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Assessing validity of decisions during planning and implementation of malaria services and ITN intervention in ZambiaMary Tuba¹ ², Paul Bloch3, Seter Siziya1, Øystein Olsen2 4, Jens Byskov3, 1 The Department of Community Medicine, School of Medicine, University of Zambia, PO Box 50110, Lusaka – Zambia, 2 Center for International Health, University of Bergen, PO Box 7804, N-5020 Bergen, Norway, 4Haydom Lutheran Hospital, P.O. Mbulu, Manyara, Tanzania, 3 DBL - Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Thorvaldsensvej 57, DK 1871 Frederiksberg, Denmark,

PresentationOutline • Background • Rationale for the study or paper • Objective of paper • Methodology • Results • Conclusion • Implications

Background 1 • “Validity of decisions” in this paper will refer to provision of malaria services and ITNs based on relevanceas defined within the Accountability For Reasonableness (AFR) conceptual model • Relevance refers to making decisions, which are based on agreed upon and balanced rationales that are relevant to legitimate stakeholders (fairness) within a given context, eliciting for values from representative group of stakeholders (inclusiveness) (Kapiriri and Martin 2007). • Validity of decisions during global priority setting processes of malaria services and ITN use have been employed, as shown by global, continental and country specific partnership building, which are multi-disciplinary and multi-sectoral approaches(WHO 2005) • One of the Millennium Development Goals (MDGs), “aims at halting malaria infections by 2015 and begin to reverse the incidence of malaria and other major diseases as well as limit the geographical extent of malaria in the world” (WHO 2004, 2005)

Background 2 • Validity studies regarding decisions made during priority setting of healthcare services and interventions within health institutions have been conducted (Reeleder et al 2005, Kapiriri and Douglas 2006, Mitton and Cam 2004) • These studies have evaluated influences of validity of decisions on fair delivery of healthcare services within health institutions and health system as a whole. • In Zambia, malaria is the highest cause of morbidity, and accounts for 45% of hospitalizations and outpatients department visits (MoH 2008). • Case management and Insecticide-Treated nets (ITNs) are two of the four core strategies prioritized to control malaria (WHO 2009)

Background 3 • REsponse to ACcountable priority setting and Trust in health system (REACT), aims to strengthen the fairness and legitimacy of priority setting at district level in Zambia, Tanzania and Kenya (Byskov et al 2009) • Within REACT and between 2006 and 2008 the validity of decisions made during priority setting processes of malaria services and ITN intervention were evaluated for the first time • We are not aware of available literature on validity of decisions during planning and implementation of malaria services and ITN intervention in Zambia. • Explicit use of the Accountability For Reasonableness (AFR) framework to isolate behaviours influencing validity of decisions during provision of malaria services and ITNs in public health institutions of Zambia

Objective of paper • Describe and evaluate validity of decisions made during planning and implementation of malaria services and ITNs use in a rural district of Zambia.

Methodology • Between 2006 and 2008 baseline data collected • Study site – Kapiri-Mponshi District, rural Zambia • A matrix was produced to guide identification and recruitment of eligible informants • 18 In-depth Interviews were held with decision makers at district, facility and community levels • 9 Focus Group Discussions were conducted with District Health Management Health Team (DHMT) management staff, outpatient male and female attendees above 15 years, antenatal women and male and female adolescents aged between 18 and 24 years

Methodology II • Analyses was manually done using the code sheet approach • Code sheet was created, which contained same or similar phrases describing relevance, fairness and inclusiveness during planning and delivery of malaria services and promotion of ITNs use. The codes were standardized and then assigned to appropriate phrases • To check for reliability of phrases, identification of frequencies and occurrences of common phrases within single IDIs and FGDs and across the IDIs and FGDs, was carried out by repeatedly reading through transcripts. • Different standardized codes were assigned to phrases that were describing emerging themes • Coded common phrases identified were then grouped together and further classified under specific conditions using the Accountability For Reasonableness (AFR) conditions relevance, publicity, appeals/revisions and leadership/enforcement.

Results: Decision-makers’ Perspectives at planning stage “We look at the health thrusts, malaria being the number one among the top-ten. We say, malaria according to the figures that we have, maybe attendances were so many on malaria and was the highest. So that’s how we come up with maybe the top fiveat the district”. (FGD with Decision-makers district level, Male participant 3: 49 years old, 22 years of service). • From the national top-ten prioritized list, used district level evidence-based data to arrive at prioritized top-five diseases

Results: Decision-makers’ Perspectives at implementation stage • But when it comes to implementation, we don’t just follow to say, it’s malaria, you know? We toss our nets wide. Implementation goes with officers and also for those NGOs who will do some activities related tomaybe malaria”. (FGD with Decision-makers district level, Male participant 3: 49 years old, 22 years of service). • Availability of health-providers and donors as legitimate stakeholders in delivery influenced decisions to effect revisions

Results: Decision-makers’ Perspectives at implementation stage “Every Monday we do meet in the District Director’s office where we map out the activities that are meant for that week. So the people who meet there are program officers from the hospital, the Hospital Administrator, the Nursing Sister and other program officers including those based here at the district office” (District Director of Health (DDH), District Manager Planning and Development (MPD), financial officer, Manager Administrator (MA), Clinical Expert, Environmental Health Technologist (EHT). (FGD with Decision-makers district level, Male participant 3: 49 years old, 22 years of service). • Planning processes during delivery were limited to legitimate stakeholders employed within facilities and DHMT

