Bottlenecks, concerns and needs in malaria operational research: the perspectives of key stakeholders in Nigeria
Onyiah et al. BMC Res Notes
Bottlenecks, concerns and needs in malaria operational research: the perspectives of key stakeholders in Nigeria
Pamela Onyiah 2
Al‑Mukhtar Y. Adamu 1
Rotimi F. Afolabi 0
Olufemi Ajumobi 2 4
Maduka D. Ughasoro 3
Oluwaseun Odeyinka 0
Patrick Nguku 2 4
IkeOluwapo O. Ajayi 0 2
0 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan , Queen Elizabeth Road, UCH Campus, Ibadan 23402, Oyo State , Nigeria
1 Department of Medical Microbiology and Parasitology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University , Kano , Nigeria
2 Nigeria Field Epidemiology and Laboratory Training Programme , Abuja , Nigeria
3 Department of Paediatrics, University of Nigeria Enugu Campus , Enugu , Nigeria
4 African Field Epidemiology Net‐ work , Abuja , Nigeria
Objective: We conducted a study to determine stakeholders' perspective of the bottlenecks, concerns and needs to malaria operational research (MOR) agenda setting in Nigeria. Results: Eighty‑ five (37.9%) stakeholders identified lack of positive behavioural change as the major bottleneck to MOR across the malaria thematic areas comprising of malaria prevention 58.8% (50), case management 34.8% (39), advocacy communication and social mobilisation 4.7% (4) while procurement and supply chain management (PSM) and programme management experts had the least response of 1.2% (1) each. Other bottlenecks were inadequate capacity to implement (13.8%, n = 31), inadequate funds (11.6%, n = 26), poor supply management (9.4%, n = 21), administrative bureaucracy (5.8%, n = 13), inadequacy of experts (1.3%, n = 3) and poor policy implementation (4.9%, n = 11). Of the 31 stakeholders who opined lack of capacity to execute malaria operational research; 17 (54.8%), 10 (32.3%), 3 (9.7%) and 1 (3.2%) were experts in case management, malaria prevention, surveillance, monitoring and evaluation and PSM respectively. Improvement in community enlightenment and awareness strategies; and active involvement of health care workers public and private sectors were identified solutions to lack of positive behavioural change.
Malaria; Bottlenecks; Stakeholders; Operational research; Nigeria
Globally, malaria has been reported as the most deadly
and life-threatening parasitic disease [
]. In 2015, an
estimated 212 million new cases of malaria and 429,000
deaths were recorded globally; African region accounted
for about 90 and 92% of these respectively [
accounted for 29% of malaria global burden and 26% of
its global deaths [
Though the incidence rate of malaria has decreased
by 41% globally between 2000 and 2015, malaria
continues to have a devastating impact and efforts must be
accelerated for reduction of the incidence rate especially
in African region [
]. Thus, World Health Organisation
(WHO) has emphasised the importance of operational
research (OR) and setting research priorities that can
help direct research towards malaria elimination specific
]. It is expected that OR significantly
contributes to influencing policy change or improving
performance at all levels . Operational research, an integral
part of disease control programme activities is
important in providing an evidence-base for context-specific
implementation of global best-practice interventions to
maximise their outcome and impact, and identifying
hindrances to programme performance [
]. Locally, OR
aims to harness the relevant answers and solutions that
can be used by a specific programme based on the
setting’s peculiarities [
In sub-Saharan Africa, access to prevention and case
management (CM) intervention is sub-optimal [
Operational research studies are meant to assess the
feasibility of new interventions in country specific
settings, identify bottlenecks in malaria control [
are essential for evaluation of integration of new methods
into routine health systems to improve malaria diagnosis
and outcomes . A huge bottleneck exists which varies
by region despite significant improvements in access to
core malaria control interventions [
In the last decade, majority (77%) of malaria OR (MOR)
projects implemented globally were from WHO Africa
region countries—Nigeria ranked 3rd (Tanzania 1st and
Kenya 2nd) [
]. Meanwhile, prioritisation of MOR for
effective malaria control and eventual elimination is a
clearly outlined strategy in the National Malaria
Strategic Plan (NMSP) [
]. The Nigeria National Malaria
Elimination Programme (NMEP) held MOR stakeholder
workshops in 2010, 2012, 2013, 2014 and produced a list
of harmonised MOR questions prioritised by relevance
and thematic areas. Only three (9%) of 33 prioritised
questions were answered between 2014 and 2016. This
very low uptake of MOR questions is a cause for
concern and recognizes the need to unravel probable
bottlenecks militating against answering these questions
. Therefore, we elicited stakeholders’ perspectives on
bottlenecks, concerns and needs of MOR agenda setting
in Nigeria as part of preliminary study towards setting a
National MOR agenda.
