Integrating psychosocial early childhood development into reproductive, maternal, newborn, and child health services in Uganda: perceptions of governance stakeholders and primary healthcare providers

Abstract

Uganda has one of the youngest populations in the world. In 2014 it was estimated that 56.7% of the population was 18 years and younger, and 35% of that population was less than 5 years old. That population distribution represents great potential, but also demands investment for its realisation. Psychosocial Early Childhood Development (ECD) is gaining global momentum in the effort to build the mental, social and emotional wellbeing of children aged 0 to 3 years, optimising their growth and development.nResearch shows children in Low and Middle Income Countries (LMICs) are exposed to psychosocial risk factors such as poor stimulation, lack of learning opportunities, parent unresponsiveness, and parental inability to understand infant behaviour. Identified strategies that address these include responsive and stimulating parenting programmes that encourage brain stimulation, language development and secure attachment between parents and their infants. These have been shown to promote mental, social and emotional capacity in infants, and positive lifecourse outcomes in school readiness, employment and mental wellbeing n critical to Ugandars growing population.nUgandars National Integrated ECD policy has reinforced the importance of ensuring positive psychosocial ECD, but recognises that there are gaps in systems and in implementation, with limited public services available for children aged 0 to 3 years. These gaps can be tackled by scaling up proven interventions through existing health services.nFor the thesis, I developed a conceptual framework focusing on national governance and the service delivery planning and implementation considerations needed to scale up psychosocial ECD in the Ugandan health context. The framework is used to identify the health system components needed to effectively integrate psychosocial ECD interventions across frontline Reproductive, Maternal, Newborn, and Child Health (RMNCH) services. It is used to show how Ugandars RMNCH services can be employed to strengthen care for psychosocial ECD, by integrating and scaling up the WHO and UNICEF Care for Child Development (CCD) package at frontline health services.nA qualitative Health Policy and Systems Research design and health systems thinking analysis werenused to explore local perceptions of ECD health governance and service delivery factors in detail. I triangulated data from ECD government documents, key informant interviews, focus group discussions and observations. A government document review was used to explore Ugandars national ECD governance environment. Additionally, 22 key informant interviews and seven focus group discussions with 61 government staff, multilateral staff and Non-Government Organisation (NGO) staff and health workers, were conducted in Uganda to explore the governance and service delivery capacities. Furthermore, to explore the service delivery environment, observation of RMNCH services at selected health facilities was used to examine how and where CCD can be integrated. A thematic analysis was employed to identify codes, categories and emerging governance and service delivery themes.nGovernance themes relating to greater ECD government commitment and increased ECD prioritisation were identified. Participants described important governance considerations relating to national government ECD commitment and leadership, partnership and collaboration, and multisectoral engagement. However, effectively achieving the multisectoral ECD approach was an identified challenge as issues around leadership, authority and implementation capacity were raised. Additionally the lack of ECD services and limited health sector involvement in psychosocial ECD was a reoccurring theme and limitation.nPerceptions of psychosocial ECD varied across health workers and lsensitisationr on the importance of psychosocial ECD to improve their knowledge and practices was frequently raised. At selected RMNCH services, frontline health workers were informally promoting psychosocial ECD, however there were no strong concepts that defined formal psychosocial ECD milestones. Additionally there are no systems and structures to support them to systematically address psychosocial ECD. Furthermore heavy workload, limited empowerment and limited resources were key health systems challenges, impacting their capacity to deliver routine child services.In conclusion, in Uganda there is national government endorsement of ECD with a multisectoral approach, however there are limited service delivery structures addressing psychosocial ECD in children aged 0 to 3 years. Uganda has established psychosocial ECD on the national agenda and recognised the need for a multisectoral approach. To achieve equitable access to quality psychosocial ECD, RMNCH models of care and service delivery need to be reorientated to proactively encourage positive psychosocial ECD and CCD. nAt a systems level, this requires an integrated multisector approach that extends the whole-of-government ECD approach to include psychosocial ECD in health. For effective integration into health, psychosocial ECD needs to be prioritised alongside other child health concerns by all governance actors. Additionally it requires reorienting health service delivery and workforce to make a space for psychosocial ECD in their new and expanded roles. nHowever, the introduction of new ECD governance actors creates tensions with established ECD players over available resources, and differing sectoral approaches and priorities. Additionally, if RMNCH services are to promote CCD, they are unable to do this with the current health worker vocational orientation and resource basen