Assessing the role of the for-profit private healthcare sector in malaria elimination efforts in Bangladesh: a cross-sectional study of challenges and opportunities | BMC Public Health
Demographic characteristics of the participants
Of the 104 participants recruited in this study, 30.8% were from the control region, 63.4% were from the endemic region, and 5.8% were from the non-endemic region. The overall mean age of the respondents was 36.3 ± 11.3 years. The majority of respondents were male (88.5%). Educational qualifications varied among the respondents. In the study, there was no illiterate participants. Almost half of the participants (n = 53, 51%) had a diploma degree in a related profession. In the endemic region, most of the participants (n = 40, 60.6%) were involved in laboratory work, whereas the majority of the owners/managers (n = 21, 65.6%) of health facilities lived in the control areas (Table 2). The p-value indicated a statistically significant difference in education level (p = 0.002) and their role at the health centre (p = 0.003) among the regions.
A total of 26 providers participated in the FGDs. Among them 88.5% were male and 50.0% of them were medical technologists employed in diagnostic services (Table 3 ).
Characteristics of the health facilities
Five types of for-profit private health facilities were listed and mapped. Among them more than half were consultancy and diagnostic centres (54.8%), followed by private clinics (18.3%), and drug stores (13.5%). Private for-profit health facilities were positioned in proximity to the corresponding Upazila Health Complexes (UHCs) but were situated at a distance from the nearest district hospitals. Health facilities in non-endemic region were located significantly (p < 0.001) closer to the UHCs and district hospitals, than were those in control and endemic regions (Table 4).
Availability of malaria diagnostic and treatment services
In total, 80.8% of the listed facilities provided malaria testing services. However, a comparison revealed that the availability of testing services, both by rapid diagnostic test (RDT) and microscopy, was highest in the endemic region (65.0%), followed by the non-endemic region (50%), and the control region (33.3%), but, this difference was not deemed statistically significant. Of the 84 facilities, 66.7% in both control and endemic regions, and 100% in non-endemic regions, utilized RDT as the primary testing method. Among them, 66.7% of both the control and non-endemic regions exclusively used WHO pre-qualified RDTs, while in the endemic regions, this percentage was only 32.5%. The cost of RDT varied across regions; in the control and endemic regions, the average cost per RDT was 150 BDT (1.5 USD) and 250 BDT (2.5 USD), respectively. However, in non-endemic regions, the cost was notably higher at 600 BDT (6 USD), and this difference was statistically significant (Table 5).
However, during FGDs, it was noted that most of the participants emphasized the blood slide method as the preferred approach for diagnosing malaria parasites. The ratio of microscopic diagnoses varies depending on weather conditions and seasonal fluctuations, ranging from 10 to 15 cases or sometimes even more.
“I have noticed that the practice of malaria diagnosis reporting is successful because it is positive or negative in Sreemongol. I may not find malaria parasites in certain cases, while it could be positive, it may be missed by me; thus, a malaria blood slide test report should be delivered mentioning ‘found’ or ‘not found’.” (Participant: FGD Sremongal, Male, Age 28).
Drug store owners and dispensers rely on RDT kits obtained from various sources such as local suppliers and third-party suppliers. In some instances, private health centres receive RDT kits from the Bangladesh Rural Advancement Committee (BRAC) consortium NGOs. Charges for microscopy and RDT vary based on management decisions, service capacity, and the reputation of the private facilities. In our study area, the cost of an RDT ranges from 60 BDT (0.6 USD) to 200 BDT (2 USD), while a blood slide microscopy test is relatively less expensive, costing only 40 BDT (< 0.5 USD) to 70/80 BDT (0.7/0.8 USD) for patients.
With respect to malaria treatment services, the opposite scenario of malaria testing services was found, where only 18.3% of the service providers provided malaria treatment services. Despite having such provisions, the health facilities in the three regions did not even start the malaria treatment before obtaining the test results. Almost all health facilities selected in this study (n = 100, 96.1%) did not provide necessary treatment to severe malaria patients.
“Serological tests are conducted in our private laboratory along with RDT, but we do not provide treatment. We only tested patients for malaria if they were referred by our residential medical officer if malaria was suspected among attending patients who had fever with cold cough symptoms. We have a 24-hours doctor on duty in our health centre, so we will be able to provide treatment if anti-malarial medication is supplied at our health centre.” (Participant: FGD Alikadam, Female, Age: 23).
Moreover, similar to RDTs, local wholesalers were the main source of anti-malarial drugs. Among the treatment providers, only four claimed to treat severe malaria patients. However, only two of them followed specific treatment protocols (Table 6).
Barriers to efficient malaria diagnosis and case management
During the FGD, the participant mentioned several practical reasons to prevent efficient malaria diagnosis. Limited equipment, inconsistent power, and poor-quality rapid diagnostic tests exacerbate this issue. One participant expressed concern about false positives from these tests, highlighting the need for better solutions.
