Defining operational research priorities to improve malaria control and elimination in sub-Saharan Africa: results from a country-driven research prioritization setting process.

BACKGROUND: In order to reignite gains and accelerate progress toward improved malaria control and elimination, policy, strategy, and operational decisions should be derived from high-quality evidence. The U.S. President's Malaria Initiative (PMI) Insights project together with the Université Cheikh Anta Diop of Dakar, Senegal, conducted a broad stakeholder consultation process to identify pressing evidence gaps in malaria control and elimination across sub-Saharan Africa (SSA), and developed a priority list of country-driven malaria operational research (OR) and programme evaluation (PE) topics to address these gaps. METHODS: Five key stakeholder groups were engaged in the process: national malaria programmes (NMPs), research institutions in SSA, World Health Organization (WHO) representatives in SSA, international funding agencies, and global technical partners who support malaria programme implementation and research. Stakeholders were engaged through individual or small group interviews and an online survey, and asked about key operational challenges faced by NMPs, pressing evidence gaps in current strategy and implementation guidance, and priority OR and PE questions to address the challenges and gaps. RESULTS: Altogether, 47 interviews were conducted with 82 individuals, and through the online survey, input was provided by 46 global technical partners. A total of 33 emergent OR and PE topics were identified through the consultation process and were subsequently evaluated and prioritized by an external evaluation committee of experts from NMPs, research institutions, and the WHO. The resulting prioritized OR and PE topics predominantly focused on generating evidence needed to close gaps in intervention coverage, address persistent challenges faced by NMPs in the implementation of core strategic interventions, and inform the effective deployment of new tools. CONCLUSION: The prioritized research list is intended to serve as a key resource for informing OR and PE investments, thereby ensuring future investments focus on generating the evidence needed to strengthen national strategies and programme implementation and facilitating a more coordinated and impactful approach to malaria operational research.

Mutuelles de santé en Afrique : caractéristiques et relations contractuelles avec les prestataires de soins pour la prise en charge de la qualité des soins.

En Afrique, une part importante de la population est encore confrontée à plusieurs barrières pour accéder aux soins. Les mutuelles de santé (MS) sont mises en place pour réduire la barrière financière et assurer à leurs membres un accès à des soins de qualité. Les MS établissent des relations avec les prestataires de soins sous forme de contrat, dont certaines clauses peuvent contenir des notions de qualité des soins (QS). A travers une vue d'ensemble de la typologie de 180 MS de 14 pays (dans Afrique Ouest et Centrale), cet article vise à analyser dans quelle mesure les caractéristiques des MS influencent la mise en œuvre de mécanismes contractuels susceptibles de faciliter la discussion sur la QS. L'hypothèse de cette association a été étudiée avec trois types de caractéristiques (taille, utilisation des services et volume des soins achetés) et huit variables relatives à la contractualisation et la QS (existence d'un contrat, organisation de rencontres, fréquence de ces rencontres, présence de notions de QS dans le contrat, négociation du contrat, révision du contrat, révision des clauses spécifiques à la QS et organisation de rencontres pour discuter de QS). Les MS de type communautaire représentent 80% des mutuelles étudiées (60% d'entre elles sont localisées en zone rurale). Les MS professionnelles représentent 17% et se concentrent principalement au Mali et en Côte d'Ivoire. La quasi-totalité des MS disposent de contrats écrits et contenant des notions relatives à la QS. Bien que les MS de grande taille ayant des résultats financiers importants négocient plus les aspects liés à la qualité des soins lors de l'élaboration de la convention, les MS de taille et aux performances financières plus modestes mettent en œuvre des mécanismes plus réguliers de concertation avec les prestataires. Ces rencontres sont susceptibles de créer un espace de prise en charge de la QS.

The impact of stakeholder values and power relations on community-based health insurance coverage: qualitative evidence from three Senegalese case studies.

Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis.

Can social capital help explain enrolment (or lack thereof) in community-based health insurance? Results of an exploratory mixed methods study from Senegal.

