Reaching the youngest children: an approach for health system integration

The foundation for lifelong health and well-being is laid during the earliest years, from pregnancy through a child’s third birthday. Emerging science underscores the life-altering benefits of providing good care, stimulation, and opportunities for learning throughout this period: children are more likely to grow up to be healthier, better-educated adults, with improved socioeconomic outcomes. In most low-resource settings, however, early childhood development investments still focus primarily on preschool-age children and miss the critical window of opportunity during the early years, when developmental delays may be mitigated – or avoided altogether.

Since 2012, PATH has been working to fill this gap by championing an approach that uses health systems to scale-up early childhood development services for the youngest children. This work began in relative isolation, with PATH often a lone voice at the national level, advocating for changes that policymakers and other influencers were not yet ready to act on decisively. But events over the past two years have dramatically altered this landscape and sparked a collective global and national shift to ensure that children not only survive, but thrive.

Because of PATH’s long-standing work to improve child health and nutrition, we recognised an opportunity to address early childhood development more broadly in the context of the health system. In 2012, an initial landscaping of early childhood development programmes and policies in Kenya, Mozambique and South Africa confirmed what PATH suspected – that beyond the health sector, few services existed that were designed for children under 3 years old. The following year, we began adapting early childhood development models for the health system and piloting the World Health Organization’s (WHO) and UNICEF’s Care for Child Development framework to train service providers in Kenya and Mozambique.

Although PATH made progress in demonstrating the feasibility of this new approach and gradually increasing programme size, these interventions for young children were still not widely seen as an issue for the health sector, and a major expansion supported by clear government policies and commitment was a distant prospect. In 2016, however, The Lancet’s landmark series on early child development affirmed the health system as the primary entry point to reach young children and their caregivers. It also introduced the concept of ‘nurturing care’ – comprising health, nutrition, responsive caregiving, early learning, and security and safety – as a critical set of linked interventions needed to achieve optimal developmental outcomes. The series highlighted the urgent need to integrate these interventions into routine health services. It also accelerated PATH’s work, spurring partnerships with WHO, UNICEF, and many national governments who were becoming increasingly interested in this effort.

Based on evidence, experience and country need, PATH uses the health system as an entry point for supporting families to enable their children to thrive, through a three-pronged approach:

• integrating early childhood services into all elements of a health system, from training service providers, to providing support and supervision, to ensuring that information systems capture relevant data
• expanding the evidence base for health sector integration of early childhood development programming in low-resource settings and disseminating lessons learned
• strengthening the enabling environment by including early childhood development content in policies, guidelines, training curricula, and government work plans and budgets.

Between 2011 and 2017, PATH implemented a large health systems strengthening programme in South Africa, where early childhood development was a critical component of the minimum package of services provided through community-based services. PATH currently supports government efforts to scale-up health systems-based early childhood development services in Côte d’Ivoire, Kenya, Mozambique, and Zambia. Notably, PATH has contributed to the integration of nurturing care into 11 district health systems in Kenya and Mozambique. Both countries are scaling-up integration, ultimately reaching a population of at least 2 million by 2020. In implementing this health systems approach, PATH works closely with policymakers, technical staff and civil society to align interventions with existing structures and resources, and to ensure that government is in the driver’s seat.

Healthcare workers are often the first and only service providers who regularly interact with children under 3 and their caregivers. PATH’s approach aims to give these staff the training, tools and resources necessary to integrate nurturing care into community- and facility-based health services. First, PATH builds a cadre of government trainers and supervisors by incorporating information on early childhood development into training on standard packages of care, such as WHO’s Integrated Management of Childhood Illness (IMCI). In addition to being cost-effective, this model enhances government ownership and reinforces the inclusion of nurturing care as an essential component of the health system.

These trained staff then build the capacity of service providers to integrate content on nurturing care into routine service delivery – including antenatal and postnatal care, child immunisations and growth monitoring, paediatric services, and community-based interventions. Health facility staff, for example, learn to provide counselling on age-appropriate play and communication activities, assess developmental milestones, and refer children with suspected developmental delays. Community-based service providers also reach children and caregivers during home visits and structured play sessions in health facility waiting areas.

Training service providers is just the first step. PATH also supports structured mentoring, whereby mentors directly observe the counselling skills of trained staff and provide coaching on areas of weakness. In Kenya and Mozambique, we are working with the government to formally incorporate supervision on early childhood development into the health system by updating supportive supervision norms and tools.

The evidence base for delivering early childhood development services through the health sector is still limited, and many existing studies may not be applicable because they take place in tightly controlled research settings. Moreover, little research completed to date focuses on sub-Saharan Africa. PATH is working to address these gaps. In Mozambique, we have conducted three evaluations on the feasibility and acceptability of integrating content on nurturing care into home visits and facility-based services, as well as implementing play sessions in health facility waiting areas. According to findings, not only is integration feasible in low-resource settings, it improves caregivers’ perceptions of service quality. This has generated the political will to scale-up such integrated services nationally. It has also created interest internationally.

Working with local partners in Kenya, PATH is conducting further research to evaluate the impact of health sector integration on the knowledge, attitudes and practices of caregivers, as well as child growth and developmental outcomes. The study will also estimate the cost-effectiveness of integration and offer learnings for anticipated expansion, led by national governments, into new regions and countries.

Political will and government commitment at all levels are essential to place early childhood development services within the health system at scale. Through advocacy, PATH aims to integrate nurturing care into relevant national policies and guidelines. In Kenya, for example, previous child health strategies and guidelines primarily focused on child survival. PATH advocated for the development of the Neonatal, Child and Adolescent Health Policy as an overarching guide for all child health services, and ensured that the policy included content on nurturing care for children from birth to age 3.

To translate policy change into service delivery, it is critical to modify curricula and job aids. In Mozambique, PATH’s advocacy efforts resulted in the inclusion of early childhood development content in the pre-service training curricula of nurses and community health workers, which are now under revision. This is particularly important for sustainability and reaching scale, as in-service training is expensive. PATH also facilitated a series of consultations in Kenya and Mozambique to strengthen content on developmental screening and counselling in revised IMCI programme packages, which guide the delivery of health services.

Finally, PATH advocates for the integration of nurturing care services into routine data collection systems. For example, we worked with the Ministry of Health in Mozambique to revise maternal and child health data registers to include relevant indicators. The significance of this is twofold. First, it will enable the government and other stakeholders to track – for the first time – the number of children receiving early childhood development services, as well as the number of children with suspected developmental delays. Second, a formally approved Ministry of Health tool helps service providers view early childhood development as a part of their routine work, rather than a partner- promoted intervention with parallel data collection.

At global and national levels, a shift in perspective is clear: increasingly, early childhood development is viewed as an important focus of the health sector. Many governments are poised to lead the introduction or expansion of nurturing care integration into the health system and are prepared to commit resources to the ‘thrive’ agenda. PATH’s approach offers a road map for governments and partners interested in this work.

We recognise that health systems are not overhauled overnight. But emerging evidence, country leadership and an aligned global community are enabling significant progress to be made in reaching children and their caregivers in their earliest years.

References can be found in the PDF version of the article.