title: A qualitative health systems effectiveness analysis of the prevention of malaria in pregnancy with intermittent preventive treatment and insecticide treated nets in Mali.
abstract: BACKGROUND
  Delivery of intermittent preventive treatment with sulphadoxine-pyrimethamine to pregnant women (IPTp-SP) through antenatal clinic (ANC) in Mali is low, and whilst ANC delivery of insecticide treated nets (ITNs) is higher, coverage is still below national and international targets. The aim of this study was to explain quantitative data from a related study which identified ineffective processes in the delivery of these interventions in one district in Mali.
  
  
  METHODS
  In-depth interviews were conducted with health workers at the national, regional, district and health facility levels on their perceptions of reasons for the ineffective processes identified in the quantitative study, and their reported practices. Themes were coded for each ineffective process, and within these a health systems lens was used. Content analysis was used for emergent themes within this framework. MindMaps were used to display the findings.
  
  
  RESULTS
  Intervention specific factors for the ineffective delivery of IPTp-SP included misunderstanding of the upper limit of the gestational age at which SP could be given and side effects of SP. Incorrect practices had been recommended in training and supervision of health workers. Pregnant women who were ill on attendance at ANC were not consistently managed across health facilities. The most common reason for not offering women an ITN on their first ANC visit was if they were from outside the health facility catchment area. Broader health systems issues influencing the effectiveness of delivery of each of these interventions were also identified.
  
  
  CONCLUSIONS
  In this setting, intervention-specific factors resulted in the ineffective delivery of IPTp-SP. These relate to complex policy guidelines, lack of guidance on how to implement the guidelines, and the institutionalising of practices that undermine the national guidelines. Interventions may be implemented and show real gains in the shorter-term whilst waiting for broader health systems issues to be addressed.
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, London, United Kingdom. Jayne.webster@lshtm.ac.uk
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
authors.forename: Kassoum
authors.initials: K
authors.lastname: Kayentao
authors.forename: Samba
authors.initials: S
authors.lastname: Diarra
authors.forename: Sory I
authors.initials: SI
authors.lastname: Diawara
authors.forename: Alhassane Ag
authors.initials: AA
authors.lastname: Haiballa
authors.forename: Ogobara K
authors.initials: OK
authors.lastname: Doumbo
authors.forename: Jenny
authors.initials: J
authors.lastname: Hill
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D019538:Health Care Surveys; D006282:Health Personnel; D006801:Humans; D057148:Insecticide-Treated Bednets; D007306:Insecticides / Q000494:pharmacology*; D008288:Malaria / Q000517:prevention & control*; D008302:Mali; D008427:Maternal Health Services; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000517:prevention & control*; D011292:Premedication; D036301:Qualitative Research; D012307:Risk Factors
chemical_list: D000962:Antimalarials; D007306:Insecticides