CBHI has achieved low population coverage in West Africa and elsewhere. Studies which seek to explain this point to inequitable enrolment, adverse selection, lack of trust in scheme management and information and low quality of health care. Interventions to address these problems have been proposed yet enrolment rates remain low. This exploratory study proposes that an under-researched determinant of CBHI enrolment is social capital. Fieldwork comprising a household survey and qualitative interviews was conducted in Senegal in 2009. Levels of bonding and bridging social capital among 720 members and non-members of CBHI across three case study schemes are compared. The results of the logistic regression suggest that, controlling for age and gender, in all three case studies members were significantly more likely than non-members to be enrolled in another community association, to have borrowed money from sources other than friends and relatives and to report having control over all community decisions affecting daily life. In two case studies, having privileged social relationships was also positively correlated with enrolment. After controlling for additional socioeconomic and health variables, the results for borrowing money remained significant. Additionally, in two case studies, reporting having control over community decisions and believing that the community would cooperate in an emergency were significantly positively correlated with enrolment. The results suggest that CBHI members had greater bridging social capital which provided them with solidarity, risk pooling, financial protection and financial credit. Qualitative interviews with 109 individuals selected from the household survey confirm this interpretation. The results ostensibly suggest that CBHI schemes should build on bridging social capital to increase coverage, for example by enrolling households through community associations. However, this may be unadvisable from an equity perspective. It is concluded that since enrolment in CBHI was less common not only among the poor, but also among those with less social capital and less power, strategies should focus on removing social as well as financial barriers to  financial protection from the cost of ill health.

Acceptability by community health workers in Senegal of combining community case management of malaria and seasonal malaria chemoprevention.

BACKGROUND: Community case management of malaria (CCMm) and seasonal malaria chemoprevention (SMC) are anti-malarial interventions that can lead to substantial reduction in malaria burden acting in synergy. However, little is known about the social acceptability of these interventions. A study was undertaken to assess whether combining the interventions would be an acceptable approach to malaria control for community health workers (CHWs). METHODS: Sixty-one interviews and six focus group discussions were conducted nested in a cluster-randomized trial assessing the impact of combining CCMm and SMC in a rural area of Senegal. Participants consisted of: (i) members of village associations, (ii) members of families who had access to the interventions as well as members of families who did not access the interventions, (iii) CHWs, and (iv) community leaders, e g, religious guides and village chiefs. RESULTS: The interventions were acceptable to the local population and perceived as good strategy to make health care services available to community members and thus, to reduce the delays in access to anti-malarial treatment as well as expenses related to patients' transfer to the health post. The use of malaria rapid diagnostic test (RDT) contributed to improving CHWs diagnostic capacity as well as malaria treatment practices. Study participants notified RDT and drugs stock-out as the major risk for sustainability of the intervention at community level. CONCLUSION: Combining CCMm and SMC is a well accepted, community-based approach that can contribute to control malaria in areas where malaria transmission is seasonal.

Editorial: a view from beneath: community health insurance in Africa.

This paper presents an overview of the development of Community Health Insurance (CHI) in sub-Saharan Africa. In 2003, nearly 600 CHI initiatives were registered in a dozen countries of francophone West Africa alone. At regional level, coordination networks have been created in Africa with the aim to support and monitor the developments of this innovative model of health care financing. At national level, governments are preparing the necessary legal frameworks for CHI implementation. CHI is increasingly seen as a strategy to meet other development goals than only health. It constitutes an interesting model to finance health care, to pool financial resources in a fair way and to empower health care users. The CHI movement however still faces many challenges. The relevance of more professional inputs in the management of CHI and the need for careful subsidy of CHI schemes are increasingly recognized. There is also need to optimize the relationship of CHI with the other actors in the health system and to scale-up CHI so as to gain in effectiveness and efficiency. The boom in the number of schemes in Africa during the last years is an indicator of the increasing attractiveness of the model. In practice however, enrolment rates per scheme remain low or are only slowly increasing. Context-specific research is needed on the reasons that prevent people from enrolling in larger numbers. On that basis, relevant action to be taken locally can be identified.