AssessingtheProgramforEarlyChildhoodProtectioninColombia:Itseffectson

theCaribbeanRegion
Introduction
Currently, one of the main objectives of governments is to conduct planning, design and
implementation of public policies that aim to improve the populations welfare and quality of life,
in general and specifically for children. The general lack of child care is a problem that worries
governments. According to a report by the World Health Organization (WHO, 2012),
approximately 6.9 million children under five years old died in 20111. The causes of death are
associated with malnutrition and respiratory and diarrheal diseases. Children who escape death have
sequelae and are less productive as they grow. Several studies show that productive and educational
performance depends largely on early childhood development2. Thus, governments in developing
countries have implemented various policies to address this problem. As has been noted, in
developing countries, social programs are paramount in terms of the quantity of resources invested
and the size of the beneficiary population, even though there is still the perennial need to ensure the
efficient use of resources3. These programs or interventions include the provision of nutritional
supplements, price subsidies, cash transfers and childcare programs. Despite these efforts,
continued attention to the pediatric population remains a priority in the public health agenda.
In Latin America and the Caribbean, various social protection schemes for the health of mothers
and children have been designed and implemented, including the following: the Seguro Universal
Materno-Infantil (SUMI, Universal Insurance for Mother and Child) of Bolivia, the Plan de Salud
Familiar (PSF, Family Health Plan) of Brazil, Ley de Maternidad Gratuita y Atencin a la Infancia
(LMGYAI, Free Maternity and Child Care Law) of Ecuador, the Bono Materno-Infantil (BMI,
Mother-Child Bonus) of Honduras, and the Programa de Educacin, Salud, y Alimentacin
(PROGRESA, Program for Education, Health, and Nutrition) of Mexico. In Colombia, the first
scheme for mother and child protection was Programa de Extensin de Servicios de Proteccin
Materno Infantil (Extension Program for Mother and Child Protective Services), which in 1973
took the name of Programa Materno Infantil (PMI, Mother-Child Program). Among its objectives,
the program sought to reduce the rate of maternal and child rates of mortality and morbidity from
infectious and parasitic diseases, to improve coverage of preventive services and to reduce the

prevalence of protein-calorie malnutrition4. As a result of these programs, child malnutrition

indicators have improved substantially since the 1970s, despite the stagnation evidenced in the first
half of the century5.
Focusing on comprehensive infant health, nutrition and stimulation in families affected by extreme
poverty and malnutrition, the research conducted by the Instituto Colombiano de Bienestar
Familiar (ICBF, Colombian Institute of Family Wellbeing) allowed the central government to
establish the Programa de Hogares Comunitarios (HCB, Community Homes Program) in 1987.
Once it established this program, the government made changes to achieve greater efficiency in
allocation and targeting. Conditional transfers were among these changes, leading to the
establishment of Programa Familias en Accin (Families in Action Program), which is still in
force, in 1999. In addition to these programs, the Programa de Crecimiento y Desarrollo (PCD,
Growth and Development Program) is a social protection program for the health of mothers and
children. This program stems from UNICEFs request to include information on childcare and
childrens play forms, which are related to early childhood development6. The PCD was established
in the 1970s and has since then been subject to change. It is worth mentioning one modification
from Resolution 0412 of 2000, which introduced the so-called Norma Tcnica para la Deteccin
Temprana de las Alteraciones del Crecimiento y Desarrollo en el Menor de 10 Aos (Technical
Standard for the Early Detection of Changes in Growth and Development in Children under the Age
of 10).
The attention on the early detection of changes in the growth and development of children under the
age of 10 is defined as the set of activities, procedures and interventions that are aimed at this
population. Among these activities, procedures and interventions, it is worth mentioning the regular
and systematic attention that is needed to detect the disease in a timely manner, facilitate diagnoses
and treatments, reduce the length of the illness, prevent sequelae, reduce disability and prevent
death7. The potential beneficiaries of this standard are all infants affiliated with contributory or
subsidized regimes, from birth until 10 years of age. For this standard, the programs basic strategy
is to provide parent education on the infants comprehensive health care. The characteristics of PCD
services include developing medical history, recording and analyzing weight and growth, providing
guidance for parents about the warning signs that must be promptly consulted, investigating the

