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.