Ann. N.Y. Acad. Sci.

ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Special Issue: Implementation Research and Practice for Early Childhood Development
ORIGINAL ARTICLE

What implementation evidence matters: scaling-up

nurturing interventions that promote early childhood
development
Pia R. Britto,1 Manpreet Singh,2 Tarun Dua,3 Raghbir Kaur,4 and Aisha K. Yousafzai4
1
Early Childhood Development, UNICEF, New York, New York. 2 Bill and Melinda Gates Foundation, Seattle, Washington.
3
Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland. 4 Department of
Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts

Address for correspondence: Pia R. Britto, Chief and Senior Advisor, Early Childhood Development, UNICEF, 3 United Nations
Plaza, New York, NY 10017. [email protected]

Research in early childhood development (ECD) has established the need for scaling-up multisectoral interventions
for nurturing care to promote ECD, for improved socioeconomic outcomes for sustainable societies. However, key
elements and processes for implementation and scale-up of such interventions are not well understood. This special
series on implementation research and practice for ECD brings together evidence to inform effectiveness, quality, and
scale in nurturing care programs; identifies knowledge gaps; and proposes further directions for research and practice.
This paper frames the dimensions and components fundamental to the understanding of implementation processes
for nurturing care interventions, factors for improving implementation of interventions, and strategies to scale
by embedding interventions in delivery systems. We discuss emerging issues in implementation research for ECD,
including (1) the role of context in adaptation and implementation, (2) standardized reporting of implementation
research, (3) the importance of feasibility studies to inform scale-up and capacity building, (4) fidelity and program
quality improvement, and (5) intervention integration into existing systems. Effective implementation of nurturing
care interventions is at the heart of achieving positive developmental outcomes for young children. It is pivotal to
adapt and implement these interventions based on evidence for high impact, especially in low-resource settings.

Keywords: implementation evidence; nurturing care; early childhood development; scale-up

Introduction The former United Nations Secretary General,

Ban Ki-moon, acknowledged that “the Sustain-
Why a special series on implementation
able Development Goals recognize early childhood
research to promote early childhood
development can help drive the transformation we
development?
hope to achieve over the next 15 years.”2 At national
Since the turn of the 21st century, the evidence
levels as well, there is a greater attention being given
in support of why early childhood development
to ECD with a significant increase in national multi-
(ECD) is critical to individuals and societies has
sector policies supporting children’s development.3
burgeoned. Early childhood development programs
A second big advancement has occurred in defin-
enable children to develop and strengthen cogni-
ing “what” is ECD? The evidence from several fields
tive and social skills, increase adult income, and
of knowledge including neuroscience, social sci-
can break the intergenerational cycle of poverty and
ences, and economics has provided valuable knowl-
lost human capital.1 The arguments of “why” tak-
edge to defining developmental potential and the
ing action to promote early development have been
process by which it occurs.4 From a bio-psychosocial
recognized at the highest levels of political com-
ecological perspective, ECD is defined along
mitment, for example, the Sustainable Develop-
two dimensions—the child (age and domains of
ment Goals endorsed by all nations of the world.
doi: 10.1111/nyas.13720
Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 C 2018 The Authors. Annals of the New York Academy of Sciences 5
published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in
any medium, provided the original work is properly cited.
 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
What ECD implementation evidence matters Britto et al.

