Scaling up Child-Centred Health Education Programmes

Last week I was very pleased to co-present a webinar on Children's Participation in Health Education and Health Promotion to Programme Managers who work for Save the Children Programmes. I invited them to send me questions which I could answer on the blog so that all readers and visitors could have a look and contribute or contact me directly. A few days after the seminar - this question came in..

Clare, a question that I think most country offices have, and it came up as a challenge in Seybou's presentation (on child centred health education in Mali) was on the ' scale up' of child-centred health education programs. As an international NGO with limited resources how do we help scale up health education programs? We did a recent costing study of our SHN program in Bangladesh and found that the costs both to Save the Children, as well as to the government in terms for their opportunity cost, ie teachers time, are relatively high on a per child and per school basis compared to the other SHN interventions ( excluding water and sanitation infrastructure of course). Add to this the need for teachers/ schools to be creative in the delivery of health education for their context, and this becomes a difficult proposition for program managers to take to scale...

Reflections from a recent field trip to Mozambique

I’m going to reflect on experience freshest in my mind as I also think it’s relevant. Following my reflections are those of 6 colleagues all of whom have relevant experience and some of these experience going back decades. A huge thank you to them for coming in to support me on this and so quickly too...

In early December 2011 I was in Tete Province, Mozambique listening to people and finding out more about the existing structures and resources that exist across several government sectors that presented as opportunities for developing or strengthening children's participation in health promotion. The programme aims to tackle the high levels of chronic malnutrition in the under 5's. They wanted someone with children’s participation experience to pinpoint what already exists that could be developed and strengthened.

There are already some features of this short assignment that already support scaleability. One is that it’s a 'programme' and not 'project' i.e. it is not to have its own infrastructure, and the other is that it’s  about strengthening state mechanisms however slow and bureaucratic these may be.

Once we started to dig, we found a huge variety of existing structures and resources that present a WIDE range of opportunities to develop the programme. Within each of the structures are people who are excited at the prospect of their roles being refreshed. Examples include: the national curricula, curricula for teacher training pre-service and in-service, curricula for the health workers, a national programme of youth mobilisation for HIV, an agricultural programme to support school based agriculture, a children’s parliament, children’s radio, amazing community based components to both the teacher training and the health training, a 20% locally developed curricula component (wow!) - and so it went on.

Admitted, some of these existing programmes felt tired and perhaps were not working that well but they all were well understood from the community and school level governance structures right through to the provincial and then national levels.

One small idea that excited everyone is to put more health education related resources into a box of materials for children that is delivered to primary schools nationally ANYWAY! These could include games, ideas for surveys, health related 'playing cards', posters, story books etc. and to drop these in would cost little more that the resources themselves (but maybe there would be scope to join forces with government printers here too?). There is already an infrastructure for district education officers to give teachers a very short input on how to use the materials and to monitor their use and the need to replace broken ones. So PRESTO! - a very good system for getting out some simple resources that could at least support if not initiate school level health activities.

I worked with a couple of colleagues to do this scoping exercise and both of them were surprised and positive about how much already exists that can support the new work. What I’ve touched on above is also ONLY the government related initiatives – we also found a huge variety of local and international INGO activity that the programme can learn from tap into etc.

So maybe spending time (and therefore money) on scoping and somehow enabling this process to be a government led process and then working to co-create to strengthen what is already there.... would be my hot tip for scaling. I spent 5 days on the scoping using workshops and meetings, field trips etc and I was amazed by how much we found out.

To help me answer this question I consulted 6 colleagues who have sent a wide variety of really good ideas….

Barbara Lil-Rastern (Consultant specialising in children participation in child protection)

My immediate thoughts about scaling up are:

1. Having very easy, clear and child appropriate tools (e.g. like picture books, drawings, posters ...) which can be used between children, between children and adults and between adults.
2. To address the underlying causes or stories leading up to health problems like  e.g. avoiding germs through washing hands more often, safer sex to prevent infections etc.
3. NGO's working in the same country need to work together.

I suggest that people could have a look at the two documents linked here :

• WHO 'Scaling up, saving lives’ document ; and
• Brady M. Taking programs for vulnerable adolescents to scale: Experiences, insights, and evidence

The documents provide interesting thoughts, case studies and examples of what different NGO's are doing in several countries. However they are not explicitly focusing on a child participatory
process,

Hugh Hawes, Co-Founder and former Director of The Child-to-Child Trust

It all depends on what you measure. They are probably trying to measure health outcomes eg. statistics of mortality and morbidity. If you do this you will get results quicker for now. If you try to make your children more health aware , surely it will have better and deeper long term results.