Results: Decision-makers’ Perspectives at implementation stage “Previously, it was working very well, because we had the Board, which was the community representation. At the hospital level yes, the advisory body knows and they do advise.But at the district level, we do not have a body, a representative group from the community”.(Decision-maker at district level, Male 36 years: 2 years residence and service) • Wider legitimate stakeholder involvement during delivery of malaria services was not in place –

Results: Decision-makers’ Perspectives on validity of decisions at planning stage of ITNs “For example, on malaria itself, while other programmes do not have extra funding, nor do they have other stakeholders working (referring to other disease programmes), malaria for district X has received a lot of support from District Planning Office (DP). So, fairness requires that the little resources that you have are actually directed towards the need that is there. So we look at the need and balance”.(Decision-maker at district level, Male 36 years: 2 years residence and service) • Local decisions were made for targetting areas of main need, but other providers and the users were not consulted or involved.

Results: Decision-makers’ Perspectives of Validity of decisions during delivery of ITNs “You find that we are receiving just few nets and we are receiving them from the donors. I think it was going to be better if the government will come in and help on that because we need more mosquito nets and we need more retreatment kits for these nets”. (43 years old female decision-maker, district level, 21 length of service) • Donors as one of the legitimate stakeholders and not the government were leading supply of ITNs. Information regarding inadequate availability of ITNswas not communicated -

Results: Decision-makers’ perspectives “We are Africans, even if a patient was brought to the hospital, he/she is not getting better, the relatives who are part of the community may say, I think this illness cannot be healed at the hospital. The nursing sister would try to say, “the doctor is the only one who could discharge this person”. There are instances where they force you (health-provider) to sign and the patient gets discharged because they want the patient to be taken to the traditional healer”(FGD with Decision-makers district level, Male participant 3: 49 years old, 22 years of service). • Non-response to treatment provided within hospital, led to demand for discharge to an unauthorised provider.

Results: Communities’ (patients) Perspectives at delivery stage “On drugs (referring to malaria drugs), government sends drugs. So they should have people who look at what drugs should be brought here according to the illness. Because here you find one person comes to the hospital continuously – not getting well “(PARTICIPANT6, G8 education, 5 years resident: FGD with Female Adolescent 18-24 years) • Dispensing drugs that could not treat diagnosed illnesses/diseases (non-response to treatment) –

Results: Community (patients) perspectivesduring delivery medicines • “They do things with no care (Deliberately). For example one time I came with my friend who had a cough, and I had malaria. I was examined and given septrin, she was also given septrin. So, I don’t know if it was the right medicine for me who had malaria or the one who had a cough”(PARTICIPANTS1, G7 education, 5 years residence:FGD withANC women 15-34 years) • Evidence relating to quality malaria medicines for effective treatment was not used when dispensing

Results:Community (patients) perspectivesValidity of decisions during delivery of ITNs “Sometime back, we were told that the items (ITNs) would come, but you find that when that happens, they don’t reach the intended people, instead other people benefit. Sometimes we wait, wait and wait. They should not tell lies, its better to tell the truth, if the items will come or not. Or its better they don’t tell us about it”.(PARTICIPANT5, std 2 schooling, 26 length of residence in district: FGD with Out Patient Males 35 years and above) • Delivering ITNs to people not intended, not telling the truth regarding information on availability of ITN, appeal mechanisms not identified

Results: Difference between provider and user priorities “These people when they are giving out mosquito nets (referring to subsidized ITNs), they give priority to pregnant women and children below the age of ten, I don’t know. But they should also consider the old men, they also need mosquito nets because most of them sleep alone”. (PARTICIPANT1: FGD with Male Adolescent 18-24 years, community level) • Elderly men were left out of priority groups for promotion of ITN use

Conclusions • Despite availability of malaria services (malaria drugs, providers, organized health system, ITNs and relevant legitimate stakeholdersto lead, the validity of decisions during delivery were weak. • The validity of decisions at planning stage was beginning to change based on a broader reference to evidence-based data such as the top-ten health problems within the national list and balanced values from legitimate stakeholders and other new participants in priority setting.

Implications • There is need to improve the image of the public health system in Zambia regarding the response to local provider and not least user values and demands during delivery of malaria services and ITN intervention • What was called for was to strengthen validity of decisions made during delivery of malaria services and ITNs intervention. • Testing of the application and adherence to and explicit ethical frameworks such as Accountability For Reasonableness (AFR) seems well justified.

QUOTE • ”The time has come to say goodbye to the simple solutions” Holm, 1998

Acknowledgement • REACT – REsponse to ACcountable priority setting for Trust in health systems project, recieved financial support from EU. • We are indebted to Ministry of Health, Zambia, for authorising this rare research to be implemented in the country. • We are thankful to The District Health Management Team (DHMT) of Kapiri-Mponshi District for their willingness to participate. • Our acknowledgements would not be valid, if we did thank ALL informants and participants who willingly responded to interviews and discussions

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