Questions/Answers

Primeira Infância Melhor (PIM) is a transversal public policy of socio-educational action to promote integral development during early childhood. Its main objective is to guide families based on their own culture and experiences in order to promote the integral development of their children, from pregnancy time until the year of six. Through home visits, PIM promotes child development, the strengthening of family bonds and the identification of the specific needs of each beneficiary, connecting the service network according to the demands that arise in the day-to-day family activities. The support axes of PIM are: family, community, and intersectoriality. They represent three basic premises: the leading role of the family, community involvement, and the active participation of different management sectors. The intersectoriality is understood as an articulated set of actions, of different areas and actors, seeking the integral care of pregnant women, children, and families. The PIM trajectory led to its recognition as one of the most important development and social transformation technologies in Latin America: Beyond the quantitative results of the presented evaluations, there are stories of life and reports from families in their daily routine that prove the Program’s quality and the power that this policy has to promote life, to transform stories, to empower families, and to potentially break the cycles of vulnerability. As PIM became structured and was strengthened, not only its results have reflected upon beneficiary families but also on society as a whole. The impact of PIM is evident in extending the culture of investment in early childhood in Brazil and Latin America. In view of all these considerations, PIM policy is a great example of technology, innovation, and social development, due to the size of its structure.

The main objective of this initiative is to guide families based on their own culture and experiences in order to promote the integral development of their children, from pregnancy time until the year of six. Through home visits, Primeira Infancia Melhor promotes child development, the strengthening of family bonds and the identification of the specific needs of each beneficiary, connecting the service network according to the demands that arise in the day-to-day family activities.

In 2003, the scenario in Brazil was only 21.8% of the population from zero to six years old with care in the infant education system. In Rio Grande do Sul, the percentage was even lower, 17.9%, representing 218,976 of a population of 1,220,351 children. By December 2006, Primeira Infancia Melhor was implemented in 45.5% of the municipalities of Rio Grande do Sul, assiting 40,125 families and benefiting 4,815 pregnant women and 44,138 children, equivalent to 6% of the children not enrolled in the formal education system for children. The visible results of this public policy strengthened the appreciation of early childhood among managers of the State Health Department and the other departments involved. At the same time, there was a recognition by the state government, which in 2006 established the Program as an integral part of the State Policy for the Promotion and Development of Early Childhood through State Law no. 12,544. The institution of this law ratified the pioneering investment in families with young children in the south of Brazil.

The integration of the Primeira Infância Melhor actions with the existing public services in the territory ratifies the intersectoriality advocated by the Program. At the same time as it identifies demands and activates the service network, also constantly referenced by other professionals to accompany families. Through this practice, Primeira Infancia Melhor is defined as an integral care policy, promoting articulated action among very different areas. This articulation seeks to optimize human and financial resources, the non-dissociation of the different services, the qualification of communication, and especially the production of significant results for the development of pregnant women, children, and their families in situations of great risk and social vulnerability.

In 2003, the scenario in Brazil was only 21.8% of the population from zero to six years old with care in the infant education system. In Rio Grande do Sul, the percentage was even lower, 17.9%, representing 218,976 of a population of 1,220,351 children. The percentage of underweight children in the areas covered by the Family Health Strategy (ESF) in Brazil was 4.8% up to the first year and reached 10.1% at two years of age. The percentage of poor children, with family per capita income of up to ½ a minimum wage, was 45% in Brazil and 28.8% in RS. The infant mortality rate in 2003 was 24.6 deaths per thousand live births in Brazil and 15.9 deaths per thousand live births in RS. The Human Development Index - HDI of Brazil was 0.79, i.e., the country ranked 63rd in the global ranking among 177 countries.

Integral care, as a principle for Primeira Infância Melhor, refers to the understanding that the factors that interfere in a child’s development are broad and span across different areas. Integrality is sustained and defended as a value for the practice of all actors involved in the management and execution of the Program. Bearing out its intersectorial character, Primeira Infancia Melhor includes Primary Health Care, Basic Social Protection and Education. Primeira Infância Melhor is one means of accessing the Unified Health System (SUS), through Primary Care, which functions as a filter capable of organizing the flow of services in healthcare networks, acting to prevent diseases and promote health, while simultaneously directing the most serious situations to higher and more complex levels of care .

