Topic 05
Strengthening the Health Workforce for Young Children
Strengthening Primary Health Care
to Promote Optimal Child Development
The health workforce — particularly maternal and child health staff, nurses, midwives, pediatricians and community health workers (CHWs) — plays a crucial role in supporting young children’s development through frequent interactions with caregivers and children during pregnancy and the early years of life. These contact points provide valuable opportunities for health workers to strengthen caregiver capacities for nurturing care alongside routine child health and nutrition services. With adequate training, supervision, and support, the health workforce can maximize these opportunities to improve early childhood development outcomes.
The health workforce is well-positioned to support young children’s development.
Embedding developmental monitoring and counseling, as well as interventions that promote responsive caregiving, early learning, safety and security, and caregiver well-being into the roles of PHC workers can benefit caregivers and children. It provides opportunities for caregivers to receive information, counseling, and support from trusted health workers, often as part of their routine health care.
Despite being well placed to support children in their early years, health workers often face significant challenges promoting nurturing care alongside routine health services. Workforce shortages and high workloads can hinder quality of care and hinder caregivers’ access to services. In addition, pre-service training programs may not adequately prepare health workers to promote responsive caregiving, early learning, safety and security and developmental monitoring. Ongoing in-service training, supportive, job aids, materials, and sufficient financing are also needed to help health workers effectively support caregivers and children.
Enabling Factors to Strengthen the Workforce to Nurture Optimal Child Development:
Three enabling factors are essential to enhancing the workforce’s capacity to promote nurturing care, and several actions can be taken to put them in place.
1. Health workers receive adequate, contextualized training and supportive supervision
Pre-service training on nurturing care
Health workers need to be equipped with the knowledge to answer common caregiver questions and the skills to promote nurturing relationships with their children. However, current medical school curricula and residency training do not cover many aspects of child development and developmental interventions, including screening for developmental delays. Similarly, continuing medical education training focuses more on theories of child development than practice-based skills.
Training that covers the science of early childhood development and interventions to promote nurturing care can be added to existing health provider training curricula. Collaborations between academic pediatric departments, medical training programs, and national pediatric associations can further strengthen pre-service training and create child development-related guidelines that are more likely to be adopted by primary health care personnel.
In-service training to further improve skills and knowledge
In-service training helps reinforce skills and fill gaps not covered in pre-service training. Studies in Kenya and Jordan found that many health workers lacked confidence in areas such as responsive caregiving, early learning, social-emotional concerns, and behavioral challenges, leaving them feeling unprepared to answer caregiver questions or facilitate supportive discussions.
In-service training can strengthen counseling and communication skills, improve provider-caregiver interactions, and increase health worker motivation and job satisfaction.
Digital tools and videos also show promise for expanding access to training while reducing costs. A series of videos developed by Global Health Media provides counseling on universal baby cues and Infant and Young Child Feeding (IYCF) that can be used in health worker training on nurturing care. While there are several in-service training packages that include modules on how to listen, ask for information, praise, advise and solve problems with caregivers, they are not yet implemented at scale. Emphasizing these counseling skills for health workers enables positive interactions with caregivers and encourages caregivers to continue to seek care from health providers.
Virtual training offers a cost-effective way to expand reach while maintaining learning outcomes for health workers. Recorded videos delivered over messaging platforms like WhatsApp can deliver and reinforce knowledge for health worker trainees. Adding accreditation or certifications to training programs can provide health workers with incentives to continue their professional development.
Supportive supervision and on-the-job coaching
Supervisors are critical to ensuring that frontline workers have ongoing support to deliver interventions that support nurturing care over time. The presence of a supportive supervision system with on-the-job workforce coaching is a strong contributing factor for how well the workforce delivers interventions to promote nurturing care.
Supportive supervision and on-the-job coaching are particularly important for lay health workers. However, the limited number of health workers with technical expertise in nurturing care means that supervisors do not always have the knowledge or skills to observe and provide feedback to frontline health workers. Cascaded training models, peer-to-peer mentoring, and coaching are all strategies that can help address this gap.
2. Tools and job aids are readily available and accurately used.
Job aids — any tools, visuals, prompts, or suggestions that help health workers carry out their work — can help standardize interventions, improve program quality, and bridge knowledge gaps for caregivers. For health workers, job aids such as decision trees, scripts, and manuals help streamline communication, support decision-making, and provide references during their interactions with caregivers. However, the effectiveness of a job aid depends on adequate supply and proper use. When materials are too complex or in short supply, they can undermine the quality of caregiver interactions rather than support them.
