Background
Myanmar is one the malaria endemic countries in the South-east Asia Region (SEAR) aiming to eliminate malaria by 2030 according to National Strategic Plan for malaria elimination [
1]. The country once reported highest mortality (53.6%) due to malaria in the region even though it shared only 7% of total cases in the region [
2]. The mortality was high among population residing in Thai and Indian borders, internally displaced population in conflict zones and among ethnic minority regions [
3,
4]. The country also noted as an epicentre for drug resistant malaria due to incomplete and inappropriate use of anti-malarial drugs, use of fake or expired anti-malarial drugs and expensive artemisinin derivatives [
3].
Despite the political crisis and conflicts, difficult geographic area and related access, spreading drug resistance in the country, it was reported that the country has reduced the malaria morbidity by 81.1% and mortality by 93.5% from 2005 to 2014 [
5]. Similarly, the high malaria transmission area (> 1 case per 1000 population) has also been reduced from 53 to 16% [
6,
7].
Plasmodium falciparum is always the most commonest infection in Myanmar which contributes to 65–70% of cases followed by
Plasmodium vivax [
7]. The key interventions quoted for the successful reduction of malaria burden were placement of village health volunteers (VHV) strategically at rural, remote, hard to reach and conflict areas, good coverage of insecticide-treated bed nets among at-risk population and improved access to artemisinin-based combination treatment [
5,
8].
Based on the evidence created through government and national/International non-government organizations (NGOs), Myanmar introduced VHV in 2007 at community level to improve the access and achieve universal coverage of malaria prevention and care services among rural and hard to reach population [
9‐
12]. A total of 40,000 VHV (half under national malaria control programme and half under various NGOs) are trained in the country, of which 15,000 are actively providing services related to malaria prevention and care [
13]. In addition to early diagnosis of malaria using rapid diagnostic kit test (RDT) and delivery of first-line anti-malarial drugs as per national malaria treatment guidelines, they also deliver the insecticide-treated bed nets, and provide malaria information and advice to at-risk population [
10,
13].
VHV are trained and supervised by basic health staffs (BHS-namely health assistant, lady health visitor, auxiliary nurse midwives, and public health supervisors) placed at different types of public health facilities like township hospitals, station hospitals, rural health centres (RHCs) and sub-RHCs. BHS deliver clinic and home based preventive, promotive and curative (treatment and referral) healthcare services related to all national health programmes namely maternal and child health (antenatal and postnatal care, immunization, contraception), communicable disease including vector borne disease surveillance and control, school health, treatment of minor illnesses like diarrhoea and acute respiratory infection, and others [
12,
14]. VHV are recruited to complement the malaria control activities of BHS at rural, hard to reach population.
A dedicated workforce like placement of VHV was successful in improving the access to and utilization of healthcare services related malaria in Cambodia, Zambia, Ghana, and other countries [
12,
15‐
20]. However, a systematic review found insufficient evidence to comment on effectiveness of malaria control interventions by VHV in reducing morbidity and mortality [
21]. Further, studies comparing the performance of VHV with existing formal healthcare workers in delivering malaria control activities are limited. As Myanmar is planning to recruit more VHV and upgrade them as integrated community malaria volunteers (additional responsibilities to provide dengue, lymphatic filariasis, HIV, tuberculosis, leprosy services) in the near future, it is time to review their performance in delivering malaria control activities before providing additional responsibilities.
This countrywide study was conducted to assess and compare the malaria diagnostic and treatment services provided by VHV and BHS under National Malaria Control Programme (NMCP) of Myanmar in 2015. The specific objectives of the study were to determine and compare VHV and BHS by: (a) number and proportion of patients screened for malaria; (b) number and proportion of patients diagnosed with malaria; (c) number and proportion of patients with malaria initiated on treatment; (d) number and proportion of patients with malaria initiated on treatment within 24 h of fever; (e) number and proportion of patients with malaria provided complete treatment; and, (f) to assess the influence of type of healthcare provider on treatment initiation after adjustment with demographic and clinical factors.
Discussion
The current study assessed the performance of VHV compared to BHS in terms of providing access and quality of malaria care to patients diagnosed in 2015 under NMCP of Myanmar. In both VHV and BHS groups, the proportion of patients diagnosed with malaria among screened was similar. However, higher proportion of children (< 15 years) and women with undifferentiated fever were provided malaria-screening services by VHV compared to BHS. Similarly, the chance of receipt of treatment and treatment initiation within 24 h was statistically significantly higher among patients who were diagnosed by VHV compared to BHS after adjustment to potential confounders. However, the receipt of complete treatment was significantly lower among patients treated by VHV than BHS.
This was a countrywide study with a large sample, including all patients with undifferentiated fever screened and treated under NMCP. The study is based on routine programme data, showing the ground realities of the national programme. Usually the performance of VHV is assessed using fixed programme cut-offs for different indicators. To the best of the authors’ knowledge, this is one of the first studies to compare the performance of VHV with BHS in providing malaria screening and treatment services in Myanmar using routine programme data. Although there was a cluster randomized controlled trial done in Bago region of Myanmar (hereafter known as Bago RCT), the primary objective was basically to assess the feasibility of placing VHV in villages to improve coverage of malaria screening and treatment services to reduce malaria mortality [
12].
