Options and Recommendations for the Development of aComprehensive, Integrated and Sustainable National ECI System

Emily Vargas-BarónRISE Institute

9 May 2018

1. Introduction

I am grateful to the Early Childhood Programme of the Open Society Foundation that made possible my memorable visit to Bulgaria, and to Ms. Mila Tashkova, Program Coordinator, “Health and Early Childhood Development” of the National Network for Children for her excellent help and guidance throughout my visit. I also wish to express my gratitude to the Deputy Minister of Education and Science, the Deputy-Minister of Labour and Social Policy, the directors of many ministerial offices and agencies, Ombudsman of Republic of Bulgaria, municipal leaders, and to representatives of many non-governmental organisations (NGOs), academic specialists and others for generously presenting their services, and sharing their plans and ideas for the future.

This Report explores options and offers recommendations for the development of a comprehensive, integrated, affordable and sustainable system of early childhood intervention (ECI) services in the Republic of Bulgaria. It includes the following sections:

1. Introduction2. Participation of Key Sectors: Existing Sectoral Strengths, Leadership Roles and

Constraints3. Development of a Legal and Normative Basis for ECI4. Preparation for the ECI Strategic Planning Process5. Reflections on the Possible Structure of the National ECI System6. Phased Financial Support for Developing the National ECI System 7. Planning for Policy Advocacy and Social Communications8. General Recommendations

Developing a National ECI System is always a challenging task. Each country must build on its strengths, identify its needs and gaps in services, address structural challenges, and design a system that will receive the strong support of policy leaders and other decision makers at every level of government: central, regional and municipal. It is also a most rewarding task, because we know that by building an affordable and sustainable system, together we shall help improve the lives and developmental status of children in Bulgaria, and ultimately we shall build a more productive economy and a more creative, stable and secure society.

To ensure effective service implementation, a participatory approach will be taken to strategic planning at each governmental level and in all participating sectors: health and nutrition, education, and child rights and protection (Vargas-Barón, 2005). Research and experience have shown that policy instruments developed by one person or small technical teams are rarely well implemented, no matter how expertly they may be drafted. Policy instruments prepared with the involvement of stakeholders and leaders of government, civil society, academia and the private sector at all levels, central, regional and municipal, are usually well implemented. Indeed, they often exceed their stated goals and objectives for policy implementation because of the enthusiastic support they receive (Vargas-Barón, 2016).

1.1 Building on Bulgaria’s strengths and human rights traditions

Bulgaria is fortunate in being able to build its ECI System on the basis of its highly educated citizenry, many excellent professionals, and strong academic and cultural institutions from village

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level to the cities. Bulgaria has demonstrated its outstanding commitment to achieving full human rights, with a special focus on children, women and persons with disabilities. These strengths augur well for the future development of Bulgaria’s National ECI System.

The Republic has demonstrated a strong adherence to international conventions related to the rights of children, persons with disabilities, and women. Bulgaria signed the Convention on the Rights of the Child (CRC) on 31 May 1990 and ratified it on 3 June 1991. For the Convention on the Rights of Persons with Disabilities (CRPD), Bulgaria signed the Convention on 27 September 2007 and ratified it on 22 March 2012. A related and equally important international human rights instrument is the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) that Bulgaria signed on 17 July 1980 and ratified on 8 February 1982.

1.2 What are ECI Services? Definition and Key Components

ECI is an interdisciplinary, intersectoral and co-ordinated system of individualised and intensive services for the parents of children, from birth to 3 years of age, and in some countries up to 5 years of age, who have at-risk situations, developmental delays, disabilities or behavioural or mental health needs. ECI services are always family-centred and are conducted in the natural environment of the child, using the daily routines of the child.

ECI services always include the full participation of the following sectors:

Health, nutrition and sanitation/hygiene; Education and culture; and Child rights and protection.

To be effective, ECI services must be integrated, which is to say that they are fully intersectoral. They are supported by one system of administration in order to minimise costs and to develop and maintain services that are high in quality.

Each sector has important roles in ECI services and works seamlessly with the other sectors to ensure every enrolled child and family receives the services they require for the child to achieve his or her full potential. For many children this means attaining and maintaining typical levels of development before the age of three. In the United States, 70% of children enrolled in ECI services complete the programme when they reach usual developmental norms and transition to general ECD services and/or to preschools. For others who continue to have delays, disabilities or other conditions, ECI services assist them to greatly improve their levels of development during the critically important period of rapid brain development from birth to 36 months of age. They help these children achieve their inborn potential. When they complete ECI services at 3 or 5 years of age, the children and their parents are helped to transition to inclusive preschools or primary schools. If a child has multiple severe disabilities, then he or she is helped to transition to special service centres. Only a small percentage of children receiving ECI services will require these centre-based services.

In most nations, governments at central, regional and municipal levels usually provide core financial support for ECI services. However, ECI services are mainly conducted through partnerships between municipal, regional or central governments with non-governmental, faith-based and community-based organisations, universities, and other institutions. Academic institutions usually play essential roles in providing pre-service training for professionals, at the Master’s degree and Ph.D. levels and sometimes at the Bachelor’s level. Universities or other types of training institutions, including some advanced ECI Service Programmes, often train paraprofessionals (non-professionals) to conduct not only community outreach (mediator) roles but also most of the home visits. Paraprofessionals require substantial pre-service and in-service

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training. In addition, in each ECI Service Programme, professionals of transdisciplinary1 or interdisciplinary teams supervise, mentor and coach the paraprofessionals to ensure a high quality of services.

ECI services are always conducted in the natural environment of the child unless the parents state they wish the visits to be conducted in other places. Visits with the parents, caregivers and child usually occur in the home but some parents request the visits be conducted where the child receives daily nursery or preschool services in order to include the caregiver or teacher and teacher’s aide. Some visits are held in playgrounds or even in markets.

Activities for good child development are conducted during daily routine activities, such as dressing, changing, feeding, playtime, playground visits, shopping, bathing and going to bed. By having the parents conduct developmentally appropriate activities with their child during their daily routines, children receive about 10 times more positive support and interventions than from work conducted solely between a therapist and a child for 45 minutes once or twice a week. Also, in their homes, parents feel free to express their concerns and fears with their home visitor or with others in their transdisciplinary or interdisciplinary team. Strong bonds of trust and mutual respect must always be built among professionals, paraprofessional home visitors, and the family.

1.3 Overview of the Key Elements of a National ECI system

To develop an effective National System of ECI Services, it is essential that each nation:

1) establish the “legal basis” of the system through an ECI Act and/or a Strategic Plan;2) prepare a good, realistic and phased ECI Strategic Plan with an Action Plan for the full

development and implementation of the ECI system; and 3) develop and achieve a full consensus regarding nationwide regulations regarding

essential ECI concepts, principles, methods, guidelines and procedures.

Basically, when a family moves from one town to another and their child transfers from one ECI programme to another, the child and family should receive the same level, quality and quantity of services they have become accustomed to receiving. Also, the nation must ensure all children with at-risk situations, developmental delays, disabilities and behavioural and mental health needs to achieve their full developmental potential through the provision of high-quality services for parents or legal guardians.

Nations usually develop and officially adopt the following types of policy instruments (documents) in order to create their National ECI System at central, regional and municipal levels. These instruments should be prepared in a fully participatory manner. The instruments are built on the strengths, resources, cultures and needs of each country.

National Act for ECI; National ECI Strategy, including a detailed Action Plan; National ECI Programme Guidelines and Procedures (sometimes referred to as national

regulations or a rule book) including such topics as: ECI concepts and principles, child and parental rights and responsibilities, service eligibility; requirements, core and optional services, and many regulations and procedures; and (based on the above)

Service and Personnel Standards.

1 Transdisciplinary teams usually have at least 2 different disciplines plus the parents, and one professional or paraprofessional is selected to conduct home visits. This person becomes the main contact and “case manager” of the family, and he or she makes most of the ECI visits to homes, day care centres or other places the child frequents on a daily basis. The parents and other caregivers (if any) are always actively involved in the visits. Interdisciplinary teams have at least 2 disciplines plus the parents but they do not designate a main person to visit the home. Rather, more than one person visits with the parents, caregivers and child. Variations can occur depending upon the needs of the child and family.

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Taken together, these instruments create processes and guidance for the ECI organisational structure and administration; annual ECI planning and budgeting cycle; intersectoral co-ordination; supervisory system; quality assurance, including pre- and in-service training and career ladders of early intervention specialists, other professionals and paraprofessionals; service and personnel standards; and accountability in terms of monitoring, evaluation and reporting with a feedback loop to annual programme and financial planning.

National ECI Systems should be built on the strengths and achievements of existing ECI and related services. They should develop plans for improving and expanding existing ECI Service Programmes as well as for establishing additional ECI Service Programmes in phases until nationwide coverage is attained.

1.4 Opportunity to Collaborate with Developing an ECD Strategy

Multisectoral and comprehensive early childhood development (ECD) Strategies usually contain vision, mission, goal and objective statements for the provision of services with families and children from preconception to early primary school.

ECD Strategies include and reinforce ECD initiatives in the sectors of health, nutrition, sanitation and hygiene, education and child rights and protection. They also reinforce and add new multisectoral and integrated services to fill identified gaps in current services and meet the needs of all children and families, usually with a focus on the most vulnerable children, including those with at-risk conditions, developmental delays, disabilities and behavioural and mental health needs and children who live in poverty and marginalised ethnic groups plus migrants affected by conflicts and other traumatic events.

Individualised and intensive ECI services should always be intimately co-ordinated with general and less intensive ECD services. As needed, children and their families are referred from general ECD services to ECI services, and once their developmental gains have been consolidated, from ECI to ECD services, such as patronage nurse services, parenting programmes and inclusive nurseries and preschools.

Inter-agency agreements, referral and co-ordination systems enable the provision of appropriate levels of services for all children and families who need them. Children who receive developmental screenings in general ECD services and are identified to have a possible at-risk condition, delay or disability are referred to ECI services for a developmental assessment. If they are eligible for ECI services, they will receive the more individualised and intensive attention they require.

As children improve their development and often attain typical levels of abilities, they and their families are referred to patronage nurse services, general parenting programmes, inclusive nurseries and inclusive preschools that will help maintain the children’s good levels of development. In all countries, general ECD services need ECI services, and ECI services need general ECD services!

It is ideal for a country to have previously established a National ECD Strategy that has a Strategic Priority (a main objective with planning steps) to develop a National ECI System. Several countries have done this, such as Bosnia and Herzegovina, Cambodia, Lesotho, Myanmar, and Tunisia (to be adopted soon). However, at this time, no ECD strategy exists in Bulgaria, although many are dedicated to establishing an ECD Strategy.

Given significant interest in developing a National ECD Strategy, I recommend all parties help develop both the ECD “umbrella” framework as well as policy instruments for the National ECI

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System. They could be prepared in a parallel manner that would be mutually beneficial to each effort.

At this time, representatives of leading non-governmental ECD services in Bulgaria have created an ECD Alliance. This represents a major positive step forward. Technical leaders from government, at national, regional and municipal levels are also required. The Alliance seeks to collaborate fully with governmental leaders while maintaining its important role representing civil society and technical expertise.

Hopefully, a Technical Working Group for ECD Strategic Planning (or a similar name) will be established, composed of leading department heads and technical specialists in ministries and agencies as well as of members of the ECD Alliance representing civil society.

Within the eventual ECD Strategic Plan, I strongly recommend the establishment of a Strategic Priority for the development of a National ECI System. ECI initiatives presented in this document should be linked with ECD policy initiatives.

2. Participation of Key Sectors: Existing Sectoral Strengths, Leadership Roles andConstraints

Below, I shall present some of the key strengths and leadership roles of each ministry as well as some thoughts about constraints they face with regard to leading the establishment of a National ECI System.