fulfillment of recommendations of the physician or nurse in previous control, taking physical

assessments according to the childs age, and reviewing the vaccination scheme, among other
activities.
The programs central objective primarily concerns the prevention of childhood death. This
objective is in line with the current Millennium Development Goals set by the United Nations
Development Programme (UNDP). By 2015, these goals seek to reduce the mortality rate of
children under five by two-thirds8. Meanwhile, Colombia is committed to reducing mortality to 17
deaths per 1,000 live births in children under the age of five and to 14 deaths per 1,000 live births in
children under the age of 1. With the Programa Ampliado de Inmunizaciones (PAI, Expanded
Immunization Program), Colombia also seeks to achieve and maintain vaccination coverage at 95%
for children under the age of five in all towns and districts of the country. The diagnosis for the
Caribbean is not the best. The results for the Caribbean region indicate that the infant mortality rate
in 2006 was 17.8 per 1000 live births, which was above the national average (15.5) and the target
for 20159. Magdalena and La Guajira are the departments with the highest rates (21.9 and 21.1,
respectively).
Notably, the Colombian Caribbean region represents 21% of the total population projected by the
Departamento Administrativo Nacional de Estadstica (DANE, National Administrative
Department of Statistics)10, and it also has 24% of the population of children under the age of 5.
Poverty levels in the region are the highest in the country. Let us take a glance at these figures. The
national poverty level reached 37.2%, while the extreme poverty level reached 12.3%. At the
national level, the results for the Caribbean region were the highest with 56.7% of the population in
poverty and 22.6% in extreme poverty. The departments of Crdoba, La Guajira, Magdalena, Sucre
and Cesar were positioned as the poorest in the country11. These figures show that the real problem
that the Caribbean region currently faces and the need to assess the impact of any policy
implemented at the national level that aims to alleviate poverty in this territory.
In turn, the Plan Nacional de Desarrollo, 2010 2014 (National Development Plan, 2010 2014)
states that in 2005, according to the Encuesta Nacional de Situacin Nutricional (ENSIN, National
Survey of Nutritional Status), global malnutrition affected 5.4% of children under the age of five

with major regional differences12. The Caribbean region showed the highest prevalence of
malnutrition: 9.6% of children under the age of five had low weights for their age, i.e., they
presented underweight and 13.6% had low heights for their age, a phenomenon called chronic
malnutrition13. In this variable, the results were also above the national average, which stood at
12%.
This article aims to assess the impact of the Programa de Crecimiento, Desarrollo y Cuidado del
Nio (PCDCN, Program for the Growth, Development and Care of the Child) in the Caribbean
region. The evaluation is performed on variables such as nutritional status, anthropometric and
health indicators of children under five years of age, and maternal childcare practices. Thus, this
research takes a step forward by becoming the first to assess Colombian public health policy at the
regional level.
For this purpose, we employ quasi-experimental propensity score matching (PSM) techniques for
two reasons. First, there are differences in the characteristics of relevant variables among children
enrolled in PCDCN and eligible children who do not receive program benefits, which may imply a
bias. Second, the scope of the programs coverage is not universal, which allows for a large control
group with adequate variability. The program is evaluated by taking into account the location of
infants. In this way, we contribute a technical evaluation of a program that, despite its importance
for childrens health in the Caribbean region, has not yet been investigated.
Despite having no evaluations for such programs at the regional level in Colombia, there are other
programs for children that have been subject to assessment at the national scale. One of these is the
so-called Hogares Comunitarios de Bienestar (HCB) of the Instituto Colombiano de Bienestar
Familiar (ICBF). Ambiguous evidence has been found of the impact of this program14. While there
are gains in chronic malnutrition for children between two and four years of age, the program
negatively affects the prevalence of acute respiratory infection and diarrhea. The impact of the
subsidized health scheme was also determined. Likewise, a null effect of HCB on childrens heights
was found, and there was a positive impact on the birth weights of infants from the poorest
households15. In a similar program, the Departamento Nacional de Planeacin (DNP, National
Department of Planning)16 finds that Familias en Accin reduces the likelihood of a child suffering

