In this first study on quality of malaria treatment in ethnic communities of Myanmar, most people with malaria received correct drugs in the correct dose and adequate duration appropriate to species, age and pregnancy status. However, the timeliness of correct treatment was seen in half, and this was due to presentation after 24 h of fever onset. Infants, those with severe malaria, Pf infection and mixed infection were less likely to receive the correct treatment. Village-based ICMVs were more likely to provide the correct treatment. Mobile teams were more likely to provide correct as well as ‘correct and timely’ treatment.
4.1. Strengths and Limitations
A study based on the nationwide malaria data of NMCP (2015) had assessed the correctness of malaria treatment. The number of tablets dispensed according to the type of malaria, age group and pregnancy status was used to assess the correctness of treatment [15
]. The definition used in our study was more rigorous and we also used ‘eligibility for referral’, ‘referred or not’ and timeliness (among those with correct treatment) to assess the quality of malaria. We were able to analyse the reasons for incorrect treatment as EHOs had good documentation practices.
There were some limitations. The risk factors assessed were limited to the variables available in records and other socio-demographic, programmatic and health system level factors were not assessed. Second, the study assessed only the prescription of the complete course of drugs (number of each type of tablet) at the time of first dose prescription. It did not include follow-up data on: (1) If people sought care elsewhere; (2) if people completed their course; (3) clinical outcomes. Finally, referred people could not be assessed for receipt of complete treatment.
4.2. Key Findings and Implications
Limitations notwithstanding, the study has some key findings. Provision of correct treatment was satisfactory. The correctness of treatment given by VHVs was 83% nationally in 2015 (did not include data from ethnic communities) while it was 95% in our study [15
]. We speculate continuous supervision of village-based ICMV, refresher training and hands-on training to new recruits by EHOs as the reasons [17
The correctness can be further improved by appropriate management of severe malaria and malaria in children (especially infants). This was mostly due to lack of referral among this sub-group despite being eligible and has to be addressed in refresher training. EHOs need to strengthen the referral system in hard to reach villages. Reason for non-receipt of correct treatment among people with mixed infections is unknown. Although drug stock-out was minimal, proper supply chain management can further improve the correctness of treatment. According to EHOs’ reports, drug stock-out was common in hard to reach villages because of unpredictable transportation time in the rainy season.
Despite most receiving the correct treatment, it was not timely in half because of presenting after 24 h of fever onset. This finding is similar to the previous study based on the nationwide malaria data of NMCP [15
]. The reasons from the patient side for delayed presentation have been studied elsewhere among migrant populations [13
]. These are inappropriate health care seeking, self-medication, not giving importance to fever, transportation difficulty (if allotted volunteer lived in another village), uninformed about the volunteer or his/her activities and lack of symptomatic treatment from a volunteer [13
]. From the volunteer side, lack of practices for malaria testing in all undifferentiated fever cases, and apprehension regarding paper workload and wastage of test kits have been reported [13
]. To improve the knowledge of community on the importance of early diagnosis and treatment and danger of self-medication, information, education and communication materials and strategy should be reviewed and revised according to local context such as using ethnic language. ICMV should improve the visibility of available services by posters or awareness sessions. Encouraging ICMV to test all undifferentiated fever is important for early diagnosis.
Mobile teams and health posts’ contribution to diagnosed patients was low. Mobile teams were significantly associated with providing a better quality of treatment when compared to health posts. We are unsure of the reason for the poor performance of health posts (was poorer than village-based ICMVs) in providing correct treatment (irrespective of timeliness). While addressing these, one must also review the role of ICMVs as they largely contribute to the diagnosis of malaria [19
]. Though they provide correct treatment, their role in providing ‘correct and timely’ treatment has scope to improve.
No or incorrect prescription of gametocidal drug contributed to a significant portion of non-receipt of correct treatment. According to narrative reports from EHOs, ICMVs had concerns about prescribing primaquine to people with unknown G6PD status. G6PD deficiency is common in Myanmar, 19.8% of people with malaria have G6PD deficiency [20
]. NMCP recommends G6PD deficiency screening before primaquine administration. Primaquine is contraindicated in severe G6PD deficiency and weekly primaquine was recommended (during study period) for mild to moderate deficiency [5
]. However, implementing this is impractical in ethnic communities as most have unknown G6PD status. Since Pv and mixed infections contribute to more than two-thirds of malaria in this setting, scaling up of G6PD testing is important. We recommend that once G6PD testing is scaled up, guidelines to treat Pv and mixed malaria infection in those with unknown G6PD status should be specified as ‘receipt of appropriate schizonticidal drug followed by referral to nearest health facility like rural health centre or station hospital for G6PD testing’.
Follow-up information after prescribing drugs or referral was not collected. Failure to comply with a full course of treatment could impact patient outcome. Therefore, this information is useful for programme design improvement, and routine data collection should contain follow-up information to assess compliance with treatment. Given the concerns regarding artemisinin resistance, future studies should assess adherence to medication and clinical improvement.
Most people with malaria were adults, despite malaria being more prevalent among children. Possible reasons such as missing malaria cases among children or an epidemiological shift in these communities because of successful preventive interventions for malaria have to be explored.
To conclude, the correctness of malaria treatment provided by EHOs under the BHT project was satisfactory. This can be moved closer to 100% in ethnic communities by improving the management of under-five children, severe malaria and mixed infection. However, timeliness of treatment needs to be improved. This calls for ensuring the early presentation of people to health workers within 24 h of undifferentiated fever through health promotion initiatives. Role of ICMVs has to be maximised for this purpose as a large proportion of people with malaria are being detected by village-based ICMVs. Addressing these issues among ethnic communities are key to eliminate malaria in Myanmar by 2030 [12