Table 5 Selected implementation outcomes and examples

Appropriateness

We found appropriateness was high across the six countries in EBIs chosen including vaccination, FBD, and facility- and community-based IMCI. For facility-based and community-based IMCI, the decision to implement reflected identified need through disease burden, gaps in coverage of the relevant preventive and curative interventions, and the need for an integrated approach shown by expert opinion. Other EBI selections reflected disease burden when they were first introduced, such as PCV and PMTCT.

Feasibility

We found feasibility was high where countries had leveraged and integrated EBIs into existing systems (ex. primary care, supply chain) while also strengthening those systems. It was more variable for EBIs that were not integrated into existing systems. For example, feasibility for community-based IMCI was high in Bangladesh. The country leveraged support from partners including WHO and UNICEF for trainings and training guidelines, and conducted phased scale-up with small-scale testing before national roll-out. Conversely, despite efforts to strengthen systems when integrating a new EBI of neonatal intensive-care units (NICUs), in Ethiopia by 2015 only 49% of NICUs were functional.

Fidelity

Evidence of fidelity, defined as the delivery of the EBI as planned and according to national standards, was not found for many of the interventions. Where there were data, it was generally at a local level. For facility-based IMCI, data from Rwanda, Nepal, Ethiopia showed low fidelity with just 2% (Nepal, 2015; Rwanda, 2007) to 5% (Ethiopia, 2014) of children assessed by healthcare providers for general danger signs per the IMCI protocol during consultations. This low fidelity was associated with challenges in strategies such as supportive supervision and training.

For pentavalent vaccination, we found data only for Bangladesh and Senegal, where fidelity was low, and associated with challenges to strategies such as supervision and health systems strengthening. In Senegal low fidelity due to in part to faults in the cold-chain with vaccines exposed to temperatures outside 2–8 degrees Celsius.