Table 4 Key challenges affecting IMCI implementation in the Philippines based on the Social Ecological Model

Super-structural Barriers

Natural Disasters (Typhoons, Floods and Earthquakes)

Compromised records and facility structures due to unprecedented calamities

“… we had posters that we posted then... there is always flooding that makes the posters disappear, when the guide was lost, it’s like there is no more IMCI.” (Nurse, 9 years implementing IMCI)

Health System Barriers

Leadership and Governance

Lack of policy clarity at local government level

“Ah, we actually don’t have (any) written policy.” (Medical Doctor, 15 years implementing IMCI)

Funding

Unavailability of IMCI specific funding allocation

“So, for IMCI alone, we don’t have (a specific fund), we don’t have a fund for IMCI alone, but our activity for (children) under 5 is included in a different program. Like in nutrition, we have a fund for the preschool, daycare, and schoolchildren … Actually, our fund for IMCI is distributed to different programs.” (Medical Doctor, 4 years implementing/supervising IMCI)

Training

Limited resources for IMCI training and refresher courses and the training structure

“If you can shorten it, it is okay, right? So that’s the issue here, the training takes too long. So the doctor in the health center will be out for so long. The 3 days alone, we are already having difficulty, how much more the 11 days. That’s the problem.” (Medical Doctor, 10 years implementing IMCI)

“… because there was also no update on the IMCI itself from DOH. It was gone for a long time.” (Medical Doctor, 17 years implementing IMCI)

“… ah, it is an add-on to my work as a supervisor because we lack staff, so I also do implementation and monitoring in all the programs.” (Nurse, 1 year implementing IMCI)

“I can’t really say anything about ICATT because the time was limited, and I was with students during that time, and you know about age gaps …” (Nurse, 16 years implementing IMCI)

Supervision and Monitoring

Shortcomings in supervision and monitoring of IMCI performance

“When the program started, it seems like nobody monitors, not even follow-ups. I even initiated it because I saw the potential of the program. I initiated because I was thinking it would be good because midwives will be able to learn how to manage …” (Medical Doctor, 20 years implementing/supervising IMCI)

“… It’s like it became a neglected program, why do we still monitor it, it is not used anymore … I also can’t remember; it just suddenly became silent.” (Medical Doctor, 10 years implementing IMCI)

Drug Procurement

Drug procurement and distribution

“There are perhaps, 1 or 2 months before the delivery of the next procurement because the procurement process is long.” (Medical Doctor, 5 years implementing IMCI)

Logistics

Poor logistical support

“I was telling you about its sustainability. It will depend on the sustainability and availability of the forms, once our form was no longer sustained, it was difficult for us to provide the program … The life of IMCI or the practice of IMCI depends on the availability of the forms because the information of IMCI management was contained in those forms … then it took long, forms were lacking, if there were no forms, we were not able to implement …” (Medical Doctor, 3 years implementing IMCI)

Community Barriers

Parental or Caretaker factors

Low community awareness regarding the IMCI program

“Sometimes, people will say that they don’t want to go to the center because they prescribe only water. Sometimes it is the negative feedback if you prescribe medicine not available in the Rural Health Unit, or the medicine is too expensive. If you told them just to drink water they will say, 'What kind of a doctor is it that prescribes water only? He is Doctor Water.'” (Medical Doctor, 4 years implementing IMCI)

Community preference for specific health workers

“… although the midwife has already examined them, they are not contented; they wanted to be examined by the physician also. Like if the doctor says, 'It's just a regular cough' that's okay, but if a midwife says that, they’ll say, 'I want a doctor’s checkup.'” (Medical Doctor, 4 years implementing IMCI)

Interpersonal Barriers

Professional hierarchy

Conflicting views about treatment management

“Then the problem was the difference with doctor’s management, especially when there are many patients, maybe she could no longer use the IMCI chart list, so she just directly goes to the distribution of the medicines … when they have children patients, they immediately give them medicines.” (Nurse, 10 years implementing IMCI)

Individual Barriers

Motivation to implement

Time consuming IMCI processes

“We had a lot of patients. The staff does not want IMCI... the staff are not motivated anymore. It is time-consuming if you will do it one-by-one, how will you cater to that number?” (Medical Doctor, 17 years implementing IMCI)