development) and the environment. With respect Network (ECDAN), and many other partners, pro-
to the child, the early childhood period is defined as vides a roadmap for action. It builds upon state-of-
beginning at conception until age of school entry, the art evidence of how child development unfolds
with developmentally distinct phases within that and of the effective policies and interventions that
age span. Commonly used domains of develop- can improve early childhood development. The
ment included in the definition are motor, cognitive, Framework provides an approach to promote and
language, and social and emotional develop- strengthen the Nurturing Care of young children,
ment. Development is a maturational process that including guiding principle, strategic actions, and
results from the optimal, bi-directional interaction the monitoring of targets and milestones that are
between the child and the environment. Though essential to progress.
developmental processes are fairly similar across As countries, implementing partners, and com-
cultures, the progression rates vary as children munities are adopting the nurturing care agenda to
acquire culture-specific skills and the influence of promote ECD, the most common questions being
other contextual factors.5 raised are about the implementation of programs in
The brain develops most rapidly in the first years the real world and the strategies to take them to scale
of life, when neurons form new connections at the and make them sustainable. The challenge is signifi-
astounding rate of upward from 1000 per second.6 cant given that more than 250 million children fail to
The science underscores that while genes provide the meet their cognitive developmental potential in the
blueprint for the developing brain, it is a child’s envi- first 5 years of life.11,12 In order to continue to build
ronment that shapes development, which occurs in the momentum for young children’s development
a relatively short period of time in order to establish and respond to the growing demand for services,
the capacity to learn, adapt to change, and develop addressing “how” in a timely manner is critical.
psychological resilience. This period of life is con- Despite consistent evidence about the types of
sidered foundational for later health and well-being; interventions that are effective in promoting ECD,
therefore, strong foundations support a healthy few interventions have gone to scale, quality is vari-
developmental trajectory, while adversity may result able, and access to early childhood interventions
in a poorer developmental trajectory, which is more remains low especially among the most disadvan-
challenging to improve with later life interventions. taged children living in low- and middle-income
The context, an important determinant of a countries.13–16 There is little understanding of how
child’s developmental potential, has been concep- best to deliver these interventions across the full
tualized as “nurturing care.”3 The five indivisible range of existing systems and in the wide diversity
components of nurturing care are health, nutrition, of possible settings. In order to thus advance access
security and safety, responsive caregiving, and to effective and quality services, greater focus on
early learning. Infants and children, early in life, implementation research of interventions promot-
who do not receive adequate health, nutrition, ing ECD is necessary.
early stimulation, learning opportunities, care, and Implementation research has been widely used
protection tend to have lowered cognitive, language, in advancing health interventions to scale. Imple-
and psychosocial outcomes.7,8 The longer term mentation research is broadly used to understand
consequences are noted not just in lowered produc- the processes used in the implementation of initia-
tivity, earnings, but also in poor physical and mental tives as well as the contextual factors that affect these
health outcomes.9 The latest evidence indicates processes. It can consider any aspect of implementa-
that early deprivation creates marks on our genetic tion, including the factors affecting implementation
endowment that are expressed in future generations (e.g., income and geography), the processes of
as well.10 Nurturing care is what the infant’s brain implementation (e.g., home visits and multisec-
needs and depends upon for healthy development. tor coordination), and the results of implemen-
With the “why” and “what” defined, the ques- tation. Implementation research is a key tool to
tion yet unanswered is “how.” The Nurturing Care understand context, assess performance, facilitate
Framework developed by the WHO and UNICEF, systems strengthening, and inform large-scale use
supported by the Partnership for Maternal, New- and sustainability of interventions. The intent is
born & Child Health (PMNCH), the ECD Action to understand what, why, and how interventions

6 Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 

C 2018 The Authors. Annals of the New York Academy of Sciences

published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.

 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Britto et al. What ECD implementation evidence matters

work in real-world settings and to test approaches with the needs of the identified target population,
to improve them.16 context, and program environment was a key deter-
The special issue of Ann. N.Y. Acad. Sci. (1419: minant in a program’s success.18,19 Content refers to
1–271, 2018, “Implementation Research and Prac- the curriculum, drawing on the theory of change,
tice for Early Childhood Development”) presents and information or commodities that are delivered
current evidence from implementation research through the program. The service provider for an
on the area of ECD, and identifies gaps and future ECD intervention is key, because change among
research directions to advance uptake and scale-up parents or caregivers, as among children, occurs as
of nurturing care interventions that promote a result of interaction with the social and physi-
young children’s development. Several important cal environment, especially with skillful adults who
questions were identified, with a specific focus on help to provide a responsive and stimulating envi-
two broad implementation research and practice ronment. The service provider therefore needs to
questions. First, in relation to enhancing the quality be well trained to deliver these important skills and
of interventions, was what features of implementa- messages to the adults, and in the programs that
tion make interventions effective? Second, how can serve children to the children. Mode of delivery, for
we transition nurturing care interventions to scale some programs group modalities are better and for
and achieve a sustainable impact? other programs, in home or clinic-based individual
delivery. Also, linked to this aspect is virtual delivery
Dimensions and components of
of services, using digital platforms.
implementation of programs for young
The third component linked to program effec-
children and families
tiveness is linked to the beneficiaries. This compo-
Two salient dimensions understanding implemen-
nent is understood from two perspectives—demand
tation processes are improving implementation of
and for whom is the program designed. Typically, in
interventions and strategies that take interventions
proof-of-concept models, beneficiaries are enrolled
to scale and make them sustainable. These two
into program, based on specific criteria and adher-
dimensions mutually inform and reinforce each
ence is measured to the treatment protocols. How-
other.
ever, when programs are implemented out of these
Dimension 1: improving implementation of inter- controlled settings to understand take-up and sus-
ventions. The most relevant aspects of implemen- tainability, the demand factor is central to program
tation that need further research and understand- effectiveness. Understanding the beneficiaries, with
ing are linked to the dose, delivery, demand of the respect to universal or more targeted approaches,
programs, and measurement of results. Dosage has and particular socioeconomic or other vulnerabili-
been identified as important for program effective- ties is key to effectiveness. The target population and
ness. Stated simply, dose is the amount of the pro- their specific needs with respect to characteristics of
gram that is delivered.17 The conceptualization of the beneficiaries and classification by risk levels but
intervention dose contains three components: dura- also strengths has been linked to program success.18
tion, frequency, and intensity. Duration is the length Critical for implementation is setting the right
of the full program from start to finish. Frequency metrics to measure results. The metrics need to be
is how often the program is delivered (e.g., daily, aligned to the program theory of change and mea-
weekly, and monthly). Intensity is the third compo- sure results at output, outcome, and impact level
nent of dose and has been defined as the strength of for the child and the context. The measurement
an intervention or how much of the intervention is of child outcomes needs to be predictive of later
delivered within each session (e.g., the time allotted life outcomes. Conducting evaluations of imple-
to each session and who is involved in the session). mentation process as well as impact evaluations is
The second component linked to program effec- important for generating results to inform program
tiveness and important to understand for imple- improvements.
mentation is delivery. This element also has three With respect to ECD interventions, implemen-
subcomponents: content, service provider, and tation research is warranted on dosage, delivery,
mode of delivery informed by a theory of change. and demand in order for implementers to make
Program with a clear theory of change consistent informed decisions on program design.20 With the

Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 C 2018 The Authors. Annals of the New York Academy of Sciences 7
published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.
 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
What ECD implementation evidence matters Britto et al.

exception of an evaluation of a home visiting service be embedded or integrated in an existing system.

in Jamaica,21 few studies have investigated the short- Implementation strategies focus on how best to
and long-term impacts of dosage on children’s embed individual interventions within existing sys-
development. While there are a number of curric- tems to increase coverage and scale. There are six key
ula available for adaptation in different contexts, strategies for the integration of ECD interventions
evidence on common ingredients and their associ- in systems.
ation with specific outcomes of children’s develop- Given the nurturing care framework and the
ment has not yet been reported. Moreover, many necessity that developing potential requires mul-
of the studies have been conducted with providers tisectoral inputs, the first strategy to expanded and
outside of existing health, education, and social effective implementation is adoption of multisec-
welfare, providers who are the likely candidates in toral intervention packages. This requires identifi-
scaled up programs; it will be necessary in order to cation of relevant delivery platforms for effective
design interventions from the outset with the char- services that can be packaged together to address
acteristics of the provider taken into consideration the developing needs of the young child and their
(e.g., burden of work and competency gaps). Phuka caregivers, which may be the bundling together of
and colleagues analysis of provider candidates from interventions to create a specific child care pack-
health and child protection sectors in Malawi is one age or the coordination of services within and
example of such research.22 Also, required consid- between sectors. An enabling environment for mul-
eration to the continuous process of improvement tisectoral strategies requires coordinated national
is necessary during the implementation process, for policies with implementable budgeted action plans
example, Plan-Do-Study-Act (PDSA) methods are that are governed by a coordinating body at national
useful for course correction and quality enhance- and subnational levels.23
ments. While demand for ECD services has grown, Second, strengthening the system to deliver qual-
as evidenced by increasing numbers of national poli- ity of care through a trained workforce. Frontline
cies on ECD, shaping demand among communities workers need to be adequately trained, have access
and programs to invest in quality services is nec- to supportive supervision, and informed of inter-
essary for uptake and sustainable impact. In sum, sectoral referral mechanisms to help them deliver
learning about how ECD programs work is nec- quality services to young children and families.
essary to improve the quality and effectiveness of Required are standards and accreditation systems
interventions, and to inform decisions about what that build the skills and knowledge of the workforce
models are best suited for scaling-up in different to desired levels of performance and competency.
contexts. Critically, given that multiple inputs (e.g., Further, an examination of competencies is needed:
stimulation and early learning, responsive care, what knowledge and skills are common for effective
nutrition, safety and security, health) are required delivery across a number of interventions and what
to support children’s development, research needs are unique to ECD?
to focus on the bundling of complex interventions Third, broadening data and evidence systems.
that enable nurturing care. For example, what inter- A key dimension to implementation is the ability
ventions are needed for which child outcomes, are to measure change, monitor progress, and use the
there unintended consequences of bundling inter- data and evidence to inform improvements. This
ventions on independent outcomes, and are there requires both the measurement metrics as indicated
additive benefits to outcomes as a result of bundling earlier and also the ability of existing information
interventions? Consideration of a proof-of-concept systems to include indicators on ECD as part of rou-
model’s relevance of scale from the outset should tine monitoring and reporting. Moreover, strate-
be examined when discussing the generalizability of gies to use these data to inform program quality
ECD interventions for future uptake by sectors. improvements must be planned.
Fourth, costing and finance for sustainable and
Dimension 2: strategies for taking intervention scaled up program delivery. Program implementa-
to scale. It is recognized that interventions for tion should be documented through costing and
promoting ECD are not stand alone, but part of expenditure monitoring. Public finance strategies
a broader framework of nurturing care that will are key for scale-up of ECD.

