Table 3 The implementation processes of Optimizing Health Extension Program sick child health services quality improvement strategies

The Optimizing Health Extension Program implementation was fully operational from 2017 to end of 2018. Many of the interventions were delayed from the planned period and in one-third of the districts the implementation activities were interrupted for about 4 months because of administrative reasons or civil unrest. Overall, the process evaluation revealed that only few of the intervention packages had high implementation fidelity. The complexity of the intervention itself, weak support from the district health offices partly due to competing priorities, and irregular supervisions of the health extension workers were the main challenges of implementation. More specifically, from the strategies aimed at improving quality of care for sick children, the training of health extension workers in integrated community case management (iCCM), and provision of supportive supervision for health posts were implemented with a median district fidelity of less than 50%. In contrast, the performance review clinical mentoring meetings were implemented with higher fidelity in the period from 2017 to 2018 with a median district fidelity of 75% (IQR: 35–100). Regarding job aids and tools, the provision of backpacks and registration books for health extension workers had a median district fidelity of 100% (IQR: 0–100). The provision of chart booklet to the health extension workers had a median district fidelity of 62% (IQR: 0–100). The distribution of iCCM registration books for 2–59 months old children and chart booklets (clinical guidelines) were not implemented in eight districts where no budget was allocated for this activity [37].