Sustainable Cities, Smart Investments: A Characterization of “A Thousand Days-San Miguel”, a Program for Vulnerable Early Childhood in Argentina

Abstract

In this paper, we provide a thorough description of the “Programa de Acompañamiento Familiar Mil Días” (A Thousand Days, Mil Días), introduced in 2015 in the Municipality of San Miguel, Buenos Aires, Argentina. The program is targeted at pregnant women and mothers with children of up to two years of age who are in a situation of extreme social and health vulnerability. While the target relevant period is the first thousand days of life, from gestation to two years of age, the intended duration is about a year, or until entrance criteria are overcome. We combine statistical analysis of the program’s primary data with qualitative analysis from two in-depth interviews. Our evidence confirms that Mil Días-SM effectively reaches a highly vulnerable population that exhibits interlocking material and educational deprivations, frequently combined with conflict-home environments, and children experiencing health neglect. The one-on-one mentoring provided through the program, along with a battery of other interventions, brings knowledge and support to these families. Children start receiving appropriate stimuli, mothers become aware of the importance of health care for them and their children, and they start feeling more empowered to take command of their lives and families. While the program exhibits remarkable attributes, we identify three aspects in which it could be improved: extending the intended duration time, reducing its dropout rate devising tools to retain the most vulnerable cases, and scaling up its coverage. Current evidence suggests programs like Mil Días are smart investments that can simultaneously contribute to achieving several Sustainable Development Goals.

1. Introduction

Human development is about expanding people’s choices and promoting the realization of every human being’s potential. Research on the economics, psychology, and neuroscience of human development has revealed that early childhood constitutes a foundational period in a person’s life [1,2]. The human brain reaches 80 percent of adult size in the first three years of life and 90 percent in the first five years [3]. Thus, early childhood is “a window of opportunity for resolving early inequity and achieving inclusive and sustainable social and economic development” ([2], p. 57). Events in early life affect the development of the brain’s circuitry, the dynamic gene-environment interactions, and the programming of the body’s immune, neurological, and endocrine systems [2], based on [4,5,6], among others.

Being born into poverty is an event that, if not counterbalanced early in life, has long-lasting implications, placing that human being on a lower human development trajectory than he or she could have had in a non-disadvantaged environment. Children born in poverty are multiply deprived, starting from poor nutrition and health neglect, which, in turn, can cause irreversible deprivations in many capabilities [3,7]. Importantly, “disadvantage arises more from lack of cognitive and noncognitive stimulation given to young children than simply from the lack of financial resources” ([1], p. 1900).

There is a substantial body of evidence, to which Nobel Laureate Prof. James Heckman and colleagues have significantly contributed, that shows that what is socially fair can also be economically efficient. Early interventions targeted toward disadvantaged children have much higher returns than later interventions. High-quality birth-to-five-year-old programs can generate returns of up to 13% per year (and prenatal investments can have even higher returns), whereas programs aimed at children between 3 and 4 years old have return rates that do not exceed 7–10% [8]. In other words, well-designed early childhood development (ECD) policies, especially those that promote parent-child interactions, are smart investments. They have high economic returns that more than pay for themselves [9,10].

One form of such ECD policies is home visit parenting programs by trained professionals or para-professionals, whose objective is “to provide caregivers the information and skills necessary to promote their children’s healthy development and learning” ([11], p. 2183). There have been several programs of this kind implemented in Latin America [3]. This paper analyzes one of such programs: the “Programa de Acompañamiento Familiar Mil Días” (A Thousand Days, Mil Días-SM hereafter), introduced in August 2015 in the Municipality of San Miguel, in the province of Buenos Aires, Argentina. It is a “Heckman-style” program aimed at pregnant women and mothers with children of up to two years of age who are in a situation of extreme social and health vulnerability. The program offers family support for childhood health and development in a deep and comprehensive way during the first thousand days of life, from gestation (270 days) to two years of age (730 days).

Argentina is a highly urbanized country which has registered high levels of poverty over the last thirty years [12,13,14,15,16]. As in other parts of the world, both income and multidimensional poverty exhibit higher rates among children: over 50% of Argentinean children are monetary poor, and 42% experience deprivation in at least one non-monetary dimension [17,18,19]. In 2017, 37% of children in the country between 0 and 5 years of age were multidimensionally poor, experiencing several simultaneous deprivations [20]. With a population of 326,215 people [21], the municipality of San Miguel belongs to the Great Buenos Aires area (GBA), the ring of urban agglomerations around Buenos Aires city (Argentina’s capital). The GBA concentrates 24% of the country’s population [22] and half of the country’s poor population [13,20,23]. In other words, Mil Días-SM is a program that has been implemented within one of the country’s pockets of urban poverty and it is targeted at a highly vulnerable group.

In this way, the Mil Días-SM program connects three of the Sustainable Development Goals (SDG). In the first place it embodies Targets 3.1 and 3.2 of SDG 3 (“Ensure healthy lives and promote well-being at all ages”), as the first goal of Mil Días-SM is the reduction of morbidity and mortality in pregnant women and children. In the second place, it naturally aims at Target 1.2 of SDG 1 (“End Poverty”), as its target population is multidimensionally deprived. Finally, it also contributes to SDG 11 of “making cities and human settlements inclusive, safe, resilient and sustainable”, reflected in the deprivations experienced by the program’s beneficiary population. Mil Días-SM also intends to fulfill the “Leave No One Behind” pledge of the 2030 Development Agenda.

The value added of this paper is threefold. First, we offer a detailed description of the program’s design, combining descriptive statistical analysis of the program’s primary data constructed by the authors with qualitative information collected throughout two in-depth interviews with the program’s general coordinator and the director of the department of Planning Public Policies for Early Childhood. This mixed-methods approach gives robustness to our analysis and informs us of the strengths and weaknesses of the program. This can help to improve Mil Días-SM itself as well as the design and implementation of other similar programs scattered throughout the country. Second, on the same lines, the analysis is useful for considering a scaling-up of the program, either reaching a broader population within the municipality or, going further, unifying a Mil Días program at the national level. Third, Mil Días-SM exhibits some features of “good policymaking” in a country in which good policymaking does not abound, so there are lessons worth highlighting.

The paper is structured as follows. In Section 2 we present a brief review of ECD programs in Latin America and in Argentina. In Section 3, based on the work of Chudnovsky et al. [24], we offer a succinct characterization of desirable features that favor a positive cycle of capacity building within the state. In Section 4, we describe the datasets and sources of information used. In Section 5, we describe the program’s design in detail and identify the features detailed in Section 3 that favor good policymaking. In Section 6, we offer a quantitative and qualitative analysis of the program. Finally, Section 7 concludes.

2. Mil Días-SM in the Regional and National Context

2.1. Previous Similar Programs in Latin America

There are different kinds of programs directed at early childhood (most commonly 0–5 years of age) in Latin America. These can roughly be classified into: (1) programs and services for childcare and early stimulation; (2) programs and services to enhance nutrition; (3) programs and services related to healthcare; and (4) other social programs, among which there are cash transfers (either conditional or unconditional) and in-kind transfers [3]. Naturally, these categories are not mutually exclusive; there are programs that combine different forms of interventions. Also, within the first kind of program, there are also different types: (a) nurseries and pre-school services; (b) childcare services run by mothers from the community in the homes of the mothers; (c) education for groups of parents; or (d) individual visits to homes to educate the family on issues of childcare, stimulation, health, and nutrition [3].

One influential study in the region was a pilot program called “Reach Up and Learn”, implemented in Jamaica between 1986 and 1989 and replicated in other countries. The program was aimed at children between 9 and 24 months, lasted for two years, and combined a component of nutritional supplementation with a component of stimulation delivered through home visits [25]. The program improved the cognitive development of the children and showed impacts in cognitive skills, education, wages, and mental health up to 20 years after its implementation. Later, Attanasio et al. [26] evaluated a large-scale randomized ECD in Colombia which tested isolated and combined interventions of stimulation and micronutrient supplementation through home visits. In that case, they found that only the stimulation component alone had significant positive impacts on cognition and receptive language.