8 Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 

C 2018 The Authors. Annals of the New York Academy of Sciences

published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.

 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Britto et al. What ECD implementation evidence matters

Fifth, advocacy and communication strategies encompassed contexts affecting implementation,

are important for building demand for services. adaption and feasibility testing of programs for
Increasing knowledge of the general public, espe- scales, documenting processes of implementa-
cially parents and caregivers, winning the support tion, evaluations of fidelity, description of how
of decision makers, and private sector partners are interventions are introduced into systems, and
important for generating demand and raising the implications for scale and sustainability.
visibility of the importance of early childhood. A key
strategy is community-based communication and Implementation research evidence on
messages to caregivers that support their caregiving dimension 1: improving implementation of
and provide the required information for creating interventions
nurturing environments. The seven case examples of implementation of nur-
Finally, the sixth strategy is to differentiate strate- turing care programs, comprising early learning,
gies based on country context. Implementation con- nutrition, safety and protection, health, and respon-
texts vary from emergency and fragility to low-, sive caregiving interventions, highlight the breadth
medium-, and high-capacity condition. In emer- of interventions that can potentially promote chil-
gency situations due to the exceptional burden on dren’s development and the range of intervention
existing resources, the implementation strategies settings, including Australia,23 Brazil,24 Colombia,25
focus on surge capacity and delivering the essen- Jamaica,26 Malawi,27 Pakistan,28 South Africa,29 and
tial interventions compared with low-capacity con- Zimbabwe,24 that will influence program planning
ditions, where the focus is on strengthening gov- with respect to dosage, delivery, and demand. Smith
ernance and accountability for services alongside and colleagues describe their implementation
building capacity of frontline workers. This differen- evaluation (or process evaluation) of the Reach Up
tiation can also occur within country, subnationally, program in Brazil and Zimbabwe.24 Reach Up
with implications for prioritization of implementa- curriculum is rooted in a home visiting program
tion strategies. originally developed in Jamaica and implemented
These scale-up implementation issues may be as a weekly home visiting service;30 however, while
common across a number of early childhood inter- efficacious to achieving beneficial ECD outcomes,
ventions. The ECD agenda and the nurturing care this dosage was not feasible in the new settings.
framework present an opportunity to build evidence Preimplementation adaptation work informed
around holistic programs of care for children recog- choices made to on how to culturally adapt cur-
nizing all outcomes (e.g., learning, safety and pro- riculum content and modify dosage. Additionally,
tection, nutritional well-being, mental health, and the implementation evaluation conducted at the
physical health) and are necessary for children to end of the research further informed modifications
thrive. that would be needed in scaling-up Reach Up in
Brazil and Zimbabwe.24 In a parenting program
The Ann. N.Y. Acad. Sci. special issue: new
in Malawi27 and in a school-based program in
evidence and emerging issues
Jamaica,26 intervention adaptation work was
Peters and colleagues describe a framework for combined with feasibility studies using the United
implementation research principles, outcomes, and Kingdom’s Medical Research Council framework
processes.16 A modified definition of implementa- for developing complex interventions allowing for
tion research is the scientific inquiry into questions an iterative process of intervention development or
concerning activities undertaken as planned with adaptation, piloting, and modifications to develop
the intention of producing an effect, which when a feasible model of implementation in a specific
applied to ECD can be on policies, programs, context.31 Findings from Malawi and Jamaica
or individual practices (interventions) promote underscore that effective and feasible adaption of
child development. Implementation variables often interventions for new settings requires an under-
include acceptability, adoption, appropriateness, standing of the core ingredients of interventions
feasibility, fidelity, implementation cost, coverage, that make them effective as well as participatory
and sustainability—all can serve as indicators of the approaches with implementing partners to opti-
success of implementation. In this series, the papers mize local relevance and feasibility, and piloting to

Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 C 2018 The Authors. Annals of the New York Academy of Sciences 9
published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.
 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
What ECD implementation evidence matters Britto et al.

understand how implementation decisions might what might be achievable in a specified duration of
influence desired outcomes. As noted in the violence implementation.
prevention in schools work in Jamaica, the core The value of an implementation evaluation is
ingredients are not only the content of curriculum dependent upon the how data are used to inform
messages, advice, and activities but also the behav- decisions about quality improvements. Data from
ior change techniques that support delivery which program monitoring in programs and implemen-
should not be overlooked in adaptation of curricula. tation evaluations need to be made available in
Understanding the context for adaption is under- a timely manner to providers as demonstrated
scored by Murphy and colleagues who describe in the large-scale implementation of an early
the urgent need for implementation of ECD childhood education program in Colombia (e.g.,
support services in humanitarian contexts where the aeioTU program) when early data on process
evidence building must be responsive to rapidly quality enabled course corrections to be made to
changing situations and embedded in practice support the skills development of teachers.25 The
partnerships.32 experience of teachers enacting the curriculum
Retaining fidelity to a program is considered and trainings that responded to the information
a critical feature in achieving desired impacts; in the early data improved quality. In Pakistan28
however, fidelity to intended program designs has and South Africa,29 supportive supervision and
not been frequently reported in nurturing care feedback loops were identified as key ingredients
interventions.20 Goldfeld and colleagues report that facilitated quality improvements informed by
three important factors related to understanding monitoring of providers. The characteristics of the
variance in effectiveness of sustained nurse home provider, identification and capacity development
visiting programs and how these were addressed activities to build competencies to effectively deliver
in the right@home program: (1) inclusion of logic nurturing care interventions, and strategies that
or a theory of change that appropriately aligns supported building relationships of trust with
program goals, inputs, and outcomes measured; caregiver and children were recognized across the
(2) fidelity to core ingredients of program; and seven case studies in this series. Measuring skills
(3) quality improvements that enable modifica- of providers and their relationships with caregivers
tion and embedment in a system.33 The lessons and young children can serve to understand
learned from this paper draw attention to the implementation quality and effectiveness.
importance of both outcome and implementation All program evaluations in this series concluded
evaluations that are designed to measure what an acceptance of interventions by program recipi-
the curriculum is intended to influence and to ents. Demand for nurturing care interventions that
inform quality improvement decisions with imple- promote ECD is shaped by caregivers’ experiences
mentation partners. Program implementation is of services. Caregivers value interventions that
dynamic and changes over time influenced by support their young children’s well-being and
context, complex systems, and the relationship education, but intentional effort to shape demand
between providers and beneficiaries. The tension is also a factor that influences quality improvements
between fidelity and flexibility to improve qual- as demonstrated in Jain and colleagues work with
ity requires knowledge of the theories, ingredi- the affordable preschool sector in India. Strategies
ents, and contextual influences (e.g., variation of that enabled parents and early educators to see
risk exposures in families and characteristics of the learning benefits of child-centered approaches
systems) that make a program effective and how rather than traditional rote learning pedagogy
these might be achieved through flexible pathways enabled scaling-up of quality improvement inter-
that allow for modification and adaptation. The ventions in preschools. More studies on dimensions
implications for program evaluation are design- of implementation and their components are
ing implementation evaluations that allow infor- needed in the field of nurturing care. These papers
mation on program quality to be collected over represent interventions researched within systems
time and to design impact evaluations with out- (both in government systems and in services
come measures that align with the theory of change provided by nongovernment organizations), which
or logic model and with realistic expectations of is critical for guiding scaling-up services.

10 Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 

C 2018 The Authors. Annals of the New York Academy of Sciences

published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.

