Table 2.

ADD-RHD implementation strategies mapped according to expert recommendations for implementing change (ERIC) discreet implementation strategies⁴⁰

Strategy	Details
Assess for readiness and identify barriers and facilitators	Assessment for readiness will be done through facility visits, surveys and engagement of local and district health officers. Patient and provider interviews will identify barriers and facilitators to decentralisation. Key stakeholder and community engagement on decentralisation logistics will serve to establish key components of the process.
Change of service sites (decentralisation)	Four health facilities were identified based on patient clusters and distances from their residences primarily geared at increasing access and reducing distances travelled.
Training healthcare workers (HCWs)/develop educational materials	HCW training was planned to include the development of education materials on RHD clinical knowledge, BPG preparation and injection skills, penicillin adverse events recognition and first aid management. A detailed description is provided below.
Change record systems	ACT application was specifically developed as a clinical tool for HCWs through stakeholder engagement and piloting.27 It encompasses in-built tools to enhance patient engagement, including clinicians’ monitoring of adherence and quality metrics for monitoring supply stocks. This will replace the current regional registry. A detailed description is provided below.
Purposefully re-examine the implementation	We built in milestones to re-examine implementation activities, identify challenges, and provide feedback and support to health facilities in order to continuously improve the quality of care. This includes looking at the use of ACT for patient management, identifying challenges and giving feedback to healthcare workers in health centres.
Identify and prepare champions	Initial assessment for readiness informed the need for local champions at each health centre, selected to drive the implementation by providing support and driving quality improvement activities such as updating stock and supplies data for quality metrics on the ACT application.
Physical supply of medicines*	Although historically used to treat other conditions, such as syphilis, its consistent availability is variable in public facilities in Uganda. Hence, through stakeholder and local engagement, temporary BPG supply was found to be an essential initial component to the success of the intervention at a few facilities. This marked an iterative adaptation in light of short-term regulatory constraints. For some facilities, increasing BPG supply through the government system was motivated by history of use, and hence a gap in supply was inevitable during the initial post-decentralisation period. Covering this gap was an important aspect to implementation.

*Not a specific ERIC implementation strategy.

ACT, active community case management tool; ADD, Active Case Detection and Decentralised Dynamic Registry; BPG, benzathine penicillin G; RHD, rheumatic heart disease.