1. Systems Thinking in malaria control: research: beyond the “input-blackbox-output” paradigm – a Qualitative Systematic Review 
Dr Sougat Ray, Associate Professor
Dr Rina Tilak, Scientist ‘F’
Dr Sandip Mukherji, Prof and HoD
Department of Community Medicine
Armed Forces Medical College
Pune

2. To Advance Our Evidence-Based Practice, Can You Help Us Get More Practice-Based Evidence? - Green Lawrence
‘Public health asks of systems science, as it did of sociology 40 years ago, help us unravel the complexity of causal forces in our varied populations’
We seek a more evidence based public health practice, but too much of our evidence comes from artificially controlled research that does not fit the realities of practice.

3. Substantial expansion of malaria interventions though sustainability a huge constraint….
42 per cent decline in malaria mortality rates globally in the recent years.
3.3 million deaths from malaria were averted
3 million young children were saved in 2012 alone
and during the same time, malaria killed an estimated 6,27,000 people2.
sustainability a constraint.
UN Millenium Development Goals. Accessed on 26 Aug 2014

4. Reasons remain elusive
Use of insecticides and drugs form the mainstays of malaria control
Overindulgence of chloroquine, extremely effective but not prepared for its failure.
Artemisin based combination therapies, changed this scenario
However, the world is now battling Artemisin resistant Plasmodium falciparum.
Though the main reason is use of monotherapy in the private sector, other causes also be responsible.
Tracking of parasite reservoirs and better use of technology in case detection are still not fool proof and effective
Integration of these measures are not in place
Greenwood B, Treatment of Malaria: A continuing challenge New England Journal of Medicine 371;5

5. What is systems thinking?
Research or analysis is the search for information on
inputs or the constraints;
strategies or interventions
and the output or effectiveness of the control programme
Systems thinking goes beyond this typical algorithm of input-output
Primarily a way of thinking in approaching constraints and in designing solutions.
Constitutes an integrated, complex, sustainable and intellectual endeavour.

6. Components of Systems thinking

7. Causal Loop Diagram in Malaria showing the Epidemic Loop, Susceptible Loop and the Mosquito control loop inherent in the system

8. Methodology Selection Criteria Search Methods
We included reviews dealing with programmatic constraints and different methods of malaria control.
We excluded standard control measures like environmental control, chemical control including insecticide treated bednets, biological control measures, physical, mechanical, legislative and genetic control measures and their trials.
Search Methods
The key words ‘systems thinking’, ‘innovations’, ‘human behaviour’, ‘health behaviour’, ‘health belief’ and ‘malaria control interventions’, to identify challenges of malaria control were used.
The studies were categorized into whether they were related to human behavioural problems, environmental causes or failure of the control programmes.
Search was conducted at Pubmed, Pubmed Central, Cochrane Library, OvidSP and Google scholar. We hand searched the Tropical Diseases Bulletin from 2005 to 2010 and the archives of the World Health Organization (up to July 2014). We also contacted colleagues in the field for relevant articles.
Data Collection and analysis
At least two authors assessed each study for eligibility.
We extracted data and at least two authors independently determined the risk of bias in the included studies.
We resolved all disagreements through discussion with a third author.

