Home Visiting Program and Public Policies for the Early Childhood Development: Lessons from Brazil
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摘要: 在整个生命周期中，生命系统的早期奠定了生物有机体各方面内外功能的基础，是大脑可塑性最强的时期。相较于后期的投资，生命早期的投资具有最高的社会回报。世界各国已经意识到制定儿童早期发展政策的重要性。处于中等收入水平的巴西政府作为大力推动儿童早期发展项目的先行者之一，发起了一个具有开拓性的儿童早期发展项目——PIM（Primeira Infancia Melhor或Better Early Childhood）项目，之后在该项目的基础上又启动了一项全国性的儿童早期发展项目，即"快乐儿童项目"（Programme Crianca Feliz），并承诺为该项目提供大量资金的保证，成立专门的政府部门来资助和推广这个项目。巴西政府在早期儿童发展项目上，有着长达15年的项目经验及与之相关的公共政策经验，特别是其入户模式的项目经验以及全国各州政府部门的跨部门协作方式和经验值得关注。具体来说，可以概括为以下三点：第一，国家和地方政府的联盟。这种联盟是基于地方的具体特点和需要，由国家长期提供技术和财政资助，然后通过行动的协调来取得项目预期的结果。同时，与多边机构加强合作，促进成功经验在特定领域内的交流和传播，从而强化干预方案。第二，社区参与的关键性。社区参与能够促进家庭的参与，促进人们对儿童早期发展的认识，并且建立一个共同努力的网络。第三，家庭的核心性。家庭是儿童早期发展项目实施成功的核心要素，充分重视以家庭为核心的项目实施导向。Abstract: The beginning of living systems sets the stage for every aspect of an organism's internal and external functioning throughout the lifespan and is the period when the brain has the greatest plasticity. Early childhood investments have the highest individual and social returns compared to later investments. Countries around the world have recognized the importance of establishing public policies for early childhood development (ECD). Among the middle-income countries, Brazil is one of the pioneers in such policies. Brazilian government launched a pioneering ECD program, PIM program, followed by a national ECD program, the Happy Child Program, and has set up a dedicated government department to fund and promote the program. This paper summarizes the lessons learned from Brazilian government's 15 years of experience in ECD projects, particularly its experiences in the home-visiting and the cross-sectoral collaboration. Specifically, there are three pillars for the program. First, the alliance of national and local governments. Such alliances are based on specific local characteristics and needs, with the long-term technical and financial support from the state, and through coordination of actions. The cross-sectoral collaboration strengthens the program by promoting the exchange and dissemination of successful experiences in specific areas. Second, community participation is critical. Community involvement promotes family involvement, awareness of the importance of ECD, and a network of joint efforts. Third, the family is the core element of the successful implementation of ECD projects.
