A Qualitative Health Systems Effectiveness Analysis of the Prevention of Malaria in Pregnancy with Intermittent Preventive Treatment and Insecticide Treated Nets in Mali

Abstract

IntroductionDelivery of intermittent preventive treatment with sulphadoxine-pyrimethamine to pregnant women (IPTp-SP) through antenatal clinic (ANC) in Mali is low, and whilst ANC delivery of insecticide treated nets (ITNs) is higher, coverage is still below national and international targets. The aim of this study was to explain quantitative data from a related study which identified ineffective processes in the delivery of these interventions in one district in Mali.MethodsIn-depth interviews were conducted with health workers at the national, regional, district and health facility levels on their perceptions of reasons for the ineffective processes identified in the quantitative study, and their reported practices. Themes were coded for each ineffective process, and within these a health systems lens was used. Content analysis was used for emergent themes within this framework. MindMaps were used to display the findings.ResultsIntervention specific factors for the ineffective delivery of IPTp-SP included misunderstanding of the upper limit of the gestational age at which SP could be given and side effects of SP. Incorrect practices had been recommended in training and supervision of health workers. Pregnant women who were ill on attendance at ANC were not consistently managed across health facilities. The most common reason for not offering women an ITN on their first ANC visit was if they were from outside the health facility catchment area. Broader health systems issues influencing the effectiveness of delivery of each of these interventions were also identified.ConclusionIn this setting, intervention-specific factors resulted in the ineffective delivery of IPTp-SP. These relate to complex policy guidelines, lack of guidance on how to implement the guidelines, and the institutionalising of practices that undermine the national guidelines. Interventions may be implemented and show real gains in the shorter-term whilst waiting for broader health systems issues to be addressed.

Effectiveness of Antenatal Clinics to Deliver Intermittent Preventive Treatment and Insecticide Treated Nets for the Control of Malaria in Pregnancy in Mali: A Household Survey

“…This may to some extent reflect poor recall or knowledge among women, nevertheless ANC card data indicated a similar proportion of women were given IPTp in the first trimester, confirming that there was some practice of providers giving women the first dose of SP in their first trimester (Figure 4). Confusion among health providers over the timing of giving IPTp-SP has been described elsewhere [34], and in the parallel study in Mali, some health providers stated that women of less than one month gestation, rather than 1 st trimester, should not be given SP [32]. On the basis of a recent meta-analysis showing that three or more doses of SP are more effective than two doses [35], WHO recently updated its policy guidance to recommend the administration of SP to pregnant women at every scheduled antenatal visit starting in the second trimester [36].…”

Operational challenges to continuous LLIN distribution: a qualitative rapid assessment in four countries

“…However, these concerns are often voiced in the discussion section of studies, while the main focus of the research is cost effectiveness, feasibility and/or scalability [12, 28–30]. In one study in Ghana, the transportation aspect of the supply chain, specifically, was seen as a contributor to stock-outs and supply shortages, which was not identified as a specific barrier in the four countries included in this study [16]. Beyond LLIN distribution, supply chain management has been a major focus of health systems research, for essential medicines, health commodities and vaccinations [23, 31–35].…”

“…Few studies have looked at the performance of these delivery systems at reaching their target groups, and the factors that influence the coverage that is actually achieved [16, 17]. …”

Determinants of Intermittent Preventive Treatment with Sulfadoxine-Pyrimethamine in Pregnant Women (IPTp-SP) in Mali, a household survey.

“…Several studies have explored the determinants of the use and completeness of IPTp-SP (9,12,(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). Nonattendance and/or completeness of ANC is considered a key determinant of IPTp-SP coverage (15,16,21,24).…”