BackgroundAs efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar.MethodsThe study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms.ResultsThe pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy.ConclusionsResults show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.
BackgroundMyanmar has the highest burden of malaria in the Greater Mekong. However, there is limited information on ownership and use of insecticide-treated nets (ITNs) in areas of Myanmar most severely affected by malaria. We describe ownership and use of ITNs among people in the malaria-endemic eastern parts of Myanmar and factors associated with ITN use.MethodsA cross-sectional household survey using a multi-stage cluster design was conducted in malaria-endemic townships in eastern Myanmar during the high malaria season of August to September, 2014. An effective ITN was defined as 1) a long-lasting insecticide-treated net obtained within the past three years, or 2) any net treated with insecticide within the past year.ResultsIn 4,679 households, the average number of ITNs per household was higher in rural compared to urban areas (0.6 vs. 0.4, p <0.001) as well as the proportion of households owning at least one ITN (27.3% vs. 15.5%, p<0.001). The proportion of households in which all members slept under an ITN was also higher in rural compared to urban areas (15.3% vs 6.9%, p<0.001). In multivariate analysis, rural households (adjusted odds ratio [aOR] 1.78, 95% CI: 1.43–2.21, p<0.001), households in which respondents knew malaria is transmitted by mosquitoes (aOR 1.35, 95% CI: 1.10–1.65, p = 0.004), and in which respondents knew malaria can be prevented by ITN use (aOR 1.86, 95% CI: 1.28–2.70, p<0.001) were more likely to have all members sleep under an ITN. Compared to the lowest socio-economic quintile, households in the richest quintile were less likely to have all members sleep under an ITN (aOR 0.47; 95% CI: 0.33–0.66, p<0.001). Households in which the main income earner was a skilled worker or a businessman were less likely to have all members sleep under an ITN (aOR, 0.70, 95% CI: 0.52–0.96, p<0.025) compared to those headed by farmers or fishermen. Households in which all children slept under an ITN were more likely to be in rural areas (aOR 1.58, 95% CI: 1.19–2.09, p = 0.002) and have a household head who knew malaria can be prevented by ITN use (aOR 2.13, 95% CI: 1.30–3.50, p = 0.003). Children were less likely to have slept under an ITN in houses headed by skilled workers or businessmen (aOR 0.50, 95% CI: 0.33–0.75, p = 0.001) or unskilled workers (aOR 0.66, 95% CI: 0.49–0.89, p = 0.006) compared to households with farmers or fishermen. Higher socio-economic level was associated with lower ITN use by children (aOR 0.56, 95% CI: 0.36–0.88, p = 0.012, highest vs. lowest quintile).ConclusionsThe study found ownership of ITNs was low in Myanmar in comparison to the goal of one for every two household members. Use of ITNs was low even when present. Findings are of concern given the study areas were part of enhanced efforts to reduce artemisinin-resistant malaria. Nonetheless, groups vulnerable to malaria such as individuals in rural settings, lower socio-economic households, and workers in high mosquito exposure jobs, had higher rates of ITN ownership. Malaria knowledge was linked to effective ITN use s...
BackgroundRapid diagnostic tests (RDTs) for malaria enable proper diagnosis and have been shown to reduce overuse of artemisinin combination therapy. Few studies have evaluated the feasibility and use of RDTs in the private sector in Myanmar. The objectives of the study were to: 1) understand the acceptability of using RDTs in the informal sector in Myanmar; 2) examine motivations for use among informal providers; and, 3) highlight decision-making and knowledge of providers for diagnostic testing and treatment.MethodsQualitative interviews were conducted with 30 informal providers. Purposeful sampling was used to enrol study participants in the Mon and Shan State in Myanmar. All interviews were conducted in Burmese, translated into English, and two researchers coded all interviews using Atlas ti.ResultsMajor themes identified included: 1) informal provider and outlet characteristics, including demographic and background characteristics; 2) the benefits and challenges of using RDTs according to providers; 3) provider experiences with using RDTs, including motivations for using the RDT; 4) adherence to test results, either positive or negative; and, 5) recommendations from informal providers to promote increased use of RDTs in their communities. This study found that introducing RDTs to informal providers in Myanmar was feasible, resulting in improved provider empowerment and patient-provider relationships. Specific challenges included facility infrastructure to use and dispose RDTs and provider knowledge. This varied across the type of informal provider, with itinerant drug vendors more comfortable and knowledgeable about RDTs compared to general retail sellers and medical drug representatives.ConclusionsThis study found informal providers in Myanmar found the introduction of RDTs to be highly acceptable. Providers discussed improvement in service quality including provider empowerment and patient-provider relationships. The study also highlighted a number of challenges that informal providers face which may be used for future development of interventions.
BackgroundIn 2012 the Artemisinin Monotherapy Therapy Replacement (AMTR) project was implemented in Eastern Myanmar to increase access to subsidized, quality-assured artemisinin combination therapy (ACT) and to remove oral artemisinin monotherapy (AMT) from the private sector. The aim of this paper is to examine changes over time in the private sector anti-malarial landscape and to illustrate the value of complementary interventions in the context of a national ACT subsidy.MethodsThree rounds of cross-sectional malaria medicine outlet surveys were conducted, in 2012, 2013 and 2014. Project intervention areas were selected from the Myanmar Artemisinin Resistance Containment (MARC) area. Provider detailing was implemented in these selected areas. Comparison areas were selected outside of this catchment area, from townships in close proximity to the MARC framework. Within each domain, multi-staged sampling was used to select areas for the survey. Outlets with the potential to sell or distribute anti-malarials in the private sector were screened for eligibility.ResultsThe total number of outlets approached for an interview was as follows in the intervention and comparison areas, respectively: 2012, N = 2046 and 1612; 2013, N = 1636 and 1884; 2014, N = 2939 and 2941. The percentage of pharmacies, general retailers and mobile providers (classed as ‘priority outlets’) with oral AMT in stock on the day of the survey decreased over time in the intervention areas (2012 = 68 %; 2013 = 48 %; 2014 = 10 %). Conversely, quality-assured ACT availability increased among these outlets (2012 = 4 %; 2013 = 62 %; 2014 = 79 %). Relative oral AMT market share among priority outlets also decreased over time (2012 = 44 %; 2013 = 18 %; 2014 = 14 %), while market share of quality-assured ACT increased (2012 = 3 %; 2013 = 59 %; 2014 = 51 %). Among priority outlets in the comparison area, similar trends were observed, though changes over time were less substantial compared to the intervention area. Other outlet types (community health workers and health facilities) performed relatively well over time though modest improvements were also observed.ConclusionThe findings point to the successful design and implementation of a strategy to rapidly remove oral AMT from pharmacies, general retailers and mobile providers and to replace its use with quality-assured ACT. The evidence also highlights the importance of supporting interventions in the context of a high-level subsidy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1292-8) contains supplementary material, which is available to authorized users.
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