Important gains towards malaria elimination have been achieved in recent years in the Greater Mekong Subregion (GMS). Although malaria cases and deaths have declined dramatically, the expansion of artemisinin resistance in the region is a growing threat to malaria control efforts. Thorough surveillance is critical to curbing the epidemic, and private sector contributions, while important, often go unreported (1, 2). Established in 2016 and funded by the Bill and Melinda Gates Foundation, Population Services International’s (PSI) Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS) program aims to increase private sector engagement to accelerate progress towards elimination.
Countries in the GMS aim to eliminate all forms of malaria by 2030. There has been a 74% decline in the number of confirmed malaria cases between 2012 and 2019 and a 95% decline in malaria deaths in the same period (3). The major vectors in the GMS—Anopheles minimus and Anopheles dirus—are now found primarily in forest and forest-fringe areas. As a result, the malarial burden is concentrated disproportionately among those who live near these zones.
Much progress has been made in the GMS, particularly during the last five years, to reduce the malaria burden. In Lao PDR, the number of malaria cases decreased between 2012 and 2019 by 80% (3). Vietnam has fewer than 5,000 confirmed cases per year, mostly concentrated in three provinces: Binh Phuoc, Dak Lak, and Gia Lai (4). In the past decade, the number of reported malaria deaths in Myanmar has dropped steadily year by year from 1,707 in 2005 to just 19 in 2018 (a 99% reduction over 10 years). The incidence of reported malaria has fallen by 85% since 2012 (from 9.94 per 1,000 population in 2012 to 1.46 per 1,000 population in 2018) (3).
Collectively, GMS countries reported the steepest decline to date in Plasmodium falciparum (Pf) malaria with cases dropping by 47% in 2019 compared to 2018. For the first time, Pf cases no longer compose the majority of cases in the Subregion, as they accounted for just 32% of all cases in 2019 (compared to 80% of all cases in 2012). This substantial achievement is even more important given the ongoing threat posed by antimalarial drug resistance in the GMS, where P. falciparum resistance to artemisinin and partner drugs is present across the region (5).
Engaging the private sector is necessary to achieve malaria elimination in the GMS, as a significant proportion of the population first seeks health care within that sector. The preference for private sector providers is likely related to accessibility and perceptions of quality and flexibility in prescribing medicines when compared to the public sector (6). However, none of the six countries in the GMS collect complete case data from private sector points of care such as pharmacies, clinics, shops and private hospitals (7). As a result, national policy makers lack access to a complete malaria case data set to inform program strategies and interventions.
In 2015 and 2016, cross sectional outlet surveys identified low availability of malaria diagnostic testing and poor access to first-line treatment in the private sector across the GMS (8). Between 2015 and 2019, the GEMS program received funding from the Bill & Melinda Gates Foundation to support national malaria control programs (NMCPs) in Cambodia, Lao PDR, Myanmar and Vietnam to capture private sector data by engaging private providers in malaria case management, generating private sector malaria case data, and integrating these data into national surveillance systems. The GEMS established network has increased access to quality case management in Cambodia, Lao PDR, Vietnam and Myanmar, where use of the private sector remains high (6), and PSI-supported providers detected between 1.8% and 18% of the national caseload in each of the four countries in 2019.
The program includes training eligible private providers according to national malaria case management guidelines, ensuring uninterrupted supply with quality assured malaria rapid diagnostic tests (RDTs) and Artemisinin Combination Therapy (ACT) for treatment, providing routine supportive supervision to providers, and carrying out quality assessments of service provision. It is implemented with a different geographic scope across the four target countries.
PSI/Myanmar implements GEMS nationally in both high and low burden areas and through Sun Quality Health (SUN) network providers, Integrated Community Malaria Volunteers (ICMVs), and Non-Formal Private Outlet network members (POs)1. SUN providers are qualified physicians, typically General Practitioners (GPs) working in a clinic setting, whereas ICMVs are similar to public sector community volunteers, some of whom have medical training (e.g., auxiliary midwife). The PO network consists of mobile drug vendors, small drug shops, and general retail stores. ICMVs and POs are located in rural and peri-urban areas throughout the country and are responsible for the vast majority of testing and case detection. As part of participation in the program, SUN providers receive a maximum incentive of $16 per month, ICMVs receive a maximum of $10 per month, and POs receive a maximum of $5 per month. Through the engagement of these private sector providers, PSI/Myanmar tested 520,341 fevers in 2019, resulting in 4,388 cases detected. This accounted for approximately 14.2% of total fevers tested in country, with 8.3% of the national caseload detected through PSI’s networks (9). The SUN providers detected 13.4% of all PSI networks’ positive cases, the ICMV channel detected 57.9%, and the PO channel detected 28.6%. Despite receiving fewer performance-based incentives (see Table 1), the PO network tends to have the highest positivity rate. SUN doctors have the second highest (despite lower testing rates than ICMVs and POs), likely due to their urban and peri-urban location and qualifications, which makes them more likely to test for confirmation of clinical diagnosis.
Table 1
| Country |
| Lao PDR | Myanmar | Vietnam |
Channel | PPM | PO (AMTR) | ICMV (CHSP) | Sun | Clinic | Pharmacy | FMCG |
Incentives: USD/month per provider; or max. possible if performance based | $ 40 | Maximum USD 5 | Maximum $ 10 | Maximum $ 16 | No monetary incentive (Promo items only, ~$20) | No monetary incentive (Promo items only, ~$5) | No monetary incentive (Promo items only, ~$5) |
In Lao PDR, the PSI program operates in the five southern provinces and the low-burden, elimination-targeted north. In 2019 PSI supported 474 public-private mix (PPM) providers, consisting primarily of doctors and pharmacists, to test for, treat and report uncomplicated Pf and Pv cases (with ACT only). For their participation in the GEMS program, the PPM providers in Lao PDR receive a maximum incentive of $40 per month intended to cover things such as internet costs. In 2019, GEMS supported providers tested 73,754 fevers (13% of total fevers tested in the country) and detected 612 cases. A total of 9.2% of the national reported caseload in Lao PDR was detected through the PSI PPM network.
