Monitor Progress: Strategic Action 4

NURTURING CARE HANDBOOK
Strategic action 4
Monitor
progress
How to monitor
populations, implementation,
and individual children’s
development
Strategic action 4
Monitor
progress
How to monitor
populations, implementation,
and individual children’s
development
Nurturing care handbook. Strategic action 4: monitor progress. How to monitor populations, implementation
and individual children’s development
(Nurturing care handbook. Start here: how to use the handbook, understand nurturing care and take action
– Strategic action 1: lead and invest. How to do governance, planning and financing – Strategic action 2: focus
on families and communities. How to listen to families, encourage communities and use the media – Strategic
action 3: strengthen services. How to build systems, improve the workforce and provide three-level support
– Strategic action 4: monitor progress. How to monitor populations, implementation and individual children’s
development – Strategic action 5: scale up and innovate. How to expand programmes, engage with the private
sector and use digital solutions)
ISBN (WHO) 978-92-4-005849-1 (electronic version)
ISBN (WHO) 978-92-4-005850-7 (print version)
© World Health Organization and the United Nations Children’s Fund (UNICEF), 2022
This joint report reflects the activities of the World Health Organization (WHO) and the United Nations Children’s
Fund (UNICEF)
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-
ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes,
provided the work is appropriately cited, as indicated below. In any use of this work, there should be no
suggestion that WHO or UNICEF endorses any specific organization, products or services. The unauthorized
use of the WHO or UNICEF names or logos is not permitted. If you adapt the work, then you must license your
work under the same or equivalent Creative Commons licence. If you create a translation of this work, you
should add the following disclaimer along with the suggested citation: “This translation was not created by the
World Health Organization (WHO) or the United Nations Children’s Fund (UNICEF). Neither WHO nor UNICEF are
responsible for the content or accuracy of this translation. The original English edition shall be the binding and
authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the
mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules).
Suggested citation. Nurturing care handbook. Strategic action 4: monitor progress. How to monitor
populations, implementation and individual children’s development. Geneva: World Health Organization and
the United Nations Children’s Fund (UNICEF), 2022 (Nurturing care handbook). Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit
requests for commercial use and queries on rights and licensing, see http://www.who.int/copyright.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as
tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and
to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-
party-owned component in the work rests solely with the user.
UNICEF and WHO Photographs. UNICEF and WHO photographs are copyrighted and are not to be reproduced
in any medium without obtaining prior written permission. Permissions may be granted for one-time use
in a context that accurately represents the real situation and identity of all human beings depicted. UNICEF
and WHO photographs are not to be used in any commercial context; content may not be digitally altered to
change meaning or context; assets may not be archived by any non-WHO or non-UNICEF entity. Requests for
permission to reproduce UNICEF photographs should be addressed to UNICEF, Division of Communication,
3 United Nations Plaza, New York 10017, USA (email: [email protected]). Requests for permission to
reproduce WHO photographs should be addressed to: http://www.who.int/copyright
General disclaimers. The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of WHO or UNICEF concerning the legal
status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet
be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed
or recommended by WHO or UNICEF in preference to others of a similar nature that are not mentioned. Errors
and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO and UNICEF to verify the information contained in this
publication. However, the published material is being distributed without warranty of any kind, either expressed
or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall
WHO or UNICEF be liable for damages arising from its use.
Design and layout: 400 Communications Ltd.
Cover photograph: © UNICEF/UN032017/LeMoyne
Contents
Overview iv
Acknowledgements v
Using this handbook 1
Monitoring implementation of
the Nurturing care framework 2
What is monitoring? 2
The logic model 3
What will this strategic action enable me to do? 4
Population monitoring 5
Suggested actions 7
Overcoming the barriers 8
Implementation monitoring 9
Suggested actions 12
Overcoming the barriers 15
Monitoring individual children’s development 16

Suggested actions 17
Overcoming barriers 19
Signs that you are making progress 20
References. Tools, case studies and

further reading 21
Annex 1. The Nurturing care framework’s

24 core indicators 23
Annex 2. Form to monitor child development 24
S T R AT EG I C AC T I O N 4 iii
Overview
This handbook is composed of 6 guides. Each of the

five strategic actions of the Nurturing care framework
has a guide dedicated to it, and the Start here guide
provides a general orientation to the handbook.
Users may read all, or parts of the handbook, The use of this handbook is supported by the
depending on their needs. It is recommended nurturing care website, a vibrant portal with
to read Start here before going to any of the country experiences, thematic briefs, tools, news
other guides. items, and expert voices. Always consult the
nurturing care website for new information that
The handbook is meant to be a living document
can be relevant to the issues that you like
with guidance and resources that will be regularly
to address.
updated as more experiences are gained in the
implementation of the Nurturing care framework.
The Nurturing care handbook is available
at https://nurturing-care.org/handbook
F O R M O R E I N F O R M AT I O N
nurturing-care.org
C O N TA C T
[email protected]
iv NURTURING CARE HANDBOOK
Acknowledgements
The development of this handbook was led by the World

Health Organization (WHO).
WHO is grateful to all those who contributed. Partners continue to collaborate in global
WHO also expresses gratitude to the authors working groups to expand this set, facilitated by
of the Lancet series Advancing early childhood staff at WHO, UNICEF, the World Bank Group,
development: from science to scale (2017) who lay the Partnership for Maternal, Newborn, and
the foundation for the Nurturing care framework Child Health (PMNCH) and the Early Childhood
that underpins this handbook. A special word Development Action Network (ECDAN).
of thanks goes to colleagues at the Institute for
WHO is grateful for the financial support provided
Life Course Health Research at Stellenbosch
by the Children’s Investment Fund Foundation and
University in South Africa, for their support in the
the King Baudouin Foundation USA that made the
development of this handbook.
development of the handbook possible.
This handbook is part of a set of resources for
implementing the Nurturing care framework.
Writing team: Rafael Perez-Escamilla, Yale University; Colleen Murray, UNICEF; Daniel Page,
Bernadette Daelmans, WHO; Kelly Linda Richter, University of the Institute for Life Course Health Research,
Gemmell, Institute for Life Course Health Witwatersrand; Mikey Rosato, Women Stellenbosch University; Kiran Patel,
Research, Stellenbosch University; and Children First UK; Sofia Segura- American Academy of Pediatrics;
Sheila Manji, WHO; Bettina Schwethelm, Pérez, Hispanic Health Council; Sweta Janna Patterson, American Academy
consultant; Mark Tomlinson, Institute Shah, Aga Khan Foundation; Kate Strong, of Pediatrics; Nicole Petrowski, UNICEF;
for Life Course Health Research, WHO; Melanie Swan, Plan International; Annie Portela, WHO; Chemba Raghavan,
Stellenbosch University; and School Zorica Trikic, International Step by Step UNICEF; Nigel Rollins, WHO; Chiara
of Nursing and Midwifery, Queens Association; Francesca Vezzini, Human Servili, WHO; Megan Song McHenry,
University, Belfast, United Kingdom of Safety Net; Cathryn Wood, Development American Academy of Pediatrics;
Great Britain and Northern Ireland. Media International. Giorgio Tamburlini, Centro per la Salute
Additional contributions were made by: del Bambino Onlus; Juana Willumsen,
Content sections were provided by: WHO; Shekufeh Zonji, ECDAN.
Betzabe Butron Riveros, WHO; Kate Jamela Al-raiby, WHO; Judi Aubel,
Grandmother Project; Frances Mary Participants in the meeting Innovating
Doyle, Promundo; Joanna Drazdzewska, for early childhood development:
Women and Children First UK; llgi Beaton-Day, World Bank Group; Claudia
Cappa, UNICEF; Vanessa Cavallera, what have we learned to strengthen
Ertem, Ankara University; Jane Fisher, programming for nurturing care, held
Monash University; Svetlana Drivdale, WHO; Terrell Carter, American Academy
of Pediatrics; Elga Filipa De Castro, 13 – 14 June 2019 in Geneva, Switzerland,
PATH; Matthew Frey, PATH; Liana Ghent, all contributed to the content of this
International Step by Step Association; UNICEF; Lucie Cluver, University of
Oxford; Tom Davis, World Vision; handbook.
Margaret Greene, Promundo; Patrick
Hoffmann, Human Safety Net; Robert Teshome Desta, WHO; Anne Detjen, The following representatives provided
Hughes, London School of Hygiene and UNICEF; Amanda Devercelli, World feedback on behalf of the Child
Tropical Medicine; Dan Irvine, World Bank Group; Erinna Dia, UNICEF; Health Task Force: Catherine Clarence,
Vision; Romilla Karnati, MOMENTUM Tarun Dua, WHO; Leslie Elder, World Zacharia Crosser, Kasungami Dyness,
Country and Global Leadership, Save Bank Group; Maya Elliott, UNICEF; Olamide Folorunso, Kate Gilroy, Debra
the Children; Vibha Krishnamurthy, Ghassan Issa, Arab Network for Early Jackson, Lily Kak, Senait Kebede,
Ummeed Child Development Center; Childhood Development; Aleksandra Allisyn Moran, Sita Strother, Lara Vaz
Joan Lombardi, Early Opportunities; Jovic, UNICEF; Boniface Kakhobwe, and Steve Wall.
Rajesh Mehta, WHO; Ana Nieto, UNICEF; UNICEF; Masahiro Kato, UNICEF;
Katie Murphy, International Rescue Jamie Lachman, University of Oxford;
Committee; Frank Oberklaid, The Royal Christina Laurenzi, Institute for Life
Children’s Hospital Melbourne and the Course Health Research, Stellenbosch
Murdoch Children’s Research Institute; University; Jane Lucas; Susanne Martin
Herz, American Academy of Pediatrics;
S T R AT EG I C AC T I O N 4 v
Photo credit: © UNICEF/UNI134957/Dormino
Using this handbook S T R AT E G I C A C T I O N S
1
This is part of the Nurturing care handbook, a practical
guide to using the Nurturing care framework to improve
early childhood development.
If you have not already, you will probably find it helpful
to take a quick look at the first part of the handbook:
Start here. This explains in more detail how the handbook
works, what nurturing care is, and how to get started.
2
It also includes practical advice on working in programme
cycles, engaging all stakeholders, and doing advocacy.
After Start here, the handbook is divided into five
strategic actions, each explained in a separate guide:
1 Lead and invest

