Non-formal private providers can make significant contributions to achieving malaria elimination. In countries where a high proportion of people seek care from these providers, elimination is unlikely without their direct engagement to test, treat, and report. In Myanmar, 50% of people seek care for fever in private sector outlets, both formal and non-formal (2016 household survey). The National Malaria Control Program (NMCP) in Myanmar is supportive of malaria testing and treatment by non-formal providers, including trained health providers, itinerant drug vendors, medical drug retailers, and general retail stores. PSI Myanmar works with non-formal providers to replace oral artemisinin monotherapies (oAMT) with quality artemisinin-combination therapy (QAACT) by working directly with distributers, and ensure quality case management and reporting through training, provision of RDTs, and performance-based supervision.
Among non-formal providers between 2012-16, the availability of oAMTs decreased from 67% to 20%, while the availability of QAACTs increased from 4% to 50%. Quality of case management was measured through supervision visits and mystery client surveys. Of 4,266 providers receiving a supervisory visit in 2017, 66% scored above 80% on correct tasks performed, with only 8% scoring below 50%. During mystery client surveys in 2017, 91% of providers appropriately described or demonstrated using RDTs, and 97% adhered to negative test results. Of 12,618 outlets active at any point in 2017, 11,248 (89%) reported case data.
Non-formal providers are often considered a liability in malaria elimination efforts because of diversity of skills and knowledge, difficulty in enforcing regulations, and lack of an organizational structure similar to the public sector. Yet the Myanmar NMCP with support from PSI have demonstrated that non-formal providers can accelerate elimination efforts through engagement to provide quality case management and report cases. These efforts can be used as a model for other countries wishing to accelerate elimination efforts.