Study design and population
The NMEP formed and led a planning committee for
country MOR dialogue comprising thematic program
officers and other malaria control partners including
Nigeria Field Epidemiology and Laboratory Training
Programme (NFELTP) [
]. The NMEP initiated the
research. The NFELTP was assigned the responsibility
of setting up and leading a MOR Agenda—Setting Task
Team which conducted a preliminary study towards
identification of OR gaps, bottlenecks and needs.
A cross-sectional study was conducted in Nigeria from
October to November 2016. The study population was
malaria researchers in and outside Nigeria who must
have conducted or involved in malaria research in
Nigeria within the last decade. They were identified from
publications and snowballing. The search was conducted
with keywords’ combination of ‘malaria, agenda setting,
operation research and priorities’ using Pubmed, Web of
Science, Google Scholar and Medline. Recent
publications from 2010 to 2016 were included. The participants
comprised of development partners, non-governmental
organisation stakeholders, malaria policy makers and
implementers at all tiers of government, healthcare
workers and malaria research experts in the academia.
Data collection and analysis
A semi-structured questionnaire was adapted from a
previous study [
] and pretested among nine malaria
stakeholders in Abuja-Nigeria prior to the survey. The
questionnaire was revised by the 12-member MOR
agenda setting task-team [
] comprising NFELTP
fellows, NMEP officers and university researchers. The
same earlier validated questionnaire was
self-administered using both paper-based and online survey
platform. The online survey was administered using Survey
Monkey® to ensure participation of malaria researchers
who were unavailable in Nigeria or were residents
elsewhere globally. The questionnaire sought information on
personal biodata, area of expertise, experience in MOR
in Nigeria, challenges, bottlenecks in MOR and needs to
address the gaps identified from the participants
(Additional file 1). The responses to bottlenecks and needs
were grouped into themes and rated using a score of 1–5
based on priority in MOR with 1 being most priority and
5 least in priority. Data were entered and cleaned using
Microsoft excel version 2007. IBM SPSS version 20 was
used for data analysis. Results based on themes in malaria
control were presented in frequencies and proportions.
Socio‑demographic characteristics of the study participants
Of 224 identified researchers, 185 (82.6%) participated
in the study out of which 85 (45.9%) participated in the
face-to-face survey and 100 (54.1%) of the participants
did the survey “Online”. The mean age of the participants
was 45.0 years (standard deviation: 9.1), and 125 (70.6%)
were males. Highest proportion of the participants
were malaria policy-makers and programme
managers (21.1%); parasitologist (16.7%) and clinicians (15.6%)
Working experience of the study participants on MOR and its
Majority (94.9%) of the participants’ work experience
were currently Nigeria-based; while only 19.8% of them
had malaria work experience outside Nigeria. About half
of the respondents (50.8%) opined that Nigeria’s MOR
agenda should be different from that of other settings.
Almost half (48.6%) of the participants had been involved
in MOR in Nigeria, of which 43.7% had expertise in CM,
40.8% in malaria prevention (MiP) and 1.4% in
Advocacy, Communication and Social Mobilisation (ACSM).
