Table 3.

Barriers and Facilitators of Structured Play Integration into Nutritional Rehabilitation from Healthcare Providers

	Category	Barriers		Facilitators
	National level
1	Policy level	Lack of coordination Nurturing care roll out was hindered by COVID-19 The different sectors not developed their own operational plans Lack of MoH strategy on ECD Lack of data on basic package for ECD for MoH No records on play activities to capture in HMIS No Play therapists in the HR structure		National Integrated ECD policy Integrated Strategy-multisectoral and plan Line Ministries involved Lead ministry: MoLGSD Adaptation of Nurturing Care Framework 2018 Community Health workers/VHTs IMAM and MIYCAN guidelines ECD indicators in HMIS tools
2	Funding	Lack of resources Implementation of ECD is in projects with no sustainability plans Partners who support ECD work in isolation		Partners like UNICEF, Action Against Hunger Training on Caring for Carers by WHO Locally available materials-not expensive/sustainable
	Health Facility Level
3	Administration level	No plans for ECD in the hospitals No budget for play materials Lack of knowledge or exposure to embrace the concept of ECD No specification of play needs given to administration No clear justification for play activities to be included in budget		Donations/funding to make buildings child-friendly-colours etc Presence of partners Presence of Play rooms/free spaces
4	Health workers	Lack of training on Play/ECD Priority is to save life Focus on providing medical care and therapeutic feeds Over worked – heavy work loads No designated person to lead play No Mindset of Play in hospitals High turn-over of staff Poor attitudes to work/patients		Presence of Play facilitators/therapists Training on value of Play to Health workers Health workers to prescribe play as part of treatment If HWs love the children, more natural to play Presence of more HWs so they have enough time to play
5	Facility characteristics	Lower levels, rural setting No space for play Government facilities		Higher level facilities, urban setting Private facilities Presence of partners
6	Play materials	No educational materials/guidance No toys, especially for younger children Children with disability not catered for Caregivers steal donated toys		Presence of toys and volunteers Local materials for play