Expanding malaria diagnosis and treatment in Lao PDR: lessons learned from a public-private mix initiative

Abstract

Background: As in other countries of the Greater Mekong Sub-region (GMS), the private health sector constitutes a significant avenue where malaria services are provided and presents a unique opportunity for public-private collaboration. In September 2008, a public-private mix (PPM) strategy was launched initially in four northern and southern provinces in Lao PDR to increase access to rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT), improve quality of care, and collect routine malaria data from the private sector. Throughout the process, key stakeholders were involved in the planning, monitoring and supervision of project sites. Following an initial assessment in 2009, the PPM initiative expanded to an additional 14 district sites to a total of 245 private pharmacies and 16 clinics covering 8 provinces and 22 districts. By June 2016, a total of 317 pharmacies, 30 clinics in 32 districts of the 8 provinces were participating in the PPM network and reported monthly malaria case data.

Methods: This descriptive study documented the process of initiating and maintaining the PPM network in Lao PDR. Epidemiological data reported through the routine surveillance system from January 2009 to June 2016 were analyzed to illustrate the contribution of case reporting from the private sector.

Results: A total of 2,301,676 malaria tests were performed in the PPM districts, which included all the PPM pharmacies and clinics (176,224, 7.7%), proportion of patients tested from 14,102 (4.6%) in 2009 to 29,554 (10.4%) in 2015. Over the same period of 90 months, a total of 246,091 positive cases (10.7%) were detected in PPM pharmacies and clinics (33,565; 13.6%), in the same districts as the PPM sites. The results suggest that the PPM sites contributed to a significant increasing proportion of patients positive for malaria from 1687 (7.4%) in 2009 to 5697 (15.8%) in 2015.

Conclusions: Ensuring adequate and timely supplies of RDTs and ACT to PPM sites is critical. Frequent refresher training is necessary to maintain data quality, motivation and feedback. In the context of malaria elimination, the PPM initiative should be expanded further to ensure that all febrile cases seen through the private sector in malaria transmission areas are tested for malaria and treated appropriately. Results from the PPM must be integrated into a centralized registry of malaria cases that should prompt required case and foci investigations and responses to be conducted as part of elimination efforts.

Keywords: Lao PDR; Malaria diagnosis; Public–private mix; Treatment.

Fig. 1

Coordinating and governance structure for the public–private mix strategy

Fig. 2

Reporting and coordination for public–private mix at national, provincial and district levels

Fig. 3

Map of the expansion of the public–private mix in Lao PDR

Fig. 4

Proportion of malaria tests performed among public health facilities, community and public–private mix sites

Fig. 5

Proportion of malaria cases among public facilities, communities and public–private mix sites

Fig. 6

Trend of number of people tested and malaria positives among public health facilities, community and public–private mix sites

Fig. 7

Trend of malaria positivity rates among public health facilities, community and public–private mix sites