Health systems offer unique opportunities for integrating services to promote early child development (ECD). However, there is limited knowledge about the implementation experiences of using health services to target nurturing care and ECD, especially in sub‐Saharan Africa. We conducted a qualitative implementation evaluation to assess the delivery, acceptability, perceived changes, and barriers and facilitators associated with a pilot strategy that integrated developmental monitoring, nutritional screening, and early learning and nutrition counseling into the existing health facility, and community‐based services for young children in rural Mozambique. We completed individual interviews with caregivers (N = 36), providers (N = 27), and district stakeholders (N = 10), and nine facility observational visits at three primary health facilities in October–November 2020. We analyzed data using thematic content analysis. Results supported fidelity to the intended pilot model and acceptability of nurturing care services. Respondents expressed various program benefits, including strengthened health system capacity and improved knowledge, attitudes, and practices regarding nurturing care and ECD. Government leadership and supportive supervision were key facilitators, whereas health system resource constraints were key barriers. We conclude that health systems are promising platforms for supporting ECD and discuss several programmatic recommendations for enhancing service delivery and maximizing potential impacts on nurturing care and ECD outcomes.

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<p class="abstract"><strong>Background:</strong> Approximately 250 million (43%) children under five years in low- and middle-income countries are at risk of sub-optimal development. Of these, 67% are found in sub-Saharan Africa due to exposure to multiple risks, including inadequate stimulation at home. In order to promote early childhood development (ECD), an intervention integrating ECD content into routine facility-based health services and supporting ECD policy and advocacy is currently being implemented in Siaya County. In addition, parental counseling on early stimulation is integrated into home-based visits by community health volunteers. We aim to evaluate the intervention’s operational feasibility, effectiveness and cost-effectiveness.</p><p class="abstract"><strong>Methods:</strong> The study is a cluster-randomized controlled trial using a mixed-methods approach. The study is being conducted in Bondo sub-county in Siaya County. The study has three arms. Arm 1 will receive a health facility-based ECD intervention. Arm 2 will receive the health facility-based ECD intervention combined with home-based ECD counselling. Arm 3 (control) will receive standard care. Six health facilities in each study arm (18 in total) will be randomly selected from wards within the sub-county. We aim to recruit and follow-up 699 mother/caregiver-child dyads, 233 in each arm. Pregnant women are recruited when they visit health facilities during the third trimester. Analysis will involve estimating the effect of the intervention using mixed linear models and the Difference-in-Differences estimator.</p><p class="abstract"><strong>Conclusions: </strong>The data generated from this study will provide much-needed information for program design and implementation of interventions aimed at promoting ECD in Kenya and other sub-Saharan African countries.</p><p class="abstract"><strong>Trial Registration:</strong> Current Control Trial is ISRCTN11561283.</p><p> </p>

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