2 Focus on families and their communities
3 Strengthen services
4 Monitor progress
5 Scale up and innovate
3
You can find out more and download the rest of the
handbook at https://nurturing-care.org/handbook
SCALE UP AND
INNOVATE *
S T R AT EG I C AC T I O N 4 * P r e v i o u s l y c a l l e d U s e d a ta 1
a n d i nn o v a te.
Monitoring
Monitoring aims to answer two questions:
“Are we doing what we

implementation of planned to do?”
the Nurturing care and

“Does this lead us to the
framework expected results?”
The importance of monitoring was referred to

What is monitoring? throughout this handbook. In this guide on Strategic
action 4. Monitor progress, more details and concrete
suggestions of what and how to monitor are
Monitoring is the process of systematically discussed.
collecting, analyzing and using information.
Monitoring implementation is context specific. The
It is an essential component of global
choice of indicators will depend on the interventions
initiatives, national programmes and and policies that are being implemented. This is
individual efforts. That is because it particularly true for indicators of input and outputs.
guides activities and investments, When efforts aim to improve nurturing care for early
which accelerate and reinforce progress. childhood development, outcome indicators for the
five components of nurturing care are likely to be
more universally applicable.
Monitoring implementation successes and
challenges is important. Not only does monitoring
demonstrate progress, but it also identifies
areas where corrective action is needed, so the
programme can achieve its objectives.
The Nurturing care framework’s logic model (see
Table 1) is the basis of monitoring progress. For
each of the five strategic actions, the logic model
specifies the outputs (such as updated standards
and service packages) that will be tracked. Together
these outputs contribute to all five components of
nurturing care and help to improve outcomes (such
as increased coverage of exclusive breastfeeding).
These can also be tracked, as can the impact
on children’s development (such as growth or
development).
2 NURTURING CARE HANDBOOK

M O N I TO R I N G I M P L E M E N TAT I O N O F T H E N U R T U R I N G C A R E F R A M E WO R K
Table 1. The Nurturing care framework’s logic model (1)
The logic model
I M PA C T
Every child is able to develop to their full potential and no child is left behind
All children are developmentally on track
OUTCOMES (COMPONENTS OF NURTURING CARE)
Good health Adequate nutrition Responsive Opportunities for Security and safety
caregiving early learning
• Caregivers are • Caregivers’ nutritional • The child has secure • Communication is • Families and children
mentally and status is adequate emotional relations language-rich live in clean and safe
physically healthy • Breastfeeding is with caregivers • There are environments
• Antenatal, childbirth exclusive and initiated • Caregivers are opportunities for age- • Families and children
and postnatal care are early sensitive and appropriate play and practise good hygiene
of good quality • Complementary responsive to the early learning at home • Children experience
• Mothers and children feeding and child child’s cues and in the community supportive discipline
are immunized nutrition are • Caregiver-child • Children do not
• Care-seeking for appropriate interactions are experience neglect,
childhood illness is • Micronutrient enjoyable and violence, displacement
timely supplementation is stimulating or conflict
• Childhood illness given as needed • Communication is
is appropriately • Childhood bi-directional
managed malnutrition is
managed
O U T P U T S ( S T R AT E G I C A C T I O N S )
1. Lead and invest 2. Focus on families 3. Strengthen 4. Monitor progress 5. Use data and
services innovate
• High-level • Families’ voices, • Opportunities for • Indicators for tracking • Multistakeholder

multisectoral beliefs, and needs strengthening existing early childhood collaboration on
coordination incorporated in plans services identified development agreed research for nurturing
mechanism • Local champions • National standards • Routine information care established
established to drive change and service packages systems updated to • Priorities identified
• Current situation identified updated generate relevant data and resources
assessed • National • The workforce’s • Data made accessible made available
• Common vision, goals, communication competency profiles in user-friendly for researching
targets and action strategies updated and capacity formats implementation
plan developed implemented strengthened • Periodic, population- • Innovations, based
• Roles and • Community promoters • Trained staff mentored level assessment on new evidence,
responsibilities at of nurturing care and supervised of early childhood implemented
national, sub-national strengthened • Children’s development • National learning and
and local levels • Community groups development conducted research platform put
assigned and leaders involved in monitored and, • Data used for in place
• Sustainable financing planning, budgeting, when needed, timely decision-making and • Research findings,
strategy put in place implementing and referrals made accountability and lessons learnt,
monitoring activities published
INPUTS
Provide leadership, Ensure families and Strengthen existing Monitor progress, using Strengthen local
coordinate and invest communities are systems and services, relevant indicators, keep evidence, and innovate
empowered to act and ensuring joint dynamic people informed and to scale up interventions
able to realize quality action between sectors account for results
nurturing care and stakeholders
ENABLING ENVIRONMENTS FOR NURTURING CARE –

C R E AT E D B Y P O L I C I E S , P R O G R A M M E S A N D S E R V I C E S
S T R AT EG I C AC T I O N 4 3
M O N I TO R I N G I M P L E M E N TAT I O N O F T H E N U R T U R I N G C A R E F R A M E WO R K
What will this strategic action

Although there are five outputs, it is helpful
enable me to do?
to divide the work required into three areas,
corresponding to the three levels of monitoring.
The Nurturing care framework describes five outputs
Different tools are needed for each of these
for this strategic action:
levels. Together, they generate information
• Agree
on the programme’s logical framework and that is useful for monitoring the programme’s
then its associated indicators for tracking progress implementation.
in early childhood development.
The three levels of monitoring are:
• U
pdate routine information systems to include
the indicators that capture data relevant to Population monitoring
the programme.
• M
ake data available to all stakeholders – This uses population-level surveys,
including families and communities. censuses or administrative databases
• S
upport the use of existing population-level to gather information about a
measurements to monitor children’s particular population – perhaps
developmental status and home-care practices
a country or a city. Standardized
in target populations.
household surveys, such as the
• U
se data to make decisions about programming
that supports caregivers to provide nurturing care, Demographic and Household
thereby ensuring accountability. Surveys (DHS) and the Multiple
Indicator Cluster Surveys (MICS),
are commonly used.
R E L E VA N T A U D I E N C E S
The suggested actions for Strategic action 4. Implementation monitoring

Monitor progress have been developed with the
following stakeholder groups in mind:
This means continuously assessing
the different components of a
• national and district programme managers;
programme, and whether progress is
• national and district statistics offices;
made towards the planned objectives.
• health facility managers;
It informs any changes to be made
• local and international implementation
in the implementation and supports
partners;
continuous quality improvement in
• researchers and programme evaluators.
programme delivery. Monitoring can
stimulate innovation to overcome
implementation barriers, and for
What follows is a collection of suggestions and advice, ensuring equity.
based on our experts’ knowledge of what has worked
in countries around the world. The suggested actions
listed in this guide are intended to support local action Monitoring individual children’s development
and decision-making. In each context, stakeholders
will need to determine together the order and priority This is an important component
of actions to be completed for this strategic action as of services that support children’s
well as the five strategic actions as a whole. development. It involves identifying
children who are at risk of not
developing as well as they could
and enables timely delivery of
interventions tailored to the needs
of young children and their families.

Population
Definitions of the indicators can be found in the
master document. To learn more about the profiles,
read the Lancet commentary Data for action on early
monitoring childhood development (3).
Measuring children’s developmental status

There are gaps in indicators related to important
aspects of nurturing care, such as responsive
Population monitoring uses data collected caregiving, maternal mental health, and the
developmental status of children younger than 5 years
from population-level surveys, censuses or of age. UNICEF, WHO and the World Bank Group
administrative databases. These measure are collaborating with experts to fill these gaps. The
demographic characteristics, health status, aim is to produce a single, validated set of indicators
service access or other characteristics of to monitor children’s development from birth to
their fifth birthday (see box Measuring children’s
a population at a specific point in time.
developmental status – ECDI and GSED).
In the context of nurturing care, the aim of
population monitoring is to draw conclusions
about the overall state of children’s
health and development, the coverage M E A S U R I N G C H I L D R E N ’ S D E V E L O P M E N TA L
of interventions and family-care practices, S TAT U S – E C D I A N D G S E D
and the underlying factors that protect Early childhood development index (ECDI)
children’s development or pose a risk to it. The ECDI is a measure of the developmental
status of children. Initially focusing on children
36 – 59 months of age, it has been included in
Using standardized household surveys for population MICS since the fourth round of surveys in 2009
monitoring allows for comparisons to be made over and has now produced estimates for more
time and between different settings or population than 70 countries. In 2020, an updated version
groups. It generates data that are relevant for many of the ECDI (ECDI2030) (4), covering children
different users – including policy-makers, researchers from 24 months of age, was recognized by
and other stakeholders. Countries can also use the UN Statistical Commission as a suitable
it to report progress on many of the Sustainable measure for assessing SDG target 4.2 – By 2030,
Development Goals (SDGs). ensure that all girls and boys have access to
quality early childhood development, care and
The Nurturing care framework suggests a set of 24 pre-primary education so that they are ready
indicators that are linked to the SDGs (see Annex 1). for primary education, and its indicator 4.2.1 –
These indicators cover all five components of nurturing Proportion of children 24 – 59 months of age
care and are measured at the population level. They who are developmentally on track in health,
can be extended using indicators from standardized learning and psychosocial well-being.
household surveys, such as DHS and MICS.
Global scales for early development (GSED)
The Countdown to 2030 Country profiles on early
childhood development (2) summarize 42 population The GSED (5) provides measures to monitor
level indicators that are relevant for different children’s development from birth to the age
components of the Nurturing care framework. They of 3 globally. Developed by a consortium,
cover context, intervention coverage and status of coordinated by WHO, it has two components: a
children’s development. Figure 1 is an exemplar of short and a long form. The short form, designed
these country profiles. to be used in surveys, consists of questions that
can be answered by the caregiver in a limited
Because they have been derived from standardized time. The long form, designed for programmes,
household surveys, the data are comparable over time takes more time and includes observations
and across countries. The profiles are updated every year of the child. Both forms have been validated
and available for 197 countries. You can find the country in seven countries and used in many more.
profiles by country and in one master document on the Materials are made available on request by
UNICEF, Early Childhood Development Action Network contacting the GSED team.
and nurturing care websites.
P opulation monitoring
Figure 1. Examples of indicators to monitor nurturing care components and the enabling environments
E A R LY C H I L D H O O D D E V E L O P M E N T
Name of country
Demographics Threats to Early Childhood Development
Population 12,345,678 Maternal mortality 60/100,000 Adolescent birth rate 108/1,000
Annual births 499,999 Low birthweight 8% Preterm births 11%
Children under 5 1,987,654 (17%) Child poverty 50% Under-five stunting 31%
Under-five mortality 70/1,000 Violent discipline 87% Inadequate supervision 7%
Young children at risk Risk by sex Lifetime cost of growth

of poor development and residence deficit in early childhood
Estimate in terms of % loss

