MAPPING THE LANDSCAPE OF CURRENT PRACTICES IN THE PRIVATE SECTOR IN 27 MALARIA ENDEMIC DISTRICTS OF NEPAL
MITRA Samaj conducted the mapping assignment to better understand current care practices for malaria patients, especially in the private healthcare sector as a basis for developing strategies to improve the quality of care.
Malaria remains a priority public health threat in Nepal with approximately 50% of the population still at risk of malaria. The trend of malaria during the last decade, with the achievement of Millennium Development Goals (MDG) in 2010 indicates that substantial progress has been made towards malaria elimination(1,2).A total of 991 confirmed cases were reported in the year 2016 and among these, 485 (~49%) were classified as imported. Plasmodium vivax malaria accounted for 84% (47.40%) of these cases, and the remaining cases (56.79%) were caused by P. falciparum (3). The trends pertinent to the malaria indicators (3) clearly suggest that Nepal is in the pre-elimination phase and is positioned strategically to achieve the vision of “a malaria-free Nepal by 2025” (1).
In spite of this laudable progress, there are a number of challenges in the road to malaria elimination. One of these remains the inadequate engagement of the private sector, which is an integral component of health service delivery to the population of Nepal. From 1995 to 2008, the proportion of private hospitals has grown from 23% of all hospitals to 78% (4). Furthermore, in 2014, there were 350 private hospitals in comparison to 97 public hospitals(5). This, alongside the flourishing of private clinics, polyclinics and pharmacy-based practitioners clearly point towards the considerable size of the private healthcare services in Nepal.
Various studies have shown that 60-80% of patients when seeking care, approach a pharmacy as the first point of care (>46% in the poorest quintile). In 2014, 55% and 57% of patients approached the private services for acute and chronic illnesses, respectively(5). Although malaria diagnosis and treatment are available free of cost at the public health facilities, the aforementioned data shows that significant numbers could still seek care in the private sector.
In settings nearing the malaria pre-elimination phase like Nepal, all malaria cases must be identified, classified, documented and investigated. As shown above, the private sector is often the first source of primary health care services. These patterns are similar for malaria treatment, and in some regions more than half of all treatment-seeking for fevers occur in the private health sector (5). The prominent role of the private health sector for health care services is likely a result of the greater availability and ease of access to private providers, perceptions of the relative quality of services compared to the public sector and the greater flexibility provided in time and prescribing of medicine. The rural poor, who are often at higher risk of malaria infection, are also more likely to use informal private providers in many settings.
According to the Nepal Health Facility Survey 2015, among private facilities (n=65) that offer malaria diagnosis and/or treatment services, less than one percent had the national guidelines (National treatment wall-chart for malaria or national clinical protocol for malaria) in the facility and only one percent of staff were trained in malaria diagnosis as well as in malaria treatment while almost all the facilities (93.1%) were offering malaria diagnosis and/or treatment services(6). Similarly, in a recently conducted health facility assessment, the private hospitals were found to have a weaker record keeping system as per the HMIS in comparison to the public hospitals (7). This mostly unregulated and profit driven private sector seldom adheres to quality diagnosis or to the national treatment guidelines(8). This will have a direct impact on the progression of the disease and prognosis of the patient. Furthermore, the complete lack of or delay in case notification from these outlets can result in further transmission in the community leading to further propagation, jeopardizing the efforts of the malaria control programme.
Timely notification of each malaria case, effective case management and follow-up is a requisite for elimination. In addition to the efforts being made in the public sector, the inclusion of the private facilities is imperative to pace towards the vision of elimination (9). In this line, the national programme should develop appropriate strategies to engage the private sector.
However, research on the role and performance of the private sector in malaria diagnosis, case management and reporting in malaria elimination settings is limited. Moreover, the most effective strategies for private sector engagement in Nepal for malaria elimination remain unclear. This survey tried to address this gap and identify the extent and quality of the diagnosis, treatment and reporting practices in the private healthcare facilities for malaria patients and recommend pertinent strategies that could be most effective in engaging them and aiding the control of malaria.
Hence, this survey attempted to map the current practices in the private sector of the malaria-endemic districts of Nepal. This will be done taking the current NMTP as the baseline and utilising the framework of the test, treat and track policy of the World Health Organization (WHO).
- Epidemiology and Disease Control Division, Government of Nepal, Ministry of Health and Population, Department of Health Services. Nepal Malaria Strategic Plan 2014-2025. 2016.
- Dhimal M, Ahrens B, Kuch U. Malaria control in Nepal 1963–2012: challenges on the path towards elimination. Malar J. 2014;13(1):241.
- Ministry of Health, Government of Nepal. Annual Report 2015/16 – Department of Health Services [Internet]. 2016 [cited 2018 Feb 12]. Available from: http://mddohs.gov.np/wp-content/uploads/2017/06/Annual_Report_2072-73_DoHS_15-may-2017.pdf
- RTI International. Overview of Public-Private Mix in Health Care Service Delivery in Nepal [Internet]. 2010. Available from: http://www.rti.org/sites/default/files/resources/42_nepal_overviewpublicprivate.pdf
- Sengupta A, Mukhopadhyaya I, Weerasinghe MC, Karki A. The rise of private medicine in South Asia. BMJ. 2017 Apr 11;357:j1482.
- Ministry of Health Nepal, New ERA, Nepal Helath Sector Support Program (NHSSP), ICF. Nepal Health Facility Survey 2015. Kathmandu; 2017.
- School of Planning Monitoring E and R (SPMER). Health Facility Assessment on Malaria Program. 2017.
- Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. Jenkins R, editor. PLoS Med. 2012 Jun 19;9(6):e1001244.
- UCSF Global Health Sciences GLobal Health Group. The private sector’s role in malaria surveillance. 2011.