from chronic malnutrition by in 7%. These programs common denominator is their relative success
in terms of nutrition, even when the results are not favorable in other child development areas.
In the international arena, we find social programs, e.g., the Transferencias Monetarias
Condicionadas (Conditional Cash Transfers), that give monetary transfers to mothers if their
children are keeping up with vaccinations and preventive health visits and/or attend school
activities. In Mexico, Oportunidades is a program whose main objective is to help families living in
extreme poverty to overcome this condition. In the long term, this program specifically aims to
break the intergenerational poverty cycle by investing in human capital through education, health,
food, property improvement and social protection17. In Brazil, the program that was initially named
Bolsa Escola gave a monthly cash amount to excluded families, as long as all school-age children
were attending classes at least 90% of schooldays18. Now called Bolsa Familia, this program
evolved into a comprehensive program that involves health and education19. We can also highlight
other programs, such as Head Start in the United States and the Health and Education Program for
Early Childhood Development in Jamaica. In Colombia, the design and implementation of Familias
en Accin was inspired by the success of its Brazilian counterpart, Bolsa Famlia.
In turn, for the Mexican program Oportunidades, which is now called PROGRESA, evidence
suggests a positive effect on childrens heights20. Meanwhile, the Brazilian program Bolsa Familia
improves the nutritional status of participating children21. This programs impact on immunization
schedule implementation in children between zero and six years of age was scrutinized. The results
suggest that Bolsa Familia does not affect the probability of child immunization22. Another relevant
intervention showed that the Head Start program in the United States had a positive impact on
childrens educational achievement23. In a similar way, the Bangladesh Integrated Nutrition
Program (BINP) became the object of an impact assessment24. The evidence showed that the BINP
had no significant impact on malnutrition indicators. Finally, the Bolivian Proyecto Integral de
Desarrollo Infantil (PIDI, Comprehensive Child Development Project) was evaluated. The results
showed that the program improved early cognitive skills and nutrition25. Each of these programs has
been assessed, and their results differ, though their goals were similar. The main idea is that these
interventions can improve the nutritional and educational conditions of children in their early years.

Methodology

Data
This article uses data from the Colombias Demographic and Health Survey (DHS), which was
developed in 2010 by PROFAMILIA. The DHS uses a stratified, clustered, multistage probability
sample design to obtain a nationally representative sample of women of childbearing age, their
spouses and their children under the age of five. The questionnaires ask about the households
socioeconomic and demographic characteristics. Mothers were asked if their infants under the age
of five were enrolled in PCDCN, and, if so, they were asked to show their membership cards. The
questionnaires include modules on health, nutrition and childcare practices. From these modules,
we extract the group of variables that we are interested in to measure the impact of PCDCN. Table
1 summarizes these variables.
Table 1.
The infants eligible to participate in the PCDCN are those who belong to contributory or subsidized
health regimes. The first of these systems is designed for people with formal labor incomes, while
the second is aimed at the poorest population. The total number of eligible children is classified in
two groups: participants and non-participants. The first consists of children enrolled in the
PCDCN at time of the survey. Children who reported being PCDCN beneficiaries but who did not
show membership cards are not considered in the analysis. This exclusion does not imply a
substantial loss of observations (4% of all children enrolled in the PCDCN). The non-participant
group includes all potential beneficiaries who reported not being enrolled in the program.
The total sample consists of 3,648 children between zero and five years of age, of which
approximately 74% participate in the program. In addition to the total sample, the PCDCN also
evaluates three characteristics: individual, household and place of residence. In terms of the first
characteristic, the variables are the ages of the head of household and the mother, the mothers
employment status, the mothers marital status, the mothers years of education, prenatal visits,