69 74%
2005 68 of annual adult wage
Sex
75
■ Girls ■ Boys
2010 55 Children with
Residence
80
40
functional difficulty
2015 45 no data
■ Rural ■ Urban
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Children
developmentally on-track
At risk in 2005, 2010 and 2015, using a composite 53%
indicator of under-five stunting or poverty
Nutrition
Health
Treatment for HIV+
Support and services pregnant women Early initiation of
breastfeeding
60
for early childhood Careseeking >95% Exclusive

breastfeeding
45
for child Postnatal
development: pneumonia visits
Minimum 15
Nurturing care
acceptable diet
45% Antenatal
care (4 or
70% 0% 25% 50% 75% 100%
more visits)
52%
Parents and caregivers need Responsive
a facilitating environment caregiving
of laws, policies, services
and community support
Early Public information about ECD
to assist them in providing learning Parental mental health
their young children with Early Parent support (groups, home visits)
stimulation
nurturing care. at home Quality child day care
Children’s
books in Playthings
at home A global indicator to
the home
39% measure responsive
caregiving at population
3% 55% Security level is urgently needed.
Attendance in
Facilitating early childhood
education
and safety
environments 20%
Birth
registration
86
Positive 10
discipline
Policies Basic
drinking water
65
None <14 14 – <18 18 – <26 ≥26 Basic 20

sanitation
Paid maternity leave (weeks)
0% 25% 50% 75% 100%
None <14 14 – <18 18 – <26 ≥26
Paid paternity leave (weeks) International conventions
Not Slightly Moderately Substantially ■
✓ Convention on the Rights of the Child
International Code of Marketing of Breastmilk Substitutes (alignment)

■
✓ Convention on the Rights of Persons with Disabilities
■
✓ National minimum wage
■
✓ CRC Optional Protocol on the Sale of Children, Child Prostitution and Child Pornography
■
✗ Child and family social protection
■
✓ Hague Convention on Protection of Children and Cooperation in Respect of Intercountry Adoption
DETAILED COUNTRY DATA SOURCES AND FOOTNOTES CAN BE FOUND IN THE MASTER DATABASE AT NURTURING-CARE.ORG
For more details on these indicators and their definitions, read the Technical Appendix of the full report
Countdown to 2030 Country profiles for early childhood development (2).

Assessing responsive caregiving and early Compile existing information

learning activities Data from past surveys can give you a baseline.
Caregiver child interactions are at the heart of Data from future surveys will then allow you to
responsive caregiving and early learning activities. measure progress, provided the indicators used are
Caregivers who are responsive are more likely to be comparable. Compile the available data from previous
sensitive to the child’s signals and able to respond surveys, and review the metadata, such as the
appropriately. To date there are few indicators to assess definition of each indicator and the methodology for
responsive caregiving and early learning activities. collecting data. Data can be compared if samples are
However, simple tools have been developed to fill this comparable and data were collected in the same way.
gap (see box Assessing responsive caregiving and
early learning activities). When planning a survey, ensure it is
representative
Population surveys provide a representative snapshot
of the population. Results can then be broken down
ASSESSING RESPONSIVE CAREGIVING AND
by gender, socioeconomic status, age, area, disability,
E A R LY L E A R N I N G A C T I V I T I E S
and mother’s education level. But large-scale surveys
Responsive interactions for learning are quite expensive. So plan carefully and make sure
the survey is representative. Survey representativeness
The Responsive Interactions for Learning
not only depends on sample size but also on sample
(RIFL) observational tool was first developed
design. Sample size considerations are important
in Canada and then adapted and validated
when generating indicators for children younger than
in Brazil (6) and Peru (7). It is freely available,
five, especially in contexts of low fertility. To make a
uses a tool to observe dyadic caregiver–
survey representative, seek expert advice. Consult with
child interaction, and can be completed in
local statistics office and with partners such as UNICEF
approximately 10 minutes. Open-source,
as they are likely to house relevant expertise.
culturally appropriate, online training for coders
is available in English, Portuguese, and Spanish.
To find out more, view the website and read this Use the data
blog post. Analysis of the data can point to gaps in progress
Proposed indicators and what to do next, as well as helping different
sectors see what role they can play. The MICS and DHS
Using a similar approach but with greater provide information across the different components
depth, a protocol is being validated for new of nurturing care, and data from different modules
indicators for responsive caregiving and early can be analyzed together. For example, data from the
learning activities. Supported by the World MICS ECD module can be analyzed together with data
Health Organization, the draft instrument can from the nutrition and health modules. Discuss all of
be accessed upon request. To find out more, this with a wide range of stakeholders (see box Using
read Indicators for measuring responsive care population data for local action in Australia). And use
and early learning activities (8). the opportunities that regular health and other sector
reviews provide at national and sub-national level to
present the data and inform future actions.
Suggested actions
Plan early how to use population surveys
Many countries invest in regular household
surveys or censuses that collect data relevant to the
Nurturing care framework. Make links with people
in government who are responsible for managing
these population-level surveys – such as officials
in the national statistics office or the ministry of health
– and find out their plans for the future.
In general, surveys are planned well in advance
and carried out every three to five years.
You do not always need a new survey: older ones are

Using population data for local action useful, especially for baseline information. Unless
in Australia there have been major changes in programming for
nurturing care, conditions for children and families
Every three years since 2009, Australia has been may not have altered significantly over the last two
assessing all its 6-year-olds using the Australian or three years.
Early Child Development Index (AEDI). This is
a survey that asks around 100 questions, filled Population-based data from large surveys, even
in by the children’s primary school teachers. when disaggregated, can mask progress in specific
It is the basis of the Australian Early Child areas where a programme operates at small scale.
Development Census (AEDC), run by the Results that have been achieved may not necessarily
Australian government in partnership with be captured or be diluted because of the size of
the Centre for Community Child Health. the survey. This enforces the point that continuous
The data can be broken down for each programme monitoring of any implementation
community, allowing local people to see how initiative including periodic assessment of outcomes
their area’s performance is changing and how and impact is important.
it compares with other places. This has made
people more of aware of the importance Lack of coverage, quality or time
of multisectoral support for families during
Once an intervention has been shown to work, there
the early years. These mechanisms have
is an understandable desire – especially by policy-
strengthened the links between caregivers,
makers – to roll it out nationwide and see the effect.
policy makers, government agencies,
But for a meaningful impact at population level, you
preschools, health services, and libraries.
need to get three factors right. The coverage needs
To find out more, visit the Australian to be comprehensive enough to reach the most
government’s webpage about the Australian vulnerable. The quality, in terms of factors such as
Early Child Development Census (9). participation, duration and intensity, needs to be high
enough. And you need to allow enough time for it
to have an effect. So wait until any routine data you
have is indicating improvements in access, quality
and utilization of services. We will discuss this in the
Overcoming the barriers next section.
Data that are not comparable

When countries and organizations use different
indicators, or focus on different ages, it becomes
impossible to compare their data – over time or For a meaningful
between places. That can make it impossible to impact at population
tell whether conditions are improving, and which
interventions are most effective. Everyone benefits
level, you need to get
if we all adopt international standards, use three factors right. The
standardized tools, and train the people who coverage needs to be
collect data in a standard way.
comprehensive enough
The high cost of population surveys to reach the most
Programme implementers should not plan
vulnerable. The quality,
their own population-level survey. Population in terms of factors such
surveys are expensive, especially when they aim as participation, duration
to be representative of a whole country or a large
population. This is even more so when they are big and intensity, needs
enough to allow for disaggregation of results, for to be high enough.
example by gender, income or other important And you need to allow
variables. Work with partners to make sure
the surveys include the recommended information enough time for it to
about early childhood development. have an effect.

