Data collection

Semi-structured discussion guides were developed, pre-tested, and refined before use in interviewing key informants, HSPs, and caregivers of children (Supplementary file 2). We conducted key informant interviews (KII) with national and district level participants and in-depth interviews (IDI) with HSPs at their workplaces. Following initial interviews, six stakeholders at the national level and two stakeholders at the district level were interviewed a second time to clarify the findings. Caregivers of children were interviewed via IDI at the household level. Interviews were audio-recorded and transcribed verbatim on the day of the interview; one respondent declined an audio-record of the interview. Average duration of an interview was 28 min. Three rounds of interviews were conducted, and after each round the study team reviewed emerging themes, discussed the findings, and revisited the interview guides. This process helped to synthesize findings and identify the point of data saturation, at which time that type of participant interview was concluded.

We asked a subset of HSPs who provided treatment for childhood pneumonia from both sub-districts and HSPs who provided treatment for PSBI from Ramganj, Lakshmipur, about their knowledge on diagnosis and provision of treatment by asking specific questions on what signs and symptoms they used to identify PSBI, pneumonia, or severe pneumonia for referral and the proper dosage instructions for medications. The accuracy of their responses was compared to the national standard treatment guidelines for childhood pneumonia and PSBI.

We also reviewed relevant documents identified during the interviews or visits by the research team to health facilities, for understanding current policy and management of childhood pneumonia and PSBI. The relevant documents included reporting forms, registers and revised IMCI guideline. We also searched literature on the operational plan relating to maternal, newborn and child health through internet. From the documents we extracted data on the children with pneumonia treated with different formulations of amoxicillin, supply and distribution of amoxicillin at the facilities, instructions provided to the HSPs on case management of childhood pneumonia and PSBI, and operational plan of MOHFW to addressing childhood pneumonia and PSBI.