In turn, Nores and Barnett [27] reviewed the evidence of 30 ECD programs (cash transfer, nutritional, educational or mixed) across 23 developing countries, including 9 from Latin America and the Caribbean, which implemented either a quasi-experimental or random assignment. They found that interventions that were either educational or combined with a nutritional intervention had the largest statistically significant effect on cognition, compared with interventions that were cash transfers or solely nutritional, but the independent effects of each intervention and potential synergistic effects have not been well-researched. Longer interventions had positive effects on health outcomes but negative effects on schooling (which was attributed to a possible trade-off between intensity and duration). They also found that behavioral effects were significantly larger for programs that begin with infant/toddlers or with preschoolers than for programs that begin with children across the full age range. On the same lines, Grantham-McGregor et al. [28]’s reviewed ECD programs combining a child development component (mostly through home visits) with a nutritional one and found that nutritional interventions usually benefited nutritional status and sometimes benefited child development, whereas stimulation consistently benefited child development. However, they found little evidence of synergistic interaction between nutrition and stimulation on child development.

Leer and Lopez-Boo [11] conducted an observational evaluation of 40 home visits of ECD programs across seven countries in Latin America and the Caribbean. They found strong rapport between visitors and families, and active participation in play-based learning activities introduced by the home visitor. However, they also found that other aspects of the home visit design, such as the revision of topics from previous sessions, demonstration of activities, and dialogue between the caregiver and the home visitor, were poorly implemented. Interestingly, Smith et al. [29] found that a low-cost parenting intervention implemented through health services (rather than home visits) in Jamaica for children ages 3 to 18 months benefited cognitive development at 18 months, but the effects faded out by age 6. The authors attributed this lack of sustained benefits to the small initial effect size and low intensity of the intervention, which ended very young, as well as a lack of impact on the home environment.

The Mil Días-SM program, whose main intervention tools are home visits alongside stimulation in Infant-Family Development Centers (CDIFs), was inspired by at-scale ECD programs implemented in other Latin American countries, specifically: Chile Crece Contigo (Chile, in 2006), Uruguay Crece Contigo (Uruguay, in 2012), Programa Red Unidos—ex Red Juntos—(Colombia, in 2011), and Familia Paranaense (State of Paraná, Brazil, in 2012). Except for the one in Brazil, the programs are of national scope. These programs involve different policy actions, some of which are universal, but others are specific interventions, such as home visits targeted to families of children in disadvantaged families, which aim at promoting the skills of the main caregivers of children as well as developing and strengthening family bonds and social networks [30].

Chile Crece Contigo showed a positive effect on children’s development skills, but this result was only observed in communes with good program implementation [31]. Uruguay Crece Contigo’s home visits produced improvements in gross motor skills and had some positive effects on communication and socio-emotional health [31]. In turn, no significant effects were found in the case of the Unidos program, which is attributed to poor implementation of the program [32]. We found no evaluations of the Familia Paranaense program.

2.2. Previous Similar Programs in Argentina

In Argentina, until the 1990s, the basis of social policy was to provide public health care and education. Then, in the 1990s, in view of the increase in income poverty, some highly focused conditional cash transfer programs started to be implemented [33,34]. In 2002, amidst one of the major economic crises, a nationwide food stamp program—Tarjeta Alimentar—was introduced for vulnerable children of up to 14 years old, vulnerable pregnant women, and vulnerable people of 70 years of age or more, but the amount of the transfer was actually very meager [35]. Importantly, in 2009, a nationwide conditional cash transfer program for pregnant women and vulnerable 0–17-year-old children—the Asignación Universal por Embarazo (AUE) and Asignación Universal por Hijo (AUH)—was introduced in an amount equivalent to about 78% of the cost of the basic food basket (the Indigence Line in Argentina). This program has remained since then, becoming the flagship national social policy.

Using simulations, AUH is estimated to reduce the overall monetary poverty rate (between 1 and 2.5 percent points) as well as the poverty gap [36,37,38], and the effects are estimated to be higher for children 0–17 years [37]. Using quasi-experimental techniques, the program has also been found to increase school attendance [39], and to produce significant improvements on intra-year dropout rates and primary school completion rates [40].

However, programs focused on ECD, with more one-on-one intervention tools have been scarce in Argentina so far. One first program of such kind was the “Primeros Años: Acompañamos la crianza”, introduced in 2006. “Primeros Años” is a national program with the aim of strengthening the parenting abilities of families with children between 0 and 4 years of age in a situation of social vulnerability. Until 2019, the main intervention tools were home visits and group meetings and workshops in community spaces, and it intended to have an inter-ministerial approach. Nevertheless, at the time the Mil Días-SM program was implemented in August 2015, “Primeros Años” was still not operational, as there had been lots of difficulties in the coordination across the different involved ministries [41,42]. Thus, in practice, Mil Días-SM was—effectively—a pioneer early childhood development program in Argentina. In November 2016, “Primeros Años” was pushed forward via a decree, which changed its coordination. This resulted in a successful implementation of this program in many provinces, including Buenos Aires [43], reaching a coverage of approximately 23,000 children [44]. While the program is still active, with the change of government in 2019, the home visits were no longer continued.

Another remarkable experience in ECD policies is that of the province of Salta, which was the first and only province in the country to have a ministry on early childhood, created in 2014. However, in 2019, this dependency was lowered in rank and became the Secretariat for Early Childhood, Childhood, and Family, which depends on the Ministry of Social Development. Notwithstanding that, some of the initiatives that existed in the ministry continued. The most important one is the UNIR Program, targeted at children from indigenous groups in rural areas. UNIR embodies several interventions, which include home visits and workshops in which parents participate with their children, to promote good parenting practices, care habits, and safe water handling while respecting cultural diversities [45].

Some years after Mil Días-SM program was implemented, other similar programs with the same name were started either at municipal or provincial level [43]. Then, in January 2021, a program with the same name was started at the national level. The law that created this national program aims to implement a very similar set of interventions to Mil Días–-SM plus some additional cash transfer benefits as a complement to the AUE and AUH programs. However, by November 2022, the national Mil Días program, in practice, only consisted of cash transfers, offering no family mentoring [43,46].

The mentioned ECD programs have not been implemented in an experimental way, and thus, their impact has not been evaluated. However, CNPS [47] offered a “before-and-after” quantitative analysis (2016 vs. 2011) as well as a qualitative analysis of the Primeros Años program, which suggested positive results. The analysis registered an increase in the number of families that read and play with their children and a higher father’s involvement in their upbringing. The study also found that participants valued the support and mentoring they received from the program. In turn, the Mil Días-SM program was qualitatively evaluated by CIPPEC [48] through in-depth interviews to 30 mothers that had participated in the program across four of the eight neighborhoods where the program is implemented. The evaluation highlighted the positive valuation the mothers gave to the support received from the program’s home visitors, which helped the mothers to sort out domestic conflicts and improve intra-household communication. The mothers also appreciated the support to schedule medical appointments, the information received on children’s care and on ways to administer material resources, the enrollment of children in the CDIFs, and the help to obtain their children’s national ID.

Then, González and Santos [43] offered the first quantitative analysis of the Mil Días-SM program using primary data digitalized, systematized, and processed by the authors. The paper studied the targeting of the program, the dropout correlates, and the “time to graduation” correlates. The paper found that the program is well targeted. It also found that program participants in more extreme, vulnerable situations are more likely to leave the program and that successful exits from the program take longer in more complex cases.

3. The Context of Policy Making in Argentina

Within the political economy literature, Argentina has been identified as a country in which the process of policymaking is—most commonly—quite poor. Institutional arenas—such as the Congress and political parties—are typically weak and thus, in practice, “alternative political technologies” have a higher prominence [49]. Spiller and Tommasi [50]’s characterization of Argentinean public policies highlights that these tend to be volatile (every new government changes policies), which affects policies’ credibility. These authors also point that Argentinean policies tend to be poorly coordinated across government levels and across ministries and secretariats within the same government’s level.

Interestingly, however, “the State capacity is an iterative construction process, such that positive and negative cycles of state capacity building can co-exist.” (…) A positive capacity building cycle occurs when “the authorities implement the policies they consider to be a priority, through the state agencies with greater capacities to carry them out, and correct actions as they learn from the experience” [24]. Chudnovsky et al. [24] identify five key capabilities that conform a positive cycle of state capacity building:

(1)

Organizational capacity, which refers to the concordance between the goals of the organization and the resources, processes, and infrastructure it has.

