Introduction: Community Health Workers (CHWs) can provide diagnosis and treatment of malaria in remote rural areas, and are therefore key to malaria elimination. As incidence declines, uptake of CHW services could be compromised if they only treat malaria. Broadening their remit to offer additional health services may be necessary to ensure continued provision of quality malaria detection and treatment.
Methods: We conducted a retrospective analysis of 571,286 malaria rapid diagnostic tests conducted between 2011 and 2016 by 1,335 CHWs supported by Medical Action Myanmar. We assessed the rate of decline in Plasmodium falciparum and Plasmodium vivax incidence and positivity rates using negative binomial mixed-effects models. We investigated whether broadening the CHW remit to provide a basic health care (BHC) package was associated with a change in malaria blood examination rates using an interrupted time series assessment.
Results: Communities with CHWs providing malaria diagnosis and treatment experienced declines in P. falciparum and P. vivax incidence of 70% (95% CI: 66%-73%) and 64% (59%-68%) respectively for each year of CHW operation. Positivity rates declined by 70% (95% CI: 66%-73%) and 65% (95% CI: 61%-69%) for P. falciparum and P. vivax respectively. In four cohorts studied, adding a BHC package was associated with an immediate and sustained increase in blood examination rates (step-change rate ratios: 2.3 (95% CI: 2.0-2.6), 5.4 (95% CI: 4.0-7.3), 1.7 (95% CI: 1.4-2.1), and 1.1 (95% CI: 1.0,1.3); and improved trends post-BHC relative to pre-BHC (p<0.0001, p<0.0001, p=0.51, and p=0.01).
Conclusions: CHWs have overseen dramatic declines in P. falciparum and P. vivax malaria in rural Myanmar. Expanding their remit to general health care sustained quality malaria control. In similar settings, expanding health services offered by CHWs beyond malaria treatment can improve rural healthcare whilst ensuring continued progress towards the elimination of malaria.