Implementation • Theory of change
A theory of change is your explanation of all the
monitoring
ways in which it would be possible to achieve the
outcomes you want. Beginning with outcomes
keeps this practical.
• Pathway of change
Implementation monitoring covers inputs Each of the ways of producing this change is called a
(such as policies, the workforce, finances) and pathway. For every pathway, you should say why you
outputs (such as the proportion of facilities think it would produce change. That forces you to
write down your assumptions, so that you can test
offering services, and their quality).
and measure them.
It also periodically generates data on
outcomes (such as the proportion of children
with an acceptable diet), impact (such as • Logic model
children’s growth and development) and You then take the single pathway of change that
equity (are the most vulnerable families and your particular programme will deal with – how you
will get from where you are now to where you want
children being reached). to be. From this, you develop a logic model. This sets
out the inputs and outputs required, along with the
outcomes and impacts you expect them to produce.
This section deals with how to monitor what actually These are the things you need to monitor.
happens in an intervention or programme. That
allows you to see what has been done, what has
been missed, and what needs improving. The Nurturing care framework includes a general
theory of change, pathways of change, and logic
What and how you monitor depends on the
model. You can use these in developing your own,
intervention and what it is designed to achieve.
tailored to where you are and what you want to
The terminology for talking about this can be
achieve. Collaborate closely with your stakeholders
confusing, as people use the terms in different ways,
on this, as the consultation process can be just
and usage has also changed over time. This is how
as important as the final product.
we use the three main terms (also shown in Figure 2).
Figure 2. Using the Nurturing care framework’s logic model to develop your own
Theory of change Logic model

Shows the big picture with all Shows just the pathway that your
possible pathways. programme deals with.
I M PAC T
CHANGE
OUTCOME
OUTPUT
INPUT
I mplementation monitoring
Implementation monitoring involves measuring all

the elements of your logic model, starting with the HOW MONITORING CHANGES A S THE
inputs (such as introducing training standards) and PR O G R A M M E C YC L E G O E S O N
outputs (such as health care workers supporting
caregivers in responsive caregiving and early learning Stage 1 – design and testing
activities). Tracking these is essential for achieving At the beginning, when designing and testing
outcomes (such as language-rich communication in interventions in demonstration sites, you
the home) and eventually impacts (such as children need to focus on three areas:
being developmentally on track). That means starting
by carefully documenting what is being implemented, • f rontline workers’ performance –
before moving on to the outcomes being achieved. how they deliver the services;
• c
lients’ demand for the services and
What to measure changes as the programme cycle
satisfaction with them;
goes on. In the design and testing stage, you pay
attention to the basics, adding in other elements • t he target population – and the services’
when you begin to scale up (see box How monitoring coverage and equitable distribution.
changes as the programme cycle goes on). Monitoring these areas will help adapt what
The way an intervention is delivered can change, is included in the intervention and how it
even during scale-up, so you need to be flexible about is delivered, helping to make interventions
what you measure and how. The COVID-19 pandemic acceptable, feasible, effective and scalable.
showed this, with face-to-face contact between
frontline workers and clients being limited, and
digital solutions used instead. Stage 2 – scaling up
Once the intervention is well developed, it
becomes important to monitor two more areas:
• q
uality – that is, whether care is given safely,
at the right time, based on evidence, without
waste, equitably, and in a way that suits the
people receiving it;
• fi
delity to what was intended – that means
sticking to the design that you have proved is
essential for achieving the intended outcomes.
Work is in progress Read the article Measuring the implementation

of early childhood programmes (10) to learn
on a full catalogue more about how to prioritize what to
of indicators for all monitor and how.
the different inputs,
outputs, and outcomes
in the Framework’s logic
model. This catalogue
will expand on the 24
core indicators, set
forth in the Nurturing
care framework, acting
as a menu from which
countries can choose
those that are
most useful.

A comprehensive monitoring system works on several Reporting on these indicators requires contributions
levels, moving up from data on individual clients, to from different sources, including population-level
programmes, facilities, districts, the whole country, surveys, administrative data collection (such as civil
and finally the world (see Figure 3). At each level of registration and vital statistics systems), facility service
monitoring, data are collected and used differently, data (including health management information
because nobody needs all of the data all of the time. systems, laboratories and supply-chain systems),
Figure 3 shows that more information is needed to community health workers’ systems and programme
make decisions and monitor performance at the lower management information systems. So, a good
levels of management and service delivery than at the protocol should offer standardized options for each
higher levels. level, beyond the recommended core set.
Every level needs to include a consistent set of Annex 1 shows the 24 core indicators proposed in
core indicators – shown in Figure 3 by the yellow the Nurturing care framework which are relevant
circles – such as the rate of exclusive breastfeeding. to all countries. They come from the monitoring
Each level also has its own specialized indicators frameworks of the Sustainable Development Goals
– shown in Figure 3 by the circles of other colours – (SDGs), and the 100 core health indicators developed
which are useful for those working at and managing to accompany Global strategy for women’s, children’s
that level, such as frontline workers or service and adolescents’ health. These examples are
managers. For example, at community level it not prescriptive or exhaustive, but show the
would be useful to know the number of trained importance of using different types of indicators
breastfeeding counsellors. But each level defines for monitoring programmes.
the core indicators in the same way, allowing
comparisons to be made, so we can see variations
over time and between countries.
Figure 3. Pyramid of data collection and use
GLOBAL
N AT I O N A L
Fig
DISTRICT
FAC I LI T Y
COMMUNIT Y OR PROGR AMME
Source: This diagram is adapted from UNICEF’s training material for District Health Information Software 2 (11).
Suggested actions List those indicators, along with who collects them,
when and how. Also summarize how the data are
analyzed and used. For each indicator of a major
Involve all stakeholders in creating outcome you will also need indicators of the required
a monitoring plan inputs and outputs. Existing data, and data collection,
While planning activities, develop a monitoring plan may take you a long way. But when you find gaps
to accompany the implementation plan. Involve all in their quality, comparability or completeness,
stakeholders who are responsible for implementation, this exercise will also allow you to discuss ways to
and develop your logic model together so that all overcome them.
stakeholders can efficiently agree on the indicators
Create new indicators
and the way data will be collected and used. Also plan
joint meetings to review the data regularly – every year For activities and outputs where there are no
or six months, for example. It has been shown that this indicators, you may need to create new ones. In
strengthens multisectoral action, so that it responds doing this, bear in mind that, for the components
quickly to any gaps that emerge. of nurturing care, measures of inputs and outputs
are less standardized than those for outcomes and
Choose the indicators to use impacts. Define the new indicators so that they
specifically measure your intervention the way it
Once your programme has a solid logic model, works on the ground. Make sure the new indicators
describing inputs, outputs, outcomes and impact, are relevant to your logic model and that they can
along with their underlying assumptions for success, be measured reliably. Analyze whether the indicator
it is time to choose indicators. These indicators is simple and meaningful, and can be effectively
should be SMART. sustained and tracked over time.
That stands for:
Take an equity lens
• specific to your expected output or outcome;
Monitoring inequalities is crucial to identify differences
• m
easurable, with defined numerators and in health and development between different
denominators from programmatic data; population subgroups. It provides evidence on who
• achievable in the programme; is being left behind and informs health policies,
• relevant to the intervention being measured; programmes and practices that aim to close existing
gaps and achieve health equity. Inequalities occur
• timebound, according to the programme cycle.
because of differences in determinants of health
It is important that you define your indicators early and wellbeing including the access and coverage of
in the programme’s implementation, because that essential interventions. In many settings, available
allows monitoring to be built into programming from data already give an indication of the communities or
the start. The earlier you begin monitoring, the earlier population groups that are mostly left out. They can
you get data, which allows you to learn lessons, make include refugees, migrants, and displaced populations.
changes and become more efficient and effective in Assess who are the disadvantaged populations in
your programme implementation. advance and tailor your monitoring plan to track
progress services and outcomes in these groups
Identify and strengthen existing indicators deliberately. Present data in a disaggregated way.
Because creating enabling environments for nurturing The WHO Health Equity Monitor is a global tool that
care builds on existing policies and services, some provides evidence on existing health inequalities
relevant indicators are probably being monitored and makes available tools and resources for health
already. For example, in maternal, newborn and child inequality monitoring (12). For details visit, https://
health and in infants’ and young children’s nutrition. www.who.int/data/gho/health-equity.

When deciding on the indicators, pay careful • Checking coverage and dosage
attention to these issues: An intervention’s impact depends on its
• F
idelity to core features and flexibility in coverage and dosage – that is, how many
monitoring people it helps, and how much help they are
given. Getting this right at the design stage
Identify the intervention’s core features and
is vital. So is monitoring to ensure that this is
agree on quality standards for delivering them.
what actually happens. Monitor how much
For example, core features of supporting
services are used, the length and content of
caregivers include paying attention to their
consultations, and group sessions’ attendance,
mental health and counselling them on
length and quality. Also carefully assess who in
responsive caregiving and early learning
the targeted population has been reached, and
activities. Fidelity, or faithfulness, to these core
which families and children have been left out.
features is essential. But they will need to be
adapted for local culture – in terms of language,
illustrations, toys, songs and stories. So flexibility
• Finding out whether families are satisfied
in how they are monitored is also important.
Demand for services – and their take-up –
depends on clients understanding and being
• Monitoring every aspect of training satisfied with those services. Use exit interviews
to find out caregivers’ perceptions, recollection
Frontline workers’ performance depends on
of key messages, and ability to put them into
the quality of their training. That is affected by
practice at home. If there are home visits, use
its length, average class size, ratio of facilitators
them to observe whether the intended changes
to participants, the methods used, the balance
are happening.
between classroom sessions and practice, how
its success is assessed, and follow-up. You need
criteria for each of these elements, and they
For more ideas, refer to the indicators provided in
need to be monitored. That is as important as
the Nurturing care framework logic model (Table 1)
the number of frontline workers who are trained,
or read the article Measuring the implementation
where they are, and the frequency and quality
of early childhood programmes (10). Work is in
of supervision they receive.
progress on a full catalogue of NCF indicators,
along with guidance on how to use them.
Decide how to measure