After this analysis, I shall recommend one ministry to become the lead ministry. However, upon saying this, regulations should be prepared to ensure the National ECI System would function effectively and appropriately with the full participation of the Ministry of Health, the Ministry of Education and Science, and the Ministry of Labour and Social Policy.

2.1 Ministry of Health

Although we made every effort to visit with the Deputy Ministers of the Ministry of Health, we were unable to meet with them. Nonetheless, by consulting colleagues and many policies and other documents, it is possible to provide a partial overview of the role of ECI in services for health and nutrition.

Strengths

Although the Ministry of Health lacks a specialised structure for maternal-child health and nutrition (MCHN), it has many policies and plans for ensuring the provision of health services for all children from birth to age 18. Bulgaria has one of the most comprehensive national programmes for child health and nutrition in the region.

Of special note is the fact that we found the active involvement and responsiveness of many hospitals and MCHN services in ECI services in all regions we visited. In addition, the personal dedication of many neonatologists, paediatricians, family doctors, nurses and health mediators (community outreach workers) in ECI programmes was outstanding. These important relationships should be maintained and strengthened wherever possible.

An excellent collaboration exists between the Medical University of Varna, the Karin Dom ECI Programme, and the Municipality of Varna. An M.A. programme for training Early Intervention Specialists at the Medical University of Varna is currently in the planning stages.

Continued ECI collaboration with hospitals, neonatology intensive care units (NICU), MCHN services, Medical University of Varna, and others should be encouraged. It is highly likely that

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other medical universities in Bulgaria will become interested in collaborating with ECI services, and a review is needed to identify those who would wish to do so.

The National Centre for Public Health and Analysis could play a fundamental role in the development of the ECI system by helping to gather and analyse data essential for assessing ECI services and their collaboration with health and nutrition services.

Leadership Roles

The Ministry of Health could expand the work of the medical and public health sector for improving the health and nutrition of couples before conception as well as for promoting expanded prenatal education and care. The early identification of high-risk pregnancies would also continue to be a service area of major importance. Neonatal screenings are essential, and current services should be reviewed to assess the completeness of screenings conducted in terms of types screenings and their use in all hospitals and other places with delivery services.

As the new ECD patronage nurse system, currently being developed with the support of UNICEF, is to be piloted further in selected municipalities, it would be good for the Ministry to participate in developing a coherent and universal system of regular developmental screenings for children from 6 to 36 months of age. The screening instrument selected should be fully validated for Bulgaria.

In each municipality, services of other sectors, such as nurseries, preschools, Centres for Complex Integrated Social Services for Children and Families and many NGOs for children and families, could also play important roles in this national effort to ensure each child is screened at the appropriate ages and referred to ECI services for in-depth developmental assessments to establish programme eligibility.

A total of 28 regional health inspectorates exist, and potentially they could play important roles, in collaboration with other sectors for ECI programme co-ordination and supervision at the regional level. In addition, the Ministry of Health could help ensure good intersectoral collaboration among municipal health entities, technical specialists and municipal ECI services.

Constraints

For uninsured pregnant women, only one prenatal visit and the delivery are provided free-of-charge. This situation is unusual because most countries guarantee the provision of a minimum of four prenatal visits, as recommended by the World Health Organisation. This means that many low-income, high-risk women lack adequate prenatal care, and cases of pre-eclampsia and other conditions threatening the lives of mothers and children sometimes are not identified in a timely fashion. In addition, the Ministry of Health conducts relatively few communications for community health and nutrition, although it seeks to identify infants with disabilities at birth.

The Ministry is currently considering providing support for the patronage home visiting system, which among other activities, will feature the identification of children with a range of special needs. This programme could help to build stronger linkages between health and other services, including ECI services. Although many physicians, nurses and health care establishments participate in and collaborate with ECI services, they do so within the framework of collaborating with other institutions, and most particularly those agencies seeking to protect young children and their families.

2.2 Ministry of Education and Science

We were grateful to the Deputy Minister of Education and Science, Denitsa Sacheva, and her department heads for a rewarding visit. She noted that good collaboration exists among the three leading ECI ministries. She observed that although the three ministries share information

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frequently, they should develop a combined database to meet specific needs. She pointed out that MoES works closely with MoH and municipalities regarding inclusive education services and preschool and school health and feeding services. She hopes that universal preschool services for four-year olds will be proposed again and accepted.

Strengths

The Ministry of Education and Science’s new Act for Preschool and School Education, which has a notable component for inclusive education, and the Ordinance for Inclusive Preschool Education, have the potential to give strong support to ECI services from two points of view:

1. Conducting developmental screenings and identifying and referring children 24 to 36 months of age to ECI services; and

2. Receiving children enrolled in ECI services who have attained typical levels development at 24 months of age or who will benefit from transitions to inclusive preschools and later to inclusive primary schools.

The Ministry and its educational services have strong communications and responsive services at the community level. They work in close collaboration with municipalities. The Ministry also has the potential to develop ECI relationships at the level of higher education.

Leadership Roles

The Ministry of Education has administrative structures and educational leadership roles at central, regional and municipal levels. This decentralised system is able to collaborate closely with ECI services at every level, and already collaborates with several ECI Service Programmes. The Ministry has offices in each of the 28 regions and in all municipalities.

At the programme level, education professionals in preschool and special education are already involved in some ECI Transdisciplinary Teams. They also work with Karin Dom for the development of inclusive education in the Varna region, thereby linking ECI strongly with inclusive education services.

The Ministry will be implementing an important activity to involve parents in needs assessments regarding the identification of learning difficulties and developmental delays of children from 3 to 3.5 years of age. Independently of the teachers, parents will fill out a questionnaire to help with the screening exercise. Based on the results, concrete measures will be identified to work with children considered to have special learning needs. In addition, for 2018 they have developed a national program on interaction with children in kindergartens, with the goal of integrating all children and parents into the educational system. Each kindergarten will be invited to prepare a plan about how they want to work with parents, such as teaching responsible parenting skills, providing preschool and educational support, or working with children on preventing violence and intolerance. Upon approval, the ministry will fund each plan.

The Ministry has 28 regional educational resource centres for inclusive education, which send specialists (teams of psychologists, speech therapists and special pedagogues) to kindergartens and schools to help guide and support resource teachers in the schools. In addition, the Ministry has 45 Centres for Special Education at preschool and school levels for children with complex disabilities. (These Centres were former “Special Needs Schools”). It was explained that parents have the right to place their children with disabilities in these Centres rather than in inclusive preschools or primary schools. The Deputy Minister noted that it is important to consider different options with parents. She emphasised that parents must choose the school or centre for their child. It was stated that specialists of the education system may not agree with the parents’ choices but they would honour their decisions.

Constraints

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The main current constraint is that education policy calls for the Ministry and its dependencies to serve children usually beginning at 24 months of age, although there is some flexibility under the School and Preschool Education Act. In contrast, ECI services must begin at birth in order to maximise early brain development, and sometimes even before then with respect to the identification of high-risk pregnant mothers.

Although the Ministry promotes parenting programmes, they do not provide them on a consistent basis, leaving this work rather to the Ministry of Labour and Social Policy. They are developing and funding local plans for parenting and parent involvement that promises to be sensitively done.

Thus, Ministry of Education and Science would find it challenging to be the lead ministry for ECI services. However, the Ministry would be an excellent collaborator at many points of common interest and concern, including the early developmental screening and identification of children with at-risk situations, developmental delays and disabilities; collaboration for the development of effective transitions from ECI services to inclusive preschools and primary schools, which greatly benefit teachers and parents as well as children; and the development of a unified system for child tracking and support.

2.3 Ministry of Labour and Social Policy

We were very pleased to visit with the Deputy Ministry of Labour and Social Policy, Rositsa Dimitrova. Leaders of the following entities were also present: Ministry Directorate of Social Inclusion, Child and Family Services; the Social Assistance Agency; and the State Agency for Child Protection.

Strengths

The Ministry of Labour and Social Policy has been responsive to the needs of infants and children with at-risk situations, developmental delays, disabilities and behavioural and mental health conditions. The Ministry has a special directorate for Social inclusion, and it is playing a leading role in the development of a Social Services Act and the amendments in the existing Child Protection Act. It works in collaboration with the State Agency for Child Protection, which is developing the new National Strategy for the Child and Family.

In 2018, the National Programme for Child Protection included an indicator to develop a Concept (Vision Paper) for an Early Childhood Development Strategy. Essentially, this Concept will become a brief “ECD policy statement,” and it is expected that it will become a basis for writing a comprehensive multisectoral ECD Strategy in 2019.

In a parallel fashion during 2019, it is highly likely that the Child Protection Act will be replaced by a new more comprehensive “Act for Children and Families.” Given the high degree of consensus regarding the need for an ECD Strategy and for a National ECI System, the establishment of an ECD Strategy as well as an ECI Strategy might become special initiatives of this Act.

The Deputy Minister affirmed that ECI is a specific model, and it needs a specific approach. She also stated that ECI services must co-ordinate closely with all related education, health and social services at municipal levels.

Leadership Roles

The Ministry of Labour and Social Policy leads the development of many protocols, methodological papers, regulations and guidelines for child protection, child rights, and social protection, oftentimes in co-ordination with the Ministry of Health and the Ministry of Education and Science.

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The Ministry’s personnel already collaborate closely with the other early childhood ministries for the provision of ECI services and other related services for children with disabilities that are provided principally by NGOs in 66 municipalities, often under municipal contracts linked to the Ministry of Labour and Social Policy and the Agency for Social Assistance and the State Agency for Child Protection that have licensing functions.

The Agency for Social Assistance has 28 Regional Social Assistance Directorates, which focus on child protection as well as on general social assistance. It has 147 Child Protection Departments at the local level, giving it a strong nationwide presence and leadership.

The Ministry collaborates closely with the State Agency for Child Protection. The Agency is the leading state authority for the implementation, co-ordination and control of State Policy on child protection. Currently, this Agency makes regular and specialised supervisory visits to kindergartens, schools, and various service providers. The Agency has regional Monitoring and Control Departments covering the whole country.

The new National Council for Child Protection has been established with the full participation of Deputy-Ministers from the Ministry of Labour and Social Policy, the Ministry of Health and the Ministry of Education and Science, child protection entities, and NGOs.

In addition, the Ministry could be a leader in collaborating with the establishment of partnerships with Bulgarian universities for developing masters’ degree programs on ECI. For example, the universities in Varna, Veliko Turnovo and Sofia might be included.

Constraints

The Ministry of Labour and Social Policy supports many ECI services and has considerable strengths in the field of ECI services. The Ministry and its agencies collaborate well with the other ministries involved in ECI services.

The main constraint of the Ministry is the lack of an ECI Strategy and an operational Action Plan, National ECI Programme Guidelines and Procedures, and national ECI service standards and personnel standards as well as formal interagency agreements that would to help to promote effective intersectoral co-ordination and to guide ECI service improvement and expansion.

2.4 Recommendation regarding the Lead Ministry for the National ECI System

The current Government administration has approximately 3 more years to go before the next national election. Children’s needs wait for no one; therefore, it is important that Government ministries, regional entities, municipalities, civil society organisations, and other stakeholders work together to move forward as soon as possible with strategic planning for ECI.

Two of the three principal Deputy Ministers told us they are supportive of developing a National ECI System: Denitsa Sacheva of the Ministry of Education and Science; and Rositsa Dimitrova of the Ministry of Labour and Social Policy.

These Deputy Ministers recognise the need for ECI services but to date their support has been informal in nature because a process for moving forward has not been established as yet.

If at all possible, a lead ministry should be selected soon, with the full participation, collaboration and co-ordination of the other two ministries, to develop feasible, affordable, high-quality and sustainable national system of ECI services.

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After reviewing the policies, strengths, leadership roles and constraints of each ministry in relation to ECI as well as to inclusive education, I recommend that the Government give serious consideration to inviting the Ministry of Labour and Social Policy to become the lead ministry.