Also what do we mean by 'going to scale'. If you allow ideas to spread gradually from school to school and from community to community - because the will and action of the school/community is driving the process - it will be slower than if you use a more rigid method of dissemination.

A possible solution is to go for the campaign model but at the same time gradually build up
the social interaction process and maybe then you can silence your critics!

These problems have been with us since the start!

Violet Mugisa, Former Director of the Child-to-Child Movement based at the institute of Teacher Education, Kyambogo, Kampala, Uganda.

Scaling up is an issue especially when it comes to health behavior. In child to child in Uganda we chose the behavior to scale up. The behavior must follow the criteria of
1.    Important that it can save lives; (important)
2.    Doable by many i.e. not complicated but easy; (do-able)
3.    That those who do it will find fun in doing it.  (fun!)

The second issue of scaling is where do you want to scale. Most people think scaling is going up, they think of how do we get on top? How do we involve  the people above in the reams of power?  For me scaling up is a multiplier system. The questions I ask myself when scaling up are:
•    Does my neighbor know about the good things I know?
•    Have I helped her to learn and practice what I find good?
•    Does she/he enjoy it etc?
The system expands slowly sideways. The snag with us development workers is to rush into policy making, where everything gets stuck. 

I will give you an example we did in Uganda and it caught up like fire! Putting messages in the compound about health education:
•    Don't step on grass it also wants to live
•    Sex is for adults after marriage,  etc. 
Schools would copy from each other and now every primary school in Uganda has those messages.  Would we call that scaling up?

The other health behavior that caught like fire was the use of tippy tap for hand washing. Children found fun in making them and using them, they taught each other and now can be found in homes and schools everywhere.  I am not saying that with those examples Uganda is a perfect example of health hazard demolition.  There are other variables into the play like population explosion, limited infrastructure etc.  But somehow there is sanity.

Claire O'Kane (Consultant with a specialism in Children's Participation)

• Advocate to include child centred health education in the school curricula, so that the training on health education becomes integrated into teacher training and into regular government budgets for school lessons.
• Advocate to include child centred health education as part of community based health education initiatives supported by health workers, health visitors and community elders.

Sarah Huxley (Consultant with a specialism in Youth Participation)

I recommend that people look at the following link on mobilising youth in policy development: Involving youth in policy development - a case study form Bahrain; and

Anise Waljee (Consultant who has been especially linked to children's participation in early years education, children with disabilities and in developing health materials including stories for children)

One way is to reach, not the schools, but the institutions that work with schools and teachers. So if you target the in-service teacher training institutions or the last year of the teacher training institutions, then to reach first-time teachers as well as currently practising teachers and you make the health education aspect of their work become embedded in their own training and education. If you work with the in-set institution, then its role is to reach teachers and you have your scale up without you dong much. Of course they need to see good practice and to be supported in their attempts to then educate those who they reach but that is far more cost-effective than trying to reach individual schools at a scale up stage. The individual schools are there as examples of good practice and as 'proof' that it can be done and as models then that the in-set organisation can use and draw from.  We found we reached the head teachers and teachers of the 315 schools in Badakhsan much more effectively when they came for their in-set courses to the in-set and were trained by their own people.  It got around the issue of the cascade model which we often have to resort to but which we know loses some things along the way.

The other approach we took was to get schools to work with surrounding schools..call them cluster schools or satellite schools (the later implies a hierarchy so you may want to stick with a cluster and let the lead school work on pd days with, say four others. Often you find that the newcomers are better than the original schools and then they can have a cluster of their own. That way the NGO only needs to
monitor a set number of schools at a time and the learning can spread, yes, slowly, but more 'organically' between equals.

Please do send comments or further questions either in the box below or at the email address. If you want the emails of any of the people listed above then please let me know too and I'll pass you on.

Comments

[Anise Waljee]

some great ideas..interesting how we all took such different perspectives on what we thought was 'scaling up' I think this could form the basis of good article on the issue. Basically we are saying 'keep it organic, use existing structures and systems, trust children and re-think the term 'scale'.' That is a great start to an article..woud any of the contributors want to write it jointly? ..I'd be happy to take the lead on it and work with Clare and anyone else who wants to..or if you don't want to write, will you be willing to vet it and for your ideas to form a part of it..with acknowledgement of course..let me know either way..
it was a pleasure to be a part of this 'together thinking'

anise.

[Mohini]

Hi Clare and All,

Thank you so much for all the brilliant suggestions. I agree with Anise Waljee that this is a great opportunity to document a holistic approach to "scaling up" child-centered health education. It means working at various levels, using different approaches, and the whole will surely be much greater than the sum of individual efforts.

I'll be very interested to contribute to this article too, citing examples from what has been done at Save the Children.

Best Wishes,
Mohini