(2)

Budgetary capacity, which refers to the amount and autonomy to administer the budget.

(3)

Civil service capacity, which refers to the technical characteristics of the civil service, training and stability.

(4)

Ability to reach, which refers to the ability to reach the target audience in the territory and overcome resistance by organized groups.

(5)

Political capacity, which refers to both the construction of power and recognition of other agencies of equal hierarchy within the public administration (horizontal political capacity), as well as of authorities superior to those of the agency (vertical political capacity).

We understand that Mil Días-SM is a case of a positive cycle of capacity building because it exhibits favorable features in most of the five key mentioned capabilities. We will briefly argue on each of them in Section 5, when describing the program’s design.

4. Data and Methodology

We use two quantitative data sources and two qualitative information sources. In the first place, we use the quantitative program’s participants dataset, with information on the 1111 participants who were admitted to the program between August 2015 and May 2019, the cutpoint for this analysis (there is no specific reason for that cutpoint other than having to select some point in time to start processing the data). This dataset was manually constructed. We digitalized over 470 surveys that had been completed on paper upon participants’ application to the program. These surveys contain information on both mothers and children who have entered the program. These data were merged with information on program participants contained in the Family Support Monitoring System (SAF), the single digital registry for monitoring vulnerable families. The merging of the data required artisanal work, as the SAF is a rudimentary system. Of the 1111 total program participants, we have data from both the paper-based survey and the SAF for 670 cases, and for the other 441 cases, we only have the SAF data because the paper-based surveys were incomplete or lost, which means we do not have information on some of the socio-economic characteristics for these participants. Also, of the 1111 program participants, 598 were mothers or pregnant women, and 513 were children.

We compare the information from the program’s participants with microdata from Sistema de Información, Evaluación, y Monitoreo de Programas Sociales (SIEMPRO) [51], our second data source, which provides information on beneficiaries of all types of social programs; in this case, the data corresponds to beneficiaries of the Municipality of San Miguel.

In the third place, we draw qualitative information from two in-depth qualitative interviews the Mil Días-SM program’s general coordinator (GC hereafter) and the director of the Department of Planning of Public Policies for Early Childhood. In such interviews, these coordinators provided valuable complementary information to the quantitative analysis. We also held repeated informal personal communications with these and other program coordinators throughout 2018 and 2019. Finally, we also articulate the analysis with CIPPEC [48]’s qualitative analysis mentioned in Section 2. This secondary source of information reinforces and validates the conclusions drawn from the quantitative analysis and our own collected qualitative information.

The quantitative method used in this paper is descriptive statistical analysis, with hypothesis tests of differences in means and proportions. That analysis is complemented with the mentioned qualitative information.

5. Mil Días-SM Program’s Design and Implementation

5.1. The Coordination of Early Childhood, Childhood, and Family (CPINF)

Until 2014, the Municipality of San Miguel had different uncoordinated ECD policies, with actions from the Secretariat of Health and Family Welfare, the Secretariat of Social Development, and the Local Council for the Promotion and Protection of Children’s Rights. In 2014, the municipality conducted a socio-economic diagnosis based on 2010 Census data complemented by municipal administrative statistics. The diagnosis revealed a great need to work much more intensely and in an interconnected way on vulnerable early childhood. Thus, the municipal government created, within the Secretariat of Health and Family Welfare, the Coordination of Early Childhood, Childhood, and Family (CPINF, hereafter, acronym for the name in Spanish), with an integral and rights-based approach [52] (CPINF, 2017). From then on, the CPINF concentrated and articulated all municipal policy actions related to early childhood, childhood, and family.

The creation of the CPINF gave the appropriate institutional framework for the implementation of the Mil Días-SM program. Three departments were created within the CPINF: (1) a department for the Planning of Public Policies for Early Childhood (DPPPI hereafter), (2) a department to provide and supervise the Infant-Family Development Centers (CDIFs), which are spaces for support, stimulation, and sociability for children between 45 days and 3 years of age who live in vulnerable situations, and (3) a department of Promotion and Family Wellbeing, which coordinates the Mil Días-SM program.

In terms of the capabilities enumerated in Section 3, the CPINF constituted the required organizational capacity for a positive cycle of state capacity building. It is an agency with the required rank and functional hierarchy in the organizational chart of the municipality to favor concordance between the goals of the program and the institutional organization to achieve them. Both the creation of the CPINF and the implementation of the Mil Días program were pushed by the highest political level of the municipality (the mayor). The Health and Family Welfare Secretary also had a great interest in the successful implementation of the program. The mayor that followed continued supporting the program. All this contributed to the construction of power, and the CPINF gained both horizontal and vertical recognition. That is, political capacity, as described in Section 3, was built.

5.2. Motivation, Target Population, Intervention Instruments and Goals

As mentioned in the introduction, early childhood constitutes a foundational period in a person’s life. Up to age 3, the brain is influenced by environmental factors, including nutrition, affection, sensory stimulation, and care, producing a greater number of synapses than those generated at later ages [5,9,52]. This is a period of great “plasticity”, i.e., the sensitivity to environmental stimuli is heightened [5]. Adverse environments characterized by food deprivation, exposure to an unhealthy environment, and lack of emotional stimuli can threaten children’s development, hindering their possibility of reaching their potential. Thus, ECD is not only the responsibility of the family but also of the state, which, through specific ECD policies, can help to level the playing field. This is the motivation of the Mil Días-SM program. The program aims to early identify families with pregnant women or children under 2 years of age in the Municipality of San Miguel in a situation of extreme social and health vulnerability, support them, and mentor them so that they can overcome certain particularly threatening deprivations or, in certain cases, learn to deal with permanent health conditions.

The first goal of Mil Días-SM is the reduction of morbidity and mortality in pregnant women and children, but it also aims at guaranteeing a broader compliance with the rights of each child, increasing their quality of life, especially regarding their health and care [52]. To achieve that, the program seeks to promote the skills and abilities of mothers, enhance family resources, and strengthen ties and networks within the community. The target period is the first thousand days of life, a period that covers gestation (270 days) to two years of age (730 days). Children and mothers can enter the program at any point within those first thousand days. However, the program is not intended to last all the first thousand days of life; the intended duration of the program is about one year.

One of the main intervention tools is the home visits over the first six months of the program, which then evolve into meetings at the primary health care centers (CAPS). The other key intervention tool is the enrollment of children in the CDIFs. The program also includes several other kinds of interventions, which are coordinated with other government areas and tailored to the needs of each family, supporting a holistic approach to health and well-being. Through the home visits (then meetings at CAPS), the program tries to compensate for the caregivers’ lack of information and skills necessary for their children’s healthy upbringing. Through the enrollment at the CDIFs, the program intends to provide adequate stimuli for the children to develop their full potential. Through the other interventions, the program tries to compensate for a lack of certain material resources, such as nutritional food.

At the time of writing this paper, Mil Días-SM operated in the eight most vulnerable neighborhoods of the Municipality of San Miguel, selected from the diagnosis conducted in 2014. Initially, four vulnerable neighborhoods were selected: Trujuy, Mitre, Obligado, and Santa Brígida. In 2016, the program was extended to three other neighborhoods: Barrufaldi, Don Alfonso, and San Miguel Centro, and in 2017, the Sarmiento neighborhood was incorporated.

Table 1. Distribution of beneficiaries by neighborhood and year of entrance to the program. 2015–2019.

Neighborhood	2015	2016	2017	2018	2019	Total	% Total
Barrufaldi	0	46	22	43	20	131	12%
Don Alfonso	0	29	41	28	14	112	10%
Mariló/San Ambrosio/Trujuy	4	60	43	25	21	153	14%
Mitre	41	55	47	43	20	206	19%
Obligado	17	41	31	46	20	155	14%
San Miguel Centro	0	24	42	48	19	133	12%
Santa Brígida	28	37	38	41	21	165	15%
Sarmiento	0	0	16	35	5	56	5%
Total	90	292	280	309	140	1111	100.0%

Source: Own elaboration based on the Mil Días-SM data.

details the number of participants by year of entrance and neighborhood, adding to the total of 1111 participants that entered the program over the period under study.