As will be shown in Section 5.6, the Ministry of Labour and Social Policy is already leading and supporting ECI services through its collaboration with many municipalities. It has demonstrated its ability to work effectively in a collaborative manner at the technical level in regions and municipalities with representatives and offices of the Ministry of Education and Science and the Ministry of Health. The Ministry of Labour and Social Policy already plays a leading role in the provision and supervision of services for disability, child rights, child protection and social protection. In addition, the National Council for Child Protection, which assists the State Agency for Child Protection with coordination, might play a helpful role in the development of the ECI system.

Finally, the Ministry’s related State Agency for Child Protection is well developed and decentralised. Potentially, it could expand its mandate to include a central office for ECI services.

2.5 Additional Ministries Needed to Support ECI Services

Close support also should be secured from the Ministry of Finance for financial planning, budgeting and reporting. The Ministry of the Interior should represent issues pertaining to the rule of law and ensuring the comprehensive decentralisation of services to regions and municipalities. The Ministry of Justice should be consulted regarding the preparation and harmonisation of laws. The Ministry of Culture should help ensure collaboration with it strong network of community services for families. The Ministry of Environment and Water is needed to ensure good sanitation, water quality and environmental protection reach all infants, young children and families. The Ministry of Transport, Information Technology and Communications could be useful with respect to social communications, the use of information technologies, and ensuring the participation of public relations channels in ECI services.

3. Development of a Legal and Normative Basis for ECI

Various options exist for developing the legal and normative basis for the National ECI System. Following is a presentation of several options:

Addition of ECI Services to the National List of Social Services National ECI Strategy and Action Plan National ECI Act National ECI Guidelines and Procedures (core guiding regulations) National ECI Service Standards and Personnel Standards

Various combinations of these policy initiatives and instruments could be considered. Recommendations are provided at the end of this section.

3.1 Addition of ECI Services to the National List of Social Services

Several people we visited said they were unable to register their ECI services because ECI is not officially recognised as a social service in the Ordinance for the Implementation of Social Assistance Act, with the responsible authority being the Agency for Social Assistance.

Without the inclusion of ECI services in this and other relevant legislation of social and health services in Bulgaria, it is our understanding that municipalities and organisations cannot secure governmental funding specifically for ECI services. Several call themselves “day care centres,” which is an inappropriate label. Therefore, it is essential that ECI services be officially listed as soon as possible.

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In addition, member organisations of the National Network for Children have suggested that “services for early childhood intervention” be officially listed, along with other services, in the forthcoming “Ordinance for Integrated Health and Social Services” that is being developed in accordance with requirements of the Health Act of the Ministry of Health.

3.2 National ECI Strategy and Action Plan

It is important that a National ECI Strategy document guide ECI service development in Bulgaria. It could be mentioned in and related to the ECD Concept (Vision Paper) that will be developed in 2018. Once fully developed and officially adopted, the ECI Strategy would establish the National ECI System.

The Strategy would help ensure the ECI System would be able to attain nationwide coverage on a phased basis with a high quality of affordable services for children with at-risk situations, developmental delays, disabilities and behavioural and mental health conditions. The Strategy would build its ECI services on the basis of the strengths and abilities of all existing relevant institutions, and would link ECI services to all other ECD services that are valued and supported by each municipality.

This Strategy would include elements such as the following:

Vision and mission statements; Goals and objectives; Core principles and concepts; Strategic Priorities for action (8 to 10); Services and activities under each strategic priority; An organisational structure; and Guidelines for investment from Government at all levels as well as additional diversified

funding support.

In addition, an Action Plan would be prepared as a detailed guide for the full implementation of the Strategy. Under each Strategic Priority, it would include:

Steps and tasks for each service and activity presented in the Strategy; Responsible parties for each step and task; Indicators and timelines; and Budget allocations per task per year and in phases, using projections and simulations

based on a cost study of selected current ECI programmes.

In addition, the National ECI System should also be described in each of the following strategies, as they are prepared:

Within the ECD Concept (Vision Paper) to be developed in 2018, and the eventual umbrella ECD Strategy, ECI should be named as a Strategic Priority of ECD services in Bulgaria.

An amended or new Child and Family Act will begin in 2019 and it will replace the current Child Protection Act. ECI would be described as a principal programme within child and family services.

A new Social Services Act will also be developed by January 2019, and once again, ECI should be described and related to all relevant social services for children and families to help ensure the development comprehensive and continuous systems of services.

3.3 National ECI Act

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To develop an effective National ECI Act, the National Association of Municipalities in the Republic of Bulgaria could work closely with Parliamentarians of the National Assembly, and especially with the Parliamentary Committees for: Children, Youth and Sports Matters; Education and Science; Health Care; Labour, Social and Demographic Policy and Budget. In addition, the Office of the National Ombudsman and his administration, representatives of ECI services, parent associations, higher education institutes, and others should participate.

The ECI Act would provide a strong legal basis for the National ECI System and all of its services. It would not be an operational document because that would be the role of the National ECI Strategy.

The Act would be best developed as a separate and independent ECI Act. However, it could be linked to the Ordinance for Social Assistance Act, Articles 35 or 36. The Ministry of Labour and Social Policy will develop a Concept (Vision Paper) of the Social Services Act, and ECI could be included in the Vision. The ECI Act could be linked to the proposed new Child and Family Act.

In any case, the ECI Act should be streamlined, focussed, and only include essential points for the phased development of the comprehensive, affordable, equitable and accountable ECI System, such as:

General provisions for the legal status of the system of services; Organisation of the ECI system; Types of organisations that may provide ECI services; Support for the ECI system from ministries, regions and municipalities; Requirements for the development of ECI Strategies and Action Plans each five years to

plan for meeting evolving needs; Requirements for the development of ECI regulations in the form of National Programme

Guidelines and Procedures and service standards and personnel standards; Requirements for developing and maintaining programme quality, equity and

accountability; and Other topics.

3.4 National ECI Programme Guidelines and Procedures

To ensure a high level of ECI programme quality throughout the nation, it is essential to develop regulations, which are usually called: ECI Programme Guidelines and Procedures.

This document is developed through a highly participatory process including the involvement of all current ECI providers, ministerial and municipal representatives and experts in ECD and ECI. The Guidelines and Procedures document provides a detailed roadmap for all of the current and future ECI Service Programmes in the nation. It includes topics such as:

Definition, purposes, objectives and expected outcomes of ECI services; Types of children served; Core concepts and principles; Types of eligible suitable organisations and locations for ECI services; ECI service provision; Training requirements for ECI personnel; Community outreach and child identification; Developmental screening, monitoring and surveillance; Referral systems; Procedural safeguards; Programme eligibility requirements; Developmental assessment; and Many other essential topics for conducting ECI services.

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The ECI Programme Guidelines and Procedures would be drafted, reviewed, revised, field-tested and revised again. Because the ECI System will encounter new situations during its first years, it will be important to review and revise the document each three years or more often, if necessary.

3.5 National ECI Service Standards and Personnel Standards

Once National ECI Programme Guidelines and Procedures have been established, then ECI Service Standards and Personnel Standards can be developed. They would need to be field tested and revised. Once in place, they would be used for supervision, programme monitoring, and performance evaluations of professional and paraprofessional personnel.

4. Preparation for the ECI Strategic Planning Process

Following are major steps entailed in successful ECI strategic planning processes. Experience and research have shown that central planning by a few specialists sitting in a ministerial office leads to the preparation of policies that will not be well implemented – if at all. In contrast, participatory policy planning is highly successful in implementing policy instruments and attaining policy outcomes.

Therefore, the following steps are highly recommended. They can be completed in from one year to 18 months. The results are worth the time invested in conducting these processes.

4.1 Selection of a Lead Ministry and All Collaborating Ministries

As described in Section 2, a lead ministry with the close collaboration of two other sectoral ministries should become the convening ministry and organisational focal point for ECI planning, co-ordination, service selection and implementation as well as for quality assurance and accountability. On that basis, all intersectoral and participatory ECI planning activities can move forward well.

4.2 Establishment of an Intersectoral ECI Technical Working Group

No matter which options for policy instruments are selected regarding the planning of the National ECI System, it is clear from our discussions with ECI services and municipal, regional and central leaders that a variety of issues must be addressed, including:

Establishment of the legal status and listing of ECI services; Clarification of the intersectoral and interdisciplinary status of ECI services and their co-

ordination with a variety of other collaborative services, as found in each region; Consideration of alternatives for the organisational status of ECI services; Importance of addressing the high demand for ECI services and the presence of long

waiting lists; Development and phased expansion of sources of permanent funding for ECI services; Creation of agreements to ensure close and effective planning and co-ordination among

municipal, regional and national entities for the phased implementation of affordable and high-quality ECI services;

Forging of a consensus regarding core concepts, methods and procedures for implementing ECI services;

Development of effective pre-service training and continuous in-service training; and Other key concerns.

After our visits, we perceived an urgent need for the establishment of an Intersectoral ECI Technical Working Group (name to be chosen) including governmental, non-governmental, civil society, academic and related private sector organisations at all levels that would help to plan the

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National ECI System in collaboration with agencies, organisations, universities, specialists and parents throughout Bulgaria.

4.3 Situation Analysis

Although we learned a lot from many studies, policy documents and our visits with institutions, ECI services, and specialists in Ruse, Sofia and Varna, it became clear that an ECI Situation Analysis is greatly needed. This study should benefit from collaboration with the current UNICEF supported assessments of the child protection system and their study on children with disabilities.

A national specialist usually conducts these studies with technical guidance regarding experiences with ECI Situation Analyses in other nations. The contents of Situation Analyses usually include:

Status and needs of:o Children with at-risk situations, developmental delays, disabilities, behavioural

and mental health needs;o Parents, legal guardians, foster parents, adoptive parents and caregivers;

Resources in terms of:o Institutions and services; o Human capacity/workforce development; o Training resources actual and planned; and o Sustainable and diversified financial resources, currently or potentially available;

and Policy analysis and issues of harmonisation and future needs.

Additional studies of specific types of programmes and of costs and financing are often also conducted.

4.4 Consultation Workshops

As a part of the preparatory period, one-day consultation workshops are held not only in the capitol but also most especially in from three to five selected regions and in one or two key municipalities of those regions. A time-proven system is used to ensure the success of these workshops. They should include the usual types of participants and most especially also parents and children from five to 12 years of age, who often provide most perceptive comments.

4.5 High-Level Interviews at Central, Regional and Municipal Levels

In addition, many countries decide to conduct structured, open-ended interviews of leaders at central, regional and municipal levels. A questionnaire is prepared for this activity and a respected national specialist is chosen to conduct the interviews.

4.6 Preparation of Policy Instruments

The Working Group reviews the reports of the Situation Analysis, Consultation Workshops and High-Level Interviews, suggests revisions and makes further overall recommendations on the basis of their findings. These reports are then finalised with their recommendations. Often, they are published electronically and in hard copy, and circulated widely. Participants in these activities usually receive copies of these reports so they are able to see their comments and suggestions were considered and included.

Based on the findings of the Situation Analysis, Consultation Workshops and High-Level Interviews, the first drafts of the policy instruments that have been prioritised for development are

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prepared by a small group designated by the Working Group. It is valuable to have an international since the consideration of options is important during the drafting period.

4.7 Reviews, Revisions, Consultation Workshops and Finalisation

Typically, each instrument is reviewed three to four times. After the second draft of the principal instruments, a second round of consultation workshops is held, usually in the same regions. During these consultations, wise observations from municipalities and regions always improve the instruments.

Once the instruments have been largely finalised, ministerial leaders review them and final changes are made.

4.8 Adoption and Implementation Activities

Depending on the type of instrument, they are usually officially adopted by the Cabinet or the National Assembly. However, this is just the beginning! At this point, a National Launching Ceremony is usually held in a conference, workshops are held and media events highlight national plans and activities that commence immediately.

As quickly as possible, it is essential to establish all structures and processes outlined in the instruments in order to enable smooth and successful policy and programme implementation.

