Study participants were first asked to list and then rank health priorities based on their relative importance. Two patterns of response were identified: 1) priorities articulated as significant health problems and diseases, and 2) priorities framed as gaps in health services that required strengthening of the overall health system.
Priorities stated in terms of diseases and specific health needs
Most respondents across the five countries ranked either malaria or HIV as priority number one or two.
There are various diseases … we can say malaria is the first one, also there are some diseases which come because of HIV and AIDS, therefore there are diseases like diarrhoea, also TB [tuberculosis] and malnutrition, another one is pneumonia.
Community member FGD participant, Malawi
According to those who ranked HIV and AIDS as the first priority, this was mostly due to the severity of the disease and the difficulties in treating it. Malaria was considered more dangerous in terms of mortality and spontaneous abortions, as explained below.
Malaria is the first health problem in our community, both adults and children suffer from it and mortality due to malaria is very high. Then, comes AIDS, which creates anxiety in our community, and lastly minor ailments such as cough and stomach pains.
Community leader, key informant interview, Burkina Faso
It [AIDS] is a bad disease, if you catch it, it's hard to heal. In the case of malaria one can be treated right away and totally recover, but AIDS is difficult to treat, that's why I ranked [it] first.
Community member FGD participant, Burkina Faso
The level of priority assigned to HIV and AIDS differed amongst the five countries, and did not always relate to national HIV prevalence levels. In both Malawi (which has a high HIV prevalence), and Burkina Faso and DRC (countries with much lower HIV prevalence), most respondents mentioned HIV and AIDS as one of the two main health priorities. The reasons provided for prioritising HIV and AIDS were concerns about the seriousness of the disease and the broader negative social and economic effects.
We are more concerned with its consequences for our children. HIV kills young people in their prime of life and leaves communities with orphans.
Community member FGD participant, Burkina Faso
Even in Madagascar, the country with the lowest HIV prevalence amongst the five study countries, the majority of respondents also mentioned HIV and AIDS as a priority. Given the seriousness of the disease and its long-term impacts, a number of respondents at all levels felt that it was important to focus on HIV prevention despite the current low prevalence:
AIDS? Ha! It is a priority. People hear about it all the time. In fact, AIDS information campaigns have become routine during community meetings …. Yes, it’s a priority for the population. Awareness-raising campaigns explain that AIDS impact is limited in Madagascar and the disease is not visible in our midst.
Community leader, key informant interview, Madagascar
AIDS has straight away been included because it was initially feared it would be devastating. Fortunately, it has been contained and has now stabilised. And the most surprising is that so far we do not understand why AIDS has not increased that much.
National level stakeholder, Madagascar
In contrast, in Ghana the majority of the community and district level respondents -including health workers - did not see HIV and AIDS as a priority. In both districts included in the study (one with high and one with low HIV prevalence), people stated that HIV and AIDS was not a problem and did not deserve the level of attention it currently received. Respondents instead emphasised the need for greater investment in health services, clean water, and education.
I think the government should stop the AIDS programmes and use the money for more important things [such as] pipe-borne water, hospitals, buying exercise books and providing free education.
Community member FGD participant, Ghana
While such sentiments were particularly common amongst study participants at community level, most health planners and development partners at district and at national level in Ghana listed HIV and AIDS as a top priority.
Other priorities mentioned by most respondents in each country were diarrhoeal disease, acute respiratory infection (ARI), tuberculosis (TB), maternal health, childhood diseases and malnutrition. In addition, community members, health workers and district level respondents mentioned skin diseases and schistosomiasis.
The source of our drinking water is not good, some people contract schistosomiasis, that is blood in urine. Malaria is also common in this community. We also have other diseases like bilharzia, gonorrhoea and hypertension. I must also mention that the sanitary conditions in this community are very poor. There are no public toilets and people defecate in the river, which is the source of our drinking water. This has led to the outbreak of some of the illnesses that I have mentioned.
Community member, key informant interview, Ghana
Furthermore, it was noteworthy that in Ghana (and to some extent Madagascar, Malawi and Burkina Faso) respondents at community and district level sometimes mentioned chronic and lifestyle diseases such as hypertension, stroke and diabetes as important priorities. National level respondents and development partners less often mentioned these.
Priorities stated as health system challenges
Community members in rural areas in Ghana and Burkina Faso expressed serious concerns regarding health system-related constraints. For example, they mentioned problems in accessing health services (due to distance), non-availability of qualified staff, the unresponsiveness of available staff, and inadequate drug supplies and equipment. These concerns were often contextualised in relation to problems in access to other basic services (schools, electricity, clean water, etc.).
The distance from this place to the clinic is too long so when one is sick it takes a long time to get to the clinic for treatment and so people die on the way.
Community member FGD participant, Ghana
In this community we need a school very badly. Also we don’t have electricity, a clinic, and a good source of drinking water. For the health conditions, malaria and fever are very common especially with the children. HIV is not present in this community.
Community leader, key informant interview, Ghana
Across all five countries, respondents at district and national level (both government respondents and development partners) identified limited infrastructure, lack of (qualified) personnel, poor material and financial resources, inadequate supplies and weak planning and management capacity as key barriers in achieving better health.
We do not have enough human, material or financial resources for the future; therefore we are reduced to just do with what we have. Our health care system is not yet capable to plan for the future, that is to say, to start planning from now.
Development partner, national level, Madagascar
I think from the perspective of the Ministry… HRH [Human Resource for Health] stands out as the main area of the health system that requires strengthening. Then from there we have the other processes and systems like procurement and financial management.
Government representative, national level, Malawi
The broader health systems challenges, which were identified by national level health planners and development partners, were mostly seen as obstacles to achieving the MDGs.
I think there is some underlying problem, which we don’t talk too much about and we should talk about it today. The WHO and lots of other development partners are pretty convinced now that for any country to achieve the MDGs or any specific programme to achieve the MDGs, the strengthening of the six major pillars of what constitute a health system must be carried out. In Ghana, we have some work to do.
Development partner, national level, Ghana
Many respondents articulated system challenges from both user and planning perspectives and felt that health system strengthening (HSS) was of key importance to address these challenges.