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Public health professionals must work across various sectors and with key stakeholders such as other professionals and community groups in order to improve health outcomes. Often, these stakeholders have competing interests and conflicting ideas about health, and about what would be the most effective ways to meet public health needs and outcomes. Stakeholders may not even share the same values related to improving public health. In some cases, using a systems thinking or intersectoral approach may pose many challenges for implementation.


To prepare for this assessment, choose one public health issue (e.g. obesity, a chronic disease) in your country of origin for which it is obvious that a systems thinking approach has not been, or is not being, applied. Then in approximately 1000 words:
? Describe the public health issue.
? Explain the roles of stakeholders, both within the health system and in other sectors in addressing this issue.
? Drawing on research evidence, explain the obstacles that are preventing the application of a systems thinking approach to this issue.
? Based on the literature, offer suggestions (e.g. new governance arrangements) for how a systems thinking approach could be applied to this issue. 

Stakeholders Involved in Malaria Control

Systems thinking is a holistic and critical way of thinking by which the individual parts are analyzed to understand a situation for better decision making (Henriksen K, 2005). The systems thinking approach is different from the traditional analysis that analyses systems by breaking them into various elements. Systems thinking states that systems behavior is as a result of from the effects of balancing and reinforcing different processes and procedures. When processes are reinforced, system components increase. However, reinforcement can lead to collapse if it is unchecked by balancing processes. When processes are balanced in a particular system, equilibrium is maintained (Adam, Hsu, De Savigny, Lavis, Røttingen, & Bennett, 2012)

In the Kenyan situation, for instance, there has been considerable progress in the fight against malaria over the past years. Even so, Kenyan statistics show that about 20 million Kenyans are at risk of contracting malaria on a regular basis and that malaria contributes 30 to 50 percent of outpatient visits to health facilities and 20 percent of all hospital admissions. Moreover, of these 20 million; the areas around the Kenyan Highlands, the coast and around Lake Victoria seem to have the highest prevalence rates of infection. For this assignment, my focus will be particularly on the Kano plains Ahero rice irrigation scheme. It is an area with black cotton soils which is characterized by very little permeability during the rainy season. The rainy season is always long awaited as it provides water for the paddy fields. The area experiences two rainy seasons: long rains in April and short rains in September. However, due to the long periods in which the water stagnates, it provides an excellent breeding ground for the mosquito larvae which on maturity feed on the human blood and infects them with malaria-causing parasites. Even with this economic resource, the families are large and as a result; whatever income gotten is spent on basics and education thus the families are left with very little for uncertainties such as diseases and other emergencies such as floods which are recurrent in this area.

Some of the stakeholders involved include researchers, policymakers, the media, and implementers. The government is both a policy-making organ as well as a financier and also at times provides technical assistance. One of the primary roles of the government through its public health agencies is to provide preventive measures such as advertising health promotion messages, and they also partner with relevant bodies to ensure that there is access to health services in an area. These agencies also encourage healthy habits such as sleeping under mosquito nets (Association, 1995).

Challenges Affecting Malaria Control in Kenya

Other key stakeholders in the fight against malaria are the researchers. Even though measures have been put in place over the years that have seen the decline in new infections, the Kenyan has experienced an upsurge of new infections of 17553 in 2017 up from 16000 in 2016 according to the Economic Survey of 2018 thus malaria being the number one killer disease in Kenya (Merab, 2018). The malaria parasite, Plasmodium, has become resistant to the drugs available, and as a result, researchers are into preventing the anopheles mosquito from carrying malaria parasites. There are also new drugs and vaccines being experimented to ascertain their effectiveness (Paul & Kramer et al., 2015). Additionally, new insecticides are being used in mosquito nets. Mote effective insecticides are being researched on since mosquitoes are becoming resistant to the often used insecticides. Another intervention done by researchers at International Development Research Centre at Mwea Rice Irrigation Scheme that can be replicated at Ahero Rice Scheme if successful is destroying mosquito breeding grounds by reducing the amount of water used in the rice fields (Kickbusch, & Gleicher, 2012). Other interventions researchers are considering is biological control whereby bacteria are brought into the stagnant water to feed on the mosquito larvae during the breeding season.

There are challenges hindering the containment of malaria in East Africa as a region. One of the challenges is decreased political commitment. In the Kenyan scenario; health is a devolved function. Although the county governments can make decisions and action plans on how to tackle malaria, there is inadequate funding from the national government which in turn is dependent on the national government for funding in order to implement its decisions and also to remunerate its health officers (WHO, 2007). Further, inadequate funding disables the county governments from funding advertisements in the media, it being a major stakeholder, that is intended to disseminate information to the public on issues such as the importance of sleeping under mosquito nets, clearing bushes around the houses to avoid breeding grounds for mosquitoes and also on the significance of being tested before malaria drugs have been administered. Thus the fight against malaria is a multisectoral approach (Andsen, 2017).

Another obstacle is decreased financial support from donors. Donors are partners especially in developing countries since they help to get commodities locally unavailable requisite for interventions (Soti & Kinoti et al., 2015). Additionally, decreased human resources especially at the community, reduced use of LLNs since these are not provided freely by the government, decreased behavior change as well as community health education by community health workers affect the efforts to eliminate malaria (Snetselaar & Njiru et al., 2017) (Afrane & Mweresa et al., 2016). Other notable challenges include misallocation of resources whereby financial resources are allocated to counties that do not have malaria burden. (MACEPA, 2015).