5. Reflections on the Possible Structure of the National ECI System

During the planning period described in Section 4, considerable time should be devoted to considering options for the future structure of the National ECI System. Following are some options, given similar experiences in other countries in the region and other regions of the world.

5.1 Intersectoral National ECI Commission or Committee

Some national level entity should have the titular leadership for ECI programme development in Bulgaria. At least two main options could be considered.

As noted in Section 2.4, The National Council for Child Protection already exists, with the participation of Deputy-Ministers of Labour and Social Policy, Health, and Education and Science, child protection entities and NGOs. Its “terms of reference” or equivalent document might be expanded to include national policy leadership of the National ECI System.

However, sometimes it is not advisable to overload a high-level council with too many roles and responsibilities. The level of functioning and the results of the National Council for Child Protection should be carefully considered as well. If any other leadership councils, commissions or committees exist that might be able to play the ECI leadership role, they should be given serious consideration.

However, usually nations designate a new Intersectoral National ECI Council, Commission or Committee. Typical members of this body often include: ministers or deputy ministers of each participating ministry who attend each meeting, municipal representatives, regional representatives, selected parliamentarians, directors of selected ECI service agencies often representing a Coalition of ECI Organisations on a rotating basis) a leading organisation for children, such as the National Network for Children (NNC), representatives of academic institutions and professional associations (such as the Bulgarian Association of Paediatricians), representatives of two or three parent associations, representative of a federation of organisations for persons with disabilities, and sometimes, representatives of international

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partners. Some countries prefer to meet separately with international partners in order to maintain the independence of national policies, structures and programmes.

5.2 Technical Working Group For ECI

Replacing the Working Group developed during the period of ECI policy planning, an Intersectoral ECI Technical Working Group is established. Its members include technical representatives of the entities listed above, and others, as needed and appropriate.

5.3 Entity for ECI Planning, Co-ordination, Supervision and Accountability

This entity should be placed at the central level, and it could be one of the following types of institutions:

A new semi-autonomous institute (both governmental and non-governmental) might be considered. An example is the Colombian Institute for Child Welfare (Instituto Colombiano de Bienestar Familiar (ICBF)) https://www.icbf.gov.co. Such an institute would be linked to the lead ECI ministry and other ministries and would be able to accept both governmental and non-governmental funding, material and technical support.

A service agency of a ministry. For example, the State Agency for Child Protection, established by the 2001 Child Protection Act, might be considered for this critically important role by adding a new department for ECI Service Development and Co-ordination. The ECI Programme Guidelines and Procedures would ensure that any child of the designated ages could be referred to ECI services for a developmental screening and/or assessment that would establish eligibility or if ineligible, provide referrals to another more general ECD service or to services for children with severe chronic illnesses or disabilities.

Department of the lead ministry. A new department might be established in the lead ministry with personnel from other ministries representing their sector’s full participation in the integrated ECI service system.

This entity usually has the following types of roles and responsibilities and others that are delegated to it:

Conducting annual programme and financial planning for ECI Service Programmes and offices at all levels (municipal to regional, regional to central ministries) in collaboration with the Ministry of Finance in order to help ensure continuous and adequate ECI funding from the central government to municipalities as they develop and expand their ECI Service Programmes.

Enabling vertical and horizontal co-ordination, including bottom to top, top to bottom and horizontal inter-sectoral co-ordination as well as the horizontal sharing of innovations, achievements, challenges, training capacities and lessons learned.

Ensuring all ECI Service Programmes know, consult and use the approved National ECI Guidelines and Procedures.

Developing ECI service and personnel standards based on good practices in ECI services.

Ensuring the annual in-service training of all ECI programme personnel to reinforce the attainment of all standards.

Promoting and guiding community outreach/Child Find activities to ensure “hidden” at-risk children are found, offered developmental screenings and if needed, referrals to ECI services to ensure no child will be left behind.

Ensuring linkages are forged and inter-agency agreements are established between neonatal screening and hospital/public health services and ECI services, along with ensuring ECI services respond to all referrals within established time intervals.

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Establishing a system of universal developmental screening and referrals to ECI services.

Promoting expanded monitoring and surveillance and referrals to ECI on the part of paediatricians, family physicians and other medical practitioners.

Developing a comprehensive plan for continuous pre- and in-service ECI training with academic and training institutions (including leading ECI services).

Designing and implementing a Child Tracking and Follow-Up system for all children enrolled in ECI services, possibly linked to other established databases while ensuring complete confidentiality.

Implementation of a continuous National ECI Monitoring and Evaluation System for ECI services, including a manual, instruments, guides and database construction and maintenance, along with regular analysis and reporting.

Guiding programme supervisors at central and regional levels, once the system is ready to establish this cadre.

Training and supporting professionals to conduct reflective supervision in ECI Service Programmes, with a special focus on supporting paraprofessionals and ensuring the quality of their work.

Preparing quarterly and annual programme and financial reports as a basis for annually programme and budget planning.

5.4 Regional ECI Units

Small Regional ECI Units should be planned, but frankly they only begin to be developed when they are truly needed for co-ordination, planning, budgeting and supervision. Therefore, a plan for the future creation of Regional ECI Units should be prepared. At first, the central ECI entity and ECI Service Programmes at the municipal level will be essential. Then pressure upward from the ECI Service Programmes as well as central needs for information about municipal activities will impel the development of regional ECI units. This pattern for the development of regional offices for ECD was found to have occurred in countries of Latin America that were included in a study (Vargas-Barón, 2009), and appears to have also been the case in other world regions.

5.5 ECI Service Programmes and Development of ECI Municipal Committees

According to National ECI Guidelines and Procedures, ECI Service Programmes are usually established at the municipal level. Under an annual agreement with the local municipality, designated geographic and programme coverage is set. These ECI Service Programmes follow ECI policy and normative instruments while adapting ECI services to meet prevailing local needs and cultures. ECI services are usually manifestly different but high in quality in urban, town and village and rural scattered hamlet populations.

In turn, with the help of the Municipal Government, ECI Service Programmes help develop ECI Municipal Committees. These Committees are linked to the Municipal Council, Government, Mayoralities, Settlements, and Wards or Quarters. The roles and responsibilities of ECI Municipal Committees are usually established in the ECI Strategy and Action Plan as well as in the ECI Programme Guidelines and Procedures.

5.6 Co-ordination with Existing Services

Based on our review of many policy and programme documents and our visits, we were able to identify some of the programmes that already provide some form of ECI services. They are described briefly below. We are cognizant of the fact that many other ECI services of various types may exist in the country. Thanks to leading representatives from several municipalities, we were able to learn about additional ECI initiatives in existing Centres for Complex Integrated Social Services for Children and Families; however, we lacked the time to visit them. We look forward to doing so in the future.

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We also identified some other centres, NGOs and networks of programmes that, with significant pre- and in-service training plus national ECI Programme Guidelines and Procedures, might be able to develop comprehensive and high-quality services for children who would benefit greatly from ECI services.

Yet other programmes or organisations will most likely continue to provide complementary services for children with at-risk conditions, developmental delays, disabilities, and behavioural and mental health needs, including centre-based services with complex challenges requiring equipment, materials and furniture that cannot be carried easily to home visits.

5.6.1 Existing ECI Services in Bulgaria

We thank the directors and personnel of each of the organisations described briefly below for their dedication to children and families, their warm welcome, and their excellent suggestions regarding the future of ECI services.

Centres for Complex Integrated Social Services for Children and Families

Under the project called “Social Inclusion,” “Centres for Services for Early Childhood Development” were established in 2010 in 66 municipalities. A total of 46 of these centres included ECI services. Initially, the World Bank financed these Centres, and the Bank expected they would become sustainable. However, the Centres needed ministerial and municipal financial and technical support that was not fully in place at the time. When World Bank support for the Centres ended, support for them was suspended from 2015 to 2016. In 2016 the European Union’s Social Fund stepped in to provide funding for the centres. As of this writing, EU financial support for the Centres is slated to end in late 2019. It is expected that the Ministry of Labour and Social Policy and many municipalities will continue to support their Centres.

For the 46 Centres that wanted to develop ECI services, in 2015 Karin Dom provided short pre-service ECI training for personnel. Some of these Centres, such as those located in Burgas, Stara Zagora, Varna, Veliko Tarnovo, and Vratza, have continued to provide ECI services. According to leading representatives of these municipal governments, they are dedicated to maintaining ECI services because they have proven to be most useful for children and families in their municipalities.

In Varna, Municipal representatives, including the Deputy Mayor and Dr. Lidiya Marinova, Paediatrician and Deputy Chairperson of the Municipal Council, stated they were the first city to provide municipal funds for ECI services. They lauded the ECI services of Karin Dom and their close collaboration with medical and other social services, the Medical University for developing graduate ECI training, and the implementation of developmental screening using ASQ III and ASQ-SE II. They recognised that the Karin Dom programme needs more personnel to meet the demand for services from families in the municipality.

For the future, Varna municipal representatives and ECD and other specialists encouraged the Government of Bulgaria to:

Develop and adopt a National ECI Strategy, including a national investment plan; Adopt a legislative Act for the National ECI System; Provide official recognition of ECI in the national list of services; Establish universal developmental screening services; Unify the methodology for the provision of ECI services; Develop national service and personnel standards; Provide professional pre- and in-service training for Early Intervention Specialists and

others working in Transdisciplinary Teams; Develop obligatory intersectoral and interagency interactions; Select a developmental screening tool for consistent nationwide use;

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Establish a defined list of accepted comprehensive developmental assessments; Design and implement a national monitoring and evaluation systems with a single registry

and tracking services for children enrolled in ECI services; Create greater awareness-building activities for municipalities; and Educate all citizens about the advantages of the ECI family-oriented model with services

provided in the natural environment of the child.

At the meeting with representatives of municipalities in Sofia, we found that although some ECI and other personnel had left the Centres during the interim period when funding was unavailable, others had stayed. Several municipalities appear to have maintained robust ECI programmes. In some Centres, ECI services have been maintained in name only. Such Centres are providing some rehabilitation services for children with disabilities but not ECI services. They do not provide home visits. Some Centres are using community “mediators” for a variety of outreach activities and basic child care activities who undoubtedly are useful but they do not provide ECI services. With additional training, those Centres that decide to improve their ECI services could maintain them.

An example is the Centre for Complex Integrated Services for Children and Families of Sofia. They received us warmly, and we reviewed their services that now are held in a former Children’s Home they have converted to family-friendly services. Many activities occur in therapy rooms in the Centre where parents bring their children for services that require specialised and heavy equipment and furniture. They noted that they believe their services will end in November 2018 (they had not heard about the extension the end of 2019 as yet) but they hoped they would become “delegated services” of the State. They said they are also going to apply for funding from the municipality of Sofia.

They said they lost their ECI specialists at the time of the ending of World Bank support. However, they provide legal advice to families, medical services for pregnant women to prevent disabilities and for children. Physicians, nurses and midwives on contract from a nearby hospital and/or clinic provide these services. They said do not do developmental screenings at this time but they would like to do so. They also provide specialised assessments and physical therapies for children. Regarding personnel, they have 1 physical therapist, 1 special educator, 2 psychologists, 3 social workers, 5 mediators, 2 lawyers, 5 rotating medical specialists who are on contract, and they are seeking to hire a speech therapist.

There is a lead specialist for each child. We were told that parents are involved in the assessments and in services for their child unless they become a problem for any reason, and then they are asked to look through a window. This approach is very different from ECI service methods. Health mediators and social workers go to the homes and also help parents with referrals to other social and health services.

In summary, the Centre is making a sincere effort to serve children and families with significant medical, developmental and social needs. At this time they do not have ECI services that meet usual ECI requirements. However, by meeting them in the future, potentially this centre – and by extension, several others – could restore or establish their ECI services.

