Improving Service Delivery for Nurturing Care

Caregivers and young children receive health services through contact points that span from the earliest stages of pregnancy into the first three years of life. These health services offer opportunities for health workers to monitor child development and counsel caregivers about responsive caregiving, early learning, and safety and security.

But there can be challenges to implementing interventions that promote nurturing care:

Health providers often attend to large numbers of patients and may not have enough time to incorporate additional interventions in the limited window they have with each caregiver.
Physical health concerns such as nutrition, growth monitoring, and illness management often take priority in these interactions.
Caregivers, especially those living in remote settings, may find it hard to access health services. Community health workers are a vital link in PHC delivery, but heavy, unsustainable workloads limit how much more can be added to their plates.
While developmental monitoring helps identify children needing extra support, referral pathways to connect them with targeted services are not always established. Where referral pathways exist, these services may not be accessible and affordable.

Still, actions can be taken to adapt and incorporate interventions that promote nurturing care into routine health services, with guidance consistently reiterated outside visits. The table below provides an overview of interventions that are relevant for PHC and promote optimal child development.

Interventions to promote nurturing care in PHC

Enabling factors to promote nurturing care through service delivery

Services must be accessible, equitable, and high quality to ensure that caregivers and children receive the nurturing care and support that they need. Five enabling factors are essential for promoting nurturing care.

1. A selection of existing contact points is prioritized for promoting nurturing care.

A range of existing contact points within facilities, homes, and communities offer avenues to promote optimal child development (see Topic 2: Promoting Nurturing Care in PHC). It is important to consider where caregiver capacities can be strengthened, and developmental monitoring can be included — while considering the real time and logistical constraints facing both health providers and caregivers.

Identifying which contact points and interventions to prioritize depends on several factors:

Does the provider have the appropriate capacity, including knowledge and time to deliver guidance to caregivers, address questions, and provide demonstrations where possible?
Will the provider have opportunities to follow-up with the caregiver to reinforce and build upon the caregiver’s capacities to support their child’s development and where to go for further assistance?
Can the intervention be integrated in a way that creates efficiencies rather than adding burden? Refer to Learning Topic 2: Promoting Nurturing Care through PHC for suggestions for how interventions can be tailored to each PHC contact point.
Is the caregiver / family receptive at this point of contact?

Once the contact points are identified, the process of adapting specific interventions can begin.

Several resources have been developed to promote nurturing care in existing contact points and platforms within the health system. Resource 8 in the full toolkit PDF compiles a selection of these existing tools. Before adopting any of these resources, it is important to take stock of a country’s existing curricula and training modules and build upon approaches grounded in the local context.

2. Community-based programs are optimized.

Community-based programs extend service accessibility to caregivers and children who may face challenges visiting facilities due to distance, transportation, time, or fear of stigma. This is especially true for rural and remote areas where traveling to a facility may be more challenging. Community-based programs focused on nurturing care include individual and group interventions— and most use a combination of both. Community-based programs can also be adapted to emergency contexts. (See the example of service delivery in complex emergency settings below.)

Community-based programs often rely on paraprofessionals hired from the local community who understand the context, including familiarity with local customs, beliefs, and challenges faced by caregivers. As a result, they can personalize interventions to suit the caregiver’s needs, making the guidance more relevant and applicable to a caregiver’s specific situation.

Home visits are especially well placed to deliver interventions that promote nurturing care. They reduce the burden for family travel, allow the health worker to observe the child and caregiver in the context of their home environment, and provide an opportunity to gain a better understanding of the caregiver’s experience.
Group sessions held in community spaces such as churches, school classrooms, or ECD centers provide social support and opportunities for peer learning for caregivers who are in attendance. A meta-analysis of programs for home-visiting and group sessions (see an example from Lebanon, Jordan and Syria in Learning Topic 5: Strengthening the Health Workforce for Young Children), found that peer interactions between caregivers in group sessions were beneficial to learning and receptiveness to program content. Larger community-based programs, such as vaccination campaigns that reach a wider community audience, also enable opportunities to educate the public about the importance of nurturing care.

Service delivery in complex humanitarian emergency settings

Baby Friendly Spaces is a program by Action Against Hunger that creates “safe places” in refugee camps in Cameroon for pregnant and lactating mothers. The purpose of the program was to address the lack of support services for pregnant and lactating women and their young children in complex humanitarian emergencies. Separate spaces were set up near women’s shelters in the camp providing interventions for strengthening parental skills, psychomotor development for babies, and psychosocial support and emotional well-being for both women and babies. Activities included anticipatory guidance for pregnancy and delivery, counseling on breastfeeding and complementary feeding, mother-child play sessions, contextualized psychosocial support, group discussion, home visits, and community awareness activities.

Discover how the program led to significant improvements for mothers and children in the full toolkit PDF.

3. Interventions use a range of light- to heavy-touch approaches.

Because antenatal, postnatal, and routine child health visits are often the most consistent contact points families have with the health system, these contacts should be the first priority for incorporating guidance to promote nurturing care. Materials such as visual aids, counseling cards, or home-based records facilitate conversations between providers and caregivers during visits. This strengthens provider-caregiver interactions and supports caregiver understanding of children’s development.