In Vietnam, the GEMS program operates in 4 provinces, primarily in the Central Highlands region. The GEMS network in Vietnam consists of private clinics (staffed by medical doctors), private pharmacies, community-based volunteers known as community malaria champions (CMCs), and fast-moving consumer goods shops (FMCGs). In agreement with some provincial authorities, PSI has trained pharmacies, CMCs, and consumer good shops to test and refer malaria cases. Providers in Vietnam do not receive financial compensation—only monthly/quarterly promotional material incentives valued at less than $43. In 2019, PSI’s 828 GEMS supported providers tested 28,421 fevers and detected 877 cases, accounting for 1.4% of the total fevers tested in country and 18.7% of the national reported caseload. The majority of cases in the PSI network are detected by clinics (74%), followed by pharmacies (13.6%).
Achieving malaria elimination will require a concerted effort from actors across the public and private sectors. Private sector involvement in malaria surveillance is a relatively recent development. In this study, we sought to understand the motivations of private sector network providers to test, treat, and report malaria cases and determine barriers to quality performance.
Motivation has been defined as, “the level of effort and desire to perform well” and is an important determinant of quality of care (10). Motivation in an employment setting is defined as “… a set of energetic forces that originate both within as well as beyond an individual’s being, to initiate work related behavior, and to determine its form, direction, intensity, and duration” (11). Motivation has been associated with lower levels of staff turnover (12), higher retention, less job burnout, increased performance (13), and higher quality of care (14). Further, motivated employees come to work more regularly, work more diligently, and are more flexible (15).
The evidence base on provider motivation in a malaria context is limited, particularly in terms of a robust, multi-country quantitative analysis. Existing studies tend to be qualitative in nature, conducted in the public, not private, sector, and largely focused on community health workers (CHWs). Available evidence suggests that providers are motivated by both financial and non-financial incentives. A study in Vietnam found the main motivating factors for public sector health workers were appreciation by managers, colleagues and the community, a stable job and income, and training (16). A study in Tanzania examined sources of CHW motivation at multiple levels: the individual, family, community, and organization. CHWs were found to be predisposed to volunteer work and were motivated to apply the knowledge gained through their work to their own personal problems and to those of their families and communities. On a family and community level, supplemental motivation was provided in the form of moral, financial, and material support, such as service fees, supplies, money for transportation, and assistance with farm work and CHW tasks. The government and development partners, at the organizational level, motivate CHWs with stipends, potential employment, materials, training, and supervision (17). Another study among CHWs in Mozambique and Uganda found CHWs are motivated by status and community standing (18).
Within the malaria context, existing literature explores provider motivations for testing and treatment (19–21), but little is known regarding provider motivations for case reporting. There is also a dearth of literature for Pf elimination contexts. A 2015 study with health providers in Myanmar identified empowerment and improved provider-patient relationships as motivations for using rapid diagnostic tests (22). Research in Cameroon and Nigeria found treatment preferences among providers were determined largely by patient preference and government recommendations, not personal motivating factors (23). Finally, a study in Uganda found community medicine distributors are motivated for altruistic reasons, but the main reported benefits of their work were self-importance, social mobility for self and family, and relationship building (21).
Quantitative measurement of provider motivation involves defining motivation, a multidimensional construct. It must also consider the multiple components of motivation that influence behavior, and the context-specific language used to discuss motivation in different cultural settings. Furthermore, employment motivations can differ in both conceptualization and measurement between different provider subgroups. Direct measures are typically derived through measurement scales within a survey or through qualitative methods. Indirect measures of motivation can be derived through surveys or qualitative methods via experimental games or observations of behavior (24). Further, where measuring motivation has been attempted, it has been focused on the public and community sectors.
In 2000, Bennett, Franco, Kanfer and Stubblebine developed a specific tool to measure the determinants and consequences of public sector health worker motivation in developing countries, which was then used in a three-part study of health worker motivation in hospitals in Jordan and Georgia (25). The tool encompasses a number of motivational and performance categories, theoretical constructs, and scales.
In 2017 Lohmann et al. developed a psychometric scale to measure motivation composition (26). The scale was grounded in the self-determination theory (SDT), a theory introduced in the 1980’s as a general framework of human motivation. The SDT captures a generalized measure of motivation toward work and identifies five dimensions of motivation that can be placed along a continuum from extrinsic (motivation to attain or avoid a consequence that is maintained by rewards/punishment) to intrinsic (motivation stemming from the enjoyment of a task).
The present study aims to identify and validate different underlying subtypes of motivation among private sector providers enrolled in the GEMS program. We then examine how these subtypes of motivation differ by provider characteristics, and whether they are associated with intentions and outcomes related to malaria service provision. These analyses will allow us to develop recommendations that influence policies on the role of the private sector in national malaria elimination strategies.
Footnote:
[1] Between data collection and publication of results, the Artemisinin Monotherapy Replacement Network (AMTR) was renamed to Private Outlets, and the Community Health Services Provider (CHSP) was renamed Integrated Community Malaria Volunteers. In the text we refer to the networks as POs and ICMVs.