Assessing supply-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study and document and record review in two regions of Uganda

Abstract

BackgroundIntermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP), provided as part of routine antenatal care (ANC), is one of three malaria-in-pregnancy prevention and control mechanisms recommended by the World Health Organization (WHO). However, despite high ANC attendance and increased efforts to address known obstacles, IPTp uptake figures have remained low. This study aimed to identify and assess barriers that continue to impede IPTp uptake in Uganda, in particular for women who attend ANC. The paper focuses on supply-side barriers, i.e., challenges relating to the health service provider.MethodsIn-depth interviews were conducted in two regions of Uganda in November 2013 and April/May 2014 with four different target audiences: seven district health officials, 15 health workers, 19 women who had attended ANC, and five opinion leaders. In addition, a document and record review was carried out at four health facilities.ResultsGuidelines with regard to IPTp provision in Uganda have been shown to be inconsistent and, at the time of the research, did not reflect the most recent WHO policy recommendation. There is a lack of training and supervision opportunities for health workers, resulting in poor knowledge of IPTp guidelines and uncertainty about the safety and efficacy of SP. ANC is not consistently offered in health facilities, leading to some women being denied services. While strengthening of the supply chain appears to have reduced the occurrence of stock-outs of SP in public facilities, stock-outs reportedly continue to occur in the private sector. There are also sources of data inaccuracy along the data recording and reporting chain, limiting policy makers’ ability to react adequately to trends and challenges.ConclusionsGiven the high ANC attendance rates in Uganda, supply-side barriers are likely to account for many missed opportunities for the provision of IPTp in Uganda. Improvements will require consistent provision of ANC, implementation of current WHO IPTp policy recommendations, supply of SP to the private sector, availability of clear guidelines, as well as improved training and supervision for health workers. Improving facility and district-level recording and reporting will further strengthen the country’s ability to address uptake of IPTp.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1405-4) contains supplementary material, which is available to authorized users.

Assessing demand-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study in two regions of Uganda

“…Though the sample size is not large enough to draw valid conclusions with regard to the accuracy of uptake figures, the research team’s difficulties in finding women who had not received a full course of IPTp may suggest higher than expected uptake compared with those reported through household surveys or HMIS. Data accuracy has been highlighted as a challenge to effective monitoring and evaluation of malaria interventions by the Government of Uganda [17], a conclusion which is also supported by supply-side findings from this study [12]. …”

“…It also provides funds to PNFP facilities to procure essential medicines, including SP. However, this study found that stock-outs appear to persist in PNFP facilities [12]. Health workers at the PNFP facility included in the study sample indicated that they may charge women for the provision of IPTp or ask them to buy SP and bring it to the facility when they are experiencing stock-outs of the drug:

Researcher: Are women required to pay for the provision of IPTp at your facility?

…”

“…This suggests that greater impact on IPTp uptake could be achieved by intervening on the supply side (see Table 4 for a summary of the supply-side recommendations resulting from this study, including the document and record review [12]). However, the following actions should be considered by policy makers, implementers and researchers in order to strengthen demand-side use of ANC and acceptance of IPTp:…”

“…Note that this includes data from respondents representing both the supply (health workers, health officials) and the demand side (women, opinion leaders). Results relating to supply-side issues have been published elsewhere [12]. …”

Low Uptake of Intermittent Preventive Treatment in Ghana; An Examination of Health System Bottlenecks

“…According to the NMCP's report, out of all SPs procured, the only local pharmaceutical company supplied could supply only 16.20% making the program depend on international companies to supply remaining 83%. Considering the bureaucracy involved in importing drugs, the inability of local companies to respond to the demand of SPs results in low responsiveness especially during emergency stock-outs [23]. Also, the growing resistance of SP viz a viz non-existence of a medicinal alternative encourages low uptake especially in instances when resistance is reported [8].…”