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

stthein@psimyanmar.org

Provider types and areas with high number of

RDT tests by class ‘C’ providers