ECD in child health services

Over the last 5 years, PATH has been supporting changes in child health policies, strategies, and plans to include attention on early childhood development. This advocacy was done through the national technical working groups on ECD and child health at the Ministries of Health of Kenya, Mozambique, and Ethiopia. As a result of these efforts by PATH and other partners, a Newborn, Child and Adolescent Health Policy (2018) in Kenya and a National Strategy for Newborn and Child Health and Development (2022) in Ethiopia, along with associated strategic plans, include promotion of ECD in their objectives.

At the subnational level, Siaya County in Kenya leads as an example of mainstreaming Nurturing Care for ECD in county level documents and plans, including allocation of dedicated budget lines.

While policies and plans indicate government commitment to ECD, it is technical guidelines that orient providers on how to actually deliver child development services in the health sector. PATH has worked with the Ministries of Health to revise relevant technical guidelines related to child health, such as the Guidelines for Healthy Child and Child at Risk Consultation in Mozambique (2021), to include developmental monitoring and counseling on child development. 

Additionally, the Integrated Management of Childhood Illnesses (IMCI) guidelines used in outpatient clinics were updated in Kenya and Ethiopia to promote monitoring of developmental milestones and to include more comprehensive counseling on child development. PATH collaborated with other technical partners to provide inputs into these Ministry documents.

Finally, the Federal Ministry of Health in Ethiopia went a step further and developed its national ECD implementation guide (currently in the process of being finalized), which includes interventions and tools piloted during the PATH-supported project in Addis Ababa. 

An important component of integration of ECD interventions in child health services is the adoption of national indicators related to child development. As one provider put it, “what is not registered is not done.” Through PATH advocacy and collaboration in the national technical working groups, all three countries—Mozambique, Kenya, and Ethiopia—adopted specific indicators to be collected at child health touchpoints. In Mozambique, the indicators quantify the number of children identified for the first time with developmental delays at well-baby and sick child services; while in Kenya the well-baby clinic register collects the number of children assessed for developmental delays, as well as identified with any disabilities. Finally, in Ethiopia, well-baby and sick child registers collect data on both identification of developmental delays and counseling on care for child development.

To support actual delivery of services, providers need job aids. Over the years, PATH has transitioned from promoting standalone flipcharts to developing wall posters and inserts into existing government tools. Posters on developmental milestones are aligned with each country’s IMCI module, while posters on age-appropriate play are generally based on the Care for Child Development counseling card. Additionally, a poster on play in daily routines has been developed to help caregivers take advantage of everyday tasks to promote early learning. 

In countries where home-based records are in use, like Kenya and Zambia, PATH has supported integration of developmental monitoring and counseling into these tools, along with needed training and Standard Operating Procedures (SOPs).

To optimize the use of waiting time for learning, PATH has designed a playbox intervention. The early playbox guide was directed at facilitators, listing steps of a typical session and needed play items (see Ethiopia playbox guide, for example). Following human-centered design, the playbox guide in Kenya and Mozambique was revised to focus on caregivers; namely, it now shows caregivers examples of age-appropriate activities. Additionally, a catalogue of simple play items was developed in Mozambique and Kenya to help in production of playbox contents.

Additional posters were developed in response to emerging needs. For example, a poster on complementary responsive feeding was designed in Mozambique to address lack of counseling materials on nutrition in health facilities and to target the practice of forced feeding, which is common among caregivers.

PATH had initially drawn on training materials from the Care for Child Development module (WHO, UNICEF 2012). Later, based on implementation lessons and formative assessment of health services, the training models were adapted (see Evolution of Approaches and Tools).

With time, standalone ECD trainings became more streamlined and responsive to realities on the ground, especially after human-centered design conducted in Kenya and Mozambique in 2022-2023. Innovations included training community and facility providers to use the Mother Child Health Handbook to promote ECD in Kenya and making better use of long hours spent in maternity wards and facility waiting rooms. By the end of 2024, Ministries of Health in Ethiopia and Mozambique will have their national ECD training manuals, developed with technical assistance from PATH. Pilot training videos have been developed in Portuguese and English to support training roll out.

In all three countries, competency-based mentoring tools were developed for use after the trainings. An assessment done in Mozambique suggested that regular mentoring using such tools led to improved provider performance. However, to increase ownership, PATH has also been working on integration of some items into existing supportive supervision tools. This work is still ongoing.

Additionally, relevant content has been gradually integrated into several government in-service training manuals, among them Integrated Management of Childhood Illnesses, Essential Newborn Care, management of malnutrition, and others.

Our current training approaches have both strengths and weaknesses. The trainings seem to be effective in conveying the importance of ECD to providers and in helping them counsel on early learning activities with user-friendly tools. At the same time, promoting responsive care and child-friendly services remains an ongoing challenge, as does increasing the consistency of developmental monitoring. We invite partners to explore and address these challenges, building on work already done.

Throughout the years, PATH has conducted formative assessments of its work to see if provider skills and caregiver recall and practices around child development were improving. Examples include initial assessment of playbox intervention conducted in 2016 in Mozambique and assessment of two ECD pilots in Ethiopia in 2022–2023.

Case studies on PATH-supported ECD interventions in the health sector in Kenya and Mozambique and, specifically, on elements that contribute to scale up were conducted by Spring Impact in 2019. More systematic evaluations of PATH’s work were done in Kenya by Africa Population and Health Research Center (APHRC) and in Mozambique by the Harvard School of Public Health in 2018–2020. Studies showed high acceptability, feasibility, and sustainability of integrated interventions, while presenting mixed results on initial impact.

The most recent wave of assessments followed human-centered design applied in Mozambique and Kenya in 2022/2023. Updated counseling solutions were co-created for the waiting rooms and child health services, among other touchpoints, and these were assessed through short pilots, which generally showed promising results. Briefs on human-centered design and co-created solutions can be found below.