A proper and accurate diagnosis is the key for the proper management of a malaria patient. As recommended by the WHO, before providing any anti-malarial treatment all suspected malaria cases should be confirmed by quality-assured microscopy or RDT[12]. As evident in this study, malaria diagnosis by means of microscopy and RDT was readily available in 80% of the surveyed facilities, but the lack of a quality assurance system for microscopy was evident and also mentioned by the FGD participants. In many sub-Saharan African countries, microscopy has been used extensively in private for-profit healthcare facilities [13, 14]. However, conducting microscopy in private clinics and drug stores is not always feasible. Barriers such as business interests, doctor preferences, and interruptions in electricity supply were considered obstacles for not conducting blood slide examinations for malaria diagnosis [15, 16]. Another challenging issue in conducting malaria diagnosis by microscopy is the lack of an appropriate number of staff in the private health care centres [17]. A laboratory technician had to perform different kinds of serological and haematological tests every day. They had to deliver malaria reports for commercial purposes within a short time frame. This was due to early reports requested by attending doctors and hospital management.
The affordability of services is an important consideration for care receivers. Charges for microscopy and RDT vary based on management decisions, service capacity, and the reputation of the private facilities [13]. Unlike other studies conducted elsewhere [18, 19], the cost of a blood slide microscopy is relatively lower than that of a single RDT.
In the past, it was recognized that a dedicated expert medical technologist was needed, if possible, to conduct malaria case diagnosis. If he/she was solely responsible for handling multiple lab tests simultaneously, there was a risk of missing malaria parasite detection [20]. Therefore, a trained technician specifically focused on diagnosing malaria cases and, if feasible, managing related issues was deemed necessary. Additionally, the involvement of trained staff enhances the precision of the diagnostic reports [21].
Sometimes, untrained private providers have been shown not to facilitate effective management of malaria cases, thus threatening to increase both mortality and lack of adherence to anti-malarial treatment [22, 23]. Participants from the FGDs also emphasized the importance of local training held every three months, as a single session was deemed insufficient. Weekday training was preferred due to the greater workload during weekends in private facilities. The training curriculum focused on developing knowledge of slide test methods, with a specific request for incorporating reference positive slides to aid in understanding parasite types. Participants also highlighted the lack of slide cross-check tests and requested feedback from different locations where referral cross-checks were conducted. Additionally, they proposed conducting training sessions alongside monthly medical camps during campaigns, especially in remote areas such as tea garden regions, to improve malaria diagnosis and treatment for underserved populations. Overall, these enhanced training initiatives played a crucial role in improving the competence and accuracy of newly graduated medical technologists in diagnosing malaria cases [24–26].
The interactions among three core service delivery channels-public, private and community, must be taken into consideration in order to achieve universal health coverage with quality-assured diagnostics and anti-malarial treatment [27]. The interactive involvement of doctors and health centre owners is also essential. Laboratory technicians depend on doctors' recommendations for conducting various laboratory tests, including malaria diagnosis. Therefore, it is necessary to convince the doctors to engagement in the proposed project with the goal of eliminating malaria. They should take the initiative to recommend malaria parasite tests for all suspected patients. Awareness and support from local diagnostic centres and clinic owners are also vital. The support of private for-profit sector owners is crucial. They should remain aware of the project and be flexible with the time required to conduct laboratory tests, especially for malaria tests where accuracy and correct interpretation are unavoidable [28].
Private providers are often excluded from routine disease reporting systems because they often fail to report duly into national level HMIS, mirroring related studies [17, 29, 30]. For establishing routine case reporting and incorporating it into the national database through the NMEP platform, a recommendation arose from respondents, stating that the Civil Surgeon office should play a pivotal role in monitoring malaria cases and reporting to the NMEP in due time. It was suggested that direction to be provided through paper-based reporting. Lab technologists were proposed to lead the supervision process. A monthly reporting format was considered convenient for private profit sectors, clinics, and diagnostic centres.
To guarantee proper case management and a periodical reporting system in the private health sector, regulation through the establishment of policies, rules and standards is inevitable [17]. A lack of proper oversight causes many for-profit health facilities to fall short achieving operational standards [16]. The issue of circulating an authorization letter arose from the realization that the initial efforts of private for-profit healthcare sectors in malaria case management were being overlooked by formal hospital staff. To prevent patients from seeking treatment from informal practitioners or drug sellers, it became crucial to address this issue. However, there was a concern regarding the capacity of selected and trained drug sellers and private clinic personnel, as their capabilities might remain unrecognized in the future. To mitigate this risk, the implementation of an authorization notice became necessary, which would be circulated to grant these healthcare providers the permission to treat malaria patients. The Civil Surgeon office could play a key role by issuing the notice to the relevant private clinics, diagnostic centres, and drug outlets. Additionally, to ensure effective monitoring of the project activities, the involvement of a reputable and efficient organization as a third-party monitor was recommended.
The availability of antimalarial drugs at healthcare centres, where doctors are present to provide treatment instead of referring patients to government health facilities or partner NGOs, can create opportunities for more efficient malaria case management. This approach not only reduces time delays and hassles in delivering treatment to patients but also enhances overall effectiveness. A participant from the FGDs emphasized this strategy, stating that their private lab conducts serological tests alongside RDT but lacks the provision of treatment. However, with the presence of a 24-hour doctor at their health centre, they expressed the capability to provide treatment if anti-malarial medication is supplied. To implement this approach successfully, these doctors would require malaria case management training based on national guidelines. Additionally, it is crucial to inform relevant health authorities about diagnostic details to ensure treatment synchronization. According to other relevant studies, subsidies for RDTs and corresponding equipment purchases can strengthen complementary activities such as strategic behaviour change communication processes, community awareness and supervision of providers with integrated financial mechanisms, according to other relevant studies [17, 31, 32].
Private for-profit healthcare centres are primarily driven by business interests, seeking to profit from each visiting patient, including those with suspected malaria cases. Furthermore, drug sellers anticipate receiving an honorarium as a service charge if RDTs are supplied to their outlets [17]. During discussions, a participant highlighted that only 30% of suspected malaria cases were referred by doctors for MP testing, while 70% were avoided. This was attributed to the test being a time-consuming procedure and having limited profitability. The participants expressed concerns about engaging with the NMEP for elimination efforts, emphasizing the need to implement service charges to compensate for low wages and the long, stressful working hours that often overburdened them. Consequently, expecting private for-profit facilities to provide free-of-cost services might not be feasible. Implementing additional service charges could enhance willingness and dedication in malaria case management, aligning with the business interests of these facilities.
Nevertheless, the for-profit service providers have shown interest in working with the NMEP. They have also expressed reservations about treating malaria patients. There is interest among the providers in working under the NMEP platform. However, they expressed a need for training to ensure a high-quality of services. They have also requested subsidies for diagnostic tools and incentives for their services. Moreover, they have desired a simple and user-friendly case referral system that is in line with phenomena seen in many countries [33, 34] such as Yemen, where the usefulness of training intervention was found to be useful for the PHP in practicing national treatment guidelines [35].
Strengths and limitations:
This study is the first to explore the willingness of for-profit private sectors in both malaria-endemic and non-endemic areas of Bangladesh to collaborate with the NMEP in eliminating malaria through a mixed-methods approach. However, the study's limitations include a short timeframe and a lack of comprehensive data from non-endemic regions. Since the data are only from one non-endemic area, they may not be generalizable to the entire non-endemic population.