S O U R C E S O F D ATA
There are many good sources of data (see the boxes
Sources of data and Collecting the data you need). Good sources of continuous data are:
Combining several of them will minimize gaps in
• facility records;
your data, and they can complement one another.
If, for example, data from the health information • health information systems;
system are incomplete or of variable quality, it can be • human resources and staff training databases.
complemented and validated by a facility assessment
or population survey. Implementation research, Good sources of intermittent data are:
described in the guides to Strategic actions 3 and 5,
• client surveys;
usually uses a mixture of sources to generate data
that are helpful for programme strengthening and • interviews with frontline workers and
impact assessment. observations of them, often in surveys;
• assessments of facilities;
• population surveys;
• interviews with stakeholders.
Assist frontline workers to build their data

literacy and use data for improvement CHILD - CENTRED MONITORING IN PERU
AND CHILE
When the monitoring plan is finished, make sure the
whole workforce knows what they need to monitor As part of their national strategies on early
and why. Frontline workers often report large amounts childhood development, Peru and Chile defined
of information without using it to improve outcomes packages of interventions to be delivered at
where they are. Make sure, for example, that they specific times from the beginning of pregnancy
not only report how many mothers are exclusively until the age of 4 or 5.
breastfeeding, but also know what to do if rates are The countries needed to know whether children
low. Build skills and use regular reviews to assess the were receiving the interventions they were
quality of routine data-entry and work to improve it. entitled to. That meant building innovative
Keep a constant focus on helping frontline workers social information systems that put children
to use data to improve the quality of services. For an at the centre of the analysis. Their ministries of
example, see the box Child-centred monitoring social development used web-based platforms
in Peru and Chile. to house databases from different sectors, as
well as a registry covering pregnancy and the
Use supervisory visits to review data
first years of life.
Staff in supervisory roles can assist frontline workers
Peru’s system is driven by the government’s
better when they use the data that are generated at
focus on results-based financing. It includes
the primary care level. Besides a review of records,
indicators covering inputs, processes and
direct observation of a provider-client interaction is
results for each region and district. It shows
another way of generating information on quality of
the coverage of each intervention, as well
care. In the absence of actual caregivers and young
as the proportion of children receiving the
children, the use of vignettes with stories can be an
complete package. This makes it easy to see,
entry point for assessing performance, followed by
for example, what percentage of one-year-
support supervision and mentorship. Using a mix of
olds have a birth certificate, were vaccinated
methods will strengthen the monitoring effort and
against rotavirus and pneumococcus, received
has the potential to build trust and confidence of
micronutrients, and had visits for growth and
frontline workers.
development monitoring. Data from surveys
of living conditions, demographics and health
are also included, showing the proportion with,
for example, safe water, sanitation and pre-
kindergarten education.
Chile’s system gives reports and data for each
region and municipality. It monitors the health
and development of each child and family;
which health services children and pregnant
women have received; which families have
social, economic or health risks, and how
services have responded; participation in the
parenting programme; which home visits
families and children have had; and how well
coordination between sectors has worked. To
give a more integrated picture of coverage and
unmet needs, the system is being upgraded to
add data on living and employment conditions.
Both countries aim to bring together data from
different sectors to monitor each child and
family’s development, making their systems
more seamless and interconnected, and
promoting children’s rights. To find out more,
visit Peru’s Redinforma (13) website, or read Chile
Crece Contigo’s full case study (14) or blog (15).

Assess data regularly Lack of time and money

Health-facility managers and staff could collate and It takes a lot of time and money to monitor results
interpret data every month, then district managers and then bring stakeholders together to discuss them.
could review it and give feedback every quarter, with These activities often take a back seat as a result.
national authorities reviewing progress every year. But this usually means the programme is less
Involving experts who are not directly responsible effective and responsive than it could have been.
for implementation in the review process can also be It is better to do less and monitor it, than to do more
helpful for making fair assessments of the data (see and monitor less well. And when stakeholders take
box Involving independent monitors). As discussed part in monitoring, they are more likely to agree on
in the previous section, we also recommend regular what is needed to achieve results, and to invest
independent and standardized assessments, such more in doing so.
as a population survey or facility assessment, at
the right time. Lack of data
There is a lack of routine data collection on some
Learn and adjust implementation
components of nurturing care, such as responsive
Make those regular reviews part of the caregiving, early learning activities, and safety
implementation cycle (described in Start here). Use and security. This can make it harder to assess
them to help you learn and make changes, so that you programmes’ performance and improve them. But
overcome barriers and improve performance. Having there are tools that can help you fill in these gaps
data enables you to tell whether you are doing what (see box Collecting the data you need). Use these to
you planned, and whether progress is on track. If identify indicators, and to increase frontline workers’
progress is slow, data – on inputs, processes, outputs and managers’ capacity to gather information and use
and outcomes – allow you to track down the problems. it. Coordinate and compile data from different sectors,
for example through dashboards.
I N V O LV I N G I N D E P E N D E N T M O N I T O R S
When developing a new service, it can help if TOOL

monitoring is supported by people who have
expertise in the field but are not responsible
for doing the work – allowing them to have Collecting the data you need
an unbiased view. For example, you could The World Bank’s A toolkit for measuring early
partner with an academic institution or an childhood development in low- and middle-
expert group. Ask them to help with regular income countries (16) is a practical guide that
data collection and analysis, and get them to will help you choose measures and adapt them
work with everyone to identify barriers and for use in low- and middle-income countries. It
find solutions. One option is to conduct small includes a step-by-step process for working with
scale implementation research that is targeted data for different purposes and projects.
to improve operationalization.
Another useful resource is from the Annals
of the New York Academy of Sciences: the
supplement Implementation research and
practice for early childhood development (17).
Overcoming the barriers We also recommend UNICEF’s Programme
guidance for early childhood development (18).
Starting too late Work is in progress on a full catalogue of
Monitoring activities are often not planned, but are indicators for nurturing care along with
included later, as an afterthought. This makes it harder monitoring guidance. Once ready, these will be
for managers to track what is happening in the field, available on https://nurturing-care.org
make adjustments and achieve results. It also makes
it much harder to know what affected progress before
monitoring began. Data – knowing what is going on –
motivates managers and frontline workers, so include
monitoring in your planning from the start.
Monitoring development. When a child reverses on a milestone
that was previously achieved, this is a reason for
concern and requires more in-depth assessment, often
individual children’s through referral to a more specialized provider. When
a child has not acquired a milestone of the age-group
development preceding his or hers, that should also ring an alert and
actions should be taken to intensify support at primary
care level or refer, as appropriate.
This means that mass screening – where all children
of a certain age are assessed to see if they have hit
Most programmes that invest in nurturing specified milestones – is unlikely to be effective, as
well as being very expensive. A better solution is for
care have the goal of supporting children’s milestones to be just one part of a regular and flexible
optimal development, and leaving no monitoring of children’s development, integrated in
child behind. To achieve those goals, it is primary care services, such as growth monitoring
important to be able to identify children who and counselling, well-child and sick-child visits,
and immunization (see box Definitions).
are at risk of a developmental difficulty, or
who experience a delay or disability, and to This should be the starting point for building
assist them, and their caregivers, to realise comprehensive services for identifying and supporting
children at risk of developmental delays, who have
their developmental potential. behavioural difficulties, or who are maltreated. For
this, frontline workers not only need skills to support
caregivers in optimizing their child’s development,
Even in high income countries such as the they also need to know where and when to refer
United States of America, at least one in six children children and their families.
experiences developmental difficulties, according to
the Centers for Disease Control and Prevention (19).
However, few young children are identified before
they reach preschool or school-going age, which means
DEFINITIONS
they cannot benefit from even earlier intervention.
Children’s development is affected by many factors, Developmental monitoring
including risks such as poverty, maternal depression, This means tracking the child’s growth and
and maltreatment, as well as whether they have good development, in collaboration with the
family or community support. These environmental family, to support nurturing care in the child’s
factors are often strong predictors of long-term daily life. Monitoring looks at risk factors in
outcomes, so we need to find ways of taking them into family life and the environment, and how the
account in the monitoring of children’s development. family is coping with these risks. It looks at
Milestones are a common way of doing that. These the child’s development and what the child
are developmental abilities that children are, on can understand and do in relation to what
average, expected to acquire by a certain age. is expected for his or her age. Families can
Children naturally develop at very different speeds, be given anticipatory guidance on the next
and they reach milestones at a wide range of ages. phase of the child’s development, along
Therefore, if you only use milestones to assess with information about children’s rights and
children’s development, you are likely to miss children community-based support.
with developmental difficulties, or wrongly identify
children as having them.
If a child misses a milestone – if he or she is still not
Screening
able to sit, for example when most others can – it This is a brief one-off assessment of all children
does not in itself indicate a developmental difficulty. or a targeted subset. It consists of specific tests
Rather, it is a cue for health care workers to ask for conditions that can be treated. Examples
more questions and look for explanations or other of screening include genetic testing during
signs of problems. pregnancy, sight and hearing tests, metabolic
and hormonal testing in the neonatal period,
There are no hard and fast rules for when to refer
and screening for motor deficits and
a child and their caregiver. First and foremost, it
poor coordination.
is important that services are available with staff
that have greater expertise in the area of child

