Table 2 Implementation strategies used to implement facility- and community-based integrated management of childhood illness in Nepal, contextual factors, and implementation outcomes

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].