Assessing supply-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study and document and record review in two regions of UgandaReport as inadecuate

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Malaria Journal

, 15:341

First Online: 04 July 2016Received: 18 February 2016Accepted: 17 June 2016DOI: 10.1186-s12936-016-1405-4

Cite this article as: Rassi, C., Graham, K., Mufubenga, P. et al. Malar J 2016 15: 341. doi:10.1186-s12936-016-1405-4


BackgroundIntermittent preventive treatment in pregnancy IPTp with sulfadoxine–pyrimethamine SP, provided as part of routine antenatal care ANC, is one of three malaria-in-pregnancy prevention and control mechanisms recommended by the World Health Organization WHO. However, despite high ANC attendance and increased efforts to address known obstacles, IPTp uptake figures have remained low. This study aimed to identify and assess barriers that continue to impede IPTp uptake in Uganda, in particular for women who attend ANC. The paper focuses on supply-side barriers, i.e., challenges relating to the health service provider.

MethodsIn-depth interviews were conducted in two regions of Uganda in November 2013 and April-May 2014 with four different target audiences: seven district health officials, 15 health workers, 19 women who had attended ANC, and five opinion leaders. In addition, a document and record review was carried out at four health facilities.

ResultsGuidelines with regard to IPTp provision in Uganda have been shown to be inconsistent and, at the time of the research, did not reflect the most recent WHO policy recommendation. There is a lack of training and supervision opportunities for health workers, resulting in poor knowledge of IPTp guidelines and uncertainty about the safety and efficacy of SP. ANC is not consistently offered in health facilities, leading to some women being denied services. While strengthening of the supply chain appears to have reduced the occurrence of stock-outs of SP in public facilities, stock-outs reportedly continue to occur in the private sector. There are also sources of data inaccuracy along the data recording and reporting chain, limiting policy makers’ ability to react adequately to trends and challenges.

ConclusionsGiven the high ANC attendance rates in Uganda, supply-side barriers are likely to account for many missed opportunities for the provision of IPTp in Uganda. Improvements will require consistent provision of ANC, implementation of current WHO IPTp policy recommendations, supply of SP to the private sector, availability of clear guidelines, as well as improved training and supervision for health workers. Improving facility and district-level recording and reporting will further strengthen the country’s ability to address uptake of IPTp.

KeywordsMalaria in pregnancy Prevention IPTp Antenatal care ANC COMDIS-HSD Malaria Consortium AbbreviationsCOREQconsolidated criteria for reporting qualitative research

ANCantenatal care

ANC1first antenatal care visit

ANC4fourth antenatal care visit

DHIS 2District Health Information System

DOTdirectly observed therapy

HChealth centre

HIVhuman immunodeficiency virus

HMISHealth Management Information System

IPT1first dose of IPTp

IPT2second dose of IPTp

IPTpintermittent preventive treatment in pregnancy

PNFPprivate not-for-profit


WHOWorld Health Organization

Electronic supplementary materialThe online version of this article doi:10.1186-s12936-016-1405-4 contains supplementary material, which is available to authorized users.

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Author: Christian Rassi - Kirstie Graham - Patrobas Mufubenga - Rebecca King - Joslyn Meier - Sam Siduda Gudoi


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