The fifteen-year trajectory of Primeira Infância Melhor enabled the learning of lessons related to overcoming the challenges inherent to innovative public policy in Brazil. In Brazil, federal, state, and municipal governments change every four years. This can cause discontinuity in actions related to PIM according to the priorities of each administration term. However, the institutionalization of the Program in the State and in the municipalities through the creation of laws, and through the establishment of positions to fill the Program, providing goals and budgets for local plans are strategies that help maintain PIM and minimize the effects of administration changes. In addition to this, the articulation of the Program along with other administrative spheres, such as the legislative sector (City Council and Legislative Assembly) and Social Control (Health, Education, and Social Assistance Councils among others);. Not only does PIM intervention focus on children, but also on other members of the families, it respects the individuality of each individual and the family dynamics. This involves the Program’s investment in valuing the historicity, culture, and habits of beneficiary families, also perceived in the development of specific efforts towards traditional (quilombolas and indigenous) and specific communities (incarcerated or formerly imprisoned mothers)

Different global initiatives were analyzed to provide a basis for the PIM implantation project. The methodology of the Cuban program Educa a tu Hijo was chosen to be the inspirational model for the Program’s basic guidelines. With this, a three-year technical cooperation agreement was established, funded by the State Health Department , which enabled the exchange of experiences and fundamental knowledge to overcome the challenges inherent in the implementation of an unprecedented public policy in Brazil. The Program also established technical cooperation with the United Nations Educational, Scientific and Cultural Organization (Unesco) in order to facilitate their State management activities.The State of Rio Grande do Sul, Brazil, as well as other countries in Latin America, recognized the importance of investing in early childhood, and that is why they started a comprehensive policy fifteen years ago, the Primeira Infância Melhor Program (PIM). After Primeira Infancia Melhor, other programs in other states appeared, such as the Legal Framework for Early Childhood (Marco Legal da Primeira Infância), and now there is a major National Program for 4 million young children called Criança Feliz (Happy Child).

Intersectoriality is a PIM hallmark and is also reflected in the human resources that make up the technical structures at both municipal and state levels. At the state level, Primeira Infância Melhor is coordinated by the Health Department with the support of the Education, Culture, Social Development, Labor, Justice, and Human Rights Departments, and the Office of Social Policies. Also at the state level, within the scope of the Health Department, there is the State Technical Group (GTE), which is the Program’s management group. It is composed by a multidisciplinary team of specialists geographically distributed among healthcare macro-regions. Each GTE member assists an average of thirty municipalities. At the municipal level, the technical structure is made up of the Municipal Technical Group, Monitors, and Visitors. The Municipal Technical Group - GTM is made up of degreed professionals from the Health, Education, and Social Assistance departments. This group fulfills a workload of at least 10 hours per week and holds the responsibility of implanting, managing, monitoring and evaluating PIM in the municipality. In Rio Grande do Sul, of the State Health Department 2016 annual budget BRL 20 million is allocated to the maintenance of PIM, representing 0.88% of the department’s budget.

Yes

The practice of Primeira Infância Melhor has made it benchmark for early childhood projects and home visits. The Program frequently receives government representatives, institutions, and professionals from the most diverse areas that want to know its structure and functioning. In Brazil, through institutional partnerships, PIM inspires and supports the implantation and implementation of different actions/ projects/programs for early childhood both technically and methodologically. In total, nine initiatives are supported by PIM in the South, Southeast, Northeast, and North regions, places with different geographic, social, cultural, political, and economic configurations. The exercise of replicating PIM for such diverse territories requires a careful reading of these contexts in order to produce models of attention compatible with them. Sometimes, significant changes are required in the original PIM model, however, some aspects have always been maintained, such as: the intersectoriality as principle for care organization; the structuring of management teams composed of members of Health, Education, and Social Assistance; the appreciation of the experiences and culture of the families and the communities; the objective of promoting the strengthening of family skills and their active participation, and investment in the qualification of the teams around the territories.

Analyzing the investment made by the State in 2016, divided by the number of pregnant women/children receiving PIM care, there Primeira Infância Melhor is able to be sustained as a permanent policy due to the consistency and structure of its methodology . Thus, the total investment made by the State and the municipality per pregnant woman/child receiving PIM care is an average of BRL 73.89, the equivalent of USD 23.90 per month19 (USD 286.8 per year). The cost-effectiveness ratio is a prime factor in the allocation of public resources in public policies for early childhood. Measuring the real cost of home visitation programs is challenging, since they contemplate different inputs, depending on the reality of each territory. However, it is a necessary calculation to encourage investment actions during the first years of life. Primeira Infância Melhor has the lowest annual cost per child (USD 289). Considering that the program’s impact goes beyond the pregnant woman/child being cared for, as it strengthens other family members, the total cost of PIM could be even lower.