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Key words:
- early childhood development /
- PIM program /
- Brazil /
- public policy /
- home visiting
1) PIM家访主要考虑以下几个方面：广泛的、半结构化的干预课程；独特的家访计划；家访脚本；访问的强度和时间；支持材料；培训有关专业人员；监督过程；现场监测。2) 该量表由家访员和参与该项目的家庭一起填写，包含五个表征：邻里或社区、家庭、孕妇、儿童和儿童发展的初始诊断(基线)。本量表可直观显示孕妇和/或儿童进入PIM后的家庭现状和发展阶段。3) 古巴儿童早期发展项目是一个非体制、以社区为基础、面向家庭的跨部门性项目，自1992-1994年实施以来一直由古巴教育部负责。项目将家庭和社区作为0-6岁儿童最重要的照护者和教育者。依靠培训志愿者成为家访员的“古巴模式”不仅在古巴成功实施，并且通过一些文化适应性方面的调整也在其他国家得到应用。其假设是，每个人的和谐和全面发展在很大程度上取决于他/她在早年是如何在家庭环境中或在日托中心得到养育和教育的。透过设立学习环境，让家庭成员、儿童和家访员通过活动和游戏进行良性的互动，发掘每个家庭文化环境的文化潜质，提高家庭成员的参与意识，使他们认识到参与对促进子女全面健康发展的重要性。4) 从具体数字上来看，通过该管控机制，目前已拒绝了约390万起福利申请，取消了约144万起福利申请，同时批准了约96万起。比如在针对老年人和残疾人的连续福利项目上，通过进行社会保障审查，修订疾病援助和残疾人士退休福利为社会保障基金节省超过3.15亿美元；所有已接受了两年以上福利但未在此期间进行任何健康评估的人都会被电话通知去接受新的评估。 -
表 1 快乐儿童项目受益人群规模
快乐儿童项目的受益人群 数量 “家庭支持计划”(Bolsa Família)的受益儿童(0-36月) 3, 000, 000 “家庭支持计划”的受益孕妇 640, 000 “针对老年人和残疾人的连续福利项目”的受益儿童(0-6岁) 75, 000 寄养儿童(寄宿家庭/政府认证机构)(0-6岁) 8, 600 数据来源：2018年11月西安儿童早期发展国际论坛会议资料 
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表 2 PIM项目家访员和社区卫生工作者的操作比较
PIM项目家访员 社区卫生工作者 访问对象 面临风险和处于社会弱势地位的孕妇和0到6岁儿童的家庭 地理位置处于微型医疗区域的家庭 访问目的 根据其家庭文化和经验指导家庭，促进孩子从怀孕到6岁前的全面发展 通过家庭或社区的行动，个别或集体地按照统一医疗体系的指导，发展预防疾病及促进健康的活动 监督 由督导员和(或)市技术小组代表进行督导。每位督导员(20小时)负责督导最多8名家访员 由家庭健康战略的护士进行督导。每位护士负责12名社区卫生工作者的督导 访问比 每个家访员最多负责20个家庭 每名社区卫生工作者最多负责750人 访问频率 每个孕妇或儿童每周1次 每个家庭1月1次 访问时长 45分钟至1小时 未规定 来源：州法令第14, 594/14条；联邦政府的指令第2, 488/11条
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表 3 州每位访问员的月资金转移
家访员工作量 每位访问员的月资金转移 一周20小时 BRL 500 一周30小时 BRL 750 一周40小时 BRL 1000 数据来源：国家指令第578/13条，2013年。注：BRL 1 = RMB 1.82(2019.1.4)
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表 4 项目操作
粘合阶段(30天) 植入阶段(90天) 实施阶段(永久) 意识培养 行动计划 持续培训 签署参与协议 PIM水平 监测儿童和孕妇的全面发展 市技术小组任命 人口普查/测绘 更新SisPIM 参加初步培训 建立家访员团队，邀请家庭参与 评估
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表 5 市政当局、受益地区和家庭的建议选择标准
选择市政当局的优先标准 低人均GDP 人类发展指数-HDI 监测家庭津贴计划的条件健康因素的范围 孕产妇/婴儿死亡率 调查育龄妇女死亡率 疫苗接种儿童基本免疫接种日历的疫苗接种率 贫困密度 青少年怀孕 有某种类型残疾的人口 儿童早期教育覆盖范围 区域选择的建议标准 孕妇和0至6岁的儿童的数量 包括在收入转移计划和/或家庭津贴计划的家庭的覆盖范围 婴儿发病率和死亡率 儿童早期教育覆盖率 城市基础设施 暴力/吸毒成瘾率 不稳定或缺乏服务 农村或难以进入的城市地区，以及安置点和特定或传统社区 家庭选择的建议标准 纳入收入转移计划和/或家庭津贴计划的家庭 人均家庭收入 生活条件 住所密度 青少年怀孕或高风险怀孕 婴儿发病率和死亡率 在生命的第一年有一次以上住院治疗的儿童 母亲被诊断患有产后抑郁症 家庭有照顾者，孕妇和/或残疾儿童 酒精或药物滥用 有接受专科护理和/或精神病治疗的家庭成员 母亲或主要照顾者是文盲或受教育程度低 未进入正规教育网络的儿童 家庭暴力 被监禁的家庭成员 来源：改编自GTM《监测和访客指南》，2007年
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