Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems

Abstract

There are striking similarities in health system and other contexts between Tanzania and Ghana that are relevant to the scaling up of continuous delivery of insecticide treated nets (ITNs) for malaria prevention. However, specific contextual factors of relevance to ITN delivery have led implementation down very different pathways in the two countries. Both countries have made major efforts and investments to address this intervention through integrating consumer discount vouchers into the health system. Discount vouchers require arrangements among the public, private and non-governmental sectors and constitute a complex intervention in both health systems and business systems. In Tanzania, vouchers have moved beyond the planning agenda, had policies and programmes formulated, been sustained in implementation at national scale for many years and have become as of 2012 the main and only publicly supported continuous delivery system for ITNs. In Ghana national-scale implementation of vouchers never progressed beyond consideration on the agenda and piloting towards formulation of policy; and the approach was replaced by mass distribution campaigns with less dependency on or integration with the health system. By 2011, Ghana entered a phase with no publicly supported continuous delivery system for ITNs. To understand the different outcomes, we compared the voucher programme timelines, phases, processes and contexts in both countries in reference to the main health system building blocks (governance, human resources, financing, informatics, technologies and service delivery). Contextual factors which provided an enabling environment for the voucher scheme in Tanzania did not do so in Ghana. The voucher scheme was never seen as an appropriate national strategy, other delivery systems were not complementary and the private sector was under-developed. The extensive time devoted to engagement and consensus building among all stakeholders in Tanzania was an important and clearly enabling difference, as was public sector support of the private sector. This contributed to the alignment of partner action behind a single co-ordinated strategy at service delivery level which in turn gave confidence to the business sector and avoided the 'interference' of competing delivery systems that occurred in Ghana. Principles of systems thinking for intervention design correctly emphasize the importance of enabling contexts and stakeholder management.

Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries

“…The re-emergence of the importance of contextual analysis is represented in HPSR in varied ways (Ssengooba et al, 2007;Mbindyo and Gilson, 2009;Zaidi et al, 2012;De Savigny et al, 2012;Belaid and Ridde, 2014;Smith, 2014). Yet in many conceptual frameworks, context is primarily an empty arena surrounding the health systems phenomena of interest.…”

Increasing anti-malaria bednet take-up using information and distribution strategies: evidence from a field trial in Senegal

“…At the national level, the share of households declaring that they owned at least one ITN increased from 45 per cent in 2005 to 63 per cent in 2010 (Agence Nationale de la Statistique et de la Démographie (ANSD) [Sénégal], and ICF International 2012). Similarly, bednet availability has recently improved across Africa (Sexton 2011;De Savigny et al 2012).…”

Increasing Anti-Malaria Bednet Uptake Using Information and Distribution Strategies: Evidence from a Randomized Experiment in Senegal

“…At the national level, the share of households declaring that they owned at least one ITN increased from 45% in 2005 to 63% in 2010 (ANSD, 2012). Similarly, bednet availability has recently improved across Africa (Sexton, 2011;de Savigny et al, 2012).…”