Reducing the Prevalence of Malaria

There are a number of ways of decreasing the prevalence. In the Kenyan context, the Ministry of Health working with National Malaria Control Programme has been able to provide long-lasting insecticidal nets, diagnose and effectively treat malaria cases and to give intermittent preventive treatment for pregnant women. The national government and the county governments should consider training health the care professionals on issues related to malaria and how well to create awareness to help in prevention (Mutero, Mbogo, Mwangangi, Imbahale, Kibe, Orindi, & Gichuki, 2015). The government should also facilitate the supply side to deliver medicines and other diagnostic kits o every corner of the country. Additionally, the National Malaria Control Programme should consider doing time to time monitoring and evaluations which are essential in formulating the malaria policies and programs (Statistics, 2016). The information derived from monitoring and evaluation will help to gauge performance against the targets and subsequent needful action. Apart from that, evaluations through community surveys should also be undertaken to give a long-term view of trends against targets.

Conclusion:

Malaria is considered to be one of the world’s deadly diseases. Although it causes approximately 881,000 deaths annually, it is highly treatable and preventable ("WHO | World Malaria Report 2008," n.d.). In Kenya, the effective treatment and control of malaria is characterized by enormous challenges in terms of logistics. The solution to these challenges lies on an integrated approach that combines long lasting insecticide treated sleeping nets, effective anti-malarial drugs, indoor residual spraying, and access to effective anti-malarial drugs. Most families in the rural Kenya still have no access to preventive measures that are fundamental to malaria control. Moreover, they cannot afford the treatment once they are infected. Therefore, a part from the human cost of malaria, its economic burden is enormous. Kenya, like other African countries, spends approximately billions of dollars annually on the treatment and prevention of malaria. This economic burden could be reduced if anti-malarial is appropriately administered.

References:

Adam, T., Hsu, J., De Savigny, D., Lavis, J. N., Røttingen, J. A., & Bennett, S. (2012).

Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions?. Health policy and planning, 27(suppl_4), iv9-iv19.

Afrane, Y. A., Mweresa, N. G., Wanjala, C. L., Gilbreath III, T. M., Zhou, G., Lee, M. C., ...

& Yan, G. (2016). Evaluation of long-lasting microbial larvicide for malaria vector control in Kenya. Malaria journal, 15(1), 577.

Andsen, T. (2017). Malawi: Media Key in the Fight Against Malaria. Lilongwe: Malawi News Agency . Retrieved October 3, 2018

Association, A. P. (1995). The Role of Public Health in Ensuring Healthy Communities . Washingto DC: American Public Health Association.

Henriksen K, B. J. (2005). Prologue:Systems Thinking and Patient Safety. In P. M. Schyve, Advances in Patient Safety:From Research to Implementation(Volume 2:Concepts and Methodology) (p. 40¬50). Rockville: U.S. National Library of Medicine. Retrieved October 3, 2018

Kickbusch, I., & Gleicher, D. (2012). Governance for health in the 21st century. Geneva:

World Health Organization.

MACEPA, P. (2015). Kenya: Accelerating toward Malaria Elimination. Nairobi: MACEPA. Retrieved October 3, 2018

Merab, E. (2018, 4 30). Efforts include finding ways of taming the mosquitoes that carry malaria parasites. Nairobi, Nairobi City, Kenya.

Mutero, C. M., Mbogo, C., Mwangangi, J., Imbahale, S., Kibe, L., Orindi, B., ... & Gichuki,

  1. (2015). An assessment of participatory integrated vector management for malaria control in Kenya. Environmental health perspectives, 123(11), 1145.

Paul, C., Kramer, R., Lesser, A., Mutero, C., Miranda, M. L., & Dickinson, K. (2015).

Identifying barriers in the malaria control policymaking process in East Africa: insights from stakeholders and a structured literature review. BMC public health, 15(1), 862.

Snetselaar, J., Njiru, B. N., Gachie, B., Owigo, P., Andriessen, R., Glunt, K., ... & Knols, B.

  1. (2017). Eave tubes for malaria control in Africa: prototyping and evaluation against Anopheles gambiae ss and Anopheles arabiensis under semi-field conditions in western Kenya. Malaria journal, 16(1), 276.

Soti, D. O., Kinoti, S. N., Omar, A. H., Logedi, J., Mwendwa, T. K., Hirji, Z., & Ferro, S.

(2015). Feasibility of an innovative electronic mobile system to assist health workers to collect accurate, complete and timely data in a malaria control programme in a remote setting in Kenya. Malaria journal, 14(1), 430.

Statistics, K. N. (2016). Kenya Malaria Indicator Survey 2015. Nairobi: Kenya National Bureau of Statistics. Retrieved October 3, 2018

World Health Organization. (2007). Everybody’s business. Strengthening health systems to improve health outcomes: WHO's Framework for Action. WHO, Geneva. (pages 1-31) https://www.who.int/healthsystems/strategy/everybodys_business.pdf
Governance

WHO | World Malaria Report 2008. (n.d.). Retrieved from https://www.who.int/malaria/publications/atoz/9789241563697/en/

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