whether the delivery is institutional, the childs sex, the infants age in months, and the childs birth
order. The second characteristics variables include total family members and the number of
children under the age of 5. The place of residence is assessed as urban or rural.
The age range subsamples are from zero to two, two to four, and four to five years of age. This
study is geographically bounded by the Caribbean region and four sub-regions. The first sub-region
consists of the departments of La Guajira, Cesar and Magdalena. The second sub-region consists of
the District of Barranquilla (metropolitan area). The third sub-region consists of the departments of
the Atlntico (without Barranquilla), San Andrs and Bolvar (north). The fourth sub-region
includes the departments of Bolvar (the rest of the territory), Sucre and Cordoba.
The exercise is not performed by simultaneously discriminating by age and health scheme type, as
this simultaneous discrimination would considerably reduce the sample size. For this reason, we do
not consider the programs effect on ADD treatment for the age sub-samples.

Empirical Strategy
In this study, we use the propensity score matching (PSM) technique. This method evaluates an
interventions impact in an effort to answer the following question: What would have happened to
the beneficiaries if the intervention had not happened?26 This method involves simultaneously
observing the same individual in two scenarios, which is naturally impossible. These authors
propose using the conditional probability of participation in the program to identify the
counterfactual of individuals in the treatment group as follows:
P(Z 1/ X )

[1]

More specifically, an individual in the control group will be the counterfactual of an individual in
the treatment group if both are about equally likely to participate in the program, given a set of
covariates. One advantage of this procedure is that it summarizes important characteristics of a
number of individuals, which makes pairing easier. The underlying assumption behind this strategy

is that the probability of program participation and the target variables only depends on variables
that the researcher observes.
Formally, the average treatment effect on the treated (hereafter, ATT) is defined as follows:
ATT E[{E[Y(1) \ Z = 1, P(X)} - E{[Y(0) \ Z = 0, P(X)} \ Z 1 ] , [2]

where

1 and

0 denote the observed result of the target variable in the control and treatment

groups, respectively. In this study, the estimate of (2) is made by imposing the common support
restriction. More specifically, we use the minimum-maximum criterion, which discards the
observations in each group whose participation is less likely (more likely) than that of the minimum
(maximum) of the other group. This criterion ensures that the compared individuals are indeed
comparable27. We use a logit model with robust errors in the functional form of participation
probability. The literature agrees that there are no critical differences between logit and probit
models when the variable defining the treatment is binary28. To identify counterfactual results in the
control group, the pairing was performed using two techniques: maximum distance (CM) and local
linear regression (LLR).

Maximum Distance
Often called caliper matching, this algorithm is one of the best-known methods in the literature.
The CM method matches the treated i with an individual j in the control group that has the closest
chance of participation in a previously set neighborhood. This procedure can be performed with or
without replacements, and this choice involves a trade-off between bias and efficiency. The
literature suggests performing replacements when the participation probability is asymmetrically
distributed between participants and non-participants29. In formal terms, the counterfactual j,
of participant i is equal to the following:

C(i) j Z 0 Pi ( X ) Pj ( X )

[3]

where is the maximum difference that may exist in the participation probability of the
counterfactual j and the treated i. We set equal to 0.2 times the standard deviation of the
participation probability30. The ATTs standard error is analytically estimated31.

Local Linear Regression Pairing

Local linear regression pairing is a non-parametric pairing method32. The basic idea of the
algorithm is to pair each participant with a weighted average of several or all individuals in the
control group. The weight,

, allocated to each control group individual depends on how far this

individual is in terms of the treated is participation probability. The more dissimilar the
probabilities of participation of the two individuals, the lower the weight allocated to the control
group individual will be. Each weight is obtained by making a weighted regression of

0 against

the participation probability in a given neighborhood by treatment group. Therefore, we need to

choose a kernel function, although it is not crucial in practical terms33. The choice of this functions
bandwidth parameter is of utmost importance because it involves a trade-off between bias and
variance34. We use the Gaussian kernel with a bandwidth of 0.06. Thus, the ATT estimator is
expressed as follows:

ATT iZ 1 Yi jZ 0Wij (Y j )

[4]

where the standard error is estimated using bootstrap or Monte-Carlo estimation, which is adjusted
for household clusters. Compared with CM, one of the benefits of LLR pairing is the gain in
efficiency, as the algorithm uses more information from the control group35. In fact, LLR tends to
be more appropriate than other non-parametric pairing techniques (e.g., PSM kernel techniques),
when the distribution of participation probability between participants and non-participants is
asymmetric.

