Assessing the Role of the Private Sector in Surveillance For

Sidibe et al. Malar J (2019) 18:408 https://doi.org/10.1186/s12936-019-3024-3 Malaria Journal RESEARCH Open Access Assessing the role of the private sector in surveillance for malaria elimination in Haiti and the Dominican Republic: a qualitative study Abigail Sidibe1†, Alysse Maglior1†, Carmen Cueto1, Ingrid Chen1, Arnaud Le Menach2, Michelle A. Chang3, Thomas P. Eisele4, Katherine Andrinopolous4, Joseph Cherubin5, Jean Frantz Lemoine6 and Adam Bennett1* Abstract Background: Haiti and the Dominican Republic (DR) are targeting malaria elimination by 2022. The private health sector has been relatively unengaged in these eforts, even though most primary health care in Haiti is provided by non-state actors, and many people use traditional medicine. Data on private health sector participation in malaria elimination eforts are lacking, as are data on care-seeking behaviour of patients in the private health sector. This study sought to describe the role of private health sector providers, care-seeking behaviour of individuals at high risk of malaria, and possible means of engaging the private health sector in Hispaniola’s malaria elimination eforts. Methods: In-depth interviews with 26 key informants (e.g. government ofcials), 62 private providers, and 63 patients of private providers, as well as 12 focus group discussions (FGDs) with community members, were conducted within seven study sites in Haiti and the DR. FGDs focused on local defnitions of the private health sector and identi- fed private providers for interview recruitment, while interviews focused on private health sector participation in malaria elimination activities and treatment-seeking behaviour of febrile individuals. Results: Interviews revealed that self-medication is the most common frst step in the trajectory of care for fevers in both Haiti and the DR. Traditional medicine is more commonly used in Haiti than in the DR, with many patients seeking care from traditional healers before, during, and/or after care in the formal health sector. Private providers were interested in participating in malaria elimination eforts but emphasized the need for ongoing support and training. Key informants agreed that the private health sector needs to be engaged, especially traditional healers in Haiti. The Haitian migrant population was reported to be one of the most at-risk groups by participants from both countries. Conclusion: Malaria elimination eforts across Hispaniola could be enhanced by engaging traditional healers in Haiti and other private providers with ongoing support and trainings; directing educational messaging to encourage proper treatment-seeking behaviour; and refning cross-border strategies for surveillance of the high-risk migrant population. Increasing distribution of rapid diagnostic tests (RDTs) and bi-therapy to select private health sector facilities, accompanied by adopting regulatory policies, could help increase numbers of reported and correctly treated malaria cases. Keywords: Malaria, Haiti, Dominican Republic, Private health sector, Private sector engagement, Care-seeking behavior, Traditional healers, Migrant population Background Haiti and the Dominican Republic (DR) are the only *Correspondence: [email protected] remaining countries in the Caribbean with endemic †Abigail Sidibe and Alysse Maglior contributed equally to this work 1 Malaria Elimination Initiative, The Global Health Group, University malaria transmission [1]. Although elimination of Plas- of California, San Francisco, CA, USA modium falciparum was almost achieved in the 1960s, Full list of author information is available at the end of the article malaria resurged in the 1970s following reductions in © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sidibe et al. Malar J (2019) 18:408 Page 2 of 14 funding. In the past decade, a new wave of funding private non-proft (e.g. non-governmental organizations and ambition has reinvigorated global goals of malaria and religious organizations), “mixed” non-proft [pri- eradication. Recognizing that elimination on the island vate management with staf paid for by the Ministry of of Hispaniola will require a coordinated approach, the Public Health and Population (French acronym MSPP)] Haitian and Dominican National Malaria Control Pro- and private for-proft organizations [5, 14]. Of more than grammes (NMCPs) developed a bi-national plan to 900 health institutions, roughly 38% are public, 42% are eliminate malaria by the year 2020, which now has been private, and 20% are mixed [15]. Informal private health extended to 2022 [2, 3]. However, malaria transmission sector providers, such as traditional medicine practition- and health care systems difer considerably between the ers, play a major role as well. An estimated 50–80% of two countries which posess unique challenges to elimi- the population use traditional medicine services, due to nation eforts. In 2017, the island of Hispaniola reported spiritual beliefs as well as lower cost and greater acces- 19,476 cases, 98% (19,135 cases) of which were reported sibility [5, 14, 16]. A 2017 census found that only 23% of in Haiti and only 2% (341 cases) were reported in the DR Haitian households live within 5 kilometres of a primary [4]. Actual case burden is likely much higher, as many care facility of good quality in the formal health sector (a cases are not reported through the national surveillance “good quality” facility was defned as having a high over- systems. all score on four service delivery domains: accessible care, In order to achieve malaria elimination on the island efective service delivery, management and organization, of Hispaniola, all malaria cases must be detected, docu- and primary care functions) [17]. mented, and treated. However, due to accessibility and Malaria cases are almost exclusively diagnosed by pas- preference, populations at high risk of malaria often seek sive detection, as there is little active surveillance in the malaria treatment in the private health sector which has country. Rapid diagnostic tests (RDTs) were introduced remained largely unengaged in these eforts [2, 5]. Engag- in 2010, became national policy shortly thereafter, and ing private providers is critical for efective case man- are currently used to confrm cases in the national sur- agement and reporting, especially in settings where the veillance system at a ratio of 3:1 compared to micros- private health sector plays a large role [6]. copy [18]. In 2011, chloroquine-primaquine bi-therapy Te private health sector consists of formal institutions, was adopted as frst-line treatment [2]. Primaquine (PQ) such as pharmacies, clinics, and hospitals, as well as is incorporated into bi-therapy for its gametocytocidal informal institutions, such as shops, itinerant drug ven- efect, although the absence of PQ during treatment dors, and traditional healers. Informal private providers with chloroquine does not render the treatment inefec- might not have received formal training and their clinical tive. Despite high utilization of the private health sector, practice might not be registered or licensed by any gov- only the public and mixed institutions have access to PQ erning body. Prior research has shown that private health to satisfy the bi-therapy strategy. However, even among sector involvement in malaria surveillance, diagnosis and these institutions the availability of PQ is low; only 31% treatment eforts has strengthened national malaria elim- of these formal institutions stocked PQ according to a ination programmes [7–12]. However, the participation 2013 government report [15]. of the private health sector in malaria surveillance and elimination eforts in Haiti and the DR is largely unex- Dominican Republic plored, as are the care-seeking behaviours of individuals Prior to 2001, the majority of the population in the at high risk of malaria (either for behavioural reasons— Dominican Republic was theoretically covered by a pub- e.g. migrant agricultural workers; or more immunological lic system fnanced by general taxes. Tis system encour- reasons—e.g. pregnant women). Tis study describes the aged growth of the formal private health sector fnanced role of private providers in case management and surveil- by voluntary reimbursement insurance, prepaid pay- lance, explores care-seeking behaviour of individuals at ment plans, and out-of-pocket expenditures. In 2001, the high risk of malaria, and investigates possible means of private health sector’s importance increased following engaging the private health sector in Hispaniola’s malaria adoption of a new healthcare framework, consisting of a elimination eforts. complex system of public, private, and non-proft institutions. As of 2012, there were 1853 public sector facilities Methods (1703 primary care units and 150 s- and third-level treat- National health system context ment centres) [19], and an estimated 7121 private sec- Haiti tor facilities (6818 for-proft facilities and 283 non-proft Te provision of

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