Most (72.2%) participants had challenges while
conducting MOR: frequent among them were “poor community
Malaria operational research concerns and needs as presented by the stakeholders
Stakeholders from all expertise believed bottlenecks
were hindering MOR in Nigeria. Lack of positive
behavioural change was observed as a bottleneck by the
stakeholders in all the malaria thematic areas comprising
MiP, CM, procurement and supply chain management
Lack of positive behavioural change 50
Inadequate funding 18
Poor supply management 3
Inadequate number of experts 3
Poor implementation of policy 6
Manpower gaps/lack of capacity 10
Administrative bureaucracy 7
Unharmonised coordination and implementa‑ 1
tion of multiple interventions
(PSM), programme management (PM) and ACSM. Of 85
responses got from stakeholders who identified lack of
positive behavioural change as a bottleneck, 50 (58.8%)
were experts in MiP, while 29 (34.1%) and 4 (4.7%) were
experts in CM and ACSM respectively. Only experts in
MiP, CM and programme management view inadequate
funding as a bottleneck. Lack of competent capacity to
execute malaria interventions was also identified as a
bottleneck in 4 thematic areas comprising CM (54.8%),
MiP (32.3%), Surveillance, Monitoring & Evaluation
(9.7%) and PSM (3.2%), having the least response. Poor
supply management systems was identified by
stakeholders in MiP, CM and PSM thematic groups as a bottleneck
impeding MOR execution and implementation. Other
bottlenecks identified include administrative
bureaucracy, poor implementation of policy and unharmonised
coordination and implementation of multiple
interventions (Table 2).
The stakeholders also presented concerns on the effects
of the identified bottlenecks in MOR in Nigeria. In most
cases the concerns raised were multi-dimensional due
to the peculiarities of the thematic areas. Some
solutions as to what need to be done were also provided by
the experts which were linked to the identified
bottlenecks (Table 3). The concerns raised by the stakeholders
in respect to behavioural change was that people at the
community, government and private levels were
resistant to positive changes especially for new programmes.
Improvement in community enlightenment and
awareness strategies is important for the government to curtail
this impediment. Public and private health care
workers also need to be actively involved in new programmes
and interventions. The major concerns presented for
inadequate funding of MOR include lack of
budgetary allocation and inadequate leveraging of the limited
a Multiple responses
# Key: MiP malaria prevention, CM case management, SME surveillance, monitoring & evaluation, ACSM advocacy, communication & social mobilisation, PSM
procurement & supply chain management, PM programme management
funds. The stakeholders agreed that identifying domestic
fund sources and prioritising areas to disburse the funds
would effectively reduce this challenge at national, state
and local government area levels (Table 3).
Concerns observed for poor supply management
system include wastages or delay in malaria commodities
supplies and unnecessary inaccessibility of the
commodities. Timely microplanning and effective logistic supply
management using alternative models were presented
as requirements to curtail this bottleneck. Experts in
MiP and PM raised concerns regarding administrative
bureaucracy to include conflict of interests and lack of
political will to implement MOR. Dedication in
partnership and involvement of relevant government sectors
was seen as a need to tackle and reduce administration
bureaucracy (Table 3).
This study revealed that malaria stakeholders encounter
bottlenecks while conducting MOR across thematic areas
of malaria control. These had been previously observed
in Tanzania during a research priority writing workshop
for experts [
Lack of positive behavioural change was identified by
majority of the stakeholders as a bottleneck; this is very
vital as both the community (towards whom the malaria
interventions are targeted) and the healthcare workers
(who directly implement the intervention) must show
commitment and determination in executing such
interventions. They must also collaborate with policy-makers
in allowing ways to improve the intervention through the
appropriate research [
]. Misconceptions due to certain
cultural norms or unsubstantiated knowledge to
certain interventions such as use of long lasting insecticidal
net, artemisinin-based combination therapy or
insecticides have been found to hinder the implementation and
thereby pose a bottleneck to conduct of research which
investigate the interventions’ efficacy let alone allow for
their improvement [
The poor community participation in MOR may be
attributed to lack of awareness and wrong perception
of malaria interventions in the community. For malaria
intervention programmes to succeed there must be full
community involvement as an integral component of the
malaria elimination [
Inadequate funding is an impediment to the conduct of
MOR. The limited fund offered mainly by external donors
is not enough to investigate the myriad of problems
encountered while executing various malaria
interventions. Often research studies are abandoned or
inconclusive due to insufficient funds as most of the OR carried
out in Nigeria are donor fund-driven [
]. Taking heed
of the dwindling international funds especially from the
year 2011 [
] which has grossly affected interventions
and OR progress in low-income countries, other sources
of funds to conduct MOR are required. Some
stakeholders opined that domestic sources of fund need to be
identified so that focus will be on national priorities for MOR.
