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When available, RDTs were said to be used for screening pregnant women at sub health centres and health posts, though in some areas participants reported that screening was not being done at health posts. RDTs were not used exclusively for screening pregnant women, they were used for any symptomatic patients at the village posts and at the health centres if the lab service was not available, e.g. if no electricity. Understanding of the SST policy at health facilities was generally high among midwife coordinators and village midwives in both sites. Midwives submitted monthly reports and requests for RDTs and anti-malarials from the health centre pharmacy ra medicine hydroxychloroquine or drug store to take to sub health centres and health posts. However, many midwives in both sites had no formal training on either malaria in pregnancy, SST or the use of RDTs with some saying they learned how to use RDTs from colleagues. While many ANC services were provided at village level, SST was not routinely provided so women were counselled on the importance of SST and referred to a health facility, yet women often didn’t go due to transport costs or other reasons. Only one health facility in Mimika reported that SST was consistently implemented at village health posts (posyandu). At the time of the study, several facility staff said they were not implementing SST, including staff at the regional hospital in West Sumba. plaquenil capsule appearance Both the District Health Office and facility heads claimed there was no specific budget for malaria in pregnancy, any requirements were integrated into the Maternal and Child Health programme budget.

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The malaria coordinator was responsible for collating all malaria data so that there was no specific report on malaria in pregnancy, and SST data were not included in the health management information system (HMIS) and general malaria reports generated at health facility or district level. RDTs hydroxychloroquine and ccca alopecia and anti-malarials were ordered based on the monthly hydroxychloroquine sulfate and weight gain consumption reports provided by health facility ANC clinics and orders placed by the pharmacy (or head of drug store) to the District Health Office on a monthly or quarterly basis (usually quarterly). Procurement and distribution of RDTs and anti-malarials was said to be managed by the pharmacist and/or head of the drug store. Responsibility for reporting to the District Health Office on the implementation of SST lies with the malaria coordinators, alongside reporting on insecticide-treated net distribution and malaria cases. It is possible therefore to draw a direct link between health workers reporting that they don't give IPTp-SP in the 8th and sometimes 7th month of gestation and a reduction in the proportion of eligible women receiving this intervention. However, together these are relatively simple as compared with issues of financing and product and supply chain management, which both link to embedded health system problems. This misunderstanding is a link between complicated policy guidelines, poor implementation of this policy (training, information communication and leadership) and poor implementation of the intervention.

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