 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Britto et al. What ECD implementation evidence matters

Implementation research evidence on tation evaluations, and adopting mixed method

dimension 2: strategies for taking approaches and quality improvement studies in
interventions to scale evaluating implementation.40 Critically to advance
The components of taking interventions to scale scale of nurturing care, greater attention on transi-
described under dimension 2 require not only tioning small programs to systems and research on
evidence-based models, but also leadership, ade- integrated child programs is needed. Partnerships,
quate workforces, effective partnerships with a range multidisciplinary research, and learning lessons
of implementation stakeholders, financing, and from other sectoral interventions are essential com-
governance as shown in the framework reported ponents of the process.
by Nores and Fernandez drawing on lessons
learned from scaling-up in the health and educa- What lessons can be learned from
tion sectors.34 However, few studies have focused implementation evidence in other
on these components. Cost data about nurturing interventions?
interventions that might inform financial planning There are lessons learned from the scale-up of paral-
for programs at scale are limited, but employing lel health, nutrition, and education programs, which
standardized costing tools outlined by Gustafsson- are applicable to the scale-up of ECD programs.
Wright and Bogglid-Jones provides a way forward.35 Given the broad scope of ECD programs, it is impor-
Radner and colleagues reviewed a portfolio of stud- tant to first define what we are trying to scale. Sec-
ies funded by the Saving Brains program, Grand ond, it is important to define what we mean by scale,
Challenges Canada and identify a series of lessons and so we will focus on lessons required to take a
that support evidence building for scale and sustain- pilot program to subnational or national impact,
ability including strong entrepreneurial leadership, within a single country. Scale in this manner is
rigorous measurement and active use of data in sup- broader than just coverage, it also includes depth
port of adaptive learning, and champions acting at (or quality), sustainability, and shift in ownership
subnational levels.36 These findings underscore the (from an external to internal program).41 This sec-
need for implementation partnerships between pol- tion primarily draws on experience from scaling-
icy makers, program implementers, communities, up antenatal care (ANC), the integrated manage-
and researchers from the outset. ment of childhood illness (IMCI), and the Alive and
If the evidence in these papers is to be built upon, Thrive nutrition initiative, with reference to other
greater attention to reporting implementation pro- programs where relevant.
cesses is needed. Too few evaluations on implemen-
tation are disseminated and there is great variation Lessons learned for dimension 1: improving
in constructs. A recommendation from this series implementation of interventions for
is to systematically report implementation evalu- effectiveness
ations of nurturing care interventions. Yousafzai When considering the service provider, we can draw
and colleagues describe guidelines developed from lessons from other programs in how to recruit, train,
an expert e-Delphi process provide an approach to supervise, and incentivize healthcare workers. For
systematically report program implementation that example, innovative training methods to strengthen
might facilitate share learning.37 In recent years, basic emergency obstetric and newborn care have
attention on measurement of ECD outcomes has moved away from a traditional 2-week offsite inten-
resulted in the development of a number of tools and sive training program to low-dose high-frequency
guidance on measurement of outcomes,38 Aboud training. This involves shorter onsite training (in
and Prado present guidance on monitoring and the facility where people work), coupled with high-
evaluating implementation processes for interven- frequency mentorship, peer practice, and text mes-
tions that promote ECD reinforcing the need for sage reminders to healthcare workers. In Ghana,
rigorous program measurement.39 low-dose high-frequency training of midwives and
Aboud and colleagues describe key research areas nurses improved health outcomes (reducing early
for strengthening evidence on quality and program newborn mortality by 48% in the first 1–6 months
effectiveness for scale including systemic adapta- following training), at cost per disability-adjusted
tion to context and program, reporting implemen- life year (DALY) of $53.42 Considering community

Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 C 2018 The Authors. Annals of the New York Academy of Sciences 11
published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.
 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
What ECD implementation evidence matters Britto et al.