Primeira Infância Melhor is able to be sustained as a permanent policy due to the consistency and structure of its methodology . There is a script for activities that provide a foundation for the Program’s adhesion, implantation, and implementation process stages. In addition to direct work with families, Primeira Infancia Melhor seeks to influence governments and society in the formulation, approval, and execution of initiatives that meet the needs of early childhood, strengthening the participation of different actors in the debates of interest to this cause. In order to keep the topic of early childhood care in the forefront, as well as to ensure the sustainability of the Program, advocacy has become a key strategy. State Baby Week, Baby Day, International Early Childhood Seminar, Salvador Celia Award, Radio Broadcaster Training, municipal events, meetings with managers, social control, publicity campaigns, information material for the media, and others are part of the Primeira Infância Melhor advocacy actions.

Yes

In 2014, a consulting project by Getúlio Vargas/RJ Foundation was done to discuss the “Evaluation for Improving the Cost-Effectiveness, Qualification, and Expansion of the Primeira Infância Melhor Program”. Despite this nomenclature, the project carried out by the institution focused more on the knowledge of the Program and its work processes. The results presented regarding the evaluation of results concern only one aspect of the study: the assessment of the caregivers’ perception. This aspect includes results regarding the degree of importance of the PIM for families, the perception about the quality of the services provided, as well as the main positive aspects of the Program. The research was carried out by a questionnaire with 1,600 respondents, selected by stratification according to the macroregions of the state, number of PIM beneficiaries per municipality, and age group of the PIM beneficiaries (0 to 3 years old and over 3 years to 6 years old) , representing a sample of 8% of the total families assisted in the state

As a general result there is great acceptance and satisfaction with PIM. Regarding the evaluation of the service provided by the Program, 96% of the caregivers considered PIM to be important or very important and 93% considered the quality of the service provided to be optimal or good. Of the respondents, 87% answered that PIM impacted their preparation for providing child care and 95% of the caregivers said that they consider the activities oriented by PIM would contribute to improving the child’s living conditions in the future. Regarding the relation between family and Visitor, more than 80% of respondents showed a high degree of confidence in the Program, including 32% who consider the Visitor as reliable one or someone they can talk to. Although, only 60% had the same Visitor during their participation in PIM.

The questionnaire was elaborated based on the results of in-depth interviews and focus groups conducted in the phases prior to the survey, and validated, considering the following analyses blocks: evaluation of the service provided by the Program; family and Visitor relationship; and perception of PIM impact

The support axes of Primeira Infância Melhor are: family, community, and intersectoriality. These axes have been present since the conception of the Program and are one of the key to success since they represent three basic premises: the leading role of the family, community involvement, and the active participation of different management sectors. The intersectoriality is understood as an articulated set of actions, of different areas and actors, seeking the integral care of pregnant women, children, and families. This is presented in the different levels of PIM activities. In the State, it happens from the articulation of different departments, and it also has the support of the Management Committee. The State, in turn, articulates with the municipalities through technical and financial cooperation. In the municipality, the intersectoral management is reaffirmed, since the technical coordination group must have representation of at least Health, Education and Social Assistance department professionals. Likewise, the integration of the Primeira Infância Melhor actions with the existing services in the territory ratifies the intersectoriality advocated by the Program. At the same time as it identifies demands and activates the service network, also constantly referenced by other professionals to accompany families. Through this practice, PIM is defined as an integral care policy, promoting articulated action among very different areas. This articulation seeks to optimize human and financial resources, the non-dissociation of the different services, the qualification of communication, and especially the production of significant results for the development of pregnant women, children, and their families in situations of great risk and social vulnerability

The fifteen-year trajectory of Primeira Infância Melhor enabled the learning of lessons related to overcoming the challenges inherent to innovative public policy in Brazil. These challenges include diverse aspects of the social, political, cultural, and economic reality of the State of Rio Grande do Sul and stimulate its constant improvement. Not only does PIM intervention focus on children, but also on other members of the families, it respects the individuality of each individual and the family dynamics. This involves the Program’s investment in valuing the historicity, culture, and habits of beneficiary families, also perceived in the development of specific efforts towards traditional (quilombolas and indigenous) and specific communities (incarcerated or formerly imprisoned mother. The Primeira Infância Melhor policy is a great example of technology, innovation, and social development, due to the size of its structure. The implementation of the actions and the achievement of solid results come from managers committed to early childhood - and consequently a better society - as well as a great team that does not measure efforts, because their technical knowledge supports permanent investments in favor of an ideal that continues with legitimacy. In general, the policy is constantly strengthened by the authenticity of its existence.