Table 4. Challenges in implementation of the guidelines and solutions.

Health System level	Challenges	Solutions
Identification of illness
Community	Delayed recognition of illness and care seeking by community	Information, education and communication (IEC) material: Flip charts, posters, wall paintings depicting the signs and symptoms of PSBI, street play on PSBI, awareness sessions on PSBI during immunization and antenatal care days, village level local government meetings to increase recognition of illness and promote earlier care seeking closer to home
		ASHAs informed families of the nearest functional health facility for prompt care seeking
	Small proportion of sick young infants identified	ASHAs were retrained on recognition of danger signs and essential newborn care
		Job aids (handouts depicting signs and symptoms of PSBI) were provided to assist during home visits
Health Work Force	ASHAs not confident in counting respiratory rate	Respiratory rate timers provided; trained in counting respiratory rate; exercises to evaluate accuracy of respiratory rate count
Confirmation and Treatment of PSBI
Health Workforce	ANM not initiating or treating infants with PSBI	Encouragement and supportive supervision by MOs on a day to day basis; support from block and district health officials. Use other opportunities like monthly meetings for sharing experiences, success stories, resolving issues, allaying apprehensions and encouraging use of simplified treatment regimen.
	Errors in classification of PSBI and dose calculation	Regular retraining, targeted training on classification and dose calculation; GoI videos shown regularly
		A chart on dose calculation put up in the outpatient area of all health facilities
Health Service Governance	Interrupted availability of MO and ANM at the health facility	AMOs trained in identification and management of PSBI
Health System Infrastructure
Health Products and Technologies	Non availability of ASHA HBNC registers	Facilitated procurement of the registers through the health system process
	Interrupted supplies of syringes, antibiotics, equipment	Supplies procured from government local purchase funds available at health centres Respiratory timers distributed to all health workers
	Maintenance of thermometers/lack of battery	Interacted with relevant MO to identify root cause in supply chain and raised issue during monthly meetings
Health Financing	Delayed payment of incentives for ASHAs	Escalated to district and state level and followed up actively with relevant authorities to hasten procurement and disbursement of incentives for ASHAs
Health Workforce	Challenges in completing RCH and HBNC registers by ANMs and ASHAs	Research team facilitated training in filling the forms and registers

A few of the salient ones were:

a. To improve early recognition of illness and care seeking by the community, communication materials like flip charts and posters were provided and street plays on the importance of early identification of infants with PSBI were staged.

b. As there are fewer MOs, Ayurvedic Medical Officers (AMO) and practitioners of alternate medicines in the block were trained in identification and management of sick young infants.

c. To support health system infrastructure, procurement of supplies was facilitated and targeted trainings were provided.