In addition, there are multiple opportunities to reach caregivers outside of these contact points and reinforce the messages provided during contacts. For example:

Waiting areas of facilities offer a favorable opportunity to engage caregivers before their visits — through demonstrations of developmentally appropriate play, modelling how to play and talk to children, or designating a play area with toys that offer caregivers the opportunity to engage their children in play and learning.
Digital tools also show promise for reaching caregivers. For example, a study of an AI-enabled chatbot providing parenting support in Peru found that it was more cost-effective than a home visiting program, though in-person home-visiting contributed to greater gains in child development.

4. Ongoing, developmental monitoring and counseling sets the foundation for caregiver-provider conversations about the child’s development.

Developmental monitoring is essential for supporting young children’s development. It identifies children who are at risk of not reaching their full developmental potential and informs timely delivery of interventions to support the child’s needs.

WHO guidance advocates for an approach to developmental monitoring that moves away from focusing only on milestone-based screening and toward a continuous, participatory, and family-centered model. Screening based solely on developmental milestones is not accurate in detecting children at risk of delay because it does not account for the wide variation of development and may not consider a child‘s environment and influences. Expanding developmental monitoring to consider familial and environmental factors, such as maternal mental health and caregiver interaction, provides a more accurate picture of a child’s developmental progress.

Monitoring child development should be an ongoing process that invites caregivers to participate by sharing their observations and concerns with providers, painting a more holistic picture of the child’s developmental progress and potential risk.

The Guide for Monitoring Child Development (GMCD) is a comprehensive package developed in Turkey that has been standardized, validated across low- and middle-income contexts, and implemented in 25 countries. It emphasizes asking caregivers open-ended questions about their child’s development across different domains, and supporting individualized guidance based on the child and family’s specific needs.

5. Targeted services, follow-up, and support are provided where needed.

All children should ideally receive universal services — like developmental monitoring — during routine visits, while those identified as at risk are referred for additional follow-up and targeted care, such as home visits.

In contexts where specialized services are limited, primary health care providers who are additionally trained in mental health and psychosocial care needs of vulnerable children may be able to provide targeted care.

Additionally, some community-based programs outside the PHC system can support case management and be leveraged as referral linkages to provide support to vulnerable families.

The Smart Beginnings model in the U.S. includes a universal primary prevention component delivered during well-child visits, as well as a secondary targeted home-visiting program for families identified as having increased needs. Indicated services are provided to children and families who require specialized services and could include referrals to mental health, social, and Early Childhood Intervention (ECI) services. ECI services support children who are at risk of or who have developmental delays or disabilities and emphasize an individualized, family-centered approach (often conducted by professionals in the home). This is delivered by a trans-disciplinary team including professionals such as doctors, nurses, speech and occupational therapists, nutritionists, and early childhood interventionists. They include a range of services to improve child development outcomes and to strengthen caregivers’ abilities to address their children’s physical and developmental needs.

Chile Crece Contigo, Chile’s comprehensive protection system for children under 4, has demonstrated the effectiveness of utilizing a tiered approach. An evaluation found that between 2006 and 2017, the proportion of children under 5 with developmental delay declined nationally from 14% to 10%, with the most dramatic reductions in developmental delay noted in children aged 2 (from 11.6% to 6.2%) and aged 3 (from 25.1% to 11.4%). Chile Crece Contigo’s system provides free education and social protection to all children and targets children assessed with developmental delays with home visiting interventions promoting stimulation, as well as extra support from child development specialists.

Examples of specific actions that PHC decision-makers can take to realize these conditions include:

Identifying high-priority contact points for further attention to promote nurturing care.
Providing targeted support to at-risk and vulnerable children through home visits.
Leveraging mass media such as radio or television to broadcast messages that promote nurturing care.
Leveraging community-based programs to provide specialized services to children with additional needs where there is insufficient capacity.

Case study: Side-by-Side campaign in South Africa: Empowering caregivers through multiple communication channels

Read the case study

Despite progress in reducing child mortality, millions of children in South Africa are still not reaching their full developmental potential. In response, the National Department of Health launched the Side-by-Side campaign — a messaging campaign designed to equip caregivers with the guidance and support they need to provide nurturing care for young children aged 0-2. Central to the campaign is the Road to Health booklet, given to families at birth and used by health workers to track child growth, developmental milestones, and nurturing care practices across five key themes: Nutrition, Love, Protection, Healthcare, and Extra Care.

More than 1 million copies of the Road to Health booklet have been distributed; yet, implementation has been a challenge. On average, only 40% of the booklet is adequately completed, with staff shortages, retraining gaps, and language barriers affecting consistent use. These challenges have shaped valuable lessons about what it takes to sustain and scale interventions that promote nurturing care within existing health systems.

For the full case study including key lessons and implementation insights from South Africa’s experience, visit the full toolkit PDF.

The following additional resources can be found via the links below, or by downloading the full toolkit PDF:

Resource 5 includes an illustrative list of interventions that promote nurturing care in PHC.
Resource 6 includes a table with the full list of enabling factors and corresponding actions for Service Delivery.
Resource 7 includes reflection questions to support discussion and planning related to Service Delivery.
Resource 8 features a description of evidence-based training packages to equip providers with skills to promote nurturing care.