Likewise, judicious use of the limited fund by leveraging
to cover all thematic areas based on the country specific
research needs is important to avoid disproportionate
allocation of funds to few NMEP thematic areas such as
MiP; CM and the neglect of other thematic areas such as
OR and PSM [
A comprehensive capacity development strategy is
required to bridge the manpower and expertise gaps in
conducting MOR. Researchers and experts in-country
could develop a cost-effective training programme for
young researchers which can be anchored by NMEP,
NFELTP or similar malaria oriented bodies [
Though translation of OR findings into policy and
practice is a complex and context sensitive process,
interaction and trust between policymakers and researchers
were found to be important factors in the use of research
for policymaking, as were political and bureaucratic
processes and the relevance or quality of the research.
Efforts to support research findings translation in lower
and middle income countries need to foster collaboration
right from the beginning of the research. This can further
improve local research capacity and full involvement of
the community [
5, 20, 22
This study revealed lack of positive behavioural change
in conducting and acceptance of malaria interventions
OR as a major bottleneck to addressing country specific
MOR needs, followed by inadequate local funds.
Adequate involvement of community members and health
care workers is essential to improve as well as ascertain
effectiveness and efficacy of interventions.
Identifying sources of domestic funds and its judicious
use, strong advocacy for increased and sustained funding
as well as effective and efficient use of existing resources
to fill existing gaps needs to be maintained at all levels of
The study relied on self-reported information which
is prone to bias due to the background and personal
interest of the respondents. This may be coupled with
their awareness of the study objectives which cannot be
Additional file 1. Agenda‑setting for operational research (national
malaria elimination programme). A semi‑structured questionnaire used
to elicit information on personal biodata, area of expertise, experience in
MOR in Nigeria, challenges, bottlenecks in MOR and needs to address the
Additional file 2. Working experience of the study participants on MOR
and its associated challenges. A tabular data summarising the study
participants’ working experiences and challenges faced while conducting
MOR in Nigeria.
OR: operational research; MOR: malaria operational research; PSM: procure‑
ment and supply chain management; WHO: World Health Organisation; NMEP:
National Malaria Elimination Programme; ACSM: advocacy, communication
and social mobilisation; PM: programme management; CM: case manage‑
ment; MiP: malaria prevention; SME: surveillance, monitoring and evaluation;
NMSP: National Malaria Strategic Plan; NFELTP: Nigeria Field Epidemiology And
Laboratory Training Programme.
OA, PN, IOA conceptualised, designed and coordinated the study. PO, AYA, OA,
MDU, OO, IOA administered the field and online interviews; PO, OO compiled
and reviewed data integrity. AYA, RFA, OA, IOA drafted and reviewed the
manuscript. RFA conducted the data analysis and interpretation. All authors
read and approved the final manuscript.
We acknowledge the contribution of all the participants in the study and the
Nigeria Malaria Elimination Programme.
The authors declare that they have no competing interests.
Availability of data and materials
All relevant data can be made available by the corresponding author based
on reasonable request.
Consent for publication
Ethics approval and consent to participate
Ethical approval for the study was obtained from the National Health Ethical
Review Committee and the joint Ethics Review Committee of the University of
Ibadan and University College Hospital, Ibadan. Written informed consent was
obtained from the participants. Confidentiality of the information provided by
the participants was ensured.
This study was supported by Cooperative Agreement Number (GH15‑1619)
U2GGH001876, funded by the Centers for Disease Control and Prevention. Its
contents are solely the responsibility of the authors and do not necessarily
represent the official views of the Centers for Disease Control and Prevention
or the Department of Health and Human Services.
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.
1. Molla E. Malaria : what are the needs for diagnosis, treatment and control ? Biol Med . 2016 . https://doi.org/10.4172/ 0974 ‑ 8369 . 1000320 .
2. World Health Organization. World malaria report. Geneva: World Health Organization; 2016 .
3. Zachariah R , Ford N , Maher D , Bissell K , Van den Bergh R , van den Boogaard W, et al. Is operational research delivering the goods? The journey to success in low‑income countries . Lancet Infect Dis . 2012 ; 12 : 415 - 21 .
4. Canavati SE , Lawford HLS , Fatunmbi BS , Lek D , Top‑Samphor N , Leang R , et al. Establishing research priorities for malaria elimination in the context of the emergency response to artemisinin resistance framework‑the Cambodian approach . Malar J. 2016 ; 15 : 120 .
