Table 1.

Activities considered but excluded as out of scope for the PRIME intervention

Potential intervention activity	Reasons for consideration drawn from formative research	Reasons not included in the PRIME intervention
Reinstate/supplement the primary healthcare fund	• Insufficient funds to meet daily health centre costs, including transporting drugs, paying for cleaning services, and purchasing supplies  • Health workers request payment for services	• Bureaucratically and administratively challenging to implement  • Opportunity for misappropriation  • Unsustainable after the study period
Fill staffing gaps at health centres in accordance with Ministry of Health guidelines	• Many patients and too few staff  • Low motivation of staff due to overburdened workloads  • Health centres not fully functional due to insufficient availability of staff  • Staff not at recommended levels	• Bureaucratically and politically challenging to implement  • Limited availability of health workers nationwide  • Requires substantial funding  • Unsustainable after the study period
Pay/supplement staff salaries	• Health workers not paid on time or in full  • Low motivation of staff due to lack of pay  • Time spent in alternative employment activities  • Health workers request payment for services	• Bureaucratically and administratively challenging to implement  • Not likely to be successful due to national payroll system challenges  • Requires substantial funding  • Unsustainable after the study period
Implement ICCM through VHTs	• Community medicine distributors/VHTs important source of care, treatment, and referral in the community  • Need to determine a sustainable VHT ICCM programme: community sensitization, training, VHT kits, drug supply, supervision	• ICCM and VHT policy under revision and implementation timelines uncertain  • Potential challenges with the operationalization of the new policy  • Required drug formulations for pneumonia not yet available
Improve the drug supply chain for AL	• Frequent stock-outs of AL and other essential drugs, leading community members to seek care elsewhere  • Stock-outs due to challenges with quantification, ordering, storage, district level stock of AL, and numerous logical barriers	• Other programmes already addressing the drug supply chain  • Imminent implementation of new ‘push’ system, potential for misalignment  • Unlikely to yield results due to challenges at higher levels of the system
Work with district and partners to ensure supply of mRDTs and thermometers	• World Health Organization guidelines for malaria case management, but limited supply of mRDTs to health centres  • Thermometers not supplied or available in health centres	• No options for partnering with other stakeholders/partners providing mRDTs and thermometers identified; therefore, they would have to be directly supplied by the PRIME intervention
Implement community sensitization	• Attract patients to health centres by communicating new/improved services using local councillors, social gatherings, word of mouth, mass media, community dialogues	• It was suggested to focus on word of mouth/VHTs to communicate information; however, the VHT programme was not implemented during the study period
Include supervision and coaching as part of HCM modules	• Supervision is described by health workers as ‘fault finding, unsupportive and infrequent’, leading to demotivation	• Weak evidence demonstrating effectiveness of supervision  • Challenging logistics of implementing supervision activities
Implement 3-month SOA to complement PCS	• Lack of patient-centred thinking due to low motivation and lack of awareness of how emotions can affect actions and relationships with others	• 3-month activities not aligned with other intervention training packages; therefore revised to weekly activities to fit within four PCS modules

ICCM=integrated community case management; VHT=village health team; AL=artemether–lumefantrine; mRDT=malaria rapid diagnostic test; HCM=health centre management; PCS=patient-centred services; SOA=self-observation activities.