Seeking research questions from implementers: considerations for leveraging ground actors research needs in the fight against malaria in West Africa

More often than not, local social determinants of health are hidden or overlooked by funding agencies, institutional researchers, and health systems, yet they may be slowing down or reducing programme implementation and impact. In addition, many of the physical constraints that impede the regular and effective delivery of health interventions to those who need them are much more pronounced in Low-to-Middle-Income Countries (LMIC) than in high income countries [1]. Hence bridging the research divide between the obligations of donors and researchers or field actors are of paramount importance in the fight against diseases, especially malaria in Africa.

Indeed, despite recent trends showing a reduction in malaria mortality rates in Africa generally, and in the region in particular [2], mortality rates remain high in countries such as Nigeria, Burkina Faso, Niger, Mali, Côte d’Ivoire, Ghana, and Guinea [3]. This raise questions about the effectiveness of the fight against malaria in these countries. An approach to identify these weaknesses, opportunities, and the search for solutions to reduce these preventable mortalities can improve control and bring these countries nearer to their pre-elimination targets.

This study reports experiences gained from collaborations between decision-makers and researchers, a part of a project undertaken in the framework of the regional World Bank funded project titled: Malaria and Neglected Tropical Diseases in the Sahel (SM/NTD)[4]. The objectives of this World Bank project were to identify bottlenecks in programme implementation as well as the related research questions they present. The results of this study can help funding agencies to prioritize and fund research activities in a bid to improve the fight against malaria in the beneficiary countries.

Local and primary providers along with malaria programme managers were approached in the 15 countries of the Economic Community of West African States (ECOWAS), including eight French-speaking, five English-speaking and two Portuguese-speaking countries using two approaches, namely: a questionnaire survey and regional validation workshops were held as part of the activities of the SM/NTD project. This study only focuses on malaria.

Out of the 15 ECOWAS countries, 11 (Benin, Burkina Faso, Côte d’Ivoire, Gambia, Ghana, Guinea, Mali, Niger, Nigeria, Senegal, and Togo) responded to questions related to malaria and Table 1 shows the bottlenecks identified by programme managers/coordinators according to the seven areas addressed in the questionnaire.

In all seven thematic areas, there were challenges that limited the effectiveness of programme implementation. In the area of governance, issues of coordination and collaboration with partners in the field came up as well as weaknesses in the managerial capacity at the regional and district levels. The human resources problems identified were mainly related to capacity, competence, motivation of community health workers, weaknesses in research skills and capacity of programme actors. There were also difficulties in the area of management of medicine logistics, from ordering commodities to the distribution to patients, and also difficulties in pharmacovigilance. In service provision thematic area, difficulties of direct observed treatment were pointed out, especially for the second and third day doses of SMC, while for prevention, low uptake of vector control measures, the absence of insecticides for the impregnation of protective materials, and the low use of protective means were the major problems mentioned. In terms of monitoring and evaluation, challenges of access to quality data, especially from the community level, and inadequacy in the dissemination of research results were reported.

Finally, in terms of public support, refusal or reluctance to participate in mass drug distribution during SMC campaigns, failure in adopting preventive measures and behaviour were reported by programme managers.

Table 2 presents the 21 priority issues as ranked by the participants by thematic areas.

The first five priority questions were related to (1) compliance with drug doses for the second and third days of SMC campaigns, (2) contribution of community-based distributors to severe malaria cases management in children under 5 year, (3) SMC efficacy, (4) ACT efficacy and tolerance of ACT under current guidelines, and (5) quality of malaria cases management at all health system levels.

