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Using Insights into Health Provider Behaviors to Improve Malaria Service Delivery

Advancing progress towards malaria elimination requires a strong focus on health provider behavior. What drives provider behavior and how can we influence it to improve malaria service delivery?

To address this, PMI Impact Malaria and Breakthrough ACTION collaborated to create A Blueprint for Applying Behavioral Insights for Malaria Service Delivery: Methods and Frameworks for Improving Provider Behavior. Learn more from PMI Impact Malaria's Mary Warsh and Keith Esch about this tool and what it can do.

What is the Blueprint, who is it for, and why is it needed?

With the primary aim of improving malaria service delivery, the Blueprint highlights best practices for designing provider behavior change interventions. It brings a behavioral lens to the service delivery context in a practical, “how to” format. The Blueprint also provides a menu of provider interventions to share ideas for program design. Implementers and governing bodies alike can benefit from using this resource to design interventions and programs to improve malaria service delivery.

Traditionally, provider behavior change interventions focus on making sure health providers have the needed resources, skills, and supervision to correctly prevent, diagnose, and treat malaria. These are absolutely fundamental components to ensuring quality malaria care, but this approach misses some of the factors that heavily influence health provider behaviors. This is where behavioral insights come in.

There is growing recognition that there are other crucial, often overlooked factors—such as workplace environment, relationships, norms, beliefs, and values—that influence provider ability and motivation to fully deliver quality malaria care. The Blueprint presents a socioecological model that illustrates the many factors within and beyond the individual that influence provider behaviors.

Provider behavior change interventions seek to address these factors, from the moment that a patient arrives at the point of care. These efforts can help to ensure that patients receive high quality services and have a positive experience—one that will help them return for future services and, in turn, maintain healthy malaria behaviors.

How does the Blueprint work?

The Blueprint outlines six steps to improving provider behaviors, many of which are already very familiar to designers and implementers of malaria service delivery interventions. But the Blueprint encourages a deeper look into powerful but rarely discussed determinants of provider behaviors to zoom in on what needs to be addressed more precisely to invoke sustained positive change.

The first step is identifying the desired behavior. While the end goal behavior may be adherence to malaria guidelines, that is ultimately a very complex behavior! The Blueprint illustrates how to break the behavior into smaller sub-behaviors to pinpoint performance gaps and aspects that providers particularly struggle with, to begin tailoring interventions for maximum impact.

Step 2 provides guidance on ways to identify and segment provider groups—appreciating that different groups of providers may experience varying challenges to performing the desired behavior—to ensure each group receives the intervention and messages they need to positively influence their behavior determinants, identified in Step 3.

The Blueprint embraces provider and patient collaboration in the design of an intervention, as outlined in Step 4, to promote ownership and true partnership, before selecting the intervention that best matches the desired behavior and the factors affecting it in Step 5.

The Blueprint also focuses a new light on monitoring and evaluation of interventions—Step 6. It points out that collecting service delivery statistics, while extremely important, may not provide a complete picture of the intervention. The Blueprint supports a more holistic approach, including monitoring changes in provider perceptions and attitudes and observing the effect on provider and client satisfaction.

How have concepts within the Blueprint been used to improve malaria service delivery?

In an ideal world, all steps in the Blueprint’s process would be embraced and followed when designing interventions. But even when that’s not feasible, concepts described in the process can be applied or layered onto existing interventions.

For example, as part of a package designed to improve the quality of malaria service delivery at health facilities, called OTSS+, PMI Impact Malaria (IM) developed “gold standard” clinical quality checklists. Then, as a crucial next step, IM worked with Sierra Leone’s national malaria control program (NMCP) to conduct a field test with the users and beneficiaries of the checklists, which included district health management teams (DHMTs) and facility health providers. IM made key changes to the checklists based on insights from both DHMTs and health providers. (As you might have guessed, this example is a nod to Step 4 of the Blueprint.)

As a second example—going back to the Blueprint’s Step 2—is a reference to the digital platform for OTSS+ that IM has been working with countries to implement. This PSI-developed platform, known as the Health Network Quality Improvement System (HNQIS), allows NMCPs to segment health facilities based on client volume and quality scores. This segmentation makes it easier for managers to prioritize and direct supportive supervision resources to those health facilities that need it most.

The Blueprint presents examples of factors affecting malaria service provider behaviors around clinical adherence to negative test results, malaria in pregnancy (MIP) prevention, and case reporting. While not an exhaustive list, it does stimulate a mindset of digging deeper into the root causes of the problems in delivering high-quality malaria care and approaching them from multiple angles, some of which might have been overlooked before.

Mary Warsh is Deputy Project Director and Keith Esch is a Technical Advisor, both with PMI Impact Malaria.

Photo Caption: Senior Nurse N'deni Annick, 42 years, gives Amadou Safoura, 34 years, malaria medicine for her child who was tested and found positive for malaria at Mouyassue Rural Health Centre on 5th August 2019. Credit: Mwangi Kirubi/PMI Impact Malaria, Côte d’Ivoire

PMI Impact Malaria is funded and technically assisted by the U.S. President's Malaria Initiative (PMI) and led by Population Services International (PSI) in partnership with JhpiegoMedical Care Development International (MCDI), and the Malaria Elimination Initiative (MEI) at UC San Francisco.

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