Table 5.
Challenges and solutions encountered during the study implementation period
| Underlying factors for non-compliance and poor performance | Proposed Actions and Solutions | Outcomes Achieved |
|---|---|---|
| Challenge: Health Care Providers performance and non-compliance to PSBI to guidelines. | ||
| Lack of knowledge and inexperience in executing the IMNCI/ PSBI guidelines | At the initial phase, TSU staff (LHVs) who were well versed with the case management of sick young infants supported the physicians in the assessment and classification of PSBI. | Enhanced the competency of the health care providers and consequently led to adequate compliance to PSBI guidelines. |
| Training of PPHI Physicians and Nurses in IMNCI guidelines | Improved confidence of physicians in recognition and management of sick younginfant. | |
| Refresher training and on-site supervision by TSU clinical coordinators | ||
| Low performance due to high volume outpatient clinics and regular engagement in supplementary polio immunization activities (SIAs) | Motivation and mentoring visits by PPHI Managers. | Improved performance and compliance of the BHU Staff. |
| Initiation of performance-based incentives by PPHI to inculcate a healthy competitive environment | ||
| Challenge: Physicians reluctance to administer I/M intramuscular injections to febrile infants. | ||
| This clinical practice adapted from peers physicians during clerkship following graduation from medical school. | A one-day technical seminar organized for BHUs physicians. AKU senior faculty members address concerns of physicians and share the standard clinical practice guidelines of antibiotic administration. | Change in practices of physicians observed. |
| Regular reinforcement and counselling by the TSU and PPHI clinical coordinators and monitors. | Improved adherence to the treatment guidelines. | |
| Challenge: Poor documentation of case summary of young sick infants with PSBI | ||
| Unaccustomed to record- keeping | The TSU staff carried out the documentation in the initial period of the implementation. Later the physicians took up the responsibility. | Documentation improved by facility staff |
| Challenge: Poor LHWs performance, motivation | ||
| Demotivation and poor performance of the LHW due to; Poor health system poor governance. | TSU carried out dialogues with the LHW program and feedback provided to the LHW program coordinator in the monthly district health management meetings. | Improvement in the LHW performance reflected by the increased referrals of PSBI cases to BHUs. |
| Delay in monthly salaries and replenishment of essential LHW delivery commodities (ORS, zinc and oral amoxicillin). | Joint field monitoring visits by the Lady Health Supervisors and TSU clinical coordinators to validate the data on pregnancy surveillance, PSBI cases and referrals. | |
| The frequent engagement of LHWs in Polio immunization campaigns. | Feedback of monitoring visits provided to LHWs and counselling to improve performance. | |
| Challenge: Family noncompliance to injectable and oral antibiotics treatment | ||
| Families declined injectable antibiotics treatment as they were afraid of injections and sharp needles. | LHWs visited households to reinforce completion of treatment. They counselled families on the importance of the prescribed duration of treatment and ensured them of the safety of injections. | These actions mitigated the issue of non-adherence to injectable/oral antibiotics treatment and follow-up compliance. |
| Parents would stop oral antibiotics if the child’s symptoms improved earlier than 7 days. | One of the reasons identified was the volume of oral syrup amoxicillin 125mg/5ml. The syrup volume was large and inconvenient to administer to small infants by parents. Syrup was replaced with oral amoxicillin drops (125 mg/0.8 ml) to reduce the liquid volume of the amoxicilin. | |
| Day 2 follow up compliance at BHU was poor. | The importance of follow-up was reiterated in the community awareness sessions conducted by LHWs | |
| Challenge: Documentation of PSBI cases | ||
| The data entry software system (Dashboard) established by PPHI did not capture PSBI cases | The TSU assisted PPHI in designing of PSBI indicators documentation in Dashboard. | PSBI cases captured in the dashboard used to monitor the monthly performance of BHUs for PSBI coverage. |
LHV: Lady Health Visitor; ORS: Oral Rehydration Solution.