The prevention theme was ranked first with five questions, followed by the governance and medicines with four questions, and the monitoring and evaluation (M and E) with three questions. The five prevention questions were related to the effectiveness and non-use of long-lasting insecticidal nets LLIN), the level of use and effectiveness of indoor residual spray (IRS), conducting a study on the effectiveness of mosquito soap, and the possibility of using two insecticides to impregnate nets. Governance issues were related to the best strategy for the implementation of SMC campaigns, quality of malaria case management at all health system levels, the place of information and communication technology in data quality management and the type of collaboration framework between the Ministry of Health and partners. For the medicines theme, the four priority questions focused on the efficacy and tolerance of ACT under current guidelines, the side effects of ACT, the efficacy of traditional medicines and the comparative advantage of the dihydroartemisinin (DHA)-piperazine combination over sulfadoxine–pyrimethamine (SP) + amodiaquine (SP-AQ). Regarding M and E, questions related to adherence for the second and third dose during seasonal chemoprevention campaigns, the performance and use of rapid diagnostic tests. In terms of human resources, the two priority issues were related to the contribution of community health workers in severe malaria case management and the supervision of the second and third doses during SMC campaigns. At the service delivery level, both issues were related to the quality and performance of the drug supply and management chains. Finally, in terms of public support, the questions were related to communication channels, media and strategies to ensure behavior change. Table 3 shows the three priority issues identified by the three project country teams, namely Burkina, Mali and Niger.

It was noted that the research questions related to factors influencing adherence to second day (day 2) and third day (day 3) doses of SMC were highlighted as first priority by Mali and Niger participants. The same questions were flagged as second priority by Burkina Faso participants. It was followed by questions related to the contribution of community health workers in the supervision of the second and third doses of drug during the SMC campaigns in Burkina and Niger. The final ones were in order of importance, the questions on the most efficient strategy in the implementation of SMC in Burkina Faso, the toxicological effects of administering multiple doses of SP-AQ in children, the impact of communication interventions in 2nd and 3rd days in Mali, and the therapeutic effectiveness of SP-AQ in Niger.

This work allowed the identification of key challenges limiting the implementation of NMCP in West Africa. Priority research themes in malaria has helped to highlight similarities between countries regarding malaria control programmes. Most of the bottlenecks highlighted by this work are related to the poor coordination and collaboration with partners, the skills and motivation of community health workers responsible for drug distribution during mass treatment. In addition, the bottlenecks were also due to weaknesses in the supply and distribution chain, poor use of prevention measures, difficulties in accessing quality data, especially at community level, and the population buy-in and acceptance of strategies. The problems that have emerged in malaria control programmes in this work have already been reported by some authors in Africa [5‐11]. The results are consistent with previous reports regarding difficulties related to malaria management. With regards to research questions, there is an urgent need for information sharing on SMC strategy and implementation to allow effective malaria control and eradication. Community health workers and the general population must be mobilized and involved in the fight against malaria. The research questions on SMC seem consistent with reports that showed that there is little implementation research in malaria eradication programmes in the three countries, Burkina, Mali and Niger. The majority of the research conducted related to SMC in West Africa, were clinical studies on the effectiveness of the malaria programmes strategies and these studies [6, 9, 12‐14] provide some answers to operational questions, however, more research is needed in malaria control across different countries.

This work was designed to assess the implementation, operational bottlenecks, and success of public health practice in West Africa. Furthermore, this study evaluated the relationship between programme implementing actors, African researchers, and the constraints they face in their respective countries. Local researchers should work in coordination with programme actors to address local problems. The New Partnership for Africa’s Development (NEPAD)’s Consolidated Plan of Action 2005–2014 (CPA) and the Science Technology Innovation Strategy 2024 [15] attempted to ensure the continent’s collective commitment towards an innovation-led knowledge development. Science and technology must be incorporated in different local strategies to address African problems, as evidence based research interventions are often required by donors and governments to improve the implementation of public health activities.

The landscape of global health keeps changing because new innovations and new discoveries are being implemented in interventions against emerging diseases (infectious and non-communicable). New discoveries either technically or “process, are not easy to incorporate in public health interventions since they require drawing new strategic plans and other logistics. Hassan [16] has reported the difficult conditions in developing countries regarding research expertise and the lack of evidence-based research required to inform interventions, this makes developing countries inexistent when it comes to research in the context of globalization. Southern partners (especially developing countries) have generally identical social burdens and environmental conditions [17], therefore, there is a need to increase intra-regional collaboration.

This study showed the effectiveness of collaboration between policy makers and researchers in identifying and funding research needed to improve malaria control programmes. The research questions identified can be adapted to other ongoing research to improve malaria control in different countries.