Date Published: January 25, 2011
Publisher: Public Library of Science
Abstract: The Malaria Eradication Research Agenda (malERA) Consultative Group on Health Systems and Operational Research outline a research and development agenda for the health systems research required for malaria eradication.
Partial Text: The last attempt at (global) eradication of malaria, which lasted from 1955 to approximately 1969, depended on vertical operations (centrally organized activities not linked to subnational administrative levels and/or communities). These operations—largely indoor residual spraying—often bypassed health systems, because it was assumed that they could be run most efficiently with minimal collaboration with general health services, which were often poorly developed in endemic areas. In the later phases of the first eradication era, it became clear that some form of chemotherapy was needed to reduce transmission, and that good surveillance was essential for achieving and maintaining malaria-free status in a given area. Increased attention was then given to integration with existing health services and to using malaria eradication strategically to build rudimentary health services in remote areas ,.
In 2000, The World Health Organization (WHO) articulated a comprehensive definition of health systems that is now widely adopted. A health system “consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health”  with goals of “improving health and health equity in ways that are responsive, financially fair and make the best, or most efficient, use of available resources.” In 2007, WHO developed a conceptual framework comprising six “health system building blocks” that has also been widely adopted (Box 2) .
The Global Malaria Action Plan (GMAP) was launched in 2008 by the Roll Back Malaria partnership against a background of greatly increased investment in research and development for malaria-control technologies since 1999 and extraordinary increases in funding for malaria control through national and global financing mechanisms since 2002 . The GMAP includes three phases. The first phase—scaling-up for impact—aims to rapidly reach universal coverage for all populations at risk with locally appropriate malaria-control interventions, supported by strengthened health systems. The second phase—sustained control—aims to prevent the resurgence of malaria by maintaining universal intervention coverage until countries enter the elimination stage. In the final phase—elimination and eradication—it is estimated that more than 20 lower burden countries around the world will be poised to eliminate malaria.
As an original approach to understanding health system impediments to sustaining malaria interventions at coverage levels sufficient to reduce malaria morbidity and mortality to very low levels, and to achieve and maintain malaria-free status, we introduce the concept of health systems effectiveness. We used this concept and a framework for analyzing constraints to scale-up (see below) as “stepping stones” during our development of a health systems research and development agenda.
The health systems research and development agenda that our group has developed derives from the ideas and concepts discussed above and proposes the creation of a set of tools for applying the systems effectiveness framework for malaria elimination and control in different health system settings. The agenda is organized both across health system levels (community, facility, district, national, regional/global, and intersectorial; more details of these levels are given later) and health system building blocks (see Box 2), but, importantly it also takes account of “country groupings.” These groupings are relevant to the phases defined in the GMAP and we discuss them here in some detail before presenting our research and development agenda in full.
From our discussions, we propose that the malERA health systems research and development agenda should consider the critical/transformational and conditional/situation goals and needs described in detail in Table 1. Some of these goals and needs are also partly covered in other papers in this series. For example, the need for tools to reduce unacceptably and avoidably low effective coverage of essential malaria interventions and malaria surveillance is also partly covered by the Monitoring and Evaluation and Surveillance malERA consultative group , the need for decision support tools to remove policy decision uncertainty for when to commit to transitioning from control to elimination is also covered in part by the malERA Consultative Groups on Modeling and Cross-Cutting Issues ,, and the need for a tool to determine the kind and mix of integrated interventions that are cost-effective in differing epidemiologic and health system contexts is covered in part by the malERA Consultative Group on Modeling .
The research questions that emerge from this above analysis are presented in Table 2 in a matrix of health system levels and health system building blocks. Below, we discuss these questions in greater detail arranged by health system organizational level. As in Table 2, when no country grouping is specified, the discussion refers to both group 1 and group 2 countries.
In our discussions and in this article we have identified and characterized the major health systems needs relevant to the elimination of malaria and have articulated key research questions that need to be addressed at various health systems levels. In Box 3, we present the summary of the research and development agenda for health systems and operational research that resulted from our discussions. With malaria elimination on the agenda, one important, generic question needs to be addressed through health systems research. To what extent does an explicit target of malaria elimination motivate other sectors to participate in malaria control? If research evidence shows that such an explicit target is a potent motivator of other sectors, then ministries of health might be more inclined to be highly vocal and explicit about elimination targets and about the possible consequences of not meeting these targets.