Results

Table 2 presents descriptive statistics of the variables that can affect the probability of program
participation and the outcome variables. These variables correspond with those commonly used in
impact assessment studies on child health and nutrition36. In general, significant differences
between PCDCN participants and non-participants are observed in the Caribbean region. We also
note that the number of PCDCN participants exceeds the number of nonparticipants.
In terms of the incidence of acute and chronic malnutrition, the odds are higher in non-participants
than in program participants. The difference is 5 p.p. and 3 p.p. (participation probability),
respectively. The early indicators of nutritional status for this analysis are obtained from the
variable heights for age. We standardize this variable for each child observed in the DHS of the
Colombian Caribbean region according to the difference between the childs height and the median
height of healthy children of the same age (Z-score). In Figure 1, we present the kernel density
function for height by age (Z-score) for children younger than five in the reference region37. This
density function indicates that chronic child malnutrition exists in the Caribbean region is a relative
degree of concern, although there are programs that attempt to mitigate the impact of this problem.
Table 2.
Figure 1.

The prevalence of ADD is higher for non-beneficiaries, which is one of the most significant
differences at approximately 23 p.p. In terms of IRA and ADD treatment, the results were very
similar: differences of 16 p.p. and 17 p.p., respectively. The average number of antenatal visits is
higher for participating mothers than for non-participants. This finding had already been evidenced
in Colombia38. The average age of household heads is approximately 45, and the average age of the
mother, considering the last childbirth, is 19. As for schooling, the mothers participating in the
program have one more year of education than do non-participants. Mothers in the treatment group
have worked less in the past week, approximately 1.31 days fewer than mothers in the control
group. Some variables (e.g., institutional delivery, mothers marital status, childs sex and number

of children under the age of 5) are similar in program participants and non-participants. The results
of their place of residence are 68 p.p. for program participants and 59 p.p. for non-participants.
The ages in months of children in the treatment and control group are 37 and 31, respectively.
Thirty-seven percent of the beneficiary children are first-born children, while this figure is 31% for
non-beneficiary children.
In sum, the evidence suggests that treated individuals are a group of infants from households with
fewer members and children, most of whom are located in urban areas. These infants mothers
make higher average prenatal visits, have higher odds of giving birth in a hospital, work in smaller
proportions and have higher educational levels. These differences in socioeconomic and
demographic variables between groups of beneficiaries and non-beneficiaries deserve to be
considered in any impact assessment. The failure to consider these differences can result in a bias in
estimating the impact of PCDCN.

Results of estimates
The logit model used to estimate the participation probability presents a good fit in all estimated
models. Figure 2 describes the common support region. Here we detail the participant group and the
comparison group selection. The distribution of observed characteristics is similar to the
distribution in the participant group. We restrict the analysis to all treated individuals and all control
individuals who meet the equilibrium property of all of the variables involved in the estimation. The
groups are thus comparable, and the PSM method can be applied to estimate the programs effects.
The final specification for each model is obtained recursively. We perform iterations until there are
no significant differences in the explanatory variables of participants and non-participants per
strata of the participation probability. On average, the number of observations was 2,561. The
significant variables are head of households age, mothers occupation, years of maternal
education, prenatal visits, institutional delivery, childs age in months, first-born child, and total
family members. As shown in Figure 2, the common support region includes [0.25 and 0.99] for the
first logistic regression, from a theoretical range between 0 and 1. A criterion is taken to choose the

