Assessment of Malaria Border Health Posts: Evaluating Malaria Services in Southern African Border Districts+

The study reported in this paper was part of a larger investigation, the E8 border post impact evaluation study, which was undertaken in seven countries in the E8 region. The methods and objectives differed between the three front-line countries (Namibia, Botswana, South Africa) in which it was conducted, and the four second-line countries. In this paper, only the results of the study conducted in second-line line countries are reported. Related studies in frontline countries were completed later and will be reported separately. Below is a description of the core intervention, and the associated study as carried out in the four second-line countries.

Core interventions

In 2017, the E8 with the help of partner organisations established malaria health posts along international frontiers within the region, supported by The Global Fund to Fight AIDS, Tuberculosis and Malaria (see Fig. 1). The locations chosen for border posts followed a desk review and a consultation with national malaria control programs in each country. Candidate locations were border areas, which were underserved in terms of health facility provision, and where there was evidence of a gradient in transmission from one side of the border to the other. The rationale was that borders with different levels of transmission on opposite sides, as evidenced by district health data for malaria, would be prone to significant parasite importation from the high to the low endemicity sides of the border in the absence of adequate malaria services along the border.

Fig. 1
figure 1

(Source: E8 Secretariat)

E8 Malaria border health posts, and study sites in second line countries

The posts offered free testing and treatment to residents of border districts and travellers, and provided outreach services to surrounding communities, as summarized in Table 2.

Table 2 Primary models of service delivery for E8 border health posts (Total 46)

Study outcomes

The following outcomes were measured in the study described in this paper: (1) Proportions of respondents receiving timely diagnosis and treatment for febrile illness; (2) Proportions of respondents able to access health facilities for malaria diagnosis and treatment; (3) Proportions of respondents with access to malaria prevention; (4) Respondents’ knowledge of symptoms and malaria prevention, and awareness of border health posts; and (5) Frequency of domestic and international travel.

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Study design and implementation

The study in second line countries, was conducted in one site located in the vicinity of a malaria border post in each of the four countries, selected in consultation with national malaria control programmes, at border crossings with high proportions of mobile populations (Fig. 1). The study population included residents of all ages within a 30 km radius of a selected malaria post.

Using census data, each study area was segmented into geographic clusters of roughly 100–125 households each. Three of these segmented clusters were randomly selected, and 25 households were randomly sampled in each segment to achieve a sample of 75 households per site. An additional 20% contingency was included to allow for non-response.

Written informed consent was sought from the head of each selected household, or from a responsible household member acting as their representative. A structured questionnaire was used to obtain information on knowledge of malaria, attitudes toward and access to malaria posts and existing health facilities, the proportion of residents receiving diagnosis and treatment for febrile illness, practices for malaria prevention, and risk factors for malaria associated with local and international travel. Sections of the questionnaire were adapted from the standard Roll Back Malaria Indicator Survey [11]. Questions were answered by the head of household or their representative on behalf of individuals within a selected household; parents or guardians responded on behalf of children under 18 years of age.

It was assumed that 75 households would need to be selected in each site to achieve a sample size of 300 individuals per site, or 1200 individuals for the four countries combined. In sites where average household size differed from 4 individuals per household, the total number of households was adjusted to achieve the target of approximately 300 individuals. The sample size of 300 per site was pragmatically chosen to match the resources that were available to conduct the study. For questions that were only asked of subgroups of participants, for example proportions seeking treatment out of those who had fever within the recall period, the sample sizes were necessarily smaller.

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In Mozambique, Centro de Investigação em Saúde de Manhiça (CISM) conducted the study. In Angola, Zambia and Zimbabwe, the study was carried out by their respective NMCPs. The studies were overseen and coordinated by Elimination 8 Secretariat. Fieldwork was conducted within 6 to 18 months of the implementation of the border posts in each country (Table 3).

Table 3 Date of implementation of border health posts and timelines by country

Ethics approval was obtained from the University of California San Francisco Committee on Human Research (IRB# 17-23221), and the ethics committees of implementing partner organisations in each country. The E8 Research Subcommittee acted as a study steering committee.

The study was funded by The Bill and Melinda Gates Foundation through a grant to the University of California San Francisco. Additional funding for the study was obtained from The Global Fund to Fight AIDS, tuberculosis and Malaria. The funders had no role in the publication of the study.