A Blueprint for Applying Behavioral Insights to Malaria Service Delivery: Methods and Frameworks for Improving Provider Behavior

"A shared framework will facilitate mutual understanding, coordination, innovation, and synergy in malaria service delivery."

Making strides in malaria control requires a strong focus on provider behaviour. As key influencers in the client-provider interaction, providers serve as gatekeepers for malaria testing, adherence to test results, and uptake of intermittent preventive treatment in pregnancy (IPTp). Furthermore, providers' interpersonal skills and the quality of counseling may affect client comprehension of medication regimens, completion of referrals, and future care-seeking. From Breakthrough ACTION and the United States (US) President's Malaria Initiative (PMI) Impact Malaria, this resource outlines a systematic method for understanding and addressing provider malaria behaviour. Users of this document might find it useful for:

• Understanding how a social and behaviour change (SBC) lens can benefit efforts to change provider behaviour;
• Identifying factors that affect provider behaviour;
• Browsing a menu of possible interventions to gather ideas for programme design;
• Learning about user-centred approaches to intervention design; and
• Developing indicators for monitoring and evaluation (M&E).

As outlined here, service delivery and SBC intersect in the following ways:

• Service communication refers to the SBC approaches used before, during, and after service delivery. Malaria service communication encompasses activities that motivate caregivers to seek treatment for children's fevers, the ways providers counsel pregnant women during antenatal care (ANC) visits, methods to encourage clients to take all artemisinin-based combination therapies (ACT) doses after a clinic visit and after symptoms subside, and ways of strengthening facility-community linkages.
• Provider behaviour change efforts reflect an understanding that many factors, such as norms and relationships, beliefs/attitudes, and values, influence the way providers deliver services. Once clients arrive at the service delivery point, provider behaviour change efforts can ensure clients have a positive experience, one that will help them return for future services and maintain healthy malaria behaviours.

From an SBC perspective, providers are both a channel for communication geared toward clients (service communication) and a group to be reached for behavioural interventions (provider behaviour change). The document was created with facility-based public sector providers in mind, though much of the content may also apply to community and private sector providers. The intended primary audience is in-country implementing partners and National Malaria Control Programs (NMCPs), though donors and other groups may find the resource relevant as well.

The proposed steps are arranged in chronological order, corresponding to the chapters in the resource:

• Step 1. Define the desired behaviour.
• Step 2. Defining priority provider groups.
• Step 3. Identifying factors that affect behaviours.
• Step 4. Involving users (providers and clients) in programme design.
• Step 5. Matching interventions to the factors uncovered.
• Step 6. Using a holistic approach to M&E.

A malaria service ecosystem model (Step 3), which shows the different levels of factors and actors that influence provider behaviour, provides a framework for understanding behavioural determinants, identifying key stakeholders and interventions, and undertaking M&E.

Editor's note: The video below shares an August 5 2020 webinar introducing the blueprint, sharing evidence about the drivers of provider behaviour and what works to improve it, discussing best practices for designing provider behaviour change activities, and exploring how they can be practically applied within the malaria service delivery context - illustrated with examples from the field.