It is important that a study of all Centres be conducted soon to assess their activities, identify the strengths, needs and quality of remaining ECI services, and also identify those Centres that plan to add ECI services in the future. The study should also address “lessons learned” because several important innovations in ECI services have been developed in some of these Centres.

Potentially, pre- and in-service training for professionals and paraprofessionals, supervisory, monitoring and evaluation services could be provided to all Centres that have the strong support of their municipal governments and wish to provide high-quality ECI services in their municipalities.

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It is highly likely that municipal representatives will decide which Centres will be continued as well as which of the services for children and families will be maintained or newly instituted in the Centres.

From our valuable discussions with municipal leaders, we found that several of the municipalities are enthusiastic about continuing, improving and expanding their ECI services, and others want to develop them. Considerable interest was also expressed for providing universal and regular developmental screening to ensure their children will develop well, and if identified with a delay or disability, will receive timely ECI services. As is often the case, the closer one gets to the people, the stronger the support for ECI services.

I believe this strong municipal support for ECI and related services is of great importance. This is a valuable dimension for achieving affordable and sustainable nationwide ECI services. We recommend that municipalities be given strong support to achieve their ECI goals through these Centres and also through traditional NGOs.

Child and Space Association

The Child and Space Association, located in Ruse with its administrative centre in Sofia, was developed to help with the closing of institutions previously housing children with mental disabilities or physical disabilities. Currently, its 10 professionals in Ruse provide centre- and home-based services for 27 children with developmental delays, disabilities, and behavioural and mental health needs. I met several children who had greatly improved in their development, according to both their parents and programme personnel.

They note: “The Day Centre for Children with Disabilities, an Early Intervention programme, which is targeted for support of parents of newborn and small children with disabilities or with low [birth] weight and for prevention of their institutionalisation. The activities of the Centre include: early intervention, accompanying the parents and doctors in the moment of announcing the potential disability in maternity ward; visiting the mother and newborn in maternity ward; acceptance and preparing of a complex program for early intervention; supporting the parents in creation of emotional link between the mother and baby; psychological counselling; ergo-therapy; home visits of ergo-therapist and rehabilitator; psychomotor stimulation and rehabilitation; social services.”

They receive referrals from regional child protection services, hospitals and clinics. They have also made links with nursery schools but rather than serving the children there, at present they mainly serve them in their centre. The Association also provides some ancillary services, including day care for children with intellectual disabilities. They have supported foster parents and family group homes for deinstitutionalised children. They serve and conduct research on children with autism, depression and Down syndrome.

The Association is also serving families in some villages near Ruse, with a special emphasis on finding and serving premature and low birth weight infants. They are working with personnel of the Children’s Home in Varna, They provide supervison to the Home’s team, assisting them with their work to support parents. They are helping the Home develop mobile teams to conduct home visits.

In addition, in three Family Consultative Type Centres for Roma communities that were supported by UNICEF in Veliki Preslav, Novi Pazar and Shumen, they provided technical assistance and training for home visitors. It is expected that these Centres in will become Community Support Centres. They currently have teams that include paraprofessional Roma home visitors who help link families to public health services. The Association believes this experience will help them to conduct future ECI services with Roma communities.

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The Association is interested in greatly expanding their ECI services and reinforcing their home visiting approach. For a variety of reasons, they believe some children with severe disabilities will continue to need centre-based services, while others could benefit more from home-based services or a combination of home- and centre-based activities. The home visiting approach, including the use of trained and supervised paraprofessionals, could enable the Association to greatly expand their services, and provide them at a lower cost per child than in their Centre, while maintaining a high quality of support for parents, caregivers and children.

Community Support Centres

In addition to the Centres for Complex Integrated Services for Children and Families, under the updated plan for the Deinstitutionalisation of Children in the Republic of Bulgaria, 2016-2020, ECI was to be expanded to provide services for the entire country.

For example, new ECI services were to be developed in 130 existing Community Support Centres of the Child Protection Department of the Social Assistance Directorate. The focus would be on social integration plus inclusion in existing day care centres for children with disabilities. Eventually specialists and paraprofessionals would be introduced in other municipalities not covered by these services. Under a separate program, specialised teams for ECI were to be developed to provide home visits in these additional municipalities. However, no detailed strategic plan and/or action plan exists for ECI services, and these general plans have not moved forward adequately as of this writing. Attention should be given to assessing the advisability of placing ECI services in Community Support Centres.

Equilibrium Association

This dedicated and complex organisation has developed 13 different types of State- and Municipal-funded services for general child development, children with severe disabilities, foster care support and family placement services, and families affected by domestic violence and child abuse and neglect.

For example, they have developed a creative Early Childhood and Family Resource Centre for parents and children where they do developmental observations and screening activities as well as conduct activities with parents and children. They plan to complement this onsite screening work with community outreach and expanded ECI home visiting services in Ruse.

Equilibrium has several services for children with developmental delays and disabilities, and an inclusive Early Childhood Centre that could be linked to a full ECI community outreach and home visiting programme in Ruse and environs. They reported that they have many referrals of children with special needs from foster care and the Child Protection Department.

The directors of Equilibrium expressed their desire to expand several of their services that include various elements of ECI work. They also have early childhood services in the town of Byala, located about 55 kilometres from Ruse. From there they felt they could provide both town and rural ECI services. They expressed interest in exploring options for serving additional municipalities in the future.For Our Children Foundation/Community Support Centre

Personnel of For Our Children Foundation received extensive training in ECI concepts and methods from Dr. Jane Newman of the University of Oregon. For Our Children Foundation reported that with her support, they learned how to conduct ECI services.

They told us that under their service general manager, they currently have two ECI staff members, and they mainly provide centre-based services in the form of therapies for families who have adopted children or are providing foster care. They said they conduct a small number of home visits, principally at the time of referral or to support Roma families who require assistance

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to secure health care services. They also have a small sensory stimulation room for children, two meeting rooms principally for working with parents, and two small therapy rooms for working with children often with the parents observing the activities.

The Foundation is playing a critically important role in supporting deinstitutionalisation and the prevention of institutionalisation in Sofia. They assist foster and adoptive families, and also provide key family services for Roma communities. These other services are much larger than their small centre-based therapy programme.

Currently, For Our Children Foundation is planning to renovate their large building, which was a former child home. Their director affirmed they would like to establish expanded ECI services in line with future national guidelines and procedures. This Foundation could potentially provide expanded ECI services, not only in Sofia but potentially also in Plovdiv and other communities where they have valuable experience in working with families and children.

In addition, under the leadership of Vanya Kaneva, For Our Children is actively engaged in ECD policy planning activities with various ministries and the ECD Alliance.

Karin Dom ECI Services

Karin Dom ECI Services are the oldest and most developed ECI services in Bulgaria. Currently they have a programme manager and 4.5 trained and experienced Early Intervention Specialists and a well-developed ECI programme.

During 2017, a total of 133 children and 710 children and family members received ECI services. Of the 133 children, 50 were served only one time, due mainly to programme ineligibility. Karin Dom receives an average of roughly 10 new requests for services per month. The average duration of children in the ECI programme is one year.

For 2018, Karin Dom has an official ECI programme capacity of 40 places funded by the Municipality of Varna; however, staff members are greatly exceeding that limit. A total of 88 children are currently receiving services. In addition, they have a waiting list of 20 eligible children. In summary, staff members have very heavy caseloads. Being dedicated, they are understandably concerned about the size of their waiting list.

The following types of children are benefiting from Karin Dom’s ECI services:

Child Conditions %Behavioural problems and autistic spectrum 10Genetic and chromosomal 12Motor challenges 14Low birth weight/premature 26Language/speech delays 38Total 100

Currently, one-third of the children are under one year of age, and the remainder are from two to three years of age. In the past two years, they have had an increase of children from child care institutions, foster families, and adoptive families. These children average about 1 year of age. This increase is due in part to the development of another programme, called “Accept Me”, implemented by the Agency for Social Assistance for developing foster care services.

In addition, Karin Dom provides well-designed centre-based services for child development and inclusive preschool education. They are considering moving their large and attractive Centre to another location.

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Karin Dom is poised for major ECI programme growth. They have a large demand for their services, and they will need considerably more personnel to be able to serve the large Varna Region and Municipality as well as other areas.

In addition to direct services, Karin Dom is interested in and capable of continuing to provide ECI in-service training services for ECI programmes throughout Bulgaria if they can expand their personnel.

For Our Premature Children Foundation: Tiny Miracles

In 2017, a small group of professionals established this new programme in Sofia. When, as mothers, they gave birth to infants who were premature and low in birth weight, they experienced major challenges. Their Neonatal Intensive Care Unit did not know how to assist them well because they lacked psychologists and training in communications. As a result, these mothers lacked guidance in how to bond with, breast feed and nurture their infants. They decided to create Tiny Miracles to serve new parents who face similar challenges.

At present, although they have a trained ECI specialist, they are only providing centre-based services to children who were born premature, low in birth weight or with disabilities. They have an occupational therapist, a speech therapist, a position for a physical therapist, and specialists in music therapy and parent support groups.

They hope to relocate and expand their promising programme, provide support to parents in hospitals, and open an ECI programme that will include services from birth and hospital care, to transition to home and individualised and intensive services, as needed, until the infant achieves typical levels of development and parents have built strong family bonds.

Other ECI Services

It is rumoured that some other ECI NGO services have been initiated in other cities and regions; however, at present we lack information about them. We shall continue to look for ECI services in other municipalities of Bulgaria. If an in-depth ECI situation analysis will be conducted, then it should include a search for other possible ECI services in the country. 5.6.2 Other Service Systems Serving Children with Disabilities

Homes for Medical and Social Care for Children

A Home for Medical and Social Care for Children, a centre-based hospital and intensive rehabilitation centre, is located in Varna. It is unlikely that the Home would want to conduct ECI services because of the intensive centre-based services they provide to children requiring 24-hour medical care, surgeries and intensive therapies requiring heavy equipment, furniture and rehabilitation gear. It is reported that 16 Homes for Medical and Social Care for Children exist in Bulgaria, serving 545 children (Information from the Ministry of Health, 31 December 2017)

These Homes should become an integral part of the service and referral networks of ECI programmes. Depending upon their needs, ECI-eligible children could be referred from the Homes to ECI services. Also, those children in ECI services found to require the services of the Homes for Medical and Social Care should be referred to them.

Services for Deinstitutionalisation, Prevention of Institutionalisation, Foster Care and Support for Adoption

Ministries and municipalities throughout Bulgaria support a plethora of similar programmes for vulnerable children and their parents to 1) prevent institutionalisation; 2) enable deinstitutionalisation; 3) promote and manage a high quality of foster care; and 4) assist adoptive

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parents as they prepare for and receive their newly adopted children, including many who have developmental delays and disabilities.

The Social Assistance Directorates of the Agency for Social Assistance help guide these local programmes. They appear to be essential for attaining deinstitutionalisation and preventing institutionalisation, and in the future they should collaborate closely with ECI services to ensure the children and families receive services they require for good parenting and child development.

Some of them may wish to add ECI services to their array of activities; however, it might prove daunting to handle so many service approaches in one institution. It may be best for them to focus on making referrals to ECI programmes and receiving referrals from them.

5.6.3 ECD and Other Services/State Institutions/Organizations that Should Complement ECI Services

Strong inter-agency agreements and linkages for mutual referrals and joint activities should be developed with the following services and state institutions:

Clinics and Private Physicians’ Offices

Clinics and private physicians are often (but not always) the place where emerging developmental delays, disabilities and behavioural and mental health needs are first identified, either because parents spot the issues and bring them to health personnel or nurses and physicians note possible challenges. It is important that physicians, and most especially paediatricians, family doctors, gynaecologists and obstetricians be trained in developmental screening and effective methods of monitoring and surveillance.

Hospitals and Neonatal Intensive Care Units

Hospitals, and specifically all maternity services, paediatric wards and Neonatal Intensive Care Units (NICU) should be closely linked with all ECI services. Many already are. However, it appears from our discussions that inter-agency cross training and collaborations are needed, along with formal inter-agency agreements spelling out the roles and responsibilities as well as the benefits to all involved.