health systems, there is an early body of evidence learn from the structure and process to develop
suggesting that emphasis on career possibilities WHO recommendations on ANC for a positive
in community health worker (CHW) recruitment, pregnancy experience, also providing methodolog-
supervision that follows up with underperform- ical recommendations for conducting implementa-
ing CHWs, tailored incentives for CHWs, and use tion research.48 The goal was not to define a single,
of mobile phone-based procedural guidance can universal ANC process, but rather to develop a
improve CHW quality of care.43 This body of re- picture of globally recommended guidance, and
search remains nascent, and caveats must be noted. context-specific guidance. For example, the 2016
In particular, CHWs have a heterogeneous range guidelines define a recommended dosage for ANC
of experience, supervision, and training, suggesting care—recently shifted from four visits to eight vis-
the external validity of research may be limited. its, based on available evidence. Some elements of
With respect to strengthening demand for ECD ANC content are globally recommended (e.g., ask-
programs, we can learn lessons from the Alive and ing all women about tobacco use and substance use);
Thrive program. From the outset, this program was whereas some content elements are context specific
focused on understanding how to deliver infant (e.g., enquiry about intimate partner violence is only
and young child feeding (including breastfeeding recommended when there is the capacity to provide
and complementary feeding) at scale, and testing a supportive response). Similarly, elements related
across three diverse country contexts—Bangladesh, to the service provider are also context specific, with
Ethiopia, and Vietnam.44 On the demand side, guidance for midwife-led continuity of care from
teams used deep national situational analyses to ANC to intrapartum and postpartum care, only
identify country-specific barriers at a household, in countries which have sufficient midwife capac-
community, and institutional level, to breastfeed- ity. The guidelines are not static and are open to
ing and complementary feeding behaviors. Com- the possibility of further adaptation and learning
munication strategies were multipronged, includ- (e.g., group ANC is recommended in the context of
ing print materials for front-line workers, “leave rigorous research).
behind” materials for mothers and families, com-
Lessons learned for dimension 2: taking
munity meetings (e.g., food demonstrations), and
interventions to scale
mass media campaigns. In addition, the Alive and
Qualitative research suggests that simple, scientifi-
Thrive program did not target mothers alone, but
cally robust programs can be scaled up, in the con-
identified critical secondary audiences—including
text of strong leadership, engagement with local
fathers, grandmothers, religious leaders, and other
implementers, when run in a phased manner.49
community elders.45
As noted by Milagros and Fernandez, taking inter-
As coverage of ECD programs scales up, it is crit-
ventions to scale typically requires integration into
ical to maintain focus on quality, as also discussed
existing delivery platforms.32 There remains limited
earlier on the elements of improving implemen-
evidence understanding how best to do this, par-
tation of interventions. Quality improvement in
ticularly in the context of a technical capacity gap
healthcare often uses a PDSA cycle—a pragmatic,
in national planning and implementing bodies in
small-scale iterative approach for testing changes
many high burden countries.50
in complex systems, often led by frontline work-
This gap in delivery capacity has been demon-
ers. Most research assessing the impact of PDSA
strated in other parallel programs, for example, the
cycles for quality improvement has been conducted
IMCI strategy, which was launched by the WHO
in high-income settings, and shows that there is
in 1996. A multicountry evaluation conducted in
evidence of impact on health outcomes, but vari-
Bangladesh, Brazil, Peru, Tanzania, and Uganda
able fidelity to process.46 Research has shown that
found that the WHO expected IMCI would be
similar quality improvement processes can improve
implemented fully regardless of the strength of the
maternal and child health processes and outcomes in
health system, and this assumption did not hold
Ghana—including an increase in early ANC atten-
true. As the authors state: “Countries that had the
dance from 37% to 48%.47
mortality level and cause profile that most required
As the ECD community seeks to develop pro-
IMCI often lacked the basic systems infrastructure
grammatic guidelines for interventions, we can
and support to deliver it.”51

12 Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 

C 2018 The Authors. Annals of the New York Academy of Sciences

published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.

 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Britto et al. What ECD implementation evidence matters

