Private sector health care providers are frequently the only source of healthcare
in the most remote communities in Myanmar, where malaria is highest and the
reach of public and formal health services is most stretched. In November 2015,
Population Services International (PSI), in collaboration with the National
malaria control program (NMCP), started the roll out of malaria Rapid Diagnostic
Tests (RDTs) among thousands of private sector providers in Myanmar. The
provider types included general retail stores, informal providers, medical drug
representatives, and trained health providers.
Providers were trained and equipped to conduct RDTs, to treat malaria cases in
accordance with national guidelines, and to report the results every month. In
2017, PSI launched the Health Network Quality Improvement System (HNQIS),
a DHIS2*-based android app to assess provider quality of malaria case
management, including RDT testing.
BACKGROUND
In 2017, 4,100 providers from 3,052 villages in 15 regions were assessed with
HNQIS. HNQIS used a comprehensive checklist, covering diagnosis, treatment,
counselling, reporting, and stock, among other areas. Following an assessment,
HNQIS automatically calculated a weighted quality score and the provider was
classified into one of three classes: class A (score >80), class B (50-80), and
class C (<50). Among the providers, 2622 (63.9%) were classified as class A,
1125 (27.4%) as class B, and 353 (8.6%) as class C.
These quality scores, in combination with data from routine monthly RDT reports
submitted throughout 2017, enabled a comprehensive analysis of the status of
case management quality among these private sector providers.
METHODS
CONCLUSION
Using HNQIS, PSI was able to assess the quality of private sector providers in
remote regions spanned across the country, and to compare the quality scores
against routine RDT testing data. Such findings led to reviews by PSI operation
teams and subsequent actions to improve quality case management among the
providers, such as case reviews, refresher trainings, prioritized supportive
supervision visits, and so on. At the same time, PSI could reduce emphasis on
providers who were performing well, and improved overall operational efficiency.
In 2017, these providers reported conducted 354,632 malaria RDTs, and
identified 3915 positive cases (1.1% positivity). Among them, 243,728 (68.7%)
RDTs were reported by class A providers, 87,468 (24.7%) by class B, and
23,436 (6.6%) by class C (Table 1). Class A providers had the highest average
number of tests (93), and the highest positivity rates (1.3%); class B were in
middle with an average of 78 tests and 0.9% positivity; and class C at the lowest
with an average of 66 tests and 0.3% positivity (Table 2).
Differences in quality scores among different provider types and different
geographic regions were also observed (Figure 1). By coupling quality
assessments with the number of RDTs performed by each provider, PSI was
able to pinpoint areas for further improvement, i.e., where a high number of RDT
tests were reported by class ‘C’ providers. There were large number of RDTs
conducted by class ‘C’ providers among general retailers and informal providers,
and in the Eastern and North Western regions of the country (Figure 1).
Provider class (N, %) Total RDT (N, %) Total RDT Positives (N, %)
A - 2622 (63.9%) 243,728 (68.7%) 3,036 (77.5%)
B - 1125 (27.4%) 87,468 (24.7%) 804 (20.5%)
C - 353 (8.6%) 23,436 (6.6%) 75 (1.9%)
TOTAL – 4100 354,632 3,915
TABLE 1 – Routine RDT data by provider quality classification
PSIHealthyLives PSIimpactwww.psi.org PSIimpact
FIG. 1 – HNQIS quality scores and number of report RDTs by outlet type and location
RESULTS
1100
Provider class (N, %)Average # of RDT per
providerRDT positive rates
A - 2622 (63.9%) 93 1.3%
B - 1125 (27.4%) 78 0.9%
C - 353 (8.6%) 66 0.3%
TOTAL - 4100 86 1.1%
TABLE 2 – Class-specific provider performance
*DHIS2 – District Health Information System 2.
More information is available at www.dhis2.org
Lessons learnt from deployment of DHIS2-based Health
Network Quality Improvement System (HNQIS) over 4,000
private sector malaria providers in Myanmar
Si Thu Thein, Phone Si Hein, Khun Thiha, Hnin Su Su Khin
Population Services International Myanmar
Provider types and areas with high number of
RDT tests by class ‘C’ providers