Table 3. Barriers and facilitators to implementation of IBCM programs.

	Risk Assessment	PEP Provisioning	Animal Investigation	One Health collaboration	Data reporting/mobile technology
Barriers	Govt health workers: Work Capacity Busy workload High patient volume Many responsibilities Other priorities Work duplication Human & Financial Resources High staff turnover Not compensated for additional IBCM work Compliance with guidelines Felt rabies not their job Reluctance to change or adopt new routine Performing risk assessment Limited knowledge of rabies incl. WHO Categories & signs of rabies in animal Focus on wound severity not rabies signs in biting animal Judicious use of PEP Hesitancy to discontinue or withhold PEP No legal basis for risk assessment to inform PEP	PEP accessibility: Costs High out-of-pocket costs of PEP High travel costs to closest clinic w/ PEP Access Most vulnerable populations don't have access to health services PEP availability: Frequent stockouts Not available in many rural/ remote areas Excessive PEP use: Free PEP policy can lead to excessive PEP-seeking behavior Indiscriminate PEP use can cause excessive costs/ stockouts Same or more demand for PEP even when low or zero risk of rabies Local beliefs: Seeking care at traditional healers	Govt animal health workers: Compliance with guidelines Investigations late or not conducted No follow-up Reluctance to change or adopt new routine Felt rabies not their job Other prioritizes Not motivated to investigate until death Human & Financial Resources Lack of personnel High staff turnover Not compensated for time or travel costs Training | Lack of formal trainingl Not comfortable handling animals Conducting animal investigation: Cannot find or identify biting animall Not able to get sample Diagnostics: Few diagnostic lab(s)| Must ship samples far without cold chain	National-level: Governance structures| Govt ministry not structured for One Health| Lack of ministry cooperation| Unbalanced sector power Policy | Rabies neglected/not priority Lack of funding Difficult integrating IBCM into national policy Regional / Local-level: Compliance with guidelines Health sector not notifying about bites Investigation results not considered for PEP decision Stakeholder Engagement Lack of local ownership No prior intersectoral communication Difficult to change routine behavior Difficult to establish and maintain communication Required Skills Limited experience with data management	Data reporting: Lack of data submission by both sectors Feedback not provided to other sectors Investigation case not formally closed Mobile technology: App issues App development timely and many iterations App not feasible in all settings – e.g., high illiteracy/no written language Limited network coverage App must be updated and re-downloaded User Issues Lack access to smartphones/tablets Reluctance to use app Required additional proficiency training
Facilitators	Workforce: Hiring staff to perform risk assessments Consistent feedback and communication Training & Materials: Apps that automatically assign case definition >Provision of hard copy protocols Routine training	Free PEP policy: Increased accessibility Increased PEP-seeking Increased PEP adherence Community Outreach: Educating local traditional healers to report bites	Workforce: Hiring staff to conduct animal investigations Training & Materials: Hook and straw sampling techniques Rapid diagnostic tests Safely handling animals Communication: Prepare stakeholders for swift rise in case detection	Communication: Consistent feedback with all involved sectors Establishing hotline to facilitate One Health link Collaboration: Involving all sectors in discussions/decisions Using existing One Health programs and networks Employing veterinary staff within public health system	Communication: Consistent feedback/ reminders to report Mobile technology: Real-time data monitoring Remote data access Quick way to establish a surveillance system Overcome language barriers