The current study has shown that a significantly higher number and proportion of patients with fever were screened for malaria by BHS compared to VHV. This is very similar to Bago RCT, where BHS (midwives) screened a higher proportion (63%) of patients compared to VHV (37%) as BHS outnumber VHV. This high number and proportion of malaria screening among the population by BHS may also be due to high population coverage (nearly 70% population), and long duration of availability in health system [
12]. According to the new NMTG, all fever cases should be suspected as malaria and tested with RDT [
25]. BHS may also have the additional opportunity to screen the population at health facility/community level when delivering services related to other national programmes, especially maternal and child health programme. Similarly, VHV role is to complement the formal health system and provide malaria care services only in rural, remote and hard to reach areas.
The lower proportion of screening among children aged < 5 years by VHV could be due to low burden of fever in the community and direct referral of all fever cases to higher health facility as per NMTG. This may be due to higher access of children aged < 5 years by BHS to deliver other health services like immunization and nutrition.
A higher proportion of children aged < 15 years and females were provided access to RDT by VHV in this study, similar to Bago RCT. This could be due to VHV: (a) immediately available in the village (less travel); (b) established good rapport/trust with the community; (c) active case detection by house-to-house survey; (d) more affordable; (e) socially and culturally acceptable; (f) immediate availability of RDT [
12,
26]. The acceptability of VHV remained high across countries irrespective of delivery of malaria screening or treatment services, either stand-alone as in Myanmar or integrated with other health interventions such as integrated management of childhood diseases as in Burkino Faso, Nigeria and Uganda [
26].
A similar proportion of malaria positivity among VHV and BHS groups indicates the risk group identification for malaria screening was same. However, the high malaria positivity among < 5, 5–14 years, females and pregnant women may be due to more active case finding by VHV at community level and opportunistic/passive screening by BHS at health facility. Similarly, the
P. falciparum positivity was also higher in the VHV group compared to BHS. Zero incidence of
P. falciparum and mortality is an important step towards malaria elimination in the country [
1]. To achieve the same, early detection and prompt treatment of all cases of falciparum malaria is needed to prevent transmission and death.
The proportion of malaria patients provided treatment by VHV (96.6%) in the current study is comparable to studies done in West Africa (90%) and the summary effect reported from a systematic review (97.7%) [
26,
27]. The World Health Organization fixed a target for providing malaria testing and treatment initiation to at least 60% patients within 24 h of onset of fever/symptom [
28]. Data on timing of malaria testing from the onset of fever, which is one of the important indicator for early detection of cases, was not available in the current study. However, the current study reported that 37.2% (44.7% in VHV and 34.1% in BHS) of patients with fever were tested and initiated treatment within 24 h of fever, which is one of the important achievements over a period of time in Myanmar compared to Bago RCT in 2012. The reported median (1st and 3rd quartile) duration for malaria test from onset of fever in the Bago RCT was 4 (2, 6) days and 3 (2, 4) days in VHV and midwives groups respectively [
12]. However, Ghana, Uganda and Nigeria reported 90% achievement in providing treatment within 24 h of fever among children aged < 5 years [
26].
Proportion of patients not initiated on treatment was higher among patients with complicated malaria (especially in VHV group) could be due to referral of all complicated malaria cases to higher health facility with or without first dose of anti-malarial drugs. Similarly, low proportion of patients aged 5–14 years were initiated on treatment. This may be due to neglect of this age group due to more importance given to under five age group and non-availability of patients as this age group is primarily a school going population. In addition, all pregnant women and children aged ≤ 1 year are supposed to be referred to higher health facility as per the guidelines which may reduced the proportion received the treatment.
Although VHV provided treatment to a higher proportion of patients, fewer of the patients received complete treatment compared to BHS. The reasons for high proportion of incomplete or inappropriate treatment could be due to different schedule of providing primaquine in VHV group (weekly once for 8 weeks) compared to BHS (daily for 14 days) in case of P. vivax and also be due to referral of complicated cases, pregnant women, and children aged ≤ 1 year to higher health facility with or without first dose of anti-malarial drugs.
The study had few limitations. Only the NMCP VHV data were analyzed since national and international NGO data were available only as aggregate data. The statistical significance observed in this study should be interpreted with caution for public health significance and practical application as the study dealt with big data which shown statistical significance even with small difference in proportion between groups. As the study was based on secondary data entered in malaria registers, the quality of data must be improved as there were missing data on severity of malaria [4% (5.5% in VHV and 3.4% in BHS)] and time of treatment initiation [14.1% (11.3% in VHV and 15.2% in BHS)], which were not included in the analysis. Complicated malaria reporting was very low (1%) which needs further review since there may be under-reporting. The study was able to assess only delivery of complete treatment and did not include follow up data on adherence to medication by the patients and status of clinical outcome at the end of treatment, which needs further research. The diagnosis and treatment outcome of patients with negative malaria test is not available as these patients are referred to BHS by VHV routinely and no data available on the same. However, it will be collected in future when VHV role is upgraded as integrated community malaria volunteers. Assessment of stock outs and other inventory difficulties were not assessed as the data was not available which needs comprehensive assessment in future. Linkage with routine surveillance system needed outbreak respose if any and further containment of transmissions.
Authors’ contributions
NYYL, SK: conception and design of the protocol, data analysis, interpretation of the results, drafting and critically reviewing the paper, approving the final version to be published. MD, BT: conception and design of the protocol, critically reviewing the paper, approving the final version to be published. MMR: conception of the idea, contributed materials/analysis tools for study and critically revised the manuscript. TMM, AMMK, AT, ZL: contributed materials/analysis tools for study and critically revised the manuscript. All authors read and approved the final manuscript.