M onitoring indi v idual children ’ s de v elopment
Suggested actions
TOOL
Raise awareness
Talk to frontline workers about the critical role they can The Guide for Monitoring Child
play in listening to caregiver concerns and identifying Development (GMCD)
children at risk of suboptimal development, or those
with developmental delays. Discuss the importance of Using an open ended interview technique,
timely screening for vision, hearing, cerebral palsy health care workers build rapport and work
and selected other conditions. And ensure frontline together with caregivers to understand
workers know where to refer families if required. the child’s development in seven domains.
Through dialogue, they also assess the broader
Discuss the stigma associated with disabilities and how environment in which the family functions. The
to help communities overcome it. Help frontline workers approach supports caregivers to appreciate in
move away from the medical model that sees disability which areas their child is developing well and
as a problem, and towards a social model that looks at explore what they can do to further support
inclusion and participation (see box The medical and their child’s development.
social models of disability). Discuss how they can counsel
caregivers and support them to overcome barriers they Visit the Bernard van Leer Foundation’s website
face in their community, in interpersonal communication, for a more detailed article – The international
the physical environment, or accessing services. Guide for Monitoring Child Development:
enabling individualized interventions (20).
Take a family-centred approach
Supporting early childhood development calls for a
partnership between caregivers and frontline workers,
starting from pregnancy or even before. Frontline
workers need to know the strengths and vulnerabilities
Decide what to screen for
of the child and family, and to watch, appreciate, Screening should begin during pregnancy for
and support their development. This family-centred common conditions (such as maternal syphilis or
approach encourages frontline workers and caregivers anaemia), and from birth for essential functions
to jointly identify solutions to difficulties, and it enables (such as vision and hearing), movement disorders
caregivers to strengthen their knowledge about how to (cerebral palsy) and metabolic conditions (such
support their child’s growth and development and ask as phenylketonuria). Beyond these examples, it is
for advice when they need it. essential that all stakeholders agree on what to screen
for, and that this follows an evidence-based approach.
The international Guide for Monitoring Child
Knowing when and where to refer children and
Development (20) is a tool designed to build the skills
caregivers for treatment that can not be given at the
of frontline workers to use this approach.
primary care level is also necessary.
The medical and social models of disability
The disability is the problem or defect The problem is the disabling world
MEDICAL MODEL
SOCIAL MODEL
Persons with disability are passive receivers Society is designed to create barriers that
of services to manage or cure the disability oppress and exclude those with impairment
Individual deﬁned by needs (e.g., needs Attitudinal barriers: discrimination

medical and care teams, needs charity,
has special needs)
Societal barriers: lack of interpreters
isolated families, poor job prospects
Individual judged by what s/he is able and
not able to do (e.g., can’t walk, see,
or hear, is housebound) Environmental barriers: inaccessible transport,
lack of parking, badly designed buildings
Source: See (21).
Decide what, when and where to monitor Choose the right tools for
Developmental monitoring and counselling can developmental assessment
be integrated well in primary health care services, For more in-depth assessment of children identified as
including in humanitarian settings. There are also having signs of suboptimal development, tools should
opportunities in child day care, social services, and be valid, standardized, easy to use, publicly available
services for children living with chronic conditions. and free or low cost. They should also improve
Some countries have set up a home visiting conversations with caregivers, giving them guidance
programme where professionals give families and leading to follow-up actions agreed
comprehensive support, referring them to facility- with them (see box Choosing in-depths
based or social services when needed. But that means developmental assessment tools).
frontline workers need to know how to do these things,
so it is essential that they have training and mentorship. When integrating milestones, it is important to choose
That should include skills, such as the one shown in the right upper age for them. Setting milestones at
Annex 2 Skills for monitoring children’s development. the 85th percentile – that is, the age at which 85%
of children achieve these milestones – will mean
fewer are wrongly flagged as having developmental
difficulties than if you set them at the 70th percentile.
Here is some guidance for how to set a To find out more, see the WHO report Monitoring
standard for follow-up and referrals, assuming children’s development in primary care services:
that adequate care is available both at primary moving from a focus on child deficits to family-
and referral levels. centred participatory support (25).
• Follow up in primary care

If the child has risk factors for delayed
development, is not meeting all milestones TOOL
for the age group, is experiencing other
developmental difficulties, or when parents
express concerns provide extra follow-up Choosing in-depth developmental
in primary care with counselling. Use the assessment tools
tools described in the guide to Strategic Children’s developmental milestones are
action 3, such as Care for child development usually grouped together in domains, such as
(22), Parenting for Lifelong Health (23), and motor skills, cognitive and language. To assess
Caregiver skills training (24). If this additional a child’s overall development across all these
primary-care support does not help the child to domains, use multidomain developmental
improve, then refer. test instruments. To find out more about these
tools and when to use them, see A toolkit for
measuring early childhood development in
• Refer to higher-level care low- and middle-income countries (16).
If the child already has signs of delayed WHO and UNICEF are currently reviewing the
development or has regressed from previously available tools, and will release more guidance.
achieved milestones, or if the parents have In the meantime, you can find ten tools that are
serious concerns – and the primary care service quick, low-cost and usable by trained frontline
is not equipped to offer a more in-depth workers in A review of screening tools for the
assessment – then refer the child quickly identification of autism spectrum disorders
to a skilled higher-level specialist. and developmental delay in infants and young
children: recommendations for use in low‐ and
middle‐income countries (26).

Build the skills of frontline workers Choose how to support children and
for developmental monitoring families with identified needs
Primary care workers, including community In many countries, developmental paediatric services
health workers, need the knowledge and skills for are still developing. That means children identified as
developmental monitoring, basic communication, and having developmental disorders or disabilities may
counselling. To be competent and feel confident, they not always get the support they need. To overcome
need regular supervision and mentoring, and a clear way this problem, invest in training frontline workers
of referring children for more advanced care. They should and specialists, helping them build up expertise in
also be able to help caregivers problem-solve concerns several disciplines, and acquire skills such as listening,
about children’s development, such as sleep and crying. empathy, and problem-solving. Tools such as the
international Guide for Monitoring Child Development
For a variety of reasons, WHO guidelines do not
are useful to build such capacities at the primary care
recommend routine monitoring or screening for child
level and in specialized services.
abuse. But all frontline workers should be alert for
signs that a child or caregiver could be exposed to Overcoming barriers
abuse. For children, those signs include regression
(losing skills or behaviours), unexplained injuries, poor
interaction between the caregiver and child, and the
Primary care services just monitor and refer
caregiver having a negative perception of the child. Just monitoring and referring is not efficient and
many children will be lost to follow-up. After all, this
Also build frontline workers’ capacity to carefully
is not what happens with health problems – primary
observe how the caregiver and child interact, picking
care services diagnose a problem, provide care and
up signals indicating strengths or difficulties in their
refer on to specialists, when that is necessary.
relationship (see box Helping frontline workers interact
with caregivers). UNICEF and WHO’s practice guide Strengthen the system so that developmental
Strengthening nurturing care through health and monitoring works the same way. Make sure frontline
nutrition services (27) has more guidance on this. workers know how to observe the way a caregiver and
child interact, and that they are sensitive to common
developmental difficulties and risks, and can offer
immediate suggestions and help – as well as referrals.
HE LPING FRONTLINE WORKE R S INTE R AC T When they do refer, make sure they have a good
WITH CAREGIVERS knowledge about where and when to do so. And make
them part of a team that supports the child and family.
It is a good idea to update frontline workers’
counselling material so it includes guidance
on asking caregivers how they and their child Poor coordination between services
are doing, observing how caregiver and child Children and families with additional needs often
interact, giving information and support, and need help from several services, but coordination
advising on community resources. between them is not always good. This makes it hard
Frontline workers should be able to: for families to access all the care they need, as well
as making frontline workers’ monitoring of children’s
• tell the family about early childhood development; development less effective.
• listen to caregivers’ concerns and respond to them;
Explore the options for setting up transdisciplinary
• a
sk open-ended questions to discover more care, meaning that one clinician – who can be
about the child’s development (including a primary health worker – takes on the main
health, functioning, activities and participation), responsibility for the child and family. This clinician
the nurturing care they are getting, and how can then find information about aspects of the
the family functions; child’s or family’s difficulties by reading or by talking
• fi
nd out about health-related and psychosocial to experts, so working across disciplines. In early
developmental risks; intervention, this kind of transdisciplinary, non-
• learn about the family’s strategies for coping fragmented care is regarded as the gold standard.
with risk factors and whether they need This approach also saves families from confusion
additional services; and uses resources more cost-effectively.
Harmonization across sectors is also key so that
• p
raise the family and acknowledge the support
adaptations in one sector can be matched by linked
it already gives the child;
actions in another sector.
• g
ive guidance on the next stage of development
and information on community resources to See the box Three ways to support children and
support it. families with identified needs, as well as the section on
support in the guide to Strategic action 3.
T H R E E WAY S T O S U P P O R T C H I L D R E N A N D Signs that you are
making progress
FA M I LI E S WI T H I D E N T I F I E D N E E D S
1 The one-stop centre

Provide multidisciplinary (and probably
multiagency) support in a single place. This
means clients are less likely to need to make
many appointments at different places. It also You can work on the activities in this
makes a coordinated response more likely, with
strategic action in different ways, and
specialists and staff from several disciplines
sharing information. it is natural that progress in some will
be faster than others.
2 Team around the child (TAC) The aim is to monitor what you are doing so
you can understand whether the activities
Set up a team for each child and family. The
team’s members might include – as well as are reaching the children and families
parents – an older child, a therapist, a teacher, who need them most and services are
a nurse, and perhaps a grandparent or implemented with quality and equity.
childminder. Parents decide on the members,
and the number is limited so as not to
become intimidating. The aim is to prevent Here are some signs of progress and targets
the fragmentation and chaos that result when to aim for:
various specialists working with the child
do not share information with each other. • A
monitoring plan with indicators of inputs,
Find out more on the approach at the TAC outputs, outcomes and impact has been
Interconnections’ webpage (28). developed and methods for data collection
and analysis are functional.
• T
ools for monitoring children’s individual
3 Routines-based approach development have been developed and integrated
into frontline workers’ counselling tools.
Get frontline workers to work with the family
and the child in natural environments, such • F
rontline workers have been trained and are
as at home, in the playground, or at the supervised to contribute to implementation
education centre. Children benefit when they monitoring and monitoring individual
learn in their natural environments and when children’s development.
what they learn is also useful in daily routines, • T
he health information system has been updated
such as getting dressed or eating meals. And and includes indicators for access, utilization and
through daily routines, new opportunities for quality of the services that support and promote
learning can be identified. Read Using routine nurturing care.
based interventions in early childhood special • P
lans have been made for population monitoring
education (29) to learn more. of early childhood development, and any available
data have been collated and reviewed.
• M
ultistakeholder meetings to review available data
are held regularly and inform planning, advocacy
and investment in health and other sectors.