5. Zachariah R , Harries AD , Ishikawa N , Rieder HL , Bissell K , Laserson K , et al. Operational research in low‑income countries: what, why , and how? Lancet Infect Dis . 2009 ; 9 : 711 - 7 .
6. Kiefer S , Knoblauch AM , Steinmann P , Barth‑ Jaeggi T , Vahedi M , Maher D , et al. Operational and implementation research within global fund to fight aids, tuberculosis and malaria grants: a situation analysis in six countries . Glob Health . 2017 ; 13 : 22 .
7. Hawkes S , Aulakh BK , Jadeja N , Jimenez M , Buse K , Anwar I , et al. Strengthening capacity to apply health research evidence in policy making: experience from four countries . Health Policy Plan . 2016 ; 31 : 161 - 70 .
8. World Health Organisation, Global Fund to Fight AIDS, Tuberculosis and Malaria. Guide to operational research in programs supported by the global fund; Geneva . 2008 . http://www.who.int/hiv/pub/operational/ or_guide_gf. pdf. Accessed 16 Aug 2017 .
9. Zhou S , Rietveld AEC , Velarde‑Rodriguez M , Ramsay AR , Zhang S , Zhou X , Cibulskis RE . Operational research on malaria control and elimination: a review of projects published between 2008 and 2013 . Malar J. 2014 ; 13 : 473 .
10. Federal Ministry of Health, National Malaria Elimination Programme. National Malaria Strategic Plan 2014 -2020; 2014 .
11. Ajumobi O , Uhomoibhi P , Onyiah P , Babalola O , Sharafadeen S , Ughasoro MD et al. Setting a Nigeria National Malaria Operational Research Agenda: The process (under review).
12. Federal Ministry of Health, National Malaria Elimination Programme ( 2017 ). Report 5th National Malaria Operations Research Stakeholders' Workshop 8-9 February 2017 ).
13. Woodward A , Sondorp E , Witter S , Martineau T. Health systems research in fragile and conflict‑affected states: a research agenda‑setting exercise . Health Res Policy Syst . 2016 ; 14 ( 1 ): 51 .
14. Ajayi IO , Ughasoro MD , Ogunwale A , Odeyinka O , Babalola O , Sharafadeen S , et al. A qualitative exploration of malaria operational research situation in Nigeria . PLoS ONE . 2017 ; 12 ( 11 ):e0188128. https://doi. org/10.1371/journal.pone. 0188128 .
15. National Institute for Medical Research. Setting national Agenda for health systems research for tuberculosis, Malaria and Neglected Tropical Diseases in the United Republic of Tanzania. Dar es Salaam: Access and Delivery Partnership ; 2015 . p. 8 - 15 .
16. Aribodor DN , Ugwuanyi IK , Aribodor OB . Challenges to Achieving Malaria Elimination in Nigeria . Am J Public Health Res . 2016 ; 4 ( 1 ): 38 - 41 .
17. Tobin‑ West CI , Kanu EN . Factors influencing the use of malaria prevention methods among women of reproductive age in peri‑urban communities of Port Harcourt city , Nigeria. Niger Postgrad Med J. 2016 ; 23 ( 1 ): 6 - 11 .
18. Adebayo AM , Akinyemi OO , Cadmus EO . Knowledge of malaria prevention among pregnant women and female caregivers of under‑five children in rural Southwest Nigeria . PeerJ . 2015 ; 3 : e792 .
19. Fall IS , Bakyaita N , Minkoulou EM , Diarra T , Ki‑zerbo GA , Chatora R . Accelerated malaria control towards its elimination in the African Region . Afr Health Monit . 2010 ; 11 : 37 - 43 .
20. Head MG , Goss S , Gelister Y , Alegana V , Brown RJ , Clarke SC. Lancet. Global Health . 2017 ; 5 : e772 - 81 .
21. Martin G , Grant A , D'Agostino M. Global health funding and economic development . Glob Health . 2012 ; 8 : 8 .
22. Woelk G , Daniels K , Cliff J , Lewin S , Sevene E , Fernandes B . Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries . Health Res Policy Syst . 2009 ; 7 : 31 .