5.3. Legal Framework

The Mil Días-SM program is founded on the following legal instruments:

• The Convention on the Rights of the Child (1989) (of constitutional status in Argentina since 1994).
• National Law No. 26,061, on the Comprehensive Protection of the Rights of Boys, Girls and Adolescents (2005).
• National Law No. 26,233, for the Promotion and Regulation of Child Development Centers (2007)
• National Law No. 26,485, on Comprehensive Protection to prevent, punish and eradicate violence against women and its Regulatory Decree No. 1011/10 (2009).
• Buenos Aires Provincial Law No. 12,569, on Family Violence and its Regulatory Decree 2875/05 (2000).
• Buenos Aires Provincial Law No. 13,298, for the Promotion and Comprehensive Protection of Children’s Rights (2005).

Altogether, these laws imply viewing children as individuals with their own rights, who “must be allowed to grow, learn, play, develop and flourish with dignity” [53], and that the State should implement active policies to guarantee those rights.

5.4. The Program’s Circuit

Figure 1 schematically depicts the program’s circuit. One key starting point is the Maternal and Child Units (UMI) of the Raúl F. Larcade Hospital, the biggest public hospital in the municipality of San Miguel. Children under two years of age and/or pregnant women attending the hospital are identified as potential candidates for the program through a multidimensional survey. The candidate’s application to the program is placed by the health care professionals into the SAF.

Another key starting point are the mobile municipal offices that are established for half a day in different neighborhoods, called “Children Points”, which are organized by the CPINF. The aim of the “Children Points” is to bring information closer to the population on the different municipal programs and benefits that are available, and conduct awareness campaigns on health care, vaccination, and other relevant topics. In these “Children Points” people can also book medical appointments, do children’s health and anthropometric checkups, and vaccinate their children; infants’ mothers can also participate in the open breastfeeding workshops. The “Children Points” are implemented precisely because it is frequently the case that the most vulnerable people do not attend the CAPS, the maternal-child units (UMIs), or the municipal offices. If potential candidates are identified in these mobile offices, the case is also submitted for the Mil Días-SM program through the SAF [52].

Once the CPINF receives an application, it evaluates the case in terms of 51 possible entrance criteria, which can be grouped into three types: health, housing, socio-economic, and family violence (detailed in the next section), and accepts or denies the case entry into the program. Since 2018, the CPINF has implemented a second survey, which is conducted after application to the program but before giving entrance to each case, to double-check that the eligibility criteria are satisfied (see Figure 1). However, the effective entrance to the program depends on the availability of vacancies. If there are no available vacancies, the family goes on a waiting list. Naturally, the effectiveness of the entrance also depends on the willingness of the family to start the program.

Once a family enters the program, a pair of family companions is assigned to the family, and a specific protocol, based on the vulnerability entrance criteria, is defined. The different protocols are detailed in the next section. This corresponds to the “follow-up” stage of the figure. Most of the family companions are social workers, but as the program evolved, other kinds of professionals were integrated into the team of companions. Compliance with the protocol is monitored through home visits (then meetings at CAPS), but these visits go beyond that. The family companions offer guidance for good parenting practices and try to bond with the mother, so she commits to the activities proposed by the program [43].

The family “graduates” from the program once the admission criteria have been reversed, or, if this is not possible due to permanent health conditions, once the family has learned to deal with this health issue. The program’s graduation is evaluated and decided by the CPINF together with the family’s companions, ensuring that the pregnant woman or mother has assimilated the necessary parenting tools and habits to care for herself and her children. If this has not yet happened, further activities and tasks are assigned to the team of family companions to work with the family.

Expectedly, not all families finish the program; a significant fraction dropout from it. This is due to several reasons. In the first place, even when a family accepts to enter the program, sometimes they do not develop adherence to it. Secondly, sometimes families move out of the neighborhood in which they lived when entering the program. That is another reason for dropping out, as the program only works in eight neighborhoods of the municipality. Another (less frequent) reason for program dropout is the family’s need for the intervention of social services to protect the child.

5.5. Entrance Vulnerability Criteria to the Program

There are 51 vulnerability criteria, detailed in

Table A1. Entrance criteria and their corresponding protocols.

Type	Criterion	Tasks Assigned by Entrance Criterion
Health	1. Children with no antenatal controls 2. Children without pediatric controls	Guarantee the corresponding pediatric controls. Refer to the corresponding health areas (CAPS, Hospital or specialists if needed), facilitate the booking of appointments, guarantee that program participants are given priority.
	3. Children with low weight/undernutrition	Confirm that he/she has received health care. Confirm he/she has and is taking the iron supplement. Book appointments with pediatrician at the home’s closest CAPS Refer to nutritionist.
	4. Children with incomplete vaccination schedule	Confirm he/she has complied with the vaccination schedule. Otherwise coordinate with CAPS to ensure that he/she receives the missing vaccines.
	5. Children with anaemia	Confirm that he/she has received health care. Confirm he/she has and is taking the iron supplement. Verify he/she has completed all the pediatric controls (every month until the first year of life). Observe whether there are personal or family risk factors (housing, school meals, family income). Encourage exclusive breast-feeding at least until 6th months of age.
	6. Children with crhonic respiratory diseases	Request a housing-conditions report to the Secretariat of Human and Social Development. Guarantee health control and access to inhalers (if necessary). Guarantee health control with a pneumonologist at least twice a year.
	7. Children with syphilis	Refer to the corresponding health specialist (pediatric dermatologist and/or pediatric urologist). Guarantee the monthly pediatric control. Guarantee he/she is taking the prescribed medicines.
	8. Children with HIV	Refer to the corresponding health specialist. Guarantee health checkups.
	9. Children with brain damage	Refer to the corresponding health specialists (stimulation, psychomotricity, neurology). Guarantee the monthly pediatric control. Guarantee he/she is taking the prescribed medicines (if applicable).
	10. Children with heart disease	Refer to the corresponding health specialist. Guarantee cardiological control. Guarantee he/she is taking the prescribed medicines (if applicable)
	11. Children or families with tuberculosis 12. Mother or family with tuberculosis 13. Pregnant women or families with tuberculosis	Confirm that a TB screening test has been conducted to all household members. Enter the child, mother or pregnant woman into the municipal TB program. Guarantee the monthly health checkups. Guarantee he/she is taking the prescribed medicines
	14. Adolescent mothers	Guarantee the monthly health checkups of mother and children.
	15. Mothers with low weight	Do the health checkups and blood tests.
	16. Mothers with epilepsy	Refer to the corresponding municipal program for specialized support. Verify that the health checkups with the corresponding specialist are being done.
	17. Multiparous mothers	Refer to the Family Planning area for advice and support.
	18. Mothers with heart disease	Book an appointment with a cardiologist.
	19. Mothers with anemia	Confirm he/she has and is taking the iron supplement.
	20. Mothers with HIV 21. Mothers with syphilis 22. Mothers with Chagas disease	Refer to the corresponding specialist. Guarantee the health checkups. Guarantee she is taking the prescribed medicines
	23. Mothers with sexually transmitted diseases	Guarantee she is doing the corresponding health checkups.
	24. Mothers with neurological problems	Guarantee the health and neurological examination.
	25. Mothers with chronic diabetes	Guarantee she is doing the health checkups. Guarantee she is taking the prescribed medicines.
	26. Mothers with drug addiction 27. Mothers with psychiatric problems 28. Pregnant women with drug addiction 29. Pregnant women with psychiatric problems	Guarantee she is doing the health checkups. Refer to Municipal Mental Health Center
	30. Mothers without no antenatal control	Give a closure to the pregnancy medical history. Refer to the corresponding health areas (CAPS, Hospital or specialists if needed), facilitate the booking of appointments, guarantee that the program participants are given priority.
	31. Mothers with disabilties	Guarantee health checkups for mother and child. Refer to the corresponding specialized area if necessary. Refer to a neurologist or physiatrist if necessary.
	32. Mothers with children with no national ID 33. Mothers with no national ID 34. Pregnant woman with no national ID	Refer to the National Register Office, or to the mobile offices periodically implemented by the municipality in which people can obtain their national ID without the need to book an appointment.
	35. Families with intervention of social services * 36. Mothers with conflicts with the law 37. Pregnant women with conflicts with the law	Coordinate the support and intervention with CAPS’ social worker. Submit an admission report to the social services Check the family’s record and meet with the social services’ intervening team to work jointly
	38. Pregnant women with anemia	Confirm she has and is taking the iron supplement.
	39. Pregnant women with neurological problems	Guarantee she is taking the prescribed medicines. Guarantee neurological examination. Follow up of medical examinations, find out a diagnosis, check whether she has or needs a national certificate of disability (which enables several benefits).
	40. Teenage pregnancy 41. Pregnant women with no antenatal care 42. Women with a risky pregnancy	Guarantee antenatal care. Refer to the corresponding health areas (CAPS, Hospital or specialists if needed), facilitate the booking of appointments, guarantee that program participants are given priority.
	43. Pregnant women with diabetes 44. Pregnant women with heart diseases 45. Pregnant women or mothers with hypertension	Guarantee antenatal care and health checkups Guarantee she is taking the prescribed medicines.
	46. Pregnant women with disabilities	Guarantee antenatal care and health checkups Refer to the Disability area.
Housing and socio-economic	47. Critical housing condition	Request a housing-conditions report to the social worker from the Secretariat of Human and Social Development. Ensure the housing-conditions report is received by the area of critical assistance. Guarantee pediatric controls for children.
	48. Critical socio-economic situation (no household member is working)	Refer to the municipal employment office, ANSES and Social Development (national administrative offices). Guarantee pediatric checkups.
Family violence	49. Family violence	Refer to the Gender Policy Office. Follow protocol for males with violent behavior.
	50. Child abuse *	Refer to social services.
Housing and socio-economic	51. Family in vulnerability situation (undernutrition and no household member is working)	Refer to the municipal employment office, ANSES and Social Development (national administrative offices). Guarantee pediatric controls. Refer to nutritionist.

