title: Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems.
abstract: There are striking similarities in health system and other contexts between Tanzania and Ghana that are relevant to the scaling up of continuous delivery of insecticide treated nets (ITNs) for malaria prevention. However, specific contextual factors of relevance to ITN delivery have led implementation down very different pathways in the two countries. Both countries have made major efforts and investments to address this intervention through integrating consumer discount vouchers into the health system. Discount vouchers require arrangements among the public, private and non-governmental sectors and constitute a complex intervention in both health systems and business systems. In Tanzania, vouchers have moved beyond the planning agenda, had policies and programmes formulated, been sustained in implementation at national scale for many years and have become as of 2012 the main and only publicly supported continuous delivery system for ITNs. In Ghana national-scale implementation of vouchers never progressed beyond consideration on the agenda and piloting towards formulation of policy; and the approach was replaced by mass distribution campaigns with less dependency on or integration with the health system. By 2011, Ghana entered a phase with no publicly supported continuous delivery system for ITNs. To understand the different outcomes, we compared the voucher programme timelines, phases, processes and contexts in both countries in reference to the main health system building blocks (governance, human resources, financing, informatics, technologies and service delivery). Contextual factors which provided an enabling environment for the voucher scheme in Tanzania did not do so in Ghana. The voucher scheme was never seen as an appropriate national strategy, other delivery systems were not complementary and the private sector was under-developed. The extensive time devoted to engagement and consensus building among all stakeholders in Tanzania was an important and clearly enabling difference, as was public sector support of the private sector. This contributed to the alignment of partner action behind a single co-ordinated strategy at service delivery level which in turn gave confidence to the business sector and avoided the 'interference' of competing delivery systems that occurred in Ghana. Principles of systems thinking for intervention design correctly emphasize the importance of enabling contexts and stakeholder management.
authors.affiliation: Swiss Tropical and Public Health Institute, Epidemiology and Public Health, Socinstrasse 57, Basel 4002, Switzerland. d.desavigny@unibas.ch
authors.forename: Don
authors.initials: D
authors.lastname: de Savigny
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
authors.forename: Irene Akua
authors.initials: IA
authors.lastname: Agyepong
authors.forename: Alex
authors.initials: A
authors.lastname: Mwita
authors.forename: Constance
authors.initials: C
authors.lastname: Bart-Plange
authors.forename: Aba
authors.initials: A
authors.lastname: Baffoe-Wilmot
authors.forename: Hannah
authors.initials: H
authors.lastname: Koenker
authors.forename: Karen
authors.initials: K
authors.lastname: Kramer
authors.forename: Nick
authors.initials: N
authors.lastname: Brown
authors.forename: Christian
authors.initials: C
authors.lastname: Lengeler
mesh_terms: D003695:Delivery of Health Care; D004059:Diffusion of Innovation; D005260:Female; D005380:Financing, Government / Q000379:methods*; D005869:Ghana; D006801:Humans; D057148:Insecticide-Treated Bednets / Q000191:economics / Q000600:supply & distribution*; D008288:Malaria / Q000517:prevention & control*; D011050:Policy Making; D011247:Pregnancy; D036301:Qualitative Research; D013636:Tanzania