References
7. Responsive interactions for learning – Peru
Schneider A, Rodrigues M, Falenchuk O, Munhoz TN, Barros
AJD, Murray J et al. Cross-cultural adaptation and validation
of the Brazilian Portuguese version of an observational
measure for parent–child responsive caregiving. International
Journal of Environmental Research and Public Health.
2021;18(3):1246 doi: 10.3390/ijerph18031246.
8. Assessing responsive caregiving and early learning

Tools, case studies and activities
further reading Hentschel E, Yousafzai AK, Aboud FE. Indicators for
measuring responsive caregiving and early learning
activities. Geneva: World Health Organization; 2021 (https://
1. Nurturing care framework nurturing-care.org/assessing-responsive-caregiving-and-
early-learning-activities/, accessed 15 July 2022).
WHO, UNICEF, World Bank Group. Nurturing care for early
childhood development: a framework for helping children
survive and thrive to transform health and human potential. 9. Case study: Using population data for local action
Geneva: World Health Organization; 2018 (https://apps.who. in Australia
int/iris/handle/10665/272603, accessed 15 July 2022). Australian Government Department of Educations, Skills
and Employment. Australian Early Development Census
2. Country profiles for early childhood development (AEDC). Canberra, Australia: Australian Government; 2021
(https://www.dese.gov.au/early-childhood-data-and-
Countdown to 2030: country profiles on early childhood
reports/australian-early-development-census-aedc,
development. New York: United Nations Children’s Fund;
accessed 15 July 2022).
2020 (https://data.unicef.org/resources/countdown-to-2030-
ecd-country-profiles/, accessed 15 July 2022).
10. Measuring implementation
3. Data for early childhood development Aboud FE, Prado EL. Measuring the implementation of early
childhood development programs. Annuals of the New
Richter LM, Cappa C, Issa G, Lu C, Petrowski N, Naicker
York Academy of Sciences. 2018; 1419(1):249-263. doi: 10.1111/
SN. Data for action on early childhood development. The
nyas.13642.
Lancet. 2020; 396(10265):1784-1786. doi: 10.1016/S0140-
6736(20)32482-X.
11. District Health Information Software 2 (DHIS2)
4. Tool: Early Childhood Development Index Health Information Systems Programme. About District
Health Information Software 2 (DHIS2). Oslo, Norway:
Early childhood development index 2030: a new tool to
University of Oslo Department of Informatics; 2020
measure SDG indicator 4.2.1. New York: United Nations
(https://www.dhis2.org/about, accessed 15 July 2022).
Children’s Fund; 2020 (https://data.unicef.org/resources/
early-childhood-development-index-2030-ecdi2030/,
accessed 15 July 2022). 12. Tool: Health equity monitor
The global health observatory: health equity monitor.
5. Global scales for early development Geneva: World Health Organization; 2021 (https://www.
who.int/data/health-equity, accessed 15 July 2022).
Global scales for early development. Geneva: World Health
Organization; 2021 (https://www.who.int/teams/mental-
health-and-substance-use/data-research/global-scale-for- 13. Case study: Peru’s child-centred monitoring system
early-development, accessed 15 July 2022). Ministerio de Desarrollo e Inclusión Social del Perú.
REDinforma: un repositorio multisectorial de información.
6. Responsive interactions for learning – Brazil Lima, Perú: Ministerio de Desarrollo e Inclusión Social del
Perú; 2019.
Rodrigues M, Schneider A, Sokolovic N, Brunsek A, Oré B,
Perlman M et al. Development and evaluation of an open-
source, online training for the measurement of adult-child 14. Case study: Chile Crece Contigo’s child-centred
responsivity at home and in early childhood education and monitoring system
care settings. The International Review of Research in Open Chile Crece Contigo. Informe técnico final: estudio de
and Distributed Learning. 2021; 22(3):1-18. doi: 10.19173/irrodl. seguimiento de casos de usuarias del sistema Chile crece
v22i3.5472. contigo. Santiago, Chile: Chile Crece Contigo, Ministerio de
Desarrollo Social y Familia; 2012.
R eferences . Tools , case studies and further reading
15. Case study: Chile Crece Contigo’s blog 23. Tool: Parenting for Lifelong Health
Chile Crece Contigo. Blogspot homepage. Chile: Chile Parenting for lifelong health: a suite of parenting
Crece Contigo, Ministerio de Desarrollo Social y Familia; programmes to prevent violence. Geneva: World Health
2020 (https://crececontigomds.blogspot.com/, accessed Organization; 2020 (https://www.who.int/teams/social-
15 July 2022). determinants-of-health/parenting-for-lifelong-health,
accessed 15 July 2022).
16. Tool: Developmental assessment tools – World Bank guide
24. Tool: WHO’s caregiver skills training course
Fernald LCH, Prado E, Kariger P, Raikes A. A toolkit for
measuring early childhood development in low and middle- Training for caregivers of children with developmental
income countries. Washington, DC: World Bank; 2017 disabilities, including Autism. In: Metal health and substance
(http://hdl.handle.net/10986/29000, accessed 15 July 2022). abuse. Geneva: World Health Organization; 2022 (https://
www.who.int/teams/mental-health-and-substance-use/
17. Implementation research and practice treatment-care/who-caregivers-skills-training-for-families-
of-children-with-developmental-delays-and-disorders,
Yousafzai AK, Aboud FE, Nores M, Britto PR (Ed). accessed 1 October 2022).
Implementation research and practice for early childhood
development – Special Issue. New York; Annuals of the
25. Monitoring children’s development in primary
New York Academy of Sciences. 2018; 1419(1):1-271 (https://
care services
nyaspubs.onlinelibrary.wiley.com/toc/17496632/2018/1419/1,
accessed 15 July 2022). Monitoring children’s development in primary care services:
moving from a focus on child deficits to family-centred
18. UNICEF’s Programme guidance for early participatory support: report of a virtual technical meeting,
childhood development 9-10 June 2020. Geneva: World Health Organization; 2020
(https://apps.who.int/iris/handle/10665/335832, accessed
Programme guidance for early childhood development. New 15 July 2022).
York: United Nations Children’s Fund; 2017 (https://www.
unicef.org/documents/unicef-programme-guidance-early-
26. In-depth developmental assessment tools
childhood-development, accessed 15 July 2022).
Marlow M, Servili C, Tomlinson M. A review of screening
19. Burden of children living with developmental disabilities tools for the identification of autism spectrum disorders
and developmental delay in infants and young children:
Centers for Disease Control and Prevention. CDC’s work on recommendations for use in low‐ and middle‐income
developmental disabilities. Atlanta, GA: Centers for Disease countries. Autism Research. 2019; 12(2):176–199. doi:10.1002/
Control and Prevention; 2019 (http://www.cdc.gov/ncbddd/ aur.2033.
developmentaldisabilities/about.html, accessed 15 July
2022).
27. Nurturing care practice guide
20. Tool: Guide for monitoring child development Nurturing care practice guide: strengthening nurturing care
through health and nutrition services (forthcoming). New
Ertem IO. The international guide for monitoring child York, Geneva: United Nations Children’s Fund, World Health
development: Enabling individualized interventions. In: Organization; 2022 (https://nurturing-care.org/practice-guide,
Early Childhood Matters. Hague, the Netherlands: Bernard accessed 31 July 2022).
van Leer Foundation; 2017 (https://bernardvanleer.org/
ecm-article/2017/international-guide-monitoring-child-
28. Team around the child
development-enabling-individualised-interventions/,
accessed 15 July 2022). TAC Interconnections. The TAC approach: the team around
the child approach as a whole system of child and family
21. Medical versus social model support. Worcester, England: TAC Interconnections; 2020
(https://www.tacinterconnections.com/index.php/tacmodel,
United Nations Children’s Fund Europe and Central Asia accessed 15 July 2022).
Regional Office, Drexel University. Systematic review and
assessment of approaches to research and data gathering on
29. Routines-based interventions
knowledge, attitudes and practices (KAP) related to children
with disabilities in the CEE/CIS Region. Geneva: United Jennings D, Frances Hanline M, Woods J. Using routines-
Nations Children’s Fund; 2019 (https://www.unicef.org/eca/ based interventions in early childhood special education.
media/13406/file, accessed 15 July 2022). Dimensions of Early Childhood. 2012; 40(2):13-22 (https://
www.wvsha.org/wp-content/uploads/events-manager-
22. Tool: Care for child development uploads/session-handouts/Handout%20Preschool%20
Language%202.pdf, accessed 1 October 2022).
WHO, UNICEF. Care for child development: improving the
care of young children. Geneva: World Health Organization;
2012 (https://apps.who.int/iris/handle/10665/75149, accessed
15 July 2022).

