Abstract
BackgroundDespite increased resources over the past few years the coverage of malaria control interventions is still inadequate to reach national and international targets and achieve the full potential of the interventions to improve population health. One of the reasons for this inadequate coverage of efficacious interventions is the limited understanding of the optimum delivery systems of the interventions in different contexts. Although there have been debates about how to deliver interventions, the methods for evaluating the effectiveness of different delivery systems have rarely been discussed. Delivery of interventions is relatively complex and a thorough evaluation would need to look holistically at multiple steps in the delivery process and at multiple factors influencing the process. A better understanding of the strength of the evidence on delivery system effectiveness is needed in order to optimise delivery of efficacious interventions. Methods A literature review was conducted of methods used to evaluate delivery systems for insecticide treated nets, intermittent preventive treatment in pregnant women, and treatment for malaria in children. ResultsThe methodology of delivery system evaluations varied. There were inconsistencies between objectives and methods of the evaluations including inappropriate outcome measures and unnecessary controls. There were few examples where the delivery processes were adequately described, or measured. We propose a cross sectional observational study design with attribution of the outcomes to a specific delivery system as an appropriate method for evaluating delivery systems at scale. ConclusionsThe proposed evaluation framework is adaptable to natural experiments at scale, and can be applied using data from routine surveys such as the Demographic and Health Surveys, modified by the addition of one to two questions for each intervention. This framework has the potential to enable wider application of rigorous evaluations and thereby improve the evidence base on which decisions about delivery systems for malaria control and other public health interventions are taken.
Highlights
The efficacy of insecticide treated nets (ITNs) [1,3,4], intermittent preventive treatment in pregnant women (IPTp) [5,6,7,8,9] and artemisinin combination therapies (ACTs) [10,11,12] have been proven
Our objective is to review the methods used in evaluations of delivery systems for ITNs, IPTp, and effective case management for febrile children; and, drawing on the findings from this review and upon elements of programme evaluation methodology, to develop a relatively simple approach to delivery system evaluation applicable to use by a wide range of programmes
Because IPTp is almost exclusively delivered through antenatal clinics (ANC), studies of coverage of IPTp were included; in contrast, ITNs and effective case management for malaria may be delivered through a myriad of systems and studies of coverage of ITNs and effective case management for malaria were excluded unless they referred to a specific delivery system(s), or a component of a specific delivery system
Summary
The efficacy of insecticide treated nets (ITNs) [1,3,4], intermittent preventive treatment in pregnant women (IPTp) [5,6,7,8,9] and artemisinin combination therapies (ACTs) [10,11,12] have been proven Coverage of these interventions is still low: the most recently available data indicate that among populations at risk, only 24% of children under 5 years of age use a treated net, 20% of pregnant women receive at least two doses of IPTp, and less than 15% of febrile children receive prompt treatment with an ACT. Interventions to improve access to ACT through public, private and community based delivery systems are being implemented Despite these debates about how to scale-up the delivery of these interventions, there has been little discussion of the methods of evaluation of the effectiveness of different delivery systems, limiting understanding of the strength of the evidence base on which the merits of different systems can be considered. A better understanding of the strength of the evidence on delivery system effectiveness is needed in order to optimise delivery of efficacious interventions
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