There are striking similarities in health system and other contexts between Tanzania and Ghana that are relevant to the scaling up of continuous delivery of insecticide treated nets (ITNs) for malaria prevention. However, specific contextual factors of relevance to ITN delivery have led implementation down very different pathways in the two countries. Both countries have made major efforts and investments to address this intervention through integrating consumer discount vouchers into the health system. Discount vouchers require arrangements among the public, private and non-governmental sectors and constitute a complex intervention in both health systems and business systems. In Tanzania, vouchers have moved beyond the planning agenda, had policies and programmes formulated, been sustained in implementation at national scale for many years and have become as of 2012 the main and only publicly supported continuous delivery system for ITNs. In Ghana national-scale implementation of vouchers never progressed beyond consideration on the agenda and piloting towards formulation of policy; and the approach was replaced by mass distribution campaigns with less dependency on or integration with the health system. By 2011, Ghana entered a phase with no publicly supported continuous delivery system for ITNs. To understand the different outcomes, we compared the voucher programme timelines, phases, processes and contexts in both countries in reference to the main health system building blocks (governance, human resources, financing, informatics, technologies and service delivery). Contextual factors which provided an enabling environment for the voucher scheme in Tanzania did not do so in Ghana. The voucher scheme was never seen as an appropriate national strategy, other delivery systems were not complementary and the private sector was under-developed. The extensive time devoted to engagement and consensus building among all stakeholders in Tanzania was an important and clearly enabling difference, as was public sector support of the private sector. This contributed to the alignment of partner action behind a single co-ordinated strategy at service delivery level which in turn gave confidence to the business sector and avoided the 'interference' of competing delivery systems that occurred in Ghana. Principles of systems thinking for intervention design correctly emphasize the importance of enabling contexts and stakeholder management.

译文

坦桑尼亚和加纳在卫生系统和其他情况下有惊人的相似之处,这些相似之处与扩大持续提供杀虫剂处理过的蚊帐 (itn) 以预防疟疾有关。但是,与ITN交付相关的特定背景因素导致两国的实施途径截然不同。两国通过将消费折扣券纳入卫生系统,为解决这一干预措施做出了重大努力和投资。折扣券需要公共、私营和非政府部门之间的安排,是对卫生系统和商业系统的复杂干预。在坦桑尼亚,凭单已经超出了规划议程,制定了政策和方案,并在全国范围内持续执行了多年,2012年已成为itn的主要和唯一的公共支持的持续交付系统。在加纳,全国范围内对凭单的实施从未超出对议程的考虑和制定政策的试点; 这种方法被对卫生系统的依赖或一体化程度较小的大规模分发运动所取代。到2011年,加纳进入了一个没有公共支持的itn连续交付系统的阶段。为了了解不同的结果,我们参考了主要的卫生系统组成部分 (治理,人力资源,融资,信息学,技术和服务提供),比较了两国的凭证计划时间表,阶段,流程和背景。为坦桑尼亚的代金券计划提供有利环境的背景因素在加纳没有这样做。凭单计划从未被视为适当的国家战略,其他交付系统也不是互补的,私营部门也不发达。坦桑尼亚所有利益攸关方在参与和建立共识方面投入了大量时间,这是一个重要且明显促成的差异,公共部门对私营部门的支持也是如此。这有助于在服务交付层面采取单一协调战略的伙伴行动,这反过来又给商业部门带来信心,避免了加纳发生的竞争性交付系统的 “干扰”。干预设计的系统思想原则正确地强调了启用环境和利益相关者管理的重要性。

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