We conducted a descriptive cross-sectional study using a Process-Outcome evaluation with the Logical Framework Approach to evaluate the IPTp Program in Chiredzi District and to determine the reasons for the district failing to achieve the target for IPTp-SP coverages. While all five facilities visited were implementing the IPTp program and had adequate policy guidelines and stationery for documentation of ANC services offered, other health system factors contributed to the program failing to meet its targets. These factors were medicine stock-outs, non-adherence to program guidelines, health worker knowledge deficits, inconsistencies in service delivery, inadequate training and mentorship. To a lesser extent, client-related factors contributed to the low IPTp coverage in Chiredzi District. These were late ANC bookings, religion, and lack of appreciation of the IPTp program benefits and function.
Our study demonstrated the availability of adequate guideline documents to guide the health workers’ approaches at participating health facilities. Only one still displayed outdated guidelines. This is a good starting point to ensure adherence to the expected program protocols. Adequacy of monitoring and evaluation (M&E) tools enable clinicians to document services provided and subsequently assess the performance of the IPTp programs. Assuming completeness of recording we would have reliable information to understand current performance enabling the development of mitigating activities to improve the program. Thus, we can exclude documentation as a cause of poor performance. A study conducted by Sande et al. 2017 also stated that the incorrect documentation on cards and registers could cause problems in IPTp program evaluation ..
Erratic medicines supply and shortages affect the effective implementation of the IPTp program. Drug supply inconsistencies contribute to missed opportunities for adequate dosing even with high ANC attendance as has been found by other scholars . Resource availability, particularly SP within the health facility, bears on the proper implementation of the IPTp program. In this current study, medicine stock-outs contributed to low coverages, much more than the effects of late booking and the number of ANC attendances. Evidence in Tanzania and Ghana shows that SP shortages do contribute largely to low IPTp coverages [9, 12]. If district health managers addressed this challenge the program performance will improve.
For a health program to be implemented the system needs trained and skilled personnel. Although there seemed to be adequate numbers of health workers in the FCH departments the majority were not trained. The majority who had been previously trained have since moved from the facilities or public health system. The failure of the health system to retain trained health workers as was reported in this study could have contributed to knowledge and skill deficits. This affects program implementation. In this study, the most deficits were on the benefits of the program and SP administration with regards to when it should be initiated, and the minimum doses required. Lack of knowledge on the correct timing and spacing of SP, adherence to current guidelines, and the benefits of the program have also been demonstrated in other studies [9, 13, 14].
Our evaluation revealed that there was a lack of regular supervision visits and health worker mentorship. This could explain some poor practices we noted. For instance, the non-adherence to SP administration guidelines despite health workers knowing the correct practice. When SP is self-administered, there is no way of monitoring to validate the adherence and assessing the impact of the intervention may be difficult. All health facilities need to innovate ways to ensure that directly observed administration of SP is done. Displaying outdated ANC guidelines causes mistakes in the administration of malaria preventive medicines and can be identified (and addressed) by adequate supervision. Other studies show that even with guidelines on IPTp in place, compliance to them remains a challenge that needs solving [4, 15, 16]. In another study, it was shown that a year after IPTp was introduced still more women missed their first dose of SP compared with tetanus immunization, even though both interventions were offered at the same time . This goes to highlight the continuous need for health worker sensitization on the program.
Client-related factors also contributed to low IPTp coverages in Chiredzi District. Late ANC booking as was evident affects health services delivery including IPTp. Additionally, drug supply inconsistencies further contributed to missed opportunities for adequate dosing even with high ANC attendance as has been found by other scholars . With most women presenting late for their first ANC visit, opportunities to receive the minimum IPTp package are reduced. This results in reduced protection of pregnant women, and their unborn babies, from malaria. Evidence shows that subsequent doses of SP decline along the IPTp cascade. Hence, starting ANC early offers more opportunities for the completion of the standard IPTp course [7, 13, 17–19]. Contrary to this finding a study in Malawi reported that even in the setting of early ANC booking IPTp coverage may still be suboptimal . Suggesting that other factors can influence IPTp uptake.
In this evaluation, living in an urban area increased the likelihood of receiving the minimum recommended SP doses whilst being of the Apostolic religious sect was a hindrance. These findings are similar to what has been found in other local studies [18, 20]. Urban residence may mean that access to health care is easier though in this study either having to walk or need a means of transportation to attend ANC did not have significant implications on receiving SP doses.
To increase program performance the beneficiaries of a program should have an adequate understanding of its function and appreciate its benefits. To increase awareness of a health program like the IPTp program, health education imparted from health workers to ANC clients is crucial and increases clients’ demand for the intervention. Health workers knowledge deficits could explain the lack of malaria-specific education for pregnant women as was evident in this evaluation. Health workers who are knowledgeable of a program may easily pass on the same knowledge to their clients [11, 13, 17].
In this study, women had good knowledge of malaria transmission and prevention, but deficits were seen in the knowledge of the benefits of IPTp and the dosages. Similarly, other scholars have attributed poor uptake of SP to a lack of knowledge of the IPTp program, its benefits and those of early pregnancy booking [9, 11, 12]. The resulting low SP coverages during pregnancy increases the risk of malaria complications for the pregnant woman and the unborn child [8, 9, 17]. However, another local study seems to suggest otherwise, as no direct relationship between client knowledge on IPTp and utilization of the program intervention was proven . In support of this, some scholars have suggested that client uptake of IPTp by women in low-income countries is a result of poor quality ANC package, inaccessible service due to high cost of getting to the service area, distance to the health facility, and the actual waiting time for the services at the facilities [7, 17, 21]. In this evaluation means of getting to a health facility were not contributory.
Though subjective, as no records were found, less than a 10th of postnatal women reported having been diagnosed and treated for malaria during pregnancy. This was much lower than the prevalence reported by Arnaldo et al., 2018 in southern Mozambique . Whilst we cannot attribute this to the IPTp-SP program, this finding could signify that other malaria preventive measures were being implemented in the community. Something that can be supported by the good knowledge on malaria prevention by postnatal women.
Our findings may not be generalizable to all health facilities since we only selected high-volume health facilities. We interviewed women who had given birth and were attending the postnatal clinics, and this could have introduced recall bias. Our sample size may be too small to make inferences on the factors associated with receiving at least 3 doses of SP, however useful information that can help hypothesis generation for future studies was obtained from these findings.