Background
Methods
Study design
Evidence-based interventions
Data collection
Desk review
Quantitative data
Key informant interviews
Analysis
Ethics
Results
Understanding steps and strategies for the implementation of facility- and community-based integrated management of childhood illness
Implementation strategy | Facility-based IMCI | Community-based IMCI |
---|---|---|
Adaptation | X | X |
Adaptation of existing training and guidelines to reflect local context | x | x |
Expansion and adaptation of existing programs | x | x |
Data use | X | X |
Data driven adaptations for cost and feasibility | x | x |
Piloting | x | x |
Local research | x | |
Strengthening management and monitoring and evaluation | x | |
Engagement | X | X |
Engagement of community and local stakeholders | x | x |
Engagement of partners in preparation and for implementation | x | x |
Engagement across sectors | x | |
Engagement of traditional healers | x | |
Integration | X | X |
Integration of program into existing structures | x | x |
Integration into existing community worker capacity | x | |
Integrating monitoring and evaluation with supervision | x | |
Integration of supervision into existing district health offices | x | |
Training | X | X |
Facility staff trained in management and monitoring and evaluation | x | |
Initial and ongoing training through refresher courses | x | |
Training of trainers and cascade to district control and responsibility | x |
Outcome | Strategy | Examples of contextual factors | Results |
---|---|---|---|
Acceptability | Training and orientation of mothers’ groups, local NGOs, traditional healers, and other community groups with the CB-IMCI guidelines; Use of FCHVs selected by local community (CB-IMCI). | Community health system and structure (facilitators) | Care-seeking for diarrhea, pneumonia, and fever for children under 5 rose to or nearly to 50% by 2014. |
Feasibility | Local research; Pilot testing; Integration into existing district structure; Partner engagement for training and other implementation support (both FB- and CB-IMCI). Use of FCHVs and other community-based health workers to implement community-based care (CB-IMCI). Integration of CB-NCP into existing CB-IMCI program to create combined CB-IMNCI; Use of FCHVs for care delivery (CB-IMNCI). | Health system strength (both facilitator and barrier) Culture of data use; Prioritization of local research; Community health system and structure; Culture of donor and partner coordination (facilitators) Geography (barrier) | By 2009, IMCI had been implemented in all 75 districts. Scale-up occurred over 10 years, with expansion beginning in districts which already had community-based health programs in place. Use of existing FCHVs helped to reduce cost of program implementation and expansion. |
Fidelity | Adaptation of existing standard WHO-IMCI training materials for Nepal’s specific needs and translation into Nepali language (both). Monitoring and supervision meetings between FCHVs, health facility supervisors, district health officers, and NGO trainers occur in the community and at health facilities (CB-IMCI). | Culture and capacity of data use; Prioritization of local research; Community health system and structure (facilitators) | An assessment of the IMCI program in 2017 found 30% of facilities reported stockouts in the previous 3 months [33]. Further, only 65% of facility health workers were found to have been trained in IMCI. |
Effectiveness and Reach | Training using a cascade (training of trainers) system to reach providers from the central MOH level to the District Health Office (the local leads) to the facility to the community; Supervision integrated into District Health Offices (both); Adaptation to include neonatal interventions (both). | Community health system and structure (facilitator) Geography (barrier) | By 2009, IMCI had been implemented in all 75 districts. Care-seeking for children under 5 between 2001 and 2016 increased: for diarrhea, from 21 to 64%; for fever from 24 to 80%. In 2009, more than half of U5s received care for pneumonia or diarrhea from FCHVs [34]. |
Exploration (E)
Preparation (P)
Implementation (I)
Adaptation (A)
Sustainment (S)
Contextual factors contributing to or hindering EBI implementation including IMCI
Contextual Factor | Facilitator, Barrier, Both, or Neither | Description |
---|---|---|
Economic development | Facilitator | Nepal’s steady economic growth during the study period was identified as an important contributor to health sector successes. Key informants observed that a growing number of Nepalese people working overseas improved economic status and increased financial access to health care through remittances; further, their exposure to other health care systems led families to have higher expectations of care and demand better quality |
Female empowerment | Facilitator | During the study period efforts to increase female empowerment included education, addressing poverty, improving asset ownership, increasing women’s economic rights, and targeting women for microcredit programs to increase financial opportunities. In the health sector, efforts included government-sponsored village mothers’ groups, and granting authority and importance to FCHVs in communities |
Focus on universal health care and equity through national leadership | Facilitator | Nepal committed to access to health care as a fundamental right of the people, prioritizing gender equality and social inclusion in health policy and delivery through policies including its Second Long Term Health Plan (1997–2017) which prioritized Nepal’s most vulnerable groups including women and children, rural populations, and underprivileged and marginalized people [41]. Following the people’s movement of 2006, a free health care policy was introduced in 2006 which provided essential health care services free of charge to the poor, disabled, elderly, and FCHVs up to primary healthcare centers and 25-bed hospitals. The following year this was expanded to all citizens at the health post level [42]. The 2007 interim constitution of Nepal enshrined health as a fundamental human right [43], and free basic primary care was extended to all citizens between 2008–11 – the same time period as the national IMCI rollout [41, 44] |
Health system strengthening | Both | Nepal’s work to strengthen health systems broadly, including efforts to address geographic access, infrastructure, and human resources for health, was essential for facilitating IMNCI implementation and U5M reduction EBIs more generally. For example, the ability to integrate new IMNCI programming into existing community-level health systems structures was important its successful scaling across the country. However, health system strength was also a barrier to EBI implementation, such as human resources in more remote areas which grew at a slower pace compared to national increases. While the country made efforts to meet these needs, this left goals for training workers unmet, for example challenging the ability to achieve a goal of 7,000 trained maternal health workers by 2015 |
Conflict | Neither | Surprisingly, this was not a major barrier to EBI implementation including IMCI. While Nepal experienced a decade of armed conflict between the Government of Nepal and the Maoist insurgency between 1996 and 2006, neither side disrupted access to health services, and KIs reflected on policies which encouraged ongoing primary care. Most key health metrics including EBI implementation improved during this time, including U5M, vaccination rates, and antenatal care visits. Much of the pilot work for Nepal’s IMCI programming took place during this period |
Strong preexisting community health system and structure including community health workers
Culture of data use and prioritization of local research
Geography
Transferable lessons
Lesson | Example |
---|---|
Plan for equity from the beginning | Taking account of variations in access to facilities-based health care due to geography, Nepal established a strong community-based health program supported by CHWs |
Develop a community health worker program | The FCHV program was expanded to include increased services rather than establish new cadres for each new community health service |
Build on existing health system capacity by integrating new projects while simultaneously strengthening the underlying system | Nepal built on its existing FCHV program to expand its IMCI program to include neonatal care, while also working to engage with communities to increase demand and improve supply from facilities and in communities |
Engage stakeholders including donors, implementing partners, and community members | This was important to increasing acceptability of EBIs and the ability to scale projects. Community engagement ensured participation of communities in program implementation, for example increasing comfort with FCHVs who were selected by village mothers’ groups |
Address other factors related to U5M | Strengthening other sectors including safe water and sanitation, access to education, and improved infrastructure, all had important direct and indirect benefits to reducing U5M |