Trust for Social Achievement

The Trust for Social Achievement was founded 2012 in Sofia, with a special focus on working with Roma families. They are now are opening a second site in Plovdiv. They use the Nurse Family Partnership (NFP) model that was licensed from David Olds, a researcher from the United States. They are in discussions with the Ministry of Health to see if they might expand programme coverage in relation to UNICEF’s ECD patronage home visiting programme. Potentially, the UNICEF programme could provide referrals to the Trust’s programme. The Trust is participating in the ECD Alliance to help develop an ECD policy framework.

The Trust is working with Karin Dom in order to teach their nurses how to administer the developmental screening instrument, ASQ III and ASQ- SE II as well as the NFP’s instrument, in order to identify children with developmental delays and disabilities. They are working with kindergartens and other centres to identify children and parents for their programme. They said they have no current plans to develop an ECI service.

The Trust for Social Achievement should collaborate closely with the future National ECI System. The Trust would identify and refer potentially eligible children to ECI services. In turn, they could receive children who have improved in their development but continue to have some level of social risk and could benefit from the NFP.

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Currently, they have five nurses serving 70 families. They also use Roma mediators. The average age of parents was reported to be 16, and all of them are under 22 years of age, including both mothers and fathers, as possible. They are first-time mothers, living in selected neighbourhoods largely composed of Roma populations. Some of the mothers are undocumented, and they have major difficulties in securing birth certificates and access to health care. Many of them are reported to be anaemic. Their programme is well designed and has an internal monitoring and evaluation system with an online database that could collaborate easily with the comparable system of ECI service programmes.

UNICEF-Sponsored Patronage Nurse Services for Children from Birth to 36 Months of Age

Vera Rangelova, UNICEF ECD Officer, presented the design of their new patronage nurse service for pregnant women and children from birth to 36 months and their parents. Focusing on nurturing care, UNICEF is co-ordinating their activities with the Ministry of Health. The programme includes prenatal education and care, and home visits focusing on infant health, nutrition, care, stimulation and early learning, family support, counselling. The nurses are to be trained to identify risks, including depression, poverty, abuse, abandonment, and children’s developmental delays and disabilities. One of the programme’s objectives is to prevent the institutionalisation of children since they are finding that some women continue to want to abandon their children.

To date, these services been piloted through Maternal and Child Health Centres in Shumen and Sliven. Services included community outreach, and they focused on serving vulnerable and minority families. During the pilot programme, 25 nurses conducted home visits in the two regions. They received 500 hours training, and subsequently they were supervised each 3 months. Parents were reported to like the services, and now they are requesting more services. A report will be issued soon.

The European Union joined UNICEF in supporting this programme. It is expected that the Ministry of Health will fund the programme in the future. Together with the Ministry, they plan to expand the programme through forming regional clusters of patronage nurses to serve each of the 28 regions of Bulgaria. These services would serve municipalities from their regional offices. It is expected that patronage nurse services would complement already existing centre-based services in municipalities.

This programme could become an important source of referrals to ECI services, which are much more intensive and individualised. Similarly, ECI services could refer children and families who either complete their services or transition to inclusive ECD services. Each of these programmes complements the other, and potentially they could help to create a continuous and comprehensive approach to services for ECD and parental support.

5.6.4 Institutions that Could Contribute to Developing Nationwide ECI Services Bulgarian Paediatric Association

Prof. Vladimir Pilossoff, President of the Bulgarian Paediatric Association, expressed strong support for ECI services. He noted the need for a strategic plan to develop a National System of ECI Services, along with training for paediatricians, other physicians and nurses in how to work with ECI services, how to conduct developmental screenings, and how to work effectively with children with disabilities and their parents. He recommended that a programme of fully designed ECI services be developed and evaluated in three to four regions of the country as a basis for expansion to full nationwide coverage.

National Assembly of Bulgaria

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At this time, it is not possible to characterise the positions of all of the Parliamentarians of the National Assembly. However, from discussions with persons working closely with them, it appears some Parliamentarians believe that improved, expanded and sustainable ECI services are essential for Bulgaria. Parliamentarians usually listen to their constituents and to representatives of their municipalities.

It was noted that a good rapport appears to exist among political parties regarding ECI services. Evidently, a draft ECI Law to benefit children and families might be most welcome. However, it would be important to explain the significance and benefits of ECI services beforehand. Therefore, considerable policy advocacy will be needed.

In addition, it was recommended that ECI services also be included in the forthcoming Act for Children and Families, and other Acts, as possible.

National Association of Municipalities in the Republic of Bulgaria

The National Association of Municipalities is of great importance to the future development of the National ECI System. We met in Sofia with representatives of the Municipalities of Burgas, Ruse (in Ruse), Stara Zagora, Varna (both in Varna and Sofia), Veliko Tarnovo, and Vratza. They expressed their firm commitment to work through their Association and local Mayors with Parliamentarians representing their regions to ensure ECI services are instituted or maintained, improved and expanded.

It was impressive to learn about their ECI services from these representatives. They have developed mediators for community outreach, maintained trained ECI specialists, are working with maternity wards in local hospitals, NICUs, paediatricians and other physicians, nurses, nurse midwives as well as with nurseries, preschools, kindergartens and schools to identify and serve children with at-risk situations, developmental delays, disabilities, and behavioural and mental health needs. They serve their entire municipalities including villages and scattered hamlets through home visits, mobile teams and satellite centres in villages. Some of them have developed formal interagency agreements between their ECI services and local hospitals, NICUs and other service agencies – a practice which is highly advised to ensure long-term good interagency co-ordination.

They said that out of the 268 municipalities, 66 municipalities still have their Centres and 46 of them still offer the full package. If this is the case, then a major strategy most likely will be the provision of technical support, guidelines and procedures as well as more pre- and in-service training in each of these municipalities. A strategy for the training and phased expansion of ECI services to the rest of the municipalities will need to be developed.

Finally, municipal representatives stated that they hope ECI services will become “delegated activities” included in the budget of the Ministry of Labour and Social Policy, along with ECI Programme Guidelines and Procedures as well as Service and Personnel Standards.

A detailed needs assessment and cost study must be made of these and other ECI services as a basis for strategic and programme planning.

National Network for Children

The National Network for Children (NNC) is playing a pivotal role in supporting the development of the ECD Alliance, and through it, the preparation of the Concept (Vision Paper) on ECD. In addition, it is hosting this effort to study options for improving and expanding ECI services through creating a National ECI System.

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The NNC is devoted to supporting the Government, NGOs, academic institutions and associations and to developing sectoral, intersectoral and integrated services for child and family development and for child and social protection. As such, NNC plays a neutral role of support to all valuable services for social protection, health and education for young children and parents, and the protection of children’s rights.

With the support of the Open Society Foundations, dedicated and knowledgeable NNC leaders are expected to continue supporting the development of the National ECI System.

Ombudsman of Bulgaria

Among its many rights mandates, the Office of the Ombudsman focuses especially on children with disabilities and young children and families living in minority groups and in poverty. Office personnel intervene in complex cases when they are needed, and most especially when children need to gain access to available services, including protective services, inclusive schools, and health services. They work with NGOs, parent associations, NNC, and many other organisations that are similarly dedicated to child and parental rights and protection.

The Office of the Ombudsman frequently supports the development and adoption of legislation and strategies for child rights, and in this regard the Office could be especially helpful in supporting the development of a National Act for ECI services.

Parent Groups and Associations

We met with many parents, foster parents, adoptive parents, Roma parents, and grandparents in the Centre for Complex Integrated Social Services for Children and Families in Sofia, the Child and Space Association in Ruse, the Equilibrium Centre in Ruse, the For our Children Centre in Sofia, and the Karin Dom Centre in Varna. All of the parents expressed gratitude for the services they were receiving. Some parents noted a need for case studies on successful programme services and positive child outcomes. A few said they wanted to establish a webpage about the importance of the services they receive. They expressed interest in participating in parent associations, and in doing all possible to support the programmes that are serving them.

It appears that parents in ECI programmes could become a useful force for policy and programme advocacy. In many nations, a federation of parent associations is formed and through this federation, all of the parent associations are represented in policy planning activities, policy advocacy events, and discussions with parliamentarians, ministerial officials and municipal leaders.

The Oak Foundation

The Oak Foundation, generously funded by a family foundation of Geneva, has conducted valuable research and evaluation work in Bulgaria on the prevention of violence, child abuse and neglect with families and group homes. They seek to strengthen parenting, support families, and link them to early childhood services.

The Foundation has made a major investment in Bulgaria over a 15-year period. Over $27 million dollars have been invested in civil society and academic institutions dealing with disability rights, deinstitutionalisation and the prevention of institutionalisation. They are becoming increasingly interested in the development and implementation of policies and legislation as well as in advocacy regarding positive social norms. Regionally, they are working in Georgia, Moldova, Romania, and Serbia.

The Oak Foundation could play a critically important role leading some of the planning and developmental activities that will be necessary for the improvement of ECI services in Bulgaria. It will be essential to secure key investments in specific elements that will be required to enable ECI

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programmes to improve their systems, personnel and services, and then go to scale and attain sustainability while maintaining high programme quality.

Universities

Faculty of Education of Shumen

The Faculty of Education in Shumen University offers both Bachelor’s and Master’s degrees that potentially might be tailored to prepare Early Intervention Specialists. They already offer degrees in Speech Therapy (logopaedics), therapies for children with intellectual deficiencies, physical therapy, social pedagogy, inclusive preschool education, and related topics.

Medical University of Varna

The Medical University of Varna strongly supports ECI and Karin Dom. Its Departments of Public Health, Paediatrics and Nutrition are currently collaborating with Karin Dom to design a Master’s degree programme for ECI but it must fit within requirements of the Ministry of Education regarding the number of students they may serve. Negotiations are underway in this regard.

Potentially, the Master’s degree programme could include ECI certification and specialisations for 1) systems and programme planning, 2) supervisory systems and reflective supervision, coaching and mentoring; 3) monitoring and evaluation; and 4) continuous in-service ECI workforce training and recertification.

In addition, they are interested in forming a Bachelor’s degree in speech therapy. They also plan to focus on preparing physicians and their personnel in effective and validated systems of developmental screening.

Other National and Regional Universities to Contact Regarding Possible Interest in ECI

In the near future, several other universities, such as the Medical University of Pleven, Plovdiv University, Ruse University, Sofia Medical University, Sofia University, Trakia University and others should be contacted to identify faculties that might be interested in training Early Intervention Specialists and others who could work in ECI Services.

6. Phased Financial Support for Developing the National ECI System

The financial dimensions of current and future ECI services must be calculated carefully in order to prepare a useful and effective Action Plan that will guide the development of affordable and sustainable services. Sustainable financing is only one part of achieving long-term programme sustainability but it is an essential dimension.

6.1 Some Types of Funding Secured for ECI Services in Other Nations

Experience in many nations has revealed that successful and sustainable ECI service systems developed a highly diversified array of funding sources including:

Service subsidies (regional or municipal) on a contractual basis for services for a certain number of children per month or per quarter (i.e. from 50 to 1,000+ children at any one time, depending upon needs in the municipality and the capacity of the ECI Service Programme). The cost per child must be well calculated. If at all possible, subsidies should cover at least 75% to 80% of the core costs of ECI services, including all salaries and benefits, modest building and utilities expenses, basic developmental costs, core equipment and supplies, and in-service training. Other developmental costs can be covered by some of the other types of sources listed below.

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Vouchers (regional or municipal) for parents to choose among ECI service programmes. This approach probably will not be possible for Bulgaria for several years. Also this approach can become unnecessarily complex.