Source: Own elaboration based on CPINF [52] and personal communications with program’s coordinators. Note: In all cases “children” refer to children 0–2 years of age and “mothers” refer to mothers of children 0–2 years of age. *: These families do not remain in the program.

of the Appendix A, which jointly or independently may be a reason for entering the program. These criteria were defined by the CPINF with input from the different professional teams in the municipality. Of the total criteria, 46 are linked to the health of the child, the pregnant woman, or the mother of children under 2 years of age; 3 criteria are associated with housing and socio-economic issues; and 2 criteria are related to situations of family violence.

Exhibiting one health-related vulnerability indicator is a sufficient condition for entering the Mil Días-SM program. Exhibiting one or more of the other vulnerability indicators (housing, socio-economic, and family violence) but no health vulnerability indicator is not sufficient for entering the program. However, these cases are quite rare, as learned from the personal communications, and, when they arise, they are referred to the corresponding area so that the family receives the required assistance or is included in a specific program.

The described initial strong filtering to enter the program guarantees good targeting, as found by Gonzalez and Santos [43] and described in Section 4, but it also reveals the efforts to optimize a scarce budget. Mil Días-SM is a program completely financed by municipal resources. On the one hand, that allows the CPINF to have full autonomy to administer the budget, which relates to the budgetary capacity, which is a convenient feature from a policy-making point of view, as detailed in Section 3. On the other hand, it means the program has tight funding limitations.

As previously detailed, once a family is admitted into the program, it is assigned a pair of family companions who implement the protocol assigned to the family. Table A1 details the tasks that the family companions need to ensure are accomplished according to each entrance criterion. It is important to note that mothers and children are registered as independent program beneficiaries because each of them needs to comply with his or her own protocol for reversing his or her entry criteria. In fact, each of them may graduate at a different time. However, their corresponding protocols are naturally addressed in an interconnected way through the same team of family companions, as Mil Días-SM is a family-centered program.

5.6. Operationalization of the Program

5.6.1. The Program’s Coordination Team

The Mil Días-SM program’s team is composed of a general coordinator (GC), a pediatric medical coordinator, a technical team, and a team of family companions. The GC (whom we interviewed) and the technical team, made up of social workers, nutritionists, psychomotor specialists, and social communicators, work in an integrated and holistic way, supporting the work conducted by the team of family companions with the families of the program. The main activities of the program’s GC and technical team are:

• Train the family companions so that they broaden their knowledge and can provide new tools to the families they mentor.
• Monitor and guarantee that family companions comply with the required tasks with each family (Table A1) and the established timeline.
• Supervise and support the work of family companions. Clarify doubts, concerns or questions that arise during the mentoring process.
• Bring together the different parts involved in the program (CDIFs, CAPS’ social workers, schools, the hospital’s social services, family companions) to think, plan and coordinate joint intervention strategies.
• Visit the families that require a specific intervention and follow-up in some area (nutrition, children’s play, development and bonding, education), complementing the work of the family companions.

Interestingly, the program’s coordination and technical team have been quite stable. While people have changed roles over time, they have all been working within the CPINF or related dependencies such as the UMI. That contributes to the building of civil service capacity (Section 3).

5.6.2. The Program’s Companion Team and Its Work

The team of family companions is composed of 16 professionals, most of whom are social workers. The companions work in pairs, with two distinct roles. The 8 teams are distributed across the 8 neighborhoods where the program is implemented, one pair per neighborhood. Each companion is assigned about twenty families in which she or he takes an active or a leadership role and another twenty families in which she or he takes a passive role. In their active role, the companion is responsible for creating and strengthening a bond of trust with the program participant and leading the home visits (then meetings at CAPS). She or he is also the intermediary between the needs of the family and the resources of the state.

As detailed in Table A1, the family companion (in their active role) is responsible for checking the immunization record, guaranteeing that women and children attend the periodic health checkups, helping families book medical appointments so that they have priority care, and, when necessary, holding meetings with doctors from health centers to evaluate progress. In cases in which there are housing and/or socio-economic deprivations and/or family violence, the family companion refers the case to the corresponding administrative department so that the family receives assistance and support or, in extreme cases, intervention. In their passive role, the companion does active listening, observes, and takes notes while her colleague is leading the meeting. The active and passive companions of each pair share their perceptions, make joint reflections after each meeting, and design short- and medium-term action plans in response to the demands and needs of the family.

When a family starts participating in the program, the companions visit the family every 15 days. In more complex cases, at the beginning, visits are made on a weekly basis. As a relationship is developed, the visits are spaced out and start to be done on a monthly basis. After six months, the meetings start to be held at the CAPS with a frequency of every two months, with the intention of promoting the caregiver’s responsibility. However, if the case is complex or if the mother does not attend the meetings at the CAPS, the monthly home visits continue. The family companions also have exchanges and communication with professionals at the CDIFs.

The team of family companions grew over time.

“We started at these 4 points [Mitre, Santa Brígida, Obligado and San Ambrosio neighborhoods], we started with four family companions (…). Little by little we trained them, trying to emphasize what they had to observe and how they had to mentor these families. (…) as new families were incorporated into the program (…) the team grew, they worked and strengthened much more, and today we have reached [a team of] 16 companions. It cost us a lot.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

Not only did the number of family companions grow, but they also went through a learning curve. As they gained experience, they professionalized their interventions. Also, the program incorporated health-related professionals into the team of family companions.

“As the program grew (…) the profile changed. (…) we started looking for companion’s profiles that were social, nursing or health-related. Now we have a wide range. A nice team was put together. But it cost a lot. When we started, the companions were just observers, but over time, as they became professionals working in the territory, their role changed, and they began to intervene. The pairs of companions are intended to complement each other, for example, someone from social work and someone from health.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

The program companions receive trainings that are designed by the technical team with advice from different government areas, such as gender policies, health, and nutritional experts, as well as based on the learnings from the ground.

“We designed the trainings based on all the entrance criteria. We try that at least once the companions have had a training day on each of these topics. (…) There are many respiratory diseases in the winter, we have many cases of syphilis, so we have trainings on these issues. There is also a lot of malnutrition.” […] Here we must take advantage of all the resources we have. San Miguel is incredible for the [human] resources it has, and they can be coordinated very well. We take advantage of the little things; we make the most of them. For example, Gender Policies offers training sessions, so the companions take advantage of those sessions.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

This quote also offers another evidence of the program’s budget optimization, as it takes advantage of human capacities from other areas within the municipality to continue building the program’s professionals’ capacity.

