title: Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: an evaluation of incentive schemes among informal private healthcare providers.
abstract: BACKGROUND
  As efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar.
  
  
  METHODS
  The study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms.
  
  
  RESULTS
  The pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy.
  
  
  CONCLUSIONS
  Results show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.
authors.affiliation: Population Services International, Yangon, Myanmar. taung@psimyanmar.org.
authors.forename: Tin
authors.initials: T
authors.lastname: Aung
authors.affiliation: Bill and Melinda Gates Foundation, Seattle, USA. Chris.White@gatesfoundation.org.
authors.forename: Christopher
authors.initials: C
authors.lastname: White
authors.affiliation: Global Health Sciences, University of California, San Francisco, CA, USA. Dominic.Montagu@ucsf.edu.
authors.forename: Dominic
authors.initials: D
authors.lastname: Montagu
authors.affiliation: Global Health Sciences, University of California, San Francisco, CA, USA. willi_mcfarland@hotmail.com.
authors.forename: Willi
authors.initials: W
authors.lastname: McFarland
authors.affiliation: Department of Health, National Malaria Control Programme, Yangon, Myanmar. thlaing@psimyanmar.org.
authors.forename: Thaung
authors.initials: T
authors.lastname: Hlaing
authors.affiliation: Population Services International, Yangon, Myanmar. hsskhin@psimyanmar.org.
authors.forename: Hnin Su Su
authors.initials: HS
authors.lastname: Khin
authors.affiliation: Population Services International, Yangon, Myanmar. aksan@psimyanmar.org.
authors.forename: Aung Kyaw
authors.initials: AK
authors.lastname: San
authors.affiliation: Global Health Sciences, University of California, San Francisco, CA, USA. chbriegleb@gmail.com.
authors.forename: Christina
authors.initials: C
authors.lastname: Briegleb
authors.affiliation: Global Health Sciences, University of California, San Francisco, CA, USA. Ingrid.Chen@ucsf.edu.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Chen
authors.affiliation: Global Health Sciences, University of California, San Francisco, CA, USA. May.Sudhinaraset@ucsf.edu.
authors.forename: May
authors.initials: M
authors.lastname: Sudhinaraset
mesh_terms: D000962:Antimalarials / Q000494:pharmacology*; D037621:Artemisinins / Q000494:pharmacology*; D004351:Drug Resistance; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D008288:Malaria / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D002052:Myanmar; D010274:Parasitology / Q000191:economics; D011331:Private Practice / Q000706:statistics & numerical data; D011933:Reagent Kits, Diagnostic / Q000191:economics / Q000706:statistics & numerical data; D012052:Reimbursement, Incentive
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D011933:Reagent Kits, Diagnostic; C031327:artemisinin