Insurance reimbursement for services that are tied to medical diagnoses and/or to developmental assessments. This approach requires that the ECI Service Programme have abundant core funding from other sources to cover salaries and other expenses for at least 3 months before reimbursements are received. Insurance reimbursements for ECI services are not recommended unless there is no other way to pay for the services. The main reason is that they tend to be inequitable.

Grants to ECI Service Programmes from national and international foundations, international and regional agencies, and national and international non-governmental and faith-based organisations. These are often used.

Income from lotteries and taxes, such as payroll taxes export/import taxes, and sin taxes (tobacco, alcohol, gambling, etc.) Although it is worth pursuing such funding, they tend to be cyclical and therefore uncertain sources of funding.

Support from corporations, banks, businesses and other private sector sources, which once they begin to support a programme, often continue to do so for many years.

Private benefactors are often contacted and long-term support is secured. Sometimes private benefactors are the parents or relatives of a child who has been helped by an ECI programme.

Parent associations often help to raise funds for ECI programmes through a variety of activities, including preparing food and crafts for sale at fairs, holding events, etc.

Fundraising events are usually held, including dances, donated musical events, marathon running or walking events, family fun days in parks, etc.

Annual fund solicitations are mailed out using hand written or at least hand signed letters (preferably) to all current and potential supporters. Each ECI Service Programme gathers a list of annual supporters, and they are asked to donate either on a one-time basis or monthly by deduction from their bank accounts. Eventually, some benefactors may wish to leave a sum of money for the services in the form of a bequest.

6.2 Need for Cost Studies, Projections and Simulations

I highly recommend that a regional specialist in ECI costing studies, projections, simulations and regional planning be invited to assist us with these important tasks.

A cost study and projections should be conducted for Karin Dom’s home visiting services. With regard to ECI services in Ruse, those of the Child and Space Association are mainly centre-based but the director and personnel have a strong commitment to expanding their home visiting services. It would be most useful to study their costs. Rough figures were secured during our discussion; however, a thorough cost study should be conducted. The Equilibrium Association mainly has centre-based services but they are also dedicated to expanding their ECI services. In addition, the costs of ECI services in three or four Complex Integrated Social Services for Children and Families should also be calculated.

By using their cost bases of Karin Dom, Child and Space Association, Equilibrium Association, and For Our Children, estimates could be developed regarding the basic costs for ECI services utilising home visits.

For planning purposes, it will be important to consider developing projections and simulations. The simulations would enable us to vary certain indicators, such as the numbers and ratios of professionals to paraprofessionals, the caseloads per type professional and paraprofessional, training and supervisory costs, the type of municipality (urban, town and rural), and transportation costs. These would be used to prepare the annual budgets of the ECI Action Plan.

6.3 Financial Support Currently Secured for Existing ECI Services

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Given the short time we had for each ECI service programme visit, we were unable to gather information on the overall funding of ECI services. However, it became clear that the main source of funding was Ministerial or international funding, frequently channelled through municipalities and occasionally from regional governments or from ministries directly. Representatives of several NGOs said they had developed highly diversified funding support, including local fundraising, which is laudable.

When the ECI Situation Analysis is conducted, a study should be designed to identify additional existing funding lines that could be used for ECI services as they work with services for social assistance, social protection, maternal child health and nutrition services in clinics, hospitals and residential homes for severely disabled children or those needing surgeries and intensive medical or rehabilitation services, and inclusive nurseries, preschools and primary schools.

It is clear that new funding lines will be needed for ECI services. However, ECI services will provide much higher coverage and at a significantly lower cost per child than centre-based services. The Strategy with its Action Plan will provide a detailed budget line for all tasks related to services and activities under each Strategic Priority of the Strategy.

6.4 Future Financial Considerations

Most likely, core funding should be secured from Parliament and the Ministry of Finance in collaboration with the Ministry of Labour and Social Policy, Ministry of Education and Science, and the Ministry of Health. This funding would be increased on a phased basis as outlined in the Action Plan of the ECI Strategy.

These ministries would place some of these funds at the central level in order to staff the central ECI entity (to be selected or developed), provide funds for selected municipalities on a phased basis, and later they would delegate small funds at the regional level, as the ECI system grows in phases and develops needs for the regional co-ordination of programme implementation and expansion.

7. Planning for Policy Advocacy and Social Communications

At the time of planning and preparing legal, planning and regulatory documents for establishing a National ECI System, it is also essential to conduct policy and programme advocacy, and social communications to build better understanding on the part of citizens regarding why the country must invest in ALL of its children and their families.

7.1 Policy and Programme Advocacy

To develop strong National ECI Systems, it is essential to conduct policy and programme advocacy. Three types of initiatives are particularly important:

Policy briefs Community outreach and programme advocacy at the municipal level Advocacy by parents of children with delays and disabilities

Policy Briefs

Policy briefs on ECI should be prepared for each level:

Leaders and personnel of central ministries and agencies; Parliamentarians of the National Assembly; Directors and personnel of regional government entities; and Leaders and members of municipal governance structures.

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Policy briefs should answer questions such as the following:

What is ECI? Which children and families receive ECI services? Why must Bulgaria invest in ECI? What are the benefits of ECI services to children and families? How are ECI services structured? Who works in ECI services? How will the ECI system be developed?

Care should be taken to assess the readability of each type of policy brief. They must be drafted and field-tested to ensure they are well understood and compelling. For linguistic minority groups, they should be translated, adapted, and field-tested. Parents of all cultural groups of Bulgaria should understand that ECI services would serve their communities.

Community Outreach and Programme Advocacy in Municipalities

In addition, in all ECI programme locations, general information about ECI services should be developed for the municipality. Information might be provided in the following ways:

Programme brochures for community outreach through visits to all homes; Posters for community agencies, parks, stores and other places where parents

congregate; Parents’ Handbook on ECI services, child and parental rights and responsibilities, how to

contact services, etc.; Websites for municipal ECI services with parenting and programme information,

scheduled events, programme achievements, requests for donations, etc. (also could use Facebook pages);

Cell phone apps for scheduling appointments, referrals, basic information, parent support, just-in-time training, etc.; and

Fundraising events and other activities.

As ECI services are expanded, these and other policy advocacy and communications activities could be used in all municipalities to increase awareness of ECI services, increase demand for services, support parent associations, and build a national ECI network, alliance or coalition.

Advocacy by Parents of Children with Delays and Disabilities

Many nations gather together specialised parent associations developed to build support for children with a variety of special needs, such as: spina bifida, Down syndrome, cerebral palsy, visual impairments, auditory impairments, mental challenges, autism spectrum disorder, mental health conditions, etc. Through these meetings, national federations of parents of children with special needs are formed.

By joining together, these organisations build considerably more strength than they can achieve singly. They conduct substantial community and policy advocacy campaigns at municipal, regional and national levels. Their joint initiatives result in empowering their parents and in expanding services for their members. Together, they help improve and expand ECI services and ensure that they and their children obtain the services they require.

To do this, the national federation of parent associations:

Develops annual plans for empowering their members and for expanding both their associations and ECI services;

Talks with parliamentarians and ministers to advocate for ECI services

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Conducts advocacy activities for ECI and other services that are needed by parents and their children;

Works with the National Association of Municipalities in the Republic of Bulgaria and with individual municipalities to maintain and expand financial and in-kind support for ECI services; and

Conducts community campaigns for services for children with developmental delays and disabilities.

7.2 Social Communications

In addition to policy advocacy, a strategy for social communications should be developed to build national awareness about the importance of celebrating diversity and the abilities of persons with developmental delays and disabilities.

During my visit, many people lamented the continuation of certain types of social stigma related to children with delays and disabilities and their families. They emphasised that there is a latent resistance to including children of all abilities in preschools, schools and society in general. Some told us about parental rejection of inclusive preschools and other social programmes due principally to a lack of awareness of the benefits that accrue to children with typical abilities when they are able to attend schools with children of all abilities. In general, it appears that a lack of understanding about diversity continues to exist, especially in some areas of the country.

Citizens should learn about why we must serve premature and low birth weight children through ECI services. They should learn about the importance of early rapid brain growth and development from pregnancy to 36 months of age. They should be informed about positive results that can be attained through providing ECI services for infants and young children with Down syndrome, cerebral palsy, and a wide array of developmental delays.

It is important to explain to all parents that neonatal screening and regular early developmental screening enables them to identify the early onset of developmental delays and disabilities and to secure ECI services for the prevention and rapid reversal of such delays. These messages should be related to achieving the full inclusion of children of all types of abilities in society, and most importantly, in nurseries, preschools, kindergartens and primary schools.

A social communications programme, such as “It’s all about ability,” might be most effective in Bulgaria. This programme would tie focused messages mentioned above to more general positive messages about inclusion. I have observed this programme to be successful in Montenegro and several other countries. The designer of this programme, Barbara Kolucki, derives messages and visuals from national cultures, and uses national media specialists, persons with disabilities, and early childhood specialists to design and create media and special events. We believe we could secure her help to design and develop the visual media, printed materials and activities of this valuable programme for cultural, social and educational inclusion.

8. General Recommendations

Based on the preceding analysis, the following recommendations regarding important options are offered.

8.1 Preparation for Strategic Planning

The main participating ministries should be selected. They would be the Ministry of Health, the Ministry of Education and Science, and the Ministry of Labour and Social Policy.

Additional ministries should be invited to collaborate fully with the planning process. They could include: Ministry of Finance; Ministry of the Interior; Ministry of Justice; Ministry of

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Culture; Ministry of Environment and Water; Ministry of Transport, Information Technology and Communications.

The lead ministry should be named. After considerable study and reflection, it appears that the Ministry of Labour and Social Policy would be the ministry best positioned to lead strategic planning, convene all leaders and stakeholders, and ensure ECI policy instruments would be developed, adopted and implemented.

All successful National ECI Systems have been developed using a broadly based and fully participatory approach to planning. The preparatory period is the most important stage because it ensures the involvement of all leaders and stakeholders at municipal, regional and central levels. Whenever possible, ECI strategic planning should be linked to general ECD strategic planning.

An “Intersectoral ECI Technical Working Group” (or a similar name) should be established, with terms of reference adopted, and its members selected. The Working Group would guide the following types of activities:

Preparing an ECI Situation Analysis; Holding consultation workshops at municipal, regional and central levels; and usually Conducting high-level interviews; Reviewing and approving each report; Providing guidance for the drafting of selected policy instruments and normative

documents; Assisting with regional consultations on second drafts of the main legal documents; Conducting reviews and recommending revisions until final versions are completed; Reporting to Ministers and others during the drafting stages and ensuring they are

involved and aware of progress; and Supporting the ministries and/or National Assembly with respect to the adoption and

initial implementation of legal documents.

8.2 Alternatives for Establishing the Legal Basis of the National ECI System

In this report, I recommend that consideration be given to preparing the following types of legal and normative policy instruments:

National Act for ECI; National ECI Strategy, including a detailed Action Plan; National ECI Programme Guidelines and Procedures (sometimes referred to as national

regulations or a rule book) including such topics as: ECI concepts and principles, child and parental rights and responsibilities, service eligibility; requirements, core and optional services, and many regulations and procedures; and (based on the above)

Service and Personnel Standards.

I suggest that, at a minimum, a National Act for ECI OR a National ECI Strategy and Action be prepared. It might be best to prepare both of these policy instruments in order to give the ECI System its strongest possible legal basis and financial support.

Secondly, the National ECI Programme Guidelines and Procedures would be essential to establish the basic regulations for all ECI services throughout Bulgaria. Once the second drafts of the National ECI Act and/or the National Strategy have been prepared, then the preparation of the Guidelines and Procedures should begin. Consensus building will be very important. Finally, the Service and Personnel Standards should not be written until the Guidelines and Procedures have been thoroughly reviewed and adopted.

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In addition, sections pertaining to the National ECI System should be included in all relevant national policies, strategies and Acts, including the future ECD Concept (Vision Paper), ECD Strategic Plan, the Act for Children and Families, the Social Services Act, and others.