9. PRISMA Flow Diagram

10. Solutions from Systemic thinking
Author
Place
Model
Constraints
Solutions
Netta Beer et al. 2012
Tanzania, Africa
Health Belief Model on use of bednets
Discomfort in sleeping under a bed net; heat barrier; cost of treatment; disruption of family life
Perceived susceptibility of malaria more important than perceived severity in adopting bed net use; bigger mesh size of the bednets; subsidized and affordable nets
Netta Beer et al. 2010
Systematic thinking model on use of bednets
ITNs having partial toxicity, fear of insecticide toxicity, seasonal variation in perceived risk of malaria; difficulty in mounting the nets; sleeping arrangements; temporary migrations;
Targeted free mass distribution of LLINs for children under five; complimentary distribution
strategies between mass distribution campaigns; IEC
Ahorlu CK et al. 1997
Ghana, Africa
Health Belief Model
Misconceptions about transmissions; Use of coils and herbs as insecticides as well as for treatment; use of over the counter drug for home treatment; low use of bed nets
Strong IEC, role of correct home treatment; Regulation of OTC drugs
World Health Organisation12 (2013)
Systematic Review
Operation Research model
Baseline information on vector presence and insecticide susceptibility missing.; Language barriers make it difficult to provide information; use of RDT useful but not universal;
Artemisin resistance
Scaling up of RDT usage;
contain or eliminate artemisinin resistance through stopping its spread, increasing monitoring and surveillance, improving access to diagnostics and rational treatment, increasing action and resourc­es, and investing in related research

11. malERA Consultative Group on Health Systems and Operational Research13
Author
Place
Model
Constraints
Solutions
malERA Consultative Group on Health Systems and Operational Research13
Systemic Review
Systems thinking
Governance, health workforce, health financing, health technologies, health information and service delivery
Responding to system-level bottlenecks;
Apply systems science to guide health
system strengthening investments;
Develop systems dynamic modelling;
Develop means to engage communities more effectively in case management, vector
control, and surveillance
malERA Consultative Group on Health Systems and Operational Research14
Ecology of malaria vectors needs to be understood
Built-in flexibility in control programs not present
Effective multiple new insecticides for LLINs/IRS
Long term resistance monitoring and management
Targetted intervention for outdoor biting and resting mosquitoes
Effective attractants/repellants for vector control
Oxfam Blog 6
Kenya
Farmers decided on a local control of the irrigation system pushing up the mosquito population
Rice planting alternated to Soya, a dry crop, which both reduced mosquito population and improved villager’s diets;
Also supported increased cattle population as alternate bait;
Ensuring children and pregnant mothers always use bednets

12. Author
Place
Model
Constraints
Solutions
Phyllida Travis7et al
Systematic Review
Systems thinking model
Financial inaccessibility; Physical inaccessibility; Inappropriately skilled staff; Poorly motivated staff; Weak planning and management; Lack of intersectoral action and partnership; Poor quality care amongst private sector providers
Exemptions/reduced prices; Outreach for the diseases in terms of diagnosis and management; Continuous education and training workshops; Building systems that incorporate representatives from health,
education, agriculture sectors; Development of accreditation and regulation systems
malERA Consultative Group on Health Systems and Operational Research15
Cambodia, Africa
Systematic thinking/Operational research
Information dissemination to stratify malaria risk at sub district levels
Use of malaria information system (MIS) through malaria workers helped in diagnosing increased cases of malaria, and also aided in a prompt treatment and control response.
Bisofi17, Tinto et al 2013
Burkina Faso
Systemic thinking
Management (in testing and treatment) of patients keeping the cost factor in mind
During dry season, low endemicity – hence presumptive treatment; no testing nor use of any treatment regime.
During rainy season, high endemicity – hence treated with amodiaquin+sulfadoxin, pyrimethamine (not tested nor treated with ACT)

13. Spectrum of interventions and their potential for system wide effects

14. Conclusion
Application of systems science to respond to system-level bottlenecks with the help of dynamic modelling
Political will to remove basic financial constraints in
Payment of health workers including lab technicians
Use of multiple newer insecticides for IRS/LLINs
Distribution of LLINs to mothers and children
Introduction of ACT as 1st line therapy
Availability of RDTs
Engaging the community in the control programme by training and advocacy
more importance to malaria susceptibility rather than malaria severity
Long term monitoring and management of resistance development
Effective agricultural/animal husbandry practices in the rural and urban areas

15. The theme of World Malaria Day 2014 - "Invest in the Future
The theme of World Malaria Day "Invest in the Future. Defeat Malaria" is apt in asking the world to think of systems strategies in control of malaria.
Thank You…….