This review underscores the need to consider a health systems approach towards resolving programmatic bottlenecks and gaps for IPTp. It highlights fundamental barriers whose resolutions are likely to see improved outcomes and eventual impact of IPTp policies.
Successful IPTp scale-up will require effective leadership and governance to ensure that first, resources are allocated for IPTp and secondly, that these resources are effectively and efficiently utilized for the benefit of pregnant mothers in need of IPTp. It is this leadership that will ensure effective utilization of financial resources, human resources, commodity availability and quality service delivery. Through robust health information systems, this leadership will also ensure that systems are in place for accurate and timely monitoring and evaluation of relevant IPTp data. The exemplary performance of Zambia, Malawi and Senegal is partly attributed to effective leadership .
Without financial resources, implementing IPTp policies is nearly impossible. Sub-Saharan countries grapple with over-reliance on donor funds. Out-of-pocket expenditure for health deters positive health-seeking behaviour, thereby contributing to low demand for ANC services including IPTp . Again, successes attained in some countries with regard to IPTp coverage are partly attributed to increased government commitment towards funding provision of IPTp drugs . Sustainable financing mechanisms complement adequate human capital.
In many health facilities within sub-Saharan Africa, staff are often overworked, poorly remunerated, and thus not adequately motivated. For instance, studies examining nurses wellbeing in a sub-Saharan setting show high burnout and low job satisfaction . Overworked and underpaid workers manifest burnout through depersonalization leading to a negative attitude towards their clients . Hostile treatment by health workers strongly influences health services-seeking behaviour of clients. Perceptions on quality of services received at the health facility may influence IPTp utilization. Therefore, health workers need to be encouraged through supportive supervision to employ DOT strategy in order to boost adherence. Even though missed opportunities for delivery of IPTp are prevalent in Africa, perhaps one of the most overlooked determinant factors for IPTp utilization is health worker awareness. Development of simplified guidelines for health workers may resolve the problem of inconsistent messaging and poor adherence to policy guidelines experienced in some countries . Guidelines for administration of IPTp stipulate the use of Directly Observed Therapy (DOT), yet in Nigeria, over three quarters of those that took SP reported that they were allowed to take the drug home . This problem further compounds poor access to services and coverage. Treatment and preventive guidelines for malaria are dynamic, and continuous professional development is imperative. However it is noted that this alone cannot translate awareness to practice and, therefore, supportive supervision from credible peers, linked to feedback on performance and benchmarking with other facilities will be game changing . Such an approach is likely to enforce the practice of administration of IPTp among health workers.
While service delivery provides the frontline interface between the health system and its beneficiaries, reviewed evidence reveals that this interface is fraught with challenges of inaccessibility and poor quality. Experience from successful countries demonstrates that interventions, such as community mobilization through involvement of community health workers, plays a role in promoting ANC attendance and educating on the need to prevent malaria in pregnancy . Once demand for ANC services is enhanced, efficiency in service delivery may be improved through such approaches like service and programme integration and improved client-provider relations. Training on customer service and IPTp policy recommendations is necessary for health workers. Concurrently, health systems must ensure that the supply chain is effective to deliver essential commodities such as IPTp and related anti-malarial drugs. Lack of supplies at health facilities due to chronic stock outs reduces the motivation of frontline health workers to effectively deliver high impact interventions such as IPTp. Also it may reduce the use of health services by clients. These could be overcome through improved management of supply chain systems that are responsive to the demand at health facilities. Robust information management systems not only contribute to better accountability but also to responsive rather than reactive systems. They provide real-time data on demands, shortages and stocks. Staff training on the need for and set-up of functional monitoring and evaluation systems is imperative. Some countries such as Senegal have taken significant steps to improve their information systems. The country has hired new staff and established a web-based management system .
While this review consolidates existing evidence on health system barriers, it is recognized that health systems research specific to identifying programmatic gaps for IPTp scale-up is scanty. More studies should be undertaken in order to inform country specific programmes. In particular, it is important to explore determinants of supply side practices that limit coverage of IPTp. In fact, missed opportunities for IPT administration could be an important indicator in monitoring and evaluation systems for malaria programmes at sub-national, national and regional levels. Lastly in consideration of the evidence provided, it is noted that the scope of reviewed literature is limited by scarcity of data from across all regions of Africa. Though the cited barriers are likely to be widespread, one cannot decisively conclude so. Again, most reviewed studies are limited in the degree to which they holistically explored barriers relating to the supply and demand side of IPTp policy implementation, both quantitatively and qualitatively. Such limitations may have trickled down to this review.