In the Sahel countries of West Africa, malaria remains a public health scourge. To strengthen the fight against malaria, it is imperative to identify weaknesses and possible solutions before programs implementation. This study reports experiences gained from collaboration between decision-makers and researchers from a project undertaken by the World Bank, titled: Malaria and Neglected Tropical Diseases in the Sahel (SM/NTD). The objectives of this World Bank project were to identify bottlenecks in malaria program implementation as well as related research questions they bring up. Questionnaire addressed to National Malaria Control Program managers and prioritization workshops were used as a medium to identify research questions. Identified research questions were implemented in selected countries and the results, as presented in this study showed that priority issues were those related to prevention, governance, drugs, monitoring and evaluation. The first five priority questions were: (1) compliance with drug doses on the second and third days during the seasonal chemoprevention (SMC) campaigns, (2) the contribution of community-based distributors to the management of severe cases of malaria in children under 5 years, (3) the SMC efficacy, (4) artemisinin-based combination therapy (ACTs) tolerance and efficacy according to existing guidelines, and (5) the quality of malaria control at all levels of the health system. In conclusion, this work showed the effectiveness of collaboration between implementers, programs managers, and researchers in identifying research questions. Furthermore, the results of this study will contribute to improving the implementation of malaria control programs across African countries.
Commentary
Seeking Research Questions from Implementers: Considerations for Leveraging Ground Actors Research Needs in the Fight against Malaria in West Africa.
https://doi.org/10.21203/rs.3.rs-65587/v3
This work is licensed under a CC BY 4.0 License
Journal Publication
published 08 Mar, 2021
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Malaria
research collaboration
West Africa
implementation science
More often than not, local social determinants of health are hidden or overlooked by funding agencies, institutional researchers, and health systems, yet they may be slowing down or reducing program implementation and impact. In addition, many of the physical constraints that impede the regular and effective delivery of health interventions to those who need them are much more pronounced in Low-to-Middle-Income Countries (LMIC) than in high income countries (1). Hence bridging the research divide between the obligations of donors and researchers or field actors are of paramount importance in the fight against diseases, especially malaria in Africa.
Indeed, despite recent trends showing a reduction in malaria mortality rates in Africa generally, and in the region in particular (2), mortality rates remain high in countries such as Nigeria, Burkina Faso, Niger, Mali, Cote d'Ivoire, Ghana, and Guinea (3). This raise questions about the effectiveness of the fight against malaria in these countries. An approach to identify these weaknesses, opportunities, and the search for solutions to reduce these preventable mortalities can improve control and bring these countries nearer to their pre-elimination targets.
This study reports experiences gained from collaborations between decision-makers and researchers, a part of a project undertaken in the framework of the regional World Bank funded project titled: Malaria and Neglected Tropical Diseases in the Sahel (SM/NTD). The objectives of this World Bank project were to identify bottlenecks in program implementation as well as the related research questions they present. The results of this study can help funding agencies to prioritize and fund research activities in a bid to improve the fight against malaria in the beneficiary countries.
Local and primary providers along with malaria program managers were approached in the 15 countries of the Economic Community of West African States (ECOWAS), including eight French-speaking, five English-speaking and two Portuguese-speaking countries using two approaches, namely: a questionnaire survey and regional validation workshops were held as part of the SM/NTD project’s activities. This paper only focuses on malaria.
a) The questionnaire survey
The questionnaire translated into the 3 official languages of ECOWAS, namely English, French and Portuguese, were sent to the malaria control programs managers in the last semester of trimester of 2016. The questionnaires were divided into two (2) parts: i) Bottlenecks in malaria program implementation ii) Priority research questions on malaria program. Each part covered seven thematic areas: governance, human resources, drugs, service provision, use of prevention methods, monitoring and evaluation (M&E), and public support or buy-in. Questionnaires were thereafter sent through electronic messages (Email) to national malaria control program managers/coordinators of the 15 ECOWAS countries, with instructions on how to fill the questionnaires.
Follow up actions were undertaken for two months to obtain a satisfactory response rate. Even though the countries have similarities as well as differences regarding their governance structure, epidemiological trends, and public health research, we conducted an initial in–depth analysis country by country. We then split bottlenecks recorded and questions into the seven “ECOWAS regional topics of interest” according to the thematic areas mentioned above. This analysis was then presented at the ECOWAS malaria regional workshop.
b) Organization of the regional validation workshop:
A two-day regional workshop was organized in Bamako by the West African Health Organization (WAHO), the ECOWAS specialized Institution dealing with health concerns such as malaria as well as NTDs program in West Africa. Participants included malaria program managers, NTDs program managers, Directors of Public Health of the various Ministries, monitoring/evaluation officers, countries project management unit coordinators, technical and financial partners (World Health Organization, World Bank, Helen Keller International, Malaria Consortium, Catholic Relief Services, and several WAHO officers). The results of the questionnaire survey were analyzed, presented, and discussed in two plenary and two breakout sessions.