“I believed that the RDTs used by local diagnostic centres and clinics were of poor quality and were unable to accurately diagnose malaria. Last year, there was a case where malaria was identified by an RDT, but I did not find any malaria parasites when examining the blood slide using microscopy in my laboratory.” (Participant: FGD Sreemongol, Male, Age: 48).
Another major challenge in conducting malaria diagnosis by microscopy in for-profit private healthcare facilities was the lack of sufficient staff. Laboratory technicians were required to perform various serological and hematological tests on a daily basis while also being pressured to deliver malaria reports quickly for commercial purposes, driven by early requests from attending doctors and hospital management. This insufficient staffing posed a significant barrier to maintaining quality in malaria diagnosis.
According to the participants’ statements, testing and interpreting malaria tests were also not easy for those who had recently attained a bachelor’s degree in medical technology. This was also attributed to the curriculum and texts taught, where malaria was given less emphasis, and lab training sessions were lacking. Furthermore, they mentioned that most newcomers were unable to understand and conduct the blood slide examinations effectively to identify malaria parasites. An FGD respondent stated,
“Laboratory technicians have enhanced their knowledge by conducting malaria tests in laboratory settings. The training will focus on malaria parasite identification strategies to bridge the knowledge gap.” (Participant: FGD Alikadam, Male, Age: 45).
Due to a lack of proper training, laboratory technicians and nurses in the private sector had very limited or no knowledge of malaria case management.
“Training and monthly medical camp arranged to conduct malaria diagnosis and treatment during a campaign will be fruitful for the people living in remote places in tea garden area.” (Participant: FGD Sreemongol, Male, Age: 45).
Service providers during FGDs mentioned that they usually refer patients to government health centres for treatment. Nevertheless, in some instances, a small number of individuals selling drugs would occasionally offer treatment for mild or uncomplicated cases, provided that they had anti-malarial medication in their store.
Malaria case reporting and referral
The median number of fever patients who experienced fever in the last two months was greater in the control region than in the endemic and non-endemic regions. However, the median number of fever patients tested for malaria was relatively low across all regions. In non-endemic regions, not a single patient with fever was tested for malaria in the past two months. Among the 23 facilities that claimed to have been diagnosed with malaria in the past two months, only 4 out of 23 reported it to the NMEP. The main reasons for not reporting to the NMEP included a lack of knowledge and uncertainty about reporting procedures. Malaria patients were primarily referred to UHC and NGO labs/healthcare workers, with limited referrals to district hospitals (Table 7).
During the FDGs, the participants preferred to report and refer malaria patients to the Govt. health facilities or NGOs working under the NMEP umbrella and suggest to establishing routine case reporting and incorporating a system with the national database of the NMEP platform. A recommendation arose from a participant from the Chakaria FGD.
“The Civil Surgeon office should play a lead role in monitoring malaria cases reported to the NMEP in due time. It was suggested that the directon be provided through paper-based reporting. However, a monthly online-based reporting format would be convenient for private profit sectors, clinics, and diagnostic centres. In addition, the continuous monitoring from the NMEP should be needed so that sincerity in duly report writing and submission can be achieved.” (Participant: FGD Chakaria, Male).
Involvement with NMEP
The collaboration between health facilities and the NMEP was found to be limited, with only a small percentage (6.7%) of facilities reporting their work with the program. The reporting of malaria positive results to higher facilities varied across regions with higher reporting rates in the endemic areas ( 56.1%) than in the control areas (21.9%), while non-endemic areas had no reporting during the study. Mobile phones were the primary method of reporting (78.4%) in both the control and endemic regions.
Most health facilities (62.9%) expressed a willingness to collaborate with the NMEP. However, concerns about the additional workload (61.1%) were the primary reason for reluctance toward such collaboration. One-third of the participants wanted to be trained through the NMEP training module. Moreover, training on malaria in the past three years was received by a very small fraction of respondents (12.5%) (Supplementary Table 1).
Private for-profit healthcare centres are primarily driven by business interests, seeking to profit from each visiting patient, including those with suspected malaria cases. Furthermore, drug sellers anticipate receiving an honorarium as a service charge if RDTs are supplied to their outlets. The FGD participants expressed concerns about engaging with the NMEP for elimination efforts, emphasizing the need to implement service charges to compensate for low wages and the long, stressful working hours that often overburdened them. Consequently, expecting private for-profit facilities to provide free-of-cost services might not be feasible. Implementing additional service charges could enhance willingness and dedication in malaria case management, aligning with the business interests of these facilities. An FGD participant from Alikadam expressed the following option.
“From this discussion, I understand that in managing malaria patients, we will be responsible for several types of work, including diagnosis with RDT, providing medication, storing the patients’ medical histories, and preserving contact information for each patient. However, since we will not receive any direct benefit from these efforts, it is necessary to allocate some financial support for our involvement in this elimination initiative.” (Participant: FGD Alikadam, Male, Age: 41).
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