It should also be remarked that the program gained acceptance among people over time.

“The truth is that at first it was very difficult. The program was known by word of mouth. Now families already know it. At first, they were afraid of us: ‘the social workers are going to take our children away from us!’, it was the first thing that mothers thought. It was very hard work and with some families it is harder than with others.”

(Director of the DPPPI, personal communication, 8 August 2018)

This reveals the development of the ability to reach the target population, described in Section 3, overcoming resistance.

The support and mentoring process is now highly valued by women participating in the program.

“What the mothers are most grateful for is the bond [they developed with the family companions], because they are very lonely women. (…). Even when the family companions are professionals, their contribution is much more from the human side. Maybe a hug, or “I will book you an appointment”, or “get some rest”, that’s very important and highly valued. That invisible job. It is much more than mentoring.”

(Director of the DPPPI, personal communication, 8 August 2018)

Like what happened with the program’s coordination and technical teams, the program’s companion team has also remained, with some of the more experienced companions becoming leaders. Again, this speaks of a process of civil service capacity building which, alongside the ability to reach the beneficiaries, favor good policymaking.

5.6.3. Complementary Interventions

There are various other interventions that complement the mentoring work done through the home-visits. Here we specify the most important ones.

First, the program implements, every 15 days, mobile health and vaccination clinics called “Maternal and Child Prevention Points” (PMI). While these points are similar to the already described “Children Points”, the PMIs are focused on vulnerable pregnant women with the aim of raising awareness of the risks of not doing antenatal controls and facilitating compliance with them, as well as with their other children’s health checkups. The clinics are made up of two trailers in which several health checkups and services are offered, such as ultrasound, the routine “healthy child” checkup, hearing and vision screenings, vaccination, nursing services, and dental check-ups. They also deliver milk for cases that need it and offer maternity care training. Alongside the clinics, the program also sets up a mobile administrative office to offer the services of the National Social Security Administration (ANSES).

Second, children who have difficulties in their psychomotor development, in their upbringing, and/or in their relationship with their mother or caregiver are monitored monthly by the psychomotor specialist of the technical team. Third, program participants with low height and/or weight, with anemia or malnutrition, or with critical labor situations (no household member is working and they have no income source) receive nutritional boxes as well as home visits by nutritionists on a quarterly basis, in which the nutritionist offers dietary guidelines and teaches to cook. “The delivery of the “food bag” is one of the mothers’ most identified and highly valued components of the program” ([48], p. 13).

“I also wanted to tell you about the food box, (…) it is explained to the families that they will receive the food box [only] while they are in the program. So the families say: “and then, what are we going to do?” (…) We have to be facilitators and at the same time give the tools (…). If you always help, you are actually hurting them (…). With the food box we work on that too.

(Director of the DPPPI, personal communication, 8 August 2018)

So “…we help them to access the “Mas Vida” benefit, which gives you a benefit for each child, a card with money. The mothers say: “but the box is better”, and we tell them: (…) “We give you the tools so that you learn to buy varied and nutritious food for your children. The box is no better.””

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

Finally, until March 2019, the program organized group meetings every 30 days in each of the neighborhoods called “mateadas” (because people drank mate, the popular Argentinean infusion, during them). The “mateadas” were a friendly and relaxed environment. Over those meetings, different topics of interest were discussed, depending on the needs of the neighborhood. The goal of these meetings was to form a social support network among the program’s participants and to build a sense of belonging to a community. The “mateadas” were organized in the CAPS and in the CDIFs. CIPPEC (2018) underscored the importance of the “mateadas” meetings: “The area of the “mateadas” is–for the majority–the first and only space for sharing with peers. They identify it as a learning space, where questions are asked, and new reflections are made.” ([48], p. 16). The attendance to these meetings varied greatly from one neighborhood to another, being more successful -according to the program’s GC- in smaller neighborhoods and in neighborhoods which had more effective family companions. After March 2019 these group meetings started to be organized on a weekly basis from a different but complementary program called “Proyecto de Vida” (“Life Project”), which was implemented in 2019.

Remarkably, the complementary actions of the program illustrate the interconnected actions across different municipal government areas, which contribute both to budgetary capacity as well as to civil service capacity.

In sum, all the activities conducted within the program seek to strengthen and empower families and to build bonds between members of the community (the neighborhood). This is motivated by the understanding that children’s care and development are shared responsibilities between the family, the community, and the state.

6. Mil Días-SM Program’s Descriptive Analysis from a Quantitative and Qualitative Approach

6.1. Program’s Scale, Entrance Waiting Time and Average Time in Program

In a municipality with a population of over 300,000 people and an estimated 18% of people living in intense multidimensional poverty [43], the scale of Mil Días-SM is certainly quite small. Over a period of three years and nine months, only 1111 people participated in the program. This has to do with limited municipal fiscal resources. It started with only 4 family companions, and over the period under study, it increased to just 16. Clearly, it would be desirable to scale up the program so that it had a higher coverage of the municipality’s vulnerable population. On the positive side, the figures we will present indicate that the program is highly focused on the poorest, corroborating the efforts to optimize scarce resources mentioned in Section 5.

Figure 2 presents each year’s average waiting days to enter the program, the average number of months in the program, and the average number of months in which participants received visits, by entrance year. The distinction between the last two variables is because, as detailed in Section 5, the home visits have either a fortnightly or monthly frequency over the first six months of the program and then are spaced out every two months (and held at the CAPS). Remarkably, the overall average number of days to enter the program is very low, with a general average of 11 days, although it increased from 5 days to 15 days as the program expanded over time. Once the beneficiary enters the program, the overall average time to overcome the entrance criteria is one year (the intended program’s duration), of which participants effectively receive home visits for an average of 10.5 months. Interestingly, both average times were reduced over time, and the gap between the two closed. The closing of the gap is consistent with the shortening of the time in the program (closer to the 6-month period during which the visits are done every month). One possible interpretation of this is that the program team became more efficient, which is in line with the idea of a learning curve experienced by the family companions expressed by the program’s GC (Section 5). At the same time, however, in previous work, we found that the higher the number of home visits received, the lower the odds of program dropout [43]. This opens the question of whether it is convenient to space out the visits after the sixth month of the program.

6.2. Dropout Rate and Excess Time to Graduation

Figure 3 classifies the cases that entered each year according to their program status by 31 May (our cutoff point). For example, by 31 May 2019, 61% of the participants who had entered the program in 2015 had graduated successfully, 37% had dropped out, and only 2% were still in the program. Naturally, the proportion of participants that graduated from the program decreases for later entrance years (closer to the cutoff point), and the proportion of participants still in the program increases as a counterpart. The dropout rate in 2016 and 2017 was substantially higher than that of 2015, but in 2018 it was significantly reduced; thus, evidence is not clear on whether there was a learning process from the program’s team to reduce dropout. On average, of the 1111 total program participants between 2015 and 2019, by 31 May 2019, 28.7% had graduated successfully, 39.1% were still in the program, and 32.2% had dropped out, which is quite a high rate.

Figure 4 complements the information in Figure 2, depicting the absolute number of cases, by entrance year, that took longer than the average of one year to graduate, which in total represents 51% of the total cases that successfully graduated from the program. The figure also indicates the proportion these cases represent of the total of successfully graduated cases by each entrance year, which naturally is a decreasing proportion as the entrance year approximates the 2019 cutoff (from 47% to 22%).

The fact that half of the successfully graduated cases take longer than one year suggests that the intended duration of 10 to 12 months is overly optimistic.

“At first when we thought about the program, we thought it would last 10 months, but the reality is different. The pregnant woman had her baby, she was going to be released, but she got pregnant again. It happens. We stand by them. When the criteria are reversed, this mother who did not have pregnancy controls, did not take her little ones to the health checkups, her children did not have the national ID… Now they have a very good bond with the health center, they go to the hospital, that little boy entered the CDIF (…), she bonds well with her baby. That is, we release only when all the admission criteria have been reversed. Thus, we have families since the beginning or the program, they are very few, but we have everything.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

In view of this, and considering that there is strong evidence to advocate for longer duration times of early childhood programs of, at least, five years [3,54], it would be advisable to plan for longer interventions that would cover the full thousand days, and include a follow-up program after that period.