Many health workers, including pediatricians, are not trained to use available tools for developmental monitoring, and existing tools covering 0–3 year-olds are not always valid, reliable, and appropriate for use in LMIC contexts. Effective tools should not only consider individual factors but also the broader spectrum of risks and protective factors that affect families (refer to Topic 6: Health Information Systems for more information on developing data collection systems). Equipping frontline health workers with practical guidance on interpreting and responding to the results of developmental assessments is essential to the quality of care they deliver. (See Topic 3: Service Delivery for more information on developmental monitoring.)
3. Staff capacity and workforce incentives are considered when designing interventions.
Staff shortages — particularly in rural and remote areas — lead to high workloads and high staff turnover. Increasing recruitment is a potential strategy to mitigate this. In addition to competitive stipends, incorporating material and social incentives such as social recognition and preferential access to services, helps to maintain morale and motivation.
Examples of specific actions that PHC decision-makers can take to realize these conditions include:
- Incorporating content on interventions that promote nurturing care into pre-service training curricula.
- Creating opportunities for on-the-job coaching and peer mentoring particularly where supervision systems are limited.
- Producing and distributing tools and job aids for health workers.
- Leveraging waiting areas and group settings to deliver guidance and demonstrations for promoting nurturing care to multiple caregivers simultaneously.
Strengthening Health Workforce in Emergency Settings
Millions of caregivers and children who were displaced by the Syrian crisis and are now living in internally displaced persons camps in Syria or refugee camps in Jordan and Lebanon. In situations of conflict and crisis, high levels of stress, trauma, and instability hinder the nurturing environments that children need for healthy growth and development. In response, the International Rescue Committee (IRC) in Syria, Lebanon, and Jordan adapted and implemented the Reach Up and Learn program, an early childhood home-visiting program that equips caregivers with the skills to stimulate their child’s development through talking, playing, and interacting with their children.
To navigate the realities of conflict, the IRC adapted the program in several important ways — training more staff than needed to account for high turnover, tailoring curriculum content and language to reflect the lived experiences of Syrian refugees, and equipping home visitors with referral information to connect caregivers with healthcare, legal aid, and financial assistance. This last element proved especially important: addressing caregivers’ basic needs helped home visitors build meaningful, trust-based relationships.
Learn how the program navigated recruiting, training, and supervising health workforce in conflict settings in the full toolkit PDF.
Some health systems alleviate health provider workload through task-shifting, which involves training paraprofessionals or health volunteers to carry out tasks typically held by traditional health workers. Another approach is to deliver coaching or demonstrations to multiple caregivers at once through group parenting sessions or health facility waiting areas, which reduces the total number of staff needed. (See Topic 3: Service Delivery for more information on group sessions and other activities in waiting areas).
Case study: Prescription to play in Bhutan
Read the case study
While adding to the responsibilities of CHWs and similar staff is feasible in some contexts, it may not be effective or sustainable over time. Risks include diluted services, poor quality delivery, staff burnout, and poor retention. Evidence from countries like Brazil and Malawi suggests that either expanding existing health personnel or establishing a new cadre of staff may be necessary to promote nurturing care effectively — with CHWs serving in a more supervisory role. As roles evolve, it is important to define core competencies and create clear, updated job descriptions.
In Bhutan, the Ministry of Health partnered with Save the Children and the LEGO Foundation to launch Prescription to Play — a program equipping health assistants nationwide to deliver playful parenting sessions to caregivers of children ages 0 to 3. By embedding training in the medical school curriculum and providing ongoing in-service support, the program built lasting workforce capacity.
After just three group sessions, the program showed meaningful improvements in caregiver understanding of playful parenting, knowledge of child development, availability of play materials at home, and father engagement in caregiving.
Learn more about how Prescription to Play was designed and implemented, as well as key lessons learned in the full toolkit PDF.
The following additional resources can be found via the links below, or by downloading the full toolkit PDF:
- Resource 6 includes a table with the full list of enabling factors and corresponding actions for Health Workforce.
- Resource 7 includes reflection questions to support discussion and planning related to Health Workforce.
- Resource 8 features a description of evidence-based training packages to equip providers with skills to promote nurturing care.