The first breakout session on malaria was organized with two groups of 12 people each. The breakout sessions brought together malaria program coordinators, researchers, partners, and the regional project team. These teams worked to validate the research problems and questions. The two breakout teams were tasked to review, complete the problems, prioritize, and justify the research questions. The two breakout teams reviewed the survey results using individual and average ratings. For the first plenary session, each group was instructed to choose the top 20 research questions. On the second plenary session, the representative of each group shared the top 20 research questions they have selected. The questions selected by the participants clarified some research questions and allowed to finalize list related to malaria management.
The second breakout session focused on individual countries’ participants. The participants worked together to select three priority research questions from the list of questions established during the plenary session. Representatives of each country were asked to prioritize the three questions they selected and to address them over a three year (2017, 2018 and 2019) period. Finally, a third plenary session allowed each country’s team to share their key questions to address and prepare a plan for the subsequent years, 2017, 2018 and 2020.
The workshop was moderated by a world-renowned parasitology and malaria research professor in West Africa and at the end, the moderator reformulated some of the questions and justifications in accordance with the adopted guidelines.
Out of the 15 ECOWAS countries, 11 (Benin, Burkina Faso, Côte d'Ivoire, Gambia, Ghana, Guinea, Mali, Niger, Nigeria, Senegal, and Togo) responded to questions related to malaria and table 1 shows the bottlenecks identified by program managers/coordinators according to the seven areas addressed in the questionnaire.
In all seven thematic areas, there were challenges that limited the effectiveness of program implementation. In the area of governance, issues of coordination and collaboration with partners in the field came up as well as weaknesses in the managerial capacity at the regional and district levels. The human resources problems identifies were mainly related to capacity, competence, motivation of community health workers, weaknesses in research skills and capacity of program actors. There were also difficulties in the area of management of medicine logistics, from ordering commodities to the distribution to patients, and also difficulties in pharmacovigilance. In service provision thematic area, difficulties of direct observed treatment were pointed out, especially for the second and third day doses of SMC, while for prevention, low uptake of vector control measures, the absence of insecticides for the impregnation of protective materials, and the low use of protective means were the major problems mentioned. In terms of monitoring and evaluation, challenges of access to quality data, especially from the community level, and inadequacy in the dissemination of research results were reported.
Finally, in terms of public support, refusal or reluctance to participate in mass drug distribution during SMC campaigns, failure in adopting preventive measures and behavior were reported by program managers.
Table 2 presents the 21 priority issues as ranked by the participants by thematic areas.
The first five priority questions were related to (1) compliance with drug doses for the second and third days of SMC campaigns, (2) contribution of community-based distributors to severe malaria cases management in children under 5 year, (3) SMC efficacy, (4) ACTs efficacy and tolerance of ACTs under current guidelines, and (5) quality of malaria cases management at all health system levels.
The prevention theme was ranked first with 5 questions, followed by the governance and medicines with 4 questions and the monitoring and evaluation with 3 questions. The five prevention questions were related to the effectiveness and non-use of insecticide-treated nets (LLIN), the level of use and effectiveness of indoor residual spray (IRS), conducting a study on the effectiveness of mosquito soap, and the possibility of using two insecticides to impregnate nets. Governance issues were related to the best strategy for the implementation of SMC campaigns, quality of malaria case management at all health system levels, the place of information and communication technology in data quality management and the type of collaboration framework between the Ministry of Health and partners. For the medicines theme, the four priority questions focused on the efficacy and tolerance of ACTs under current guidelines, the side effects of ACTs, the efficacy of traditional medicines and the comparative advantage of the Dihydroartemisinin (DHA)-Piperazine combination over sulfadoxine–pyrimethamine (SP) + amodiaquine (SP-AQ). Regarding M&E, questions related to adherence for the second and third dose during seasonal chemoprevention campaigns, the performance and use of rapid diagnostic tests. In terms of human resources, the two priority issues were related to the contribution of community health workers in severe malaria case management and the supervision of the second and third doses during SMC campaigns. At the service delivery level, both issues were related to the quality and performance of the drug supply and management chains. Finally, in terms of public support, the questions were related to communication channels, media and strategies to ensure behavior change.
Table 3 shows the three priority issues identified by the three project country teams, namely Burkina, Mali and Niger.