Improving the quality of paediatric malaria diagnosis and treatment by rural providers in Myanmar: an evaluation of a training and support intervention

The country is classified by the United Nations as one of the least developed countries in the world. Health indicators in Myanmar are some of the worst in the world, with a life expectancy of only 65 years and high rates of child and maternal mortality. Additionally, there are high rates of child malnutrition and stunting, diarrheal diseases, and pneumonia are common, and Myanmar has more than half of all malaria-related deaths in southeast Asia. Government spending on healthcare in Myanmar is minimal. Between 2007 and 2011, expenditures were only US$17 per person per year, the lowest in Asia and far below the $60 per person benchmark recommended by the World Health Organization (WHO) for low-income countries hoping to reach the Millennium Development Goals by 2015. The health system challenges are large and ongoing, with major new investments beginning. However, in the 2011/12 fiscal year, the government spent just 1.3% of its overall budget (US$110 million) on healthcare. This lack of government support means that more than 90% of healthcare expenditures in Myanmar are out of pocket. National health service coverage is low, and access to healthcare is limited. General practitioners, voluntary organizations, and international non-governmental organizations (INGOs) provide a significant fraction of all healthcare in Myanmar. In 2010, there were 24,536 total doctors: 9728 in the public sector and the remainder in the private sector. The number of physicians per 1000 people was 0.5 in 2008, constituting a shortage of health workers according to WHO norms. The shortage is worst in rural areas, where 66% of Myanmar's population is concentrated. In addition to health worker deficits, travel restrictions within the country often prevent reliable access to healthcare when it is available; travel restrictions are most common in rural areas. In the absence of sufficient public health services, 80% of the Myanmar people seek their healthcare from the private sector. There is a perception that the private sector can provide a more reliable drug supply, better responsiveness, and a more client-centered focus. A common method for dealing with healthcare worker shortages and improving access to healthcare services, especially in rural and poor areas, is "task shifting." Task shifting is the simplification and delegation of health tasks from medically trained doctors to other providers. In some Myanmar villages, the Department of Health has trained community health workers (CHW) and auxiliary midwives to deliver care in the absence of primary healthcare services. However, these CHW positions are non-salaried and have a high rate of attrition. Recent systematic reviews for low- and middle-income countries (LMICs) have highlighted the need to standardize and ensure the levels of quality offered by both public and private providers, especially in rural settings. By increasing the quality of care, both sectors can improve cure rates and decrease unnecessary treatment, reducing out-of-pocket expenditures on healthcare, especially among the poor. Since the 1990s, clinical social franchising has become an increasingly popular method for delivering healthcare to the poor. Social franchising aims to strengthen business practices through economies of scale. The franchisor, typically an international NGO with an in-country office, recruits and supports network members through branding private clinics and purchasing drugs in bulk at wholesale prices.