Introduction to the Toolkit

Primary health care (PHC) systems have made remarkable gains in child survival, nutrition, and growth over the past three decades. Yet even as those investments succeed, a critical dimension of early childhood lags behind: fewer than one in three children ages 2-5 in LMICs receives adequate developmental stimulation or is protected from physical punishment. This not only hinders optimal child development — reflecting linguistic, cognitive, physical, motor, and socioemotional outcomes — but carries consequences for health and economic success well into adulthood.

PHC systems, which are already delivering key interventions like growth monitoring and immunizations, can be further optimized to promote nurturing care, a set of conditions that provide for children’s health, nutrition, safety and security, responsive caregiving and opportunities for early learning.

Given that children ages 0-3 and their caregivers access PHC services through multiple consistent and standardized contact points — such as antenatal care, postnatal care, and well-child visits — and have trusted relationships with health care providers, PHC systems are well-positioned to promote holistic child development. There is growing experience and evidence on the value of leveraging these contact points to promote components of nurturing care that have traditionally been outside the scope of the PHC system including:

• Responsive caregiving: The ability of a parent or caregiver to notice, understand, and respond to their child’s signals in a timely and appropriate manner.
• Safety and security: Environments where children are protected from physical, emotional, and environmental risks and have access to safe water, clean air, and nutritious food.
• Early learning: Any opportunity for a child to interact with a person, place or object in their environment. Every interaction (positive or negative) or absence of an interaction contributes to the child’s brain development and lays the foundation for later learning.
• Developmental monitoring and counseling: The ongoing tracking of a child’s growth and development across domains over time, in partnership with caregivers. Essential for early identification of developmental conditions and timely intervention.
• Caregiver well-being: The mental health and well-being of parents and caregivers, which directly shapes their ability to provide nurturing care. Frontline workers can support caregiver well-being through counseling, stress management, and connecting caregivers to additional resources.

Furthermore, there is emerging evidence that PHC providers that incorporate components of nurturing care can actually increase utilization and perception of the quality of PHC services, including well-child visit attendance.

Purpose of this toolkit

This toolkit focuses on how governments and their partners can identify and carry out actions to promote responsive caregiving, early learning, and safety and security across health systems by:

• Providing practical guidance to national and sub-national health sector decision-makers, with a focus on LMICs.
• Focusing particularly on children aged 0 to 3, because it is a critical window of child development and a period in which the health system is uniquely positioned to provide support.
• Highlighting how to support the three specific components of nurturing care — responsive caregiving, safety and security, and early learning — as well as caregiver well-being and developmental monitoring and counseling as cross-cutting intervention areas.
• Informing the health sector’s role within the multisectoral landscape and highlighting opportunities to improve sectoral collaboration, such as through referrals to specialized services.

How to use the toolkit

Decision-makers can use this toolkit to:

• Identify, prioritize, and plan actions to strengthen developmental monitoring and counseling and promote responsive caregiving, safety and security, early learning, and caregiver well-being throughout one or more health system building blocks.
• Access existing tools, resources, and training packages to promote nurturing care.
• Learn from country experiences across the health systems building blocks from featured case studies.

This toolkit can be used in whole or in parts, depending on country needs and priorities.

Health System Building Blocks

The toolkit utilizes the WHO’s Health Systems Building Blocks as an organizing and analytical framework:

• Leadership and governance: policy frameworks, oversight, incentives, and system design and accountability.
• Health workforce: recruitment, training, and ongoing support of health workforce cadres, as well as how they are supported and remunerated to deliver health services.
• Sustainable financing: management and mobilization of resources for financing health services including financial protection to households to ensure affordability.
  Information systems: how data are systematically collected, analyzed, and used to monitor and improve system performance.
• Medical products, vaccines and technologies: medical products, vaccines and technologies which are of high quality, safe, efficacious, cost-effective, and scientifically sound. (not a focus given the areas of nurturing care addressed in the resource.)
• Service delivery: the provision of high quality and widely accessible health services.

These building blocks are interrelated. Leadership and governance is foundational to a health system supportive of nurturing care. A well-functioning health workforce, the availability of sustainable financing, and effective information systems provide a supportive environment to ultimately facilitate high quality, accessible, and equitable service delivery. These intersections are referred to across the toolkit.