8.3 Reinforcing Existing ECI Services

Several NGOs are conducting ECI services. They have many similarities and strengths, as well as differences and needs. All of them are facing challenges but with good technical support, they can overcome them because they demonstrated to us that they are very dedicated to the children and families they serve.

The following programmes should be given special consideration for participating in the National ECI System. They has shown that they deserve support, and with intensive training and the establishment of a well-organised National ECI System, undoubtedly most of them would be able to provide excellent ECI services. We may find a few more ECI programmes when we conduct a thorough ECI Situation Analysis.

Centres for Complex Integrated Social Services for Children and Families (those of the 46 Centres with ECI services or wishing to reinstitute them)

Child and Space Association, Ruse region and Sofia Community Support Centres (officially slated to provide ECI services) Equilibrium Association, Ruse region For Our Children Foundation/Community Support Centre, Sofia and potentially Plovdiv Karin Dom ECI Services, Varna region Tiny Miracles, Sofia (ECI programme being developed)

8.4 Linking ECI with Other Services

Other services for children with complex disabilities should be strongly linked to ECI services. Some are centre-based services for children who are briefly boarding or living in the centres. Some receive surgeries and other medical services while others come and go. Others are social protection services for parents, foster parents and adoptive parents. They include:

Homes for Medical and Social Care for Children, (There are 16 Homes in Bulgaria.) Services for Deinstitutionalisation, Prevention of Institutionalisation, Foster Care and

Support for Adoption, found in several municipalities. (According to the Annual Report of the Agency for Social Assistance, in 2017, 124 Community Support Centres had 4,940 places.)

It is possible that some of the deinstitutionalisation services might wish to develop ECI services; however, they are exceedingly busy with their centre-based activities and they may prefer to make interagency agreements with ECI services that would be better able to provide home-based services in close collaboration with them. Such collaborations should not be seen as a duplication of services because their activities and methods are different and complementary.

Services that complement ECI services and that most probably will not decide to develop ECI services include:

Clinics and Private Physicians Offices Hospitals and Neonatal Intensive Care Units Trust for Social Achievement UNICEF-Sponsored Patronage Nurse Services for Children from Birth to 36 Months

8.5 Institutions that Could Contribute to Developing Nationwide ECI Services

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The following institutions are dedicated to assisting with the development of the National ECI System. They would not develop ECI services themselves. Rather, they would provide strong technical support, policy advocacy and organisational support for ECI programmes. Bulgaria is fortunate to have such a strong array of supportive programmes and leaders for child rights and development.

Bulgarian Paediatric Association National Assembly of Bulgaria National Association of Municipalities in the Republic of Bulgaria National Network for Children Ombudsman of Bulgaria Parent Groups and Associations The Oak Foundation Universities: Medical University of Varna, and potentially others

8.6 Investing in ECI Services for Bulgaria’s Children

Special attention should be given to addressing governmental support for ECI services. In most nations, core support for salaries, benefits, and recurrent costs are borne by the Government at central, regional and municipal levels. Most ECI services around the world develop a diversified array of funding sources to complement core governmental support as well as to cover their developmental costs and additional needs. Several suggestions regarding diversified funding sources are provided in this report.

I recommend that a study be conducted on ECI revenue sources as well as cost studies of ECI programmes. Based on these studies, projections and simulations should be prepared. These studies would be essential to the preparation of plans for the improvement and phased expansion of ECI services.

8.7 Policy Advocacy and Social Communications

It is clear that both policy advocacy and social communications are urgently needed to help with building the National ECI System and assisting parents and all citizens to understand the need for and benefits of ECI services. These activities could include:

Policy briefs; Community outreach and programme advocacy in municipalities; Advocacy conducted by parents of children with delays and disabilities; and Social communications for building national awareness regarding ECI services and the

importance of serving children of all abilities in Bulgaria.

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References

Vargas-Barón, E. (2005). Planning policies for early childhood development: Guidelines for action. Paris, France: UNICEF, UNESCO, ADEA, CINDE and Red Primera Infancia.

Vargas-Barón, E. (2009). Going to scale: Early childhood development in Latin America. Washington, DC: World Bank and RISE Institute.

Vargas-Barón, E. (2016). Policy planning for early childhood care and education: 2000-2014. Prospects: Quarterly Review of Comparative Education, 176, 4-26. doi:10.1007/s11125-016-9377-2.

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List of Visits in BulgariaEmily Vargas-Barón and Mila Tashkova

26 March – 5 April 2018

Date Location Type of Visit Persons Visited Role26/03 National Network

for ChildrenBriefing on national systems involved in ECI programs

Mila Tashkova,

Elka Nalbantova

Programme Coordinator Health and Early Childhood Development Programme

Program Director

26/03 For Our Children, Community Support Centre

Visit to Centre and discussions

Kiril Kirilov

Raya TsvetanovaPetya Uzunova

Manager of the service

Early Childhood Intervention Specialists

26/03 For Our Children, Community Support Centre

Meeting for discussing the progress of ECD policy work

Vanya Kuneva,

Alexandar Malinski

Advocacy and Projects Team Leader Regional Manager Sofia

27/03 Varna Municipality Meeting with local partners

Mr Bazitov Deputy-Mayor

D-r Lidiya Marinova Paediatrician, deputy chairperson of Municipal Council

D-r Ruzha Pancheva Medical University VarnaTanya Vasileva Director, Social Activities

Directorate Ms Gancheva Head of department,

Social services and projects

Ivelina Kirilova Varna Municipality Rumyana Haralambova

Health Directorate, Varna Municipality

Maria Stefanova Social worker, Child Protection Department

Maria Genova Social worker, Child Protection Department

Daniela Biyacheva Manager of Services for Early Childhood Development (the former Community centres, established with the loan of World Bank with Team for Early Intervention

D-r Jivka Mihailova Services for Early Childhood Development (the former Community centres

Lilyana Vasileva Social worker, Services for Early Childhood Development (the former Community centres)

Jordanka Stoyanova Mother and Baby Unit, Varna

Simoneta Popova Cvetno Budeshte Association

Leilya Husein Mediator, Suychastie

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AssociationAntoaneta Ivanova Spina Bifida and

Hidrocefaliya – Bulgaria Association

D-r Nely Nikolova Home for medical and social care for children

D-r Kaloyan Tsochev St. Marina Hospital Stefka Yaneva Midwife Radka Dimitrova Midwife Mariana Nikolova Consultant, Karin DomMagdalena Tsoneva Karin DomZhenislava Sapundzhieva

Manager Services for children and Families, Karin Dom

Marina Peicheva Karin Dom27/03 Additional meeting

in Varna Municipality

D-r Kaloyan Tsochev, Daniela Biyacheva, D-r Lidiya Marinova, D-r Ruzha Pancheva

Medical doctors and professors at Medical University of Varna

28/03 Karin Dom, Varna Team meeting Zhenislava Sapundzhieva

Manager Services for children and Families

Magdalena Tsoneva Education and Development Specialist

Mariana Nikolova Consultant, Karin DomAndrele Andreas Kinezitherapist, trainer Zvezdelina Atanasova Training Centre Director Maria Peicheva Early Intervention Centre

Coordinator Dimana Miteva Psychologist, trainer Svetlana Angelova Speech therapist, special

pedagogic in Early Intervention Centre

Svetla Lazarova Speech therapist, special pedagogic in Early Intervention Centre

Veneta Mileva Marketing specialist Veselina Vasileva Director “Development”

29/03 Ruse Child and Space Association

Team meeting Рumyana Velikova Manager and special pedagogic

Veselina Toncheva Psychologist

Nadezhda Stoyanova, Lyubina Dimitrova

Students on stagier

29/03 Ruse Meeting with local partners

Galina Biset Executive Director, Equilibrium Association

Elena Petkova Program Director, Equilibrium Association

Nadezda Petrova Equilibrium AssociationMiroslava MonovaNesrin IndjievaNatalia Lakova Nadezda Hristova Child and Space

Association Rumyana Velichkova Child and Space

AssociationVeselina Toncheva Child and Space

AssociationMilena Nedelcheva Head of Child Protection

Department, Ruse

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Snezana Georgieva Regional Directorate for Social Assistance, Ruse

Mariela Licheva Ruse Municipality Radostina Petkova Ruse MunicipalityKrasimira Kuleva Ruse hospital, midwife

29/03 Ruse, Equilibrium Association

Team meeting Galya Bisset Executive Director

Elena Petkova Program Director30/03 Ruse, Equilibrium

AssociationEarly Childhood and Family Resource Centre

David Bisset Manager of the Centre

02/04 Sofia Child and Space Association

Vesela Banova Deputy Chairperson and Therapeutic Director of Child and Space Association

02/04 Sofia Centre for Complex integrated social services for children and families

Antoaneta Andonova Director

Viara Petrova Director Directorate “Integration of people with disabilities”, Sofia Municipality

Vesela Radeva Expert in Directorate “Integration of people with disabilities” and administrative secretary of the project Services for ECD, Sofia Municipality

Veselina Mekicharska Social worker in the Complex

Victoria Tsekova Special Pedagogic Encho Enchev Kinezitherapist Joan KrastitelskiNikolay Milanov Sonya Kitova Psychologist Daniela Titkova Mediator Severina Tsonkova MediatorDiana Medikova Health Mediator

02/04 Sofia Meeting in Ministry of Labour and Social Policy

Rositsa Dimitrova Deputy-minister of Labour and Social Policies

Daniela Kicheva Expert in Social Inclusion Directorate

Reneta Manolova Head of Department „Social services” in Social Assistance Agency

Tsvetelina Kioseva Expert in Child Protection Directorate in Social Assistance Agency

Iliana Hristova State Agency for Child Protection

03/04 Sofia Meeting in Ministry of Education and Science

Denitsa Sacheva Deputy-minister

Greta Gancheva Experts in the Ministry Vanya TraykovaElena Vitanova

03/04 Sofia OAK Foundation

Presiana Manolova Director

03/04 Sofia Meeting in Tiny Petya Bankova Director of the Centre

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Our Premature Children

Miracles Centre

Inna Minkova Clinic psychologist and coordinator

Margarita Gabrovska Speech Therapist and ECI specialist

04/04 SofiaNational Assembly

Meeting with representative of the Education and Science Committee

Detelina Arnaudova Chief Expert Advisor

04/04 Sofia,Park Hotel Vitosha

Meeting with representatives from National Assembly of Municipalities in Bulgaria

Joro Kovachev Veliko Turnovo Municipality

D-r dilyana Vachkova Veliko Turnovo Municipality

Iva Stancheva Vratsa Municipality D-r Antonia Todorova Stara Zagora Municipality Maya Kazandgieva Burgas Municipality D-r Lidiya Marinova Varna Municipality Anastasiya Georgieva Varna MunicipalityTanya Vasileva Varna Municipality

04/04 Sofia Ombudsman Administration

Meeting with representatives of Ombudsman Administration

Maya Manolova Ombudsman of Republic of Bulgaria

Eva Jetcheva Director Directorate “Child Rights”

Nurten Patraklu Expert, Directorate “Child Rights”

Hyusein Ismail Head of Division “Rights of People with Disabilities and Discrimination”

04/04 SofiaNNC office

Meeting with Bulgarian Paediatric Association

Prof. Vladimir Pilossoff President

05/04 SofiaUNICEF

Meeting with representatives of UNICEF office

Maria Jesus Conde UNICEF Representative for Bulgaria

Vera Rangelova Early Childhood Development Officer

05/04 SofiaTrust for Social Achievement

Meeting Sara Perin Executive Director

Eugenia Volen Program Director “Development and Education”

05/04 Sofia, NNC office Meeting with representative of World Bank

Desislava Kuznetsova Specialist in Education Global Practice

05/04 Sofia, NNC office Meeting for discussion and feedback, planning

Nurbek Teleshaliev OSI

Mila Tashkova NNC program coordinator

George Bogdanov Executive Director NNC

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