Strengthening field-informed for-profit private sector engagement strategy in malaria elimination: insights from a single-group quasi-experimental pilot study in Bangladesh

Abstract

Background

Despite the dramatic achievements in malaria control, Bangladesh continues to face persistent transmission in high-endemic regions such as Bandarban in the Chittagong Hill Tracts. One important strategy to close surveillance and case management gaps is to involve the for-profit private sector that serves marginalized populations including high-risk occupational groups and communities facing geographical obstacles. The objectives of this study were to determine the practicality and the effects of involving the private healthcare providers in the national malaria surveillance system in Alikadam Upazila, Bandarban.

Methods

A One-month pilot study was conducted in March 2023 in 10 for-profit private healthcare facilities in Alikadam Upazila, Bandarban. The providers were trained to do rapid diagnostic tests on suspected malaria patients and to refer positive cases to government or partner NGO facilities. Data on adherence to diagnostic protocols, the detection of malaria cases, the reporting, the referral and patient satisfaction were collected using standard registers, reporting forms and supervision checklists. These data were entered into an electronic database and analysed descriptively. Quality assurance was taken care of by monitoring and evaluation mechanisms, including regular supervisory visits.

Results

Rapid diagnostic tests were done on 440 patients in the pilot, and 1.8% were positive of malaria (Plasmodium falciparum and P. vivax were equally distributed). The study period has shown that the private sector has a share of 20% in all the reported cases of malaria in Alikadam. Most of the participants were males (54.6%), and 4.0 percent of the women were pregnant. The level of patient satisfaction was also good as 100 percent of the people who were surveyed claimed that they were confident in the private providers and the referral process. The accuracy of data recording rose as the providers performed better over time with a rate of 37.5 in week one but in the fifth week, it was 87.5. Although these successes have been achieved, referral gaps and lack of financial incentives to the private providers were a challenge.

Conclusions

The research highlighted private healthcare providers’ potential in malaria surveillance and case detection in remote, vulnerable populations. Integrating them into national programs could strengthen health systems and eradication efforts, but scaling requires addressing challenges like sustained training, financial incentives, and adequate service coverage.

Highlights

• 440 patients underwent rapid diagnostic tests, with 1.8% testing positive for malaria, indicating the prevalence of the disease.

• The majority of participants were male (54.6%), and among the women, 4.0% were pregnant.

• The private sector accounted for 20% of all malaria cases reported in Alikadam during the study period, showcasing their involvement.

• High patient satisfaction, with 100% of surveyed individuals expressing confidence in private providers and the referral process.

• Providers showed significant improvement in performance, with the accuracy of data recording increasing from 37.5% in week one to 87.5% by week five.

Introduction

Malaria remains a significant issue of public health worldwide, as in 2022, the prevalence of the disease in 85 endemic countries has reached 249 million cases and 608,000 deaths. The World Health Organization (WHO) has gone far in the fight against the disease especially in the southeast Asian region where the number of cases has reduced by 76% between 2000 and 2022, contributing to only 2% of the global cases of malaria and 1.31 percent of deaths in 2022, respectively [1]. Bangladesh has also shown the outstanding successes, cutting the number of malaria cases by 93% in 2008 to 2020 [2]. Nonetheless, the load continues to be high in 13 districts, and in 2022, 76 percent of the total number of cases in the country were recorded in Bandarban, which is why specific efforts are necessary [3].

As part of the requirement of the WHO 2030 objective of universal access to malaria prevention, diagnosis, treatment and elimination, the Bangladesh National Strategic Plan