A nne x es
Annex 1. The Nurturing care framework’s 24 core indicators
EXISTING
I M PA C T
I N D I C AT O R S
Proportion of children 24-59 months who are developmentally on track in health, learning SDG 4.2.1
and psychosocial well-being, by sex
Maternal mortality ratio SDG 3.1.1
Under-five mortality rate SDG 3.2.1
Neonatal mortality rate SDG 3.2.2
Adolescent birth rate SDG 3.7.2
G O O D H E A LT H
Coverage index of essential health services, including those for RMNCAH: family planning, SDG 3.1.2, 3.7.1,
antenatal care, skilled birth attendance, breastfeeding, immunization, and childhood 3.8.1
illnesses treatment
Proportion of women aged 15–49 who received four or more antenatal care visits Global Strategy
Proportion of mothers and newborns who have postnatal contact with a health care Global Strategy
provider within two days of delivery
Percentage of children fully immunized Global Strategy
Proportion of children with suspected pneumonia taken to an appropriate health care provider Global Strategy
Percentage of children with diarrhoea receiving oral rehydration salts (ORS) Global Strategy
A D E Q U AT E N U T R I T I O N
Prevalence of stunting (height for age <-2 standard deviation from the median of the WHO SDG 2.2.1
Child Growth Standards) among children under 5 years old
Prevalence of malnutrition (weight for height >+2 or <-2 standard deviation from the median SDG 2.2.2
of the WHO Child Growth Standards) among children under 5 years old, by type (wasting or
overweight)
Prevalence of anaemia in women aged 15–49, disaggregated by age and pregnancy status Global Strategy
Percentage of infants under 6 months old who are fed exclusively with breast milk Global Strategy
Percentage of children aged 6–23 months who had at least the minimum dietary diversity Global Strategy
and the minimum meal frequency during the previous day (minimum acceptable diet)
RESPONSIVE CAREGIVING
Percentage of children aged 0–59 months left alone, or in the care of another child under MICS
10 years old, for more than an hour at least once in the past week
O P P O R T U N I T I E S F O R E A R LY L E A R N I N G
Percentage of children aged 0–59 months who have three or more children’s books at home MICS
Percentage of children aged 0–59 months who play with two or more of the playthings at home MICS
SECURIT Y AND SAFET Y
Proportion of population living below the national poverty line, by sex and age SDG 1.2.1
Proportion of children aged 1–17 years who experienced any physical punishment and/or SDG 16.2.1
psychological aggression by caregivers in the past month
Proportion of children under 5 years old whose births have been registered with a civil authority SDG 16.9.1
Percentage of population using safely managed drinking water services SDG 6.1.1
Percentage of population using safely managed sanitation services, including a hand- SDG 6.2.1
washing facility with soap and water
Source: Nurturing care framework (1).
A nne x es
Annex 2. Form to monitor child development with inclusion of internationally validated milestones – exemplar*
W H AT T O A S K W H AT T O D O I F T H E R E I S C O N C E R N O R D E L AY
Orient the caregiver. “Just as it is important to follow [Child’s Name]’s Address all caregiver concerns
physical health and growth, it is important to follow and support Assess and address child’s health problems
development. A child’s brain develops most rapidly during the early (eg: growth, nutrition, perinatal problems,
years. It is useful to monitor development and to see if there are any chronic illness) using history, comprehensive
areas that need extra support. By development I mean, learning, physical and neurological exam, labs when
communicating, understanding, relating to people, moving body, using
hands and fingers, and also hearing and vision. Let me ask you about needed
how [Child’s Name]’s is developing in all of these areas. Please give me
examples of what she does in her daily life.” W H AT T O E X P E C T B Y C O M P L E T E D A G E
1. Caregiver’s concerns. “I’d like to first ask you, do you have any
concerns about [child’s name]’s development in any of these areas?” 6 MONTHS
2. Expressive language. “How does your child let you know when she Laughs aloud
wants something? What kind of sounds, gestures words does she use?” Vocalizes vowels (“aa, uu”)
3. Receptive language. “How does she show you that she understands Responds by making sounds when
when you talk to her? For example, what does she do when you say: caregivers talk
Where’s daddy? Where’s ball? Come here!”
4a. Gross (large) movements. “Tell me about her movement, like Lifts head 90° (prone)
holding and raising her head, sitting, walking.” Sits with support
When held erect, straightens legs, pushes
against object rather than bending legs
4b. Fine movements. “How does she use her hands and fingers, like Reaches towards objects with hands
holding objects?” Holds, handles toys/objects
5. Relating. “How does your child relate to people she knows? How does Has prolonged, meaningful eye contact
she show interest in them?” What does she do to engage them? How is Shows preference, recognition and desire to
her eye contact? engage with caregivers by reaching, smiling,
Wait for caregiver to respond, then ask: “How does she relate to inspecting their faces
strangers or show that she knows they are strangers?”
6. Play activities. “Tell me about your child’s play. How does she play Makes sounds in response to face-to-face
with people, with objects or toys?” play
Ask if needed: “What playthings or toys does she have, how does she Brings toys/objects to mouth
play with them?”
7. Self-help activities. “What does she do for herself, like feeding Children in this age range may not be
herself?” (Ages of attainment of self-help skills may vary across cultures) expected to attain self-help milestones
8. Nurturing care environment. “Thank you for telling me so much about (child name) development, you know her so well.
Now please tell me about her daily life. What do you and your family do at home, in your daily life to help her develop, learn,
communicate?” Listen to what the caregiver is telling you. Prompt by asking: “What do other family members and friends
do with her?” Support caregivers by acknowledging and praising all their efforts. Provide ideas from WHO/UNICEF Care
for Child Development, or the “GMCD Support Component” or other interventions when necessary.
9. Developmental risks. “Sometimes caregivers may have a lot going on. For example, they may feel overwhelmed, stressed
or depressed, there may be financial problems or illness in the family, and caregivers may find it hard to support their
child’s development. Are there such or other difficulties in your family situation?” Listen with empathy, identify and help
address psychosocial risk factors.
10. Planning for interventions and follow-up. “What are some ideas or plans you have to support (child’s name) development
despite these difficulties? At this early age when development is so important, what could you, your family, friends and
community do to help her develop?” Support caregivers’ efforts. If caregivers do not have ideas or plans, tell them you
would like to talk further with them about these. Provide your feedback on development, make referrals and plan
follow-up together with the caregiver.

A nne x es
Assess and addressnurturing care, opportunities for learning, psychosocial

risk and protective factors (Questions 8, 9, 10)
Assess all domains of development using appropriately standardized, reliable, validated tool
Follow closely (eg: see back in 1-month)
Refer for consultations and/or services when needed
Conduct valid hearing test and vision test as needed
12 MONTHS 18 MONTHS 30 MONTHS
Babbles by repeating many syllables Uses at least 2 meaningful words Uses sentences with 3 words to
Has one meaningful word Uses index finger to point communicate
Uses arm or hand to point to people Caregivers understand some of Uses pronouns (I, me, you)
or objects child’s communication Caregivers understand most of child’s
communication
Understands names of familiar Waves “bye” or uses other common Understands one preposition (other
people (mummy, daddy) gesture in response to command than “in”) such as “under” or “on top”
Understands verbs/action words Understands one simple command
(come, take) (bring shoes)
Understands names of objects (ball,
toy)
Sits steady without support Walks alone Climbs, jumps

Pulls to stand holding on to objects Kicks ball or other object
Stands alone momentarily
Walks holding onto objects
Picks up small objects using pincer Holds pencil or stick (in any way) and scribbles on paper or on ground/floor
(thumb and index finger) only
Spontaneously seeks to share Initiates specific interactions with Initiates increasingly warm and varied
enjoyment and interest with others people interactions with people
(cuddles caregiver, kisses, inspects Imitates others’ behaviors (waving
toy together) back, scribbling, washing hands,
Shows recognition of stranger (turn stacking clothes in imitation)
away, stare)
Initiates game “peek-a-boo” Inspects how toys/objects work (how Involves others in play
Inspects toys/objects with curiosity doll moves, bells ring)
Imitates gestures during play Has simple imaginary play like
(clapping hands, make face) feeding doll, driving cars
Uses fingers to feed herself (knows it May use one feeding utensil Takes a piece of clothing off
is food and eats) Drinks from cup Washes hands with assistance
*Adapted from the International Guide for Monitoring Child Development (GMCD) Training Package with permission
from its authors. The milestones provided here were attained by at least 85% of healthy children in the international
GMCD Study standardization sample at the given ages. For more details, see (25).
F O R M O R E I N F O R M AT I O N
nurturing-care.org
ecdan.org
J O I N T H E C O N V E R S AT I O N
#NurturingCare
@NurturingCare
C O N TA C T
[email protected]

Monitor Progress: Strategic Action 4

Uploaded by

Document Informationclick to expand document information

Document Informationclick to expand document information

Copyright:

Available Formats

Monitor Progress: Strategic Action 4

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Monitor Progress: Strategic Action 4

Uploaded by

Copyright:

Available Formats

NURTURING CARE HANDBOOK

Using this handbook 1

Monitoring individual children’s development 16

Signs that you are making progress 20

References. Tools, case studies and

Annex 1. The Nurturing care framework’s

Annex 2. Form to monitor child development 24

This handbook is composed of 6 guides. Each of the

The development of this handbook was led by the World

1 Lead and invest

“Are we doing what we

the Nurturing care and

The importance of monitoring was referred to

2 NURTURING CARE HANDBOOK

Table 1. The Nurturing care framework’s logic model (1)

The logic model

OUTCOMES (COMPONENTS OF NURTURING CARE)

• High-level • Families’ voices, • Opportunities for • Indicators for tracking • Multistakeholder

ENABLING ENVIRONMENTS FOR NURTURING CARE –

What will this strategic action

The suggested actions for Strategic action 4. Implementation monitoring

4 NURTURING CARE HANDBOOK

Measuring children’s developmental status

Young children at risk Risk by sex Lifetime cost of growth

Estimate in terms of % loss

for early childhood Careseeking >95% Exclusive

None <14 14 – <18 18 – <26 ≥26 Basic 20

International Code of Marketing of Breastmilk Substitutes (alignment)

6 NURTURING CARE HANDBOOK

Assessing responsive caregiving and early Compile existing information

You do not always need a new survey: older ones are

Data that are not comparable

8 NURTURING CARE HANDBOOK

Theory of change Logic model

Implementation monitoring involves measuring all

Work is in progress Read the article Measuring the implementation

10 NURTURING CARE HANDBOOK

Figure 3. Pyramid of data collection and use

COMMUNIT Y OR PROGR AMME

12 NURTURING CARE HANDBOOK

Decide how to measure

Assist frontline workers to build their data

14 NURTURING CARE HANDBOOK

Assess data regularly Lack of time and money

When developing a new service, it can help if TOOL

16 NURTURING CARE HANDBOOK

The medical and social models of disability

Individual deﬁned by needs (e.g., needs Attitudinal barriers: discrimination

Source: See (21).

• Follow up in primary care

18 NURTURING CARE HANDBOOK

1 The one-stop centre

20 NURTURING CARE HANDBOOK

8. Assessing responsive caregiving and early learning

22 NURTURING CARE HANDBOOK

Annex 1. The Nurturing care framework’s 24 core indicators

Source: Nurturing care framework (1).

“Are we doing what we

• High-level • Families’ voices, • Opportunities for • Indicators for tracking • Multistakeholder

Assess and addressnurturing care, opportunities for learning, psychosocial

Sits steady without support Walks alone Climbs, jumps