6.3. Entrance Criteria and Time in Program

Figure 5 presents the frequency of each entrance criteria. As each mother or child may present more than one entrance criteria, percentages do not add up to 100. The most frequent entrance criteria are lack of mother’s control during pregnancy (26%) and lack of children’s antenatal controls (22%), followed by critical socio-economic situation (22%), teenage mothers (16.7%), children without pediatric controls (16.3%), and critical housing situation (11.4%). While critical socio-economic and critical housing situations are not sufficient criteria to enter the program, this graph indicates that they are highly frequent complementary entrance criteria to the health ones.

Figure 6 depicts the number of entrance criteria by program status. On average, four out of ten participants enter the program with a single vulnerability indicator, three out of ten with two, and another three out of ten enter the program with three or more deficits (Figure 6). The figure also shows that participants with a higher number of vulnerability criteria find it more difficult to remain in the program: almost four out of ten people who drop out of the program have three or more vulnerability criteria, whereas this is only two out of ten among those who successfully graduate from the program.

Figure 7 summarizes several items of information. It is composed of three groups of mutually exclusive sets in terms of entrance criteria, and for each of them, it shows the incidence of such criterion and compares the average months in the program with the average months in which home visits were effectively received. One can see that 28% of program participants enter with at least one critical socio-economic vulnerability criteria (criterion #47, #48, and/or #51 of Table A1), and that this group stays, on average, longer in the program when compared with the group that enters with no critical socio-economic criteria: 16.3 months vs. 12.6; the months effectively receiving home visits are also longer: 13.6 months vs. 9.2. The 71.4% of participants “without any critical socio-economic criteria” should not be understood as non-poor. It is only that they do not exhibit the critical indicators mentioned.

Figure 7 also indicates that 14.3% of the cases enter the program with domestic violence (criterion #49 of Table A1), and this group exhibits a longer time to graduation from the program (20.5 months vs. 13.2 months) as well as a longer time in which home visits were effectively received. We come back to this in Section 6.4. Finally, when program participants are grouped into pregnant women, mothers, and children, we see that children represent 47% of total program participants, mothers 43%, and pregnant women 10%. Expectedly, pregnant women stay less time in the program, being able to reverse their entrance criteria within pregnancy, and mothers and children stay about the same time on average: 14.8 and 14 months, respectively.

6.4. Dropout Reasons

Figure 8 depicts the different reasons for program dropout, the main one being non-adherence to the program (41%), frequently a consequence of violent home environments and/or very poor education.

“There are people not interested in being in the program and we cannot force them. We have various reasons [for program dropout], a lot due to ignorance of the program, fear, and yes, sometimes there are situations of extreme family violence, there is control by someone else who tells [the woman] ‘don’t even think about opening your mouth’. Think that tools are given to those mothers. That’s what gives them the chance to get out.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

This observation is in line with our previous results in Gonzalez and Santos [43], where we found that the odds of program dropout for households that suffer from domestic violence are between 1.5 and 2 times the odds of households without domestic violence. In that study, other cases found to have higher odds of program dropout were those of children with low weight or undernourishment, children with no national ID, and cases with more vulnerability criteria at entrance, as also depicted in Figure 6. In other words, program participants in situations of extreme vulnerability are more likely to drop out. This suggests that further efforts and different strategies are needed to retain the worst cases in the program, presumably at a much higher cost.

6.5. Beneficiaries’ Housing and Basic Services Deprivations

Figure 9 presents indicators of habitat, housing, and subsistence comparing Mil Días-SM participants with those from SIEMPRO [51]. The living conditions and subsistence capacity of the Mil Días-SM program’s participants are critical, and, in several indicators, deprivation rates among Mil Días-SM participants are statistically higher than those among beneficiaries of all social programs contained in the SIEMPRO database. Specifically, almost 6 out of 10 Mil Días-SM beneficiaries live in overcrowded conditions, compared to 3.6 out of 10 in SIEMPRO data. Also, the proportion of beneficiaries simultaneously deprived of piped water and sanitation (sewage or toilet) is much higher among Mil Días-SM participants than among beneficiaries of all social programs (35.8% vs. 23.6%).

In terms of subsistence capacity, Mil Días-SM program beneficiaries live in households where an average of five people live (similar to the average household size in SIEMPRO dataset), but only one works. Also, nearly a third of children, either beneficiary of Mil Días-SM or of social programs in general, are not being reached by AUH.

6.6. Beneficiaries’ Home Environment and Maternal Bonding

A high proportion of Mil Días-SM program participants live in families with bonding problems, and many experience domestic violence. In the Venn diagram of Figure 10, one can see that set “B”, which corresponds to mothers who define the relationship between the adults in the home as “poor to very bad”, is 60% (the full scale is: very good, good, poor, bad, very bad, no-relationship; the proportion of cases with "no relationship” is negligible). The incidence is just above a third when the question is about mother-child bonding, represented in set “A”. Virtually all cases of “poor to very bad” mother-child bonds occur in homes with “poor to very bad” family bonds in general. On the contrary, 40% (=25/60) of those who report “poor to very bad” family bonding do not report problematic mother-child bonding. Also, according to our data, only 14.7% of cases require the intervention of the social services. This relatively low proportion could reflect under-reporting of violence and abuse, as documented in the literature [55,56,57]. Although there is no concrete evidence, it could also reflect the effectiveness of the program’s tools in dealing with cases that would have otherwise ended under social services.

In fact, the program’s coordinator highlighted the critical role the home-visits play in cases of violent home environments.

“It costs a lot, there is a lot of violence, many cases of abuse that are very entrenched and accepted. (…) You have no idea… until you are in there. There are situations of extreme family violence. We even had a [human] trafficking situation. At that level. (…) you uncover situations (…) that’s where the technical team has a lot of work. There is where we reinforce the visits.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

The qualitative study performed by CIPPEC [48] also highlighted that domestic violence is a constant among program participants and that the program’s intervention helps the mothers deal with and resolve this situation. “[Without the program’s support] I would not have made important decisions that kept me and my children from violent situations” ([48], p. 15).

6.7. Mothers’ Characteristics

Most of the mothers in the program are very young (23 years old on average) and have a very low educational level: 93% have not finished secondary school (Figure 11). During the home visits, the family companions insist upon the importance for mothers of completing their education and working on their life projects so that they can achieve greater autonomy and increase their possibility of inclusion in society.

“There is a mother [referring in general to mothers] who did not finish high school and so on, we work on her life project (…). Sometimes it’s finishing primary school, something so basic. It is a project for them (…) There is a mother in Barrufaldi that participated in the program, and is finishing high school, she has completed a kitchen assistant course and has also started working in the CDIF as a cook. These are impressive achievements in her case.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

The results of the joint work on the life project of the mothers are also evidenced in the in-depth interviews conducted by CIPPEC [48], where the mothers express important changes in their self-perception, self-assessment, confidence, and self-respect, as well as the loss of "fears” increased security, and favorable decision-making for them and their children regarding family situations.

As noted in Figure 5, one highly prevalent entrance criterion is the lack of antenatal care. Figure 11 shows that, prior to entering the program, 59% of the mothers did not carry out medical check-ups.

“In 2014 we started making a diagnosis by interviewing the women who attended the perinatal area of the Larcade hospital. It was detected that there were many mothers who did not undergo check-ups during pregnancy and came to have their baby with very few or no check-ups at all, for different reasons… they had young children and could not attend the health center, or they had not come due to situations of violence; there was a wide variety of reasons.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

Also, the following health conditions are frequent among women entering the program: 24% of mothers have some type of non-sexual disease, 8% have some sexually transmitted disease (HIV, syphilis), and 10% have serious psychological problems (Figure 11).

