When looking for tools to support the integration of ECD services into routine health care, PATH identified a Care for Child Development (CCD) package (WHO, UNICEF, 2012) as a suitable resource. This package was originally developed as an Integrated Management of Childhood Illnesses (IMCI) module, and several IMCI flipcharts adopted in eastern and southern Africa after 2012 have indeed included a Care for Child Development counseling card.
Minimal adaptations were done to the original CCD package at the initial stage. These primarily had to do with breaking down long texts in the participant manual with discussion questions, adding exercises, and introducing developmental monitoring. The Ministries of Health in Mozambique and Kenya were not ready to prioritize counseling without addressing developmental concerns; therefore, content on developmental monitoring had to be integrated. At this stage, the same job aids and training manual were used for both health facilities and community providers.
When initial implementation was observed, it became clear that health providers were not adequately integrating ECD services into their routines. Facility providers tended to offer standalone counseling on care for child development after completing clinical work, which unnecessarily prolonged consultation time, and many community health workers, enthusiastic after the training, were focusing their household visits on early childhood development to the exclusion of other health areas.
Confronted with this reality, the PATH team decided to take a step back to understand how routine clinical and community services are actually delivered in Mozambique and Kenya, and how ECD components can be integrated into these services. As a result, we have learned that: 1) preventive or promotive counseling during routine services is rare; counseling is usually done in response to an identified need; 2) different touchpoints offer different opportunities for counseling; 3) there is little warmth and empathy in communication between providers and clients; child-friendly interactions are not common; and 4) few counseling job aids are used routinely. Lack of preventive nutritional counseling was noted as a particular concern in the context of high rates of child malnutrition and importance of nutrition for healthy brain development.
As a result, PATH designed pictorial cards that encouraged warm communication with caregivers and children and offered age-appropriate guidance on responsive care, early learning, and nutrition, indicating relevant content for different touchpoints. The cards also suggested who to prioritize for counseling. Training was redesigned to strengthen the quality of counseling and to help integrate counseling into normal service routine.
While revised facility and community counseling job aids and training approaches proved to be feasible and acceptable to health providers, and facility counseling cards were observed to be the main tool used for counseling in routine services both in Kenya and Mozambique, due to the high unit cost of the facility cards, the Mozambique Ministry of Health (MOH) did not approve its use beyond the Maputo province. Instead, it emphasized the need for either developing simpler standalone materials or integrating ECD into existing MOH packages.
As a result, PATH has supported the development of posters that facility providers could either place on their desks or hang on the wall. The posters depicted developmental milestones, play in daily routines, and age-appropriate play and communication activities. In Mozambique, an additional poster on complementary infant feeding was developed based on an identified need. The training manuals were adapted accordingly. Subsequently, PATH has also begun to work on integrating ECD content into existing government packages and tools (see this more recent work described in other sections of the knowledge hub).
