the impact of the ECS Program (delivered with the NNS) on children’s anthropometric outcomes?
3. What is the impact of the ECS Program on mothers’ knowledge and parenting behaviors?
4. What are the benefits of the ECS Program relative to the program’s cost?
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Design: Treatment and Control Groups
Treatment Group Control Group
National Nutrition Service program (NNS) + Early Childhood Stimulation (ECS) Program
National Nutrition Service program (NNS)
39 community clinics1287 households with children
0-3 years old
39 community clinics1287 households with children
0-3 years old
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Results
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Impacts on intermediate outcomes
ES=0.01
ES=0.02
ES=0.06
ES=0.09†
ES=0.1*
Treatment Control
Home
Variety play materials
Variety learning activities with
parents
No. of Picture books
Knowledge
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Child development outcomes
ES=0.08**
ES=0.14**
Treatment Control
Bayley
Cognitive
Bayley Language
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Wolke behavioral rating scale
Treatment Control
Approach
Emotion
Activity
Cooperation
Vocalization
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Impacts on nutritional outcomes
ES=0.11**
ES=0.18**
ES=-0.02
Treatment Control
Weight for Age
Weight for Height
Height for Age
-2.25 -1.5 -0.75 0
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Impacts on NNS
TreatmentControl
Had growth monitoring card
No. of growth monitoring check-ups
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Framing of Results towards Policy and Programming
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06/03/2017 22
Uptake of intervention
Larger impacts of ECS were found for the following groups:
• Girls: Linguistic and behavioral skills, and anthropometric development marginally larger for girls
• Younger children: Impacts were generally larger among younger children (28-34 months old)
• Poor: Impacts on anthropometric outcomes were larger among the poor
• Less educated mothers: Impacts on anthropometric outcomes were larger among the children of less educated mothers
• Closer to the clinics: Impacts were generally larger for the children living closer to the clinics.
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Cost
• The ECS program, as it was implemented, proved to be cost effective.
• The program cost per beneficiary child was US$ 6.84 for 1.5 years of implementation.
• 18,644 children took up the interventions of the ECS program.
• The program cost per clinic is $3,270.
• This calculation does not include the cost of community clinics.
• The effect size per US$100 spent on a child is internationally comparable or even higher depending on the outcomes area.
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Policy/program implications
• Possible to integrate nutrition programs and early childhood
stimulation programs in cost-effective ways
• The add-on ECS program enhanced uptake of NNS rather
than competing with the program
• Service delivery structure is already established nationwide
• Relatively limited costs would be required for roll out
• This evaluation shows how experimenting on nutrition
programs like the NNS has the potential to improve child
outcomes and effectiveness of ECD programs
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Policy/program implications
ECD Program Integrations with Nutrition:
• Policy dialogue and expert and stakeholder consultation to design next course of action – GoB to take lead
• MOH&FW includes ECS in the Essential Service Package (ESP)
• Develop necessary operational mechanisms – training, job-description, supervision, SBCC, community engagement
• Include in the 4th HNP sector program being designed. Phased scale up
• MOWCA, MOPME and MOLGRD should explore opportunities to introduce and scale up ECD
• GO-NGO complementary partnership approach
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Future Research Agenda:More research is needed to identify ways to increase take up by
families and to create worker incentives to increase program reach
and quality:
• Policy research for better sub-sector governance and institutional arrangements
• Component specific efficacy and effectiveness
• Nation-wide ECD status
• Integration of ECD with existing program platforms
Policy/program implications
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Research Information
Marjorie Chinen, PhD
Principal Researcher
American Institutes for Research (AIR)
Shinsaku Nomura
Senior Economist
World Bank Group
Program Information
Marianne O’Grady
Advisor, ECCD
Save the Children, US
Hosneara Khondker
Program Director, Shishuder Jonno
Save the Children, Bangladesh
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THANK YOU
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Successful randomization andminimal attrition (3%)
Covariates Control Treatment
Children Characteristics
Age in months 11.81 11.34
Gender (Female) 0.49 0.47
Household Characteristics
Single parent household 0.17 0.17
Percent Muslim 0.85 0.87
Mother education (years) 6.60 6.62
Mother age (years) 25.70 25.74
Mother employed 0.06 0.05
Household size (persons) 5.94 6.04
Percent with mother-in-law in the household 0.43 0.42
Baseline Results
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Equivalent on impact outcomes
Outcome measures Control Treatment Diff p-value Diff ES
Child development outcomes
Cognitive (composite score) 97.96 99.14 0.430 0.08
Language (composite score) 94.51 96.07 0.290 0.10
Nutrition outcomes
Weight for age (z-score) -0.993 -0.956 0.537 0.03
Weight for height (z-score) -0.356 -0.328 0.660 0.022
Height for age (z-score) -1.377 -1.329 0.472 0.039
Percent underweight 0.199 0.186 0.449 -0.032
Percent wasted 0.067 0.069 0.844 0.008
Percent stunted 0.287 0.272 0.537 -0.033
Baseline Results
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Longitudinal design and analysis
Baseline (Nov 2013-Jan 2014) & Endline (Sep-Dec 2015): 20 months apart on average; Monitoring data (6 rounds, 2014 & 2015)
Intent-to-treat (ITT): estimates the impact between the HHs assigned to the treatment group and the HHs assigned to the control group
Treatment-on-the-treated (TOT): estimates the impact between
the HHs that actually receive the treatment and the control group
Clustered standard errors; 4 model specifications
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Theory of change
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Outcomes indicators1. Program 2. Outcomes 3. Impact
outcomesImplementation:Training, Delivery, Exposure, Take up,
Challenges
Program Cost data
Intermediate outcomes:Parenting Knowledge
Parenting behaviorHome environment scale
(HOME)
NNS outcomes:Take up of NNS
Feeding practicesHealth practices
Hand washing practices
Secondary outcomes:Responsive feeding
Mother’s depression
Child development: cognitive & language
(Bayley test)Wolke behavioral rating
scale
Nutrition:Anthropometric measures
(WAZ, WHZ, HAZ)
Other covariates:Families: Socioeconomic characteristics, family composition, distance to community to clinic, etc.