Why are IPTp coverage targets so elusive in sub-Saharan Africa? A systematic review of health system barriers

Abstract

BackgroundUse of intermittent preventive treatment (IPTp) is a proven cost-effective intervention for preventing malaria in pregnancy. However, despite the roll-out of IPTp policies across Africa more than ten years ago, utilization levels remain low. This review sought to consolidate scattered evidence as to the health system barriers for IPTp coverage in the continent.Methods and findingsRelevant literature from Africa was systematically searched, reviewed and synthesized. Only studies containing primary data were considered. Studies reveal that: (i) poor leadership and governance contribute to slow decentralization of programme management, lack of harmonized guidelines, poor accountability mechanisms, such as robust monitoring and evaluation systems; (ii) low budgetary allocation towards policy implementation slows scale-up, while out-of-pocket expenditure deters women from seeking antenatal services that include IPTp; (iii) there are rampant human resource challenges including low staff motivation levels attributed to such factors as incorrect knowledge of IPTp recommendations and inadequate staffing; (iv) implementation of IPTp policies is hampered by prevailing service delivery barriers, such as long waiting time, long distances to health facilities and poor service provider/client relations; and (v) drug stock-outs and poor management of information and supply chains impair sustained availability of drugs for IPTp.ConclusionsFor successful IPTp policy implementation, it is imperative that malaria control programmes target health system barriers that result in low coverage and hence programme ineffectiveness.

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

“…Governments and implementing partners in many countries have stepped up efforts to increase uptake of IPTp, addressing some of the known bottlenecks, such as stock-outs of drugs and commodities at ANC clinics and lack of guidance and supervision for health workers [7, 8]. However, IPTp coverage remains low in many countries where malaria is endemic [9].…”

Achieving development goals for HIV, tuberculosis and malaria in sub-Saharan Africa through integrated antenatal care: barriers and challenges

“…Structural barriers often manifest in the characteristics of the health system (Table 3). Weak program links, health systems, and financial infrastructure are cited as a prominent barriers to ANC attendance and integrated ANC service delivery (systematically reviewed in [18, 39, 40]). For example, the provision of HIV treatment at specialised ART clinics separate to ANC clinics reduced uptake of HIV services in pregnant women by around 50% [21, 29, 30].…”

“…While IPTp is given presumptively in ANC, thus removing the need for testing, women are often required to purchase the drug elsewhere or are not directly observed taking therapy having been given the drug to take home, both of which have been identified as a significant barrier to IPTp coverage [45–47]. Effective procurement and distribution systems are also important determinants of success for integrated services, with inadequate and irregular supplies of essential drugs and interventions, in both the public and private healthcare sector, representing a major barrier in the uptake of both integrated HIV and malaria services [18, 39, 40]. …”

Evaluation of Malaria Screening during Pregnancy with Rapid Diagnostic Tests Performed by Community Health Workers in Burkina Faso

“…4 Reasons for low coverage are a lack of coordination and leadership, financial constraints, unmotivated and unsupported health staff, perceived risk of the medication, logistic challenges, and ANC attendance among others. [5][6][7] Adolescents and primigravidae, who have among pregnant women the highest risk of malaria, are even less likely to receive sufficient doses of IPTp-SP, mainly due to low ANC attendance.…”