optimal number of strata39. The optimal number of strata is 8. The most relevant variables that
explain the decision to participate in the program concern household composition, the mothers
characteristics and geographic location.
In addition, infants from families with fewer children between zero and five years of age and with
mothers who do not work are more likely to be enrolled in the PCDCN. Higher numbers of prenatal
visits and years of maternal schooling indicate a higher probability of enrolling children in the
program. Territoriality was not a determinant element to belong to the treatment group due to
problems of collinearity and non-significance with the rural variable.
Figure 2.
Table 3 shows the distribution of participation probability among beneficiaries and nonbeneficiaries in the total sample. In these results, there is a degree of asymmetry between the two
groups. In essence, while there is a higher proportion of participants in the highest percentiles of the
distribution, the opposite is true in the lowest percentiles, which suggests the need to perform the
pairing with CM replacements. To assess the quality of the matching, we test whether the set of
explanatory variables for participation probability is balanced between treated and untreated
individuals. To do so, we calculate the standardized size bias (TSE)40. If the pairing quality is good,
the TSE value for each variable should be approximately 3% to 5%41. As seen in Figure 3, most of
the TSE values are larger before pairing. When we compare treated individuals with their respective
counterfactuals in the control group, these values are significantly reduced, except for the mothers
marital status; they are thus located near the thresholds of tolerance. In this regard, the evidence
suggests that the match quality is good.
In terms of the ATT estimates for the Caribbean region that are described in Table 3, the results
indicate that the PCDCN has a positive impact on ADD reduction, complete vaccination and the
treatment of ARI / fever. More specifically, the probability that a child has the full immunization
scheme for his/her age increases by almost 6 p.p. if he/she participates in the program. Likewise,
beneficiary infants are approximately 12 p.p. more likely than non-recipients to receive medical

treatment when ARI or fever symptoms arise. Meanwhile, the programs impact on the prevalence
of ADD is negative, while it is null in the other outcome variables.
Table 3.

Discussion
The impact assessment of PCDCN in the Colombian Caribbean region shows evidence that ADD
decreased and that immunization and seeking treatment to address ARI or fever symptoms
increased. It is important to note that the program has no impact on chronic malnutrition and acute
malnutrition in the region. Mothers lack of education on issues related to early childhood care,
which seems to play a major role in the region, may partly explain this finding. There is evidence
that malnutrition is a major cause of the prevalence of ADD42. The data reported here are irrefutable
evidence of the problem that arises around childrens nutritional statuses and the prevalence of
ADD, which implies that the effects of PCDCN are essentially confined to children from the
regions poorest families.
We find a null impact of PCDCN on chronic malnutrition for all of the evaluated groups. A similar
result was found for the PINB. Indeed, the PINB had no significant impact on child malnutrition
indicators in Bangladesh43. However, our result differs from those found for the Brazilian Bolsa
Familia program. Evidence has shown that this latter program improves the nutritional status of
participating children44. Our result also differs from that obtained for the HBC program in
Colombia. The HBC program has positive effects on the nutritional status of Colombian children
between two and four years of age. One possible reason for this difference is that the HCB program
is only intended for poor families, and we do not discriminate by household economic status and
age groups in this study45.
As relates to measuring the program impact, it is worth mentioning that the PSM enabled the
fulfillment of the conditional independence assumption. In other words, once all relevant observed
characteristics were controlled, comparison units should have had, on average, the same results as
the treatment units would have had in the absence of intervention.

As enunciated above, there is a TCM program called Familias en Accin, which has many more
variables that can influence the growth, development and care of children in Colombia. This lack of
variables can be considered a limitation of PCDCN. However, although checking all suspected
variables that may influence treatment participation is advisable, controlling many variables can
also be troublesome. This consideration is particularly important in fulfilling the common support
hypothesis, which is critical in properly characterizing the PSM. Finally, we recommend that further
studies increase the sample size to the extent that it will enable the performance of simultaneous
contrasts with different variables. This fact would facilitate the observation of various program
impacts. In addition, studies should also consider how long children have been in the program and
perform estimates using temporal information to improve these estimates in terms of the incomes of
participating households.

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