The Alive & Thrive nutrition program (alive- PIPs were similar to theories of change and outlined
andthrive.org) also noted this gap in national deliv- impact pathways linking interventions to desired
ery capacity. While they attempted to integrate the outcomes. Critically, the Alive & Thrive PIPs were
intervention into existing maternal, newborn, and complex, interconnected, and nonlinear, articulat-
child health delivery platforms, the implementers ing multiple potential pathways to impact. The
noted that “rapid geographic expansion places addi- mixed methods implementation or process eval-
tional burdens on service delivery systems.”52 Like uation was linked to these PIPs, using country-
Gladstone and colleagues’ work to introduce care for specific process metrics and intermediate outcomes
child development in Malawi,27 the Alive & Thrive that emerged from the complex impact pathways.56
implementers assessed delivery capacity in each This process was high cost, requiring close collab-
country when planning implementation, includ- oration between implementers and evaluators from
ing an assessment of human resource capacity, day 1 but has enabled the generation of a large body
and ability of service delivery platform to scale. of implementation evidence on how best to deliver
Using the WHO’s health system building blocks nutrition programming at scale.
model, they identified country-specific needs in: (1)
service delivery—specifically guidelines and pro-
Conclusions
tocols; (2) health workforce—specifically training
and performance support at all levels, from CHWs As we look toward strengthening implementation
to subnational managers and national program practice, there are key areas that need to be informed
organizers; and (3) health information systems— by research. While there is a lot we already know,
specifically monitoring and evaluation for program there needs to be a systematic process of inquiry
improvement.52 Alive & Thrives infant and young that identifies and draws attention to the gaps in
child feeding package did not include nutrition knowledge and an understanding of why these areas
interventions alone, but also included an emphasis have not been addressed. In areas we have made
on targeted elements of systems strengthening, with progress, such as community delivery and build-
deliberate investments to strengthen the broader ing capacity, there are still gaps in evidence that are
health system capacity.53 handicapping effectiveness and scale up. For exam-
Identifying and strategically strengthening gaps ple, we know more about public and community
in service delivery capacity raises programmatic delivery than about private (for fee) services. More
costs, threatening financial sustainability of a attention needs to be paid to the role of private
program. As recommended by Gustafsson-Wright sector in the provision of services and also shap-
and Bogglid-Jones,35 systematically gathering ing demand for services. Also, understanding that
comprehensive costing data for ECD interventions often private and public are not separate, imple-
will allow for more direct comparison between pro- mentation research also needs to investigate local or
grams and an assessment of a comprehensive return community-level partnerships, for example, public–
on investment (ROI). This kind of ROI analysis has private, that enable the scale up of services. Another
been developed for health interventions, and forms area where we have some understanding is in capac-
an important part of global and national advocacy. ity building for delivery of services. The papers
Two examples are the Lancet Commission on address training and capacity building as key foci of
investing in health54 and the 2015 WHO report implementation; however, we know more about the
“Strengthening Primary Health Care through one-to-one service delivery (e.g., service provider
Community Health Workers: Investment Case and to caregiver) and less about service providers to a
Financing Recommendations,” which found that group of beneficiaries. What is the type of train-
investment in CHWs can result in an economic ing and supervision that will address that delivery
return of 10:1.55 modality and what can we learn from adult educa-
A final note from the Alive & Thrive program is tion services?
the importance of early, theory-driven process eval- There are other areas of implementation where
uation. Alive & Thrive evaluators developed detailed the evidence is quite sparse and knowledge is emerg-
project implementation plans (PIPs) for each coun- ing. For example, we know very little about how to
try, in collaboration with the implementers. These shape demand which occurs at several levels from

Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 C 2018 The Authors. Annals of the New York Academy of Sciences 13
published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.
 17496632, 2018, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.13720 by Cochrane Philippines, Wiley Online Library on [28/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
What ECD implementation evidence matters Britto et al.

Box 1.
Recommendations from the Ann. N.Y. Acad. Sci. special issue
r Transparent reporting of implementation research
r Improved use of existing data
r Implementation research questions (e.g., action research and implementation tools)
r Partnerships for implementation research
r Funding of communication, knowledge hubs, and advocacy
r Technical expertise for local research leadership
r Innovation in delivery of multisectoral interventions
r Better alignment between supply and demand

the beneficiaries to the policy makers. While the sarily represent the views, decisions, or policies
former requires compelling communication strate- of the institutions with which the authors are
gies to demonstrate “what quality looks like” to affiliated.
systematic advocacy approaches at the level of deci- This paper was invited to be published indi-
sion makers. Other areas where the implementation vidually and as one of several others as a special
research agenda needs to be bolstered are in cost- issue of Ann. N.Y. Acad. Sci. (1419: 1–271, 2018).
ing and governance of finance for taking programs The special issue was developed and coordinated
to scale. There is a need for systematic investiga- by Aisha K. Yousafzai, Frances Aboud, Milagros
tion in public finance, cost to expenditure data, and Nores, and Pia Britto with the aim of presenting cur-
understanding of effective models of resource allo- rent evidence and evaluations on implementation
cation. Finally and key to implementation is devel- processes, and to identify gaps and future research
oping differentiated response strategies based on directions to advance effectiveness and scale-up of
the geography and context for deliver. Our review interventions that promote young children’s devel-
demonstrated that there are more data from Latin opment. A workshop was held on Dec. 4 and 5,
America on these varied contexts; however, from 2017 at and sponsored by the New York Academy
other regions, this information is thin and even of Sciences to discuss and develop the content of
more limited from implementation in humanitarian this paper and the others of the special issue. Fund-
contexts. ing for open access of the special issue is gratefully
As has been presented in the Nurturing Care acknowledged from UNICEF and the New Venture
Framework, we now know that the developing child Fund.
and brain need and expect in order to achieve
their potential. This special issue provides evi- Competing interests
dence to operationalize that framework, by present- The authors declare no competing interests.
ing a series of papers to strengthen interventions
and strategies for embedding them within systems References
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C 2018 The Authors. Annals of the New York Academy of Sciences

published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.

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16 Ann. N.Y. Acad. Sci. 1419 (2018) 5–16 

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published by Wiley Periodicals Inc. on behalf of New York Academy of Sciences.