Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: an evaluation of incentive schemes among informal private healthcare providers

Abstract

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.

Availability and quality of anti-malarials among private sector outlets in Myanmar in 2012: results from a large, community-based, cross-sectional survey before a large-scale intervention

“…After this study took place, the two interventions suggested above were indeed carried out, to successfully replace oral artemisinin-based monotherapies with subsidized QA-ACT [ 8 ], and then to ensure their proper use through the use of subsidized RDTs [ 14 – 16 ]. Interestingly, educational campaigns to both the provider and the community proved to be effective, with increased educational visits to providers leading to increased levels of RDT use [ 14 – 16 ]. This follow-up intervention also offered the potential to crowd out the supply of sub-standard and counterfeit ACT, offering a relatively simple solution to an otherwise challenging problem [ 7 ].…”

Malaria incidence in Myanmar 2005–2014: steady but fragile progress towards elimination

“…Myanmar has the greatest malaria incidence in the Greater Mekong Region [ 1 , 8 ] and its new government and poorly resourced public health system will have to overcome a variety of political, economic and logistic challenges if malaria is to be eliminated [ 9 ]. Several interventions have already been implemented and these include the training and deployment of community health workers [ 10 , 11 ], the provision of insecticide-treated bed nets [ 12 ] and strategies to improve access to rapid diagnostic tests [ 13 ] and artemisinin-based combination therapy (ACT) [ 14 ]. There has also been a concerted effort to improve diagnosis and management of the disease in the private sector where the majority of malaria cases are managed [ 15 ]; here there has been a particular focus on the removal of poor quality ACT and artesunate monotherapy [ 14 , 16 ].…”

Can Plasmodium’s tricks for enhancing its transmission be turned against the parasite? New hopes for vector control

“…The hrp2 gene, however, is dispensable, and parasite strains that have deleted this gene and escape RDT detection are on the rise. In a recent modeling study, false-negative rates with HRP2-based tests were predicted to attain 20% in many parts of Africa by 2030 [80]. Nucleic acid amplification tests (NAAT) are superior for detecting mixed infections, cases with low parasitemia.…”