Table 2. Matrix of health systems research and development needs.

Level/Building Block	Governance	Human Resources	Financing	Informationa	Service Delivery, Medicines, and Technology
Community level	How can lay boards (community leader councils) strengthen local health service delivery? (Group 1 countries)	What is the role of CHWs and private sector providers in treatment of malaria and nonmalaria fevers, and in what settings are they crucial?	What are the main financial (and other) barriers to health services use and how can these be overcome?	What is the best approach to community-based monitoring of malaria and other communicable diseases building on existing and past efforts?	How can the community components of integrated approaches (IMCI and IMAI) be strengthened and adapted to different epidemiological and system settings?
	What is the role of communities in active efforts at transmission reduction (as opposed to reducing morbidity and mortality from malaria)?	How can they be incentivized and integrated with the health system to support and sustain their performance?	—	How can health information systems include information from and to CHWs? (Group 1 countries)	—
Facility level	Tools for assessing illicit payment for services	What are the most effective and appropriate methods for monitoring health worker performance?	—	How can modeling and evaluation innovations for malaria eradication strengthen health systems?	Development of IMCI and IMAI updated with new diagnostic tools and adapted to the malaria elimination context
	—	What types of financial and nonfinancial incentives can best support and sustain improved health worker performance?	—	Tools for assessing local coverage, quality, and equity to apply to systems effectiveness framework	Development of appropriate multidisease diagnostic tools
	—	—	—	—	Tools for drugs and supplies stock management
District level	What model(s) for district management of malaria-control programmes are effective in achieving and maintaining near zero malaria burden en route to elimination?	What are the appropriate organization and management, skill mix, human resource structure, and enabling factors to support effective service delivery?	Tools for developing efficient decentralized decision making and administration	How do we engage private providers and capture their data?	How can private provider involvement in case management, surveillance and vector control be harnessed?
	—	—	—	How can district managers be supported to use the systems effectiveness framework and tools to remove bottlenecks in service delivery?	How can data for decision-making skills be taught such that responses to resurgences in malaria burden are swiftly responded to? [17]Tools for systems effectiveness framework
National level	What investment and tools will ensure the quality of governance and accountability required for malaria elimination? (Groups 2 and 3).	What experience is there of strengthening health worker motivation and performance through disease-specific programmes, especially looking at global elimination initiatives (positive synergies)?	What financial resources will be required to manage the certification process at subnational and national levels? (Groups 2 and 3).	What experience is there of strengthening health management information systems through disease-specific programmes, especially looking at global elimination initiatives (positive synergies)?	What is the cost-effectiveness of different delivery modes in different national/subnational settings (e.g., community strategy versus facility, integrated curative services versus specialized, integrated vector management) malaria vector control; operations research on effect of scale on optimal organizational structures?
	What governance structures are required to manage the elimination certification process?	—	What financing mechanisms are optimal at the national level to ensure a predictable and sustained flow of resources for malaria elimination? (Group 2)	—	What experience is there of strengthening service delivery and logistics/distribution chains through disease-specific programmes, especially looking at global elimination initiatives (positive synergies)?
	What experience is there of strengthening health system governance through disease-specific programmes, especially looking at global elimination initiatives (positive synergies).	—	—	—	—
	Tools to identify and evaluate possible interventions required in health system governance	—	—	—	—
Regional and global level	What are the determinants of successful intercountry collaboration on shared public health targets?	Tools: development of better regional training	—	—	What are the strengths and weaknesses of current malaria surveillance and case-management practices in endemic countries belonging to group 2?
Intersectoral level	Does the formulation of time-specific malaria elimination targets strengthen the participation of public and private stakeholders?	—	What are the macroeconomic benefits of malaria elimination? (Group 3)	—	What are the local geographic, economic, ecological, cultural determinants of malaria, and community and health system response? Includes operations research on service provision for mobile and marginalized populations
	—	—	—	—	What architecture and dynamics of complex intersectoral intervention strategies are required to achieve a major, sustainable, and cost-effective city-wide impact on persistent urban malaria?

Group 1, countries that are scaling up and entering the sustained control phase, where most of the population lives in areas where malaria elimination is considered impossible with existing tools; group 2, countries with focal malaria, where a large part of the population lives in malaria-free areas, and where health systems strengthening could play a crucial role in interrupting transmission in many but not necessarily all of the existing foci. These are often countries with very diverse and complex health systems challenges; group 3, elimination-ready countries. When a group of countries is not indicated, the text applies to group 1 and group 2 countries alike.

^aResponsibility for these issues shared with malERA Monitoring, Evaluation, and Surveillance group.

IMAI, integrated management of adult and adolescent illness; IMCI, integrated management of childhood illness.