| Community’s lack of awareness about service availability at the health post level and community perception that HEWs were not able to take care of sick young infants. |
Use of radio services (in local language) to inform about service availability. HEWs used different community fora/gatherings to disseminate information about the availability of services for sick young infants at health posts. This led to an improvement in the utilization of services by the community. |
| Weak community networks–HDA networks were supposed to play key roles in mobilizing the community and assisting HEWs in the identification of pregnancies, births and sick young infants, but did not do so. In most cases, HDAs were unaware that HEWs were able to manage sick young infants. However, they did relatively better in the identification of pregnancies and births than the identification of sick young infants. |
Regular meetings and discussions with the district health offices were used to stress the importance of strengthening and monitoring of community networks. This remains a challenge which needs further work from the community and the local government to improve and sustain the coverage of CBNC. |
| Unavailability of HEWs and closure of health posts- during random visits, we found that some health posts were closed. Some of the reasons included: a single HEW assigned to the health post was on anassignment elsewhere; even when there was more than one HEW, at times all of them went out at the same time for other activities (campaigns, meetings, trainings); HEWs lived far from the health post; and HEWs were away for social or personal reasons, including maternity leave. |
Discussions were held with local health authorities, health centre staff and HEWs to consider task shifting and also to increase the number of HEWs. Although there were some improvements, this challenge remained throughout the study period, requiring serious consideration and commitment from all stakeholders. Local, regional and national political leaders, as well as the multiple nongovernmental and governmental organizations working on the health extension programme, need to be actively involved in addressing this issue to ensure the uninterrupted availability of services at health posts. |
| Inappropriate management of sick young infants—during the supportive supervision visits, especially during the first few months of implementation, both HEWs and health centre staff were observed to have deficiencies in managing sick young infants. This included treating at the health post even when a referral was indicated. |
TSU and the implementing partner provided close supportive supervision to the HEWs and health centre staff during which cases were reviewed and feedback was given. Review meetings and additional training were also provided. Through this continuous support and feedback, the situation improved substantially, but continuous mentoring and support will be required to have a sustainable effect. |
| Stock-out of medicines for the management of PSBI in some health facilities for a few months was observed. |
When informed, JSI/L10K re-filled the medications for the management of PSBI until the district health offices took over. |
| Poor documentation, including incomplete or missing data, on clinical assessment, treatment provided and follow-up appointments were noted. |
The TSU provided additional skills-building and refresher training to HEWs and health centre staff. Jointly with the district health office, we provided continuous supportive supervision and conducted review meetings during which we reviewed the documentation of each health facility and provided necessary corrective feedback. This led to an improvement in the documentation at the health facilities. |
| Less attention given to health centres and poor linkage between health posts and health centres–staff not trained in WHO PSBI management guideline, different treatment guideline used at the health centre creating confusion and disagreements when health centre staff were supervising HEWs, and during the referral of sick young infants from health posts to health centres. |
In collaboration with the JSI/L10K and the district health offices, the TSU facilitated the harmonization of the management protocol for PSBI used at the two levels and provided the necessary training and supportive supervision to health centre staff. These interventions improved the alignment between the two levels of care. |