6.8. Children’s Characteristics

Children participating in the program had experienced health neglect, as evidenced in Figure 12. Some of these indicators were their reasons for entering the program. In the first place, two out of 10 children were born before the 36th week of pregnancy. Secondly, 81% of the children had not received any pediatric control until they entered the program, despite the national and international recommendation of performing pediatric controls every month in the first year of life and then quarterly until two years of age. Third, 29% of children were not complying with the mandatory vaccination calendar. Fourth, 81% of the children in the program were taking or had taken complementary food during the first 6 months of life, despite national and international recommendations for exclusive breastfeeding up to 6 months of age [58]. Fifth, 58% of the children older than 6 months were not receiving the daily recommended oral iron intake they should receive between the 6th month and first year of life (recommendations done by WHO [59] and Ministry of Health of Argentina [60]), increasing their risk of anemia [61,62]. Anemia in children has been associated with increased morbidity in childhood and deficiencies in cognitive development and school performance [59]. Finally, and while this is not a reason for entering the program, more than 7 out of 10 children sleep with their parents, meaning that they sleep in the same bed, this being more prevalent among children in overcrowded households vs. non-overcrowded ones (76% vs. 69%). There is robust evidence that, under several circumstances, infants sharing the bed with their mothers have an increased risk of sudden infant death syndrome [63,64,65,66,67]. Such circumstances include smoking mothers, mothers with drug addictions or alcohol consumption, unsuitable beds (sofas), or extenuating circumstances, all of which are quite frequent among mothers participating in the Mil Días-SM program.

The health neglect these children experienced is presumably strongly connected with their mother’s lack of education, which the Mil Días-SM program helps to remedy. Home visits are the fundamental intervention to explain to the mother the importance of all these health care issues.

“We go to the houses (…) The social worker is faced with an incredibly complex panorama. We have a technical team that supervises and mentors. I always say: “let’s focus on our entry criteria”. We can’t fix everything. We prioritize that the little one does the [health’s] controls.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)

“The mentoring [of the program] stands out as an opportunity to learn issues related to care. In the interviews, the women refer to “things they did not know” regarding food, breast-feeding, cleanliness, water maintenance and symptoms of respiratory diseases, among others.”

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7. Concluding Remarks

In this paper, we have described in detail the Mil Días—San Miguel program, a small-scale municipal program (in the municipality of San Miguel, Buenos Aires province, Argentina) for early childhood development. The program is targeted at the first thousand days of life and is highly focused on the most vulnerable population. San Miguel is located within an area that contains half of the total urban poor population in Argentina. The program has been motivated by strong empirical evidence, which indicates that the earliest interventions aimed at guaranteeing child development occur, the higher the returns these investments have. The first thousand days of life constitute a foundational and critical period for human development. Thus, a program such as Mil Días-SM is a smart investment that simultaneously contributes to at least three SDGs: SDG 1, 3, and 11.

The descriptive quantitative and qualitative analysis of the program confirms that Mil Días-SM effectively reaches a highly vulnerable population. When compared to beneficiaries in the same municipality of social programs in general, Mil Días-SM participants exhibit much higher deprivation rates in living conditions such as overcrowding (60% vs. 36%) and simultaneous deprivations in water and sanitation (35.8% vs. 23.6%). Twenty-eight percent of program participants enter the program with at least one critical socio-economic criteria. The mothers are very young, with an average age of 23 years old, and with a low educational level: 93% have not finished secondary school. Material and educational deprivation are also combined with high-conflict home environments. Sixty percent of mothers participating in the program recognized “poor to very bad” family bonding, and just over 30% declared to have a “poor to very bad” bond with their children. Fourteen percent of the cases entering the program experience domestic violence.

Material deprivation, coupled with low education and conflicting homes, results in serious health neglect for women and children. Prior to entering the program, 59% of the mothers were not doing the antenatal checkups; not surprisingly, 21% of children were born preterm. Also, many mothers suffer from some health condition. Twenty-four percent of mothers have some type of non-sexual disease, 8% have some sexually transmitted disease, and 10% have serious psychological problems with no proper health care. Child’s health is also neglected: 81% of the children had not received any pediatric control until they entered the program, 29% were not complying with the mandatory vaccines, 81% had taken complementary food before the 6th month, and 58% were not receiving the daily iron supplement recommended between the 6th month and 1 year of life. Also, a high proportion—73%—shares the bed with his or her parents.

In this context of multiple deprivations for mothers and children, the Mil Días-SM program brings order, guidance, orientation, knowledge, and support to these families. The home visits done by family companions, which then become meetings at the health centers, constitute a one-on-one mentoring work that is complemented with the enrollment of children in the Infant-Family Development Centers (CDIFs), where they receive appropriate stimuli. There is a battery of other interconnected interventions depending on the needs of the family. Complementary interventions include facilitating access to health care, sometimes specialized care, providing nutritional food bags and nutritional advice, and articulating assistance for improving critical housing conditions, among several other interventions. The program also offers community support through group meetings called “mateadas”. In this way, mothers start to become aware of the importance of health care for them and their children; they start to have better parenting tools to stimulate their children, control their growth, take them to CDIFs, give them nutritious food, and comply with vaccines. Moreover, mothers start feeling more empowered to deal with violent partners and start thinking about their own life projects, like finishing secondary school, for example.

In this way, Mil Días-SM program shows that even with the limited resources a municipality may have, a lot can be done to reduce vulnerability. “Home visiting programs are a short-term investment in long-term outcomes for mothers, children, and families”; these programs “help policymakers strengthen families through the natural desire of parents to be the best possible parents” [54]. The role of the CDIFs is also fundamental. Studies of programs that offered center-based high-quality care, such as the Abecedarian project in North Carolina in the 1970s, showed that children who received this kind of care had significantly better life outcomes than those who didn’t, not only in terms of cognitive and non-cognitive abilities but also in terms of health outcomes [8,54,68]. Moreover, childcare “pays off by freeing mothers to enter the workforce, build skills, and earn income”; that is, “it provides two generations of benefits: parents grow their income and children grow smarter” [54].

From a policymaking point of view, Mil Días-SM is an example of a positive cycle of state capacity building. We have identified the development of five key capacities (organizational, budgetary, civil service, ability to reach, and political capacity) detailed by Chudnovsky et al. [24] that contribute to good policymaking, something that is not frequent in Argentina. Indeed, the program successfully coordinates actions across different government offices and secretariats.

However, naturally, there is scope for improvement in the design and implementation of the Mil Días-SM program. In the first place, our evidence suggests that the program should last longer. In fact, over 50% of the successfully graduated cases required longer than the intended one-year treatment. More complex cases, either because they enter with a higher number of vulnerability criteria, because they have critical socio-economic deprivations, or because they experience family violence, take significantly longer to reverse their entrance criteria than their counterparts. Heckman’s evidence indicates that high-quality childhood development programs that start at birth and continue to age five produce permanent gains in IQ and social-emotional skills, i.e., with no fade-out [54].

Second, the program exhibits a high dropout rate: almost a third of total program participants over the study period dropped out, 41% of them due to non-adherence to the program, which are in general the “worst cases” (with a higher number of vulnerability criteria at entrance and cases with home violence). Thus, there is scope for devising smarter ways and even more specific training of the family companions to retain the most vulnerable cases, possibly entailing a larger budget.

Finally, the scale of the program is still too small. In a municipality with over 300,000 residents and 18% multidimensional poverty in 2010, a program reaching only 1111 people in almost four years is certainly extremely small. Scaling up the program would naturally require a larger budget, which may require municipal re-allocations from other spending. Evidence suggests this would be a smart reallocation. The obvious alternative would be that this municipal program, as well as the replicas that were implemented in other municipalities and provinces in the country, were subsumed in the Mil Días national program, which started in December 2021. The problem is that, so far, the national version of the program has been restricted to cash transfers [46], which differs from the “Heckman’s style” Mil Días-SM interventions. Thus, to achieve the intended goals, such restructuring should respect and enhance the Mil Días-SM kind of interventions.

Admittedly, scaling up a home-visiting program represents a significant challenge, as it brings difficulties in building the teams of family companions and supervising the protocols that are followed [25]. In fact, there seems to be a quantity-quality trade-off in scaling up this kind of programs [69]. Still, the Mil Días-SM experience is inspiring, and a lot can be learned from what has already been accomplished.

“This is a public policy where the results will be seen 20 years from now… that is our project, that this boy grows up healthy, that he finishes secondary school, that he goes to university… because his mother accessed other resources and she could transmit… that’s why I say that the results reach the whole family (…) At the beginning, from outside, they told us: “You are crazy, (…) in a year everything will fall apart”. Well, let’s try at least… We were very hard-headed at that time (…). And here we are. There’s a lot to go but we’re on our way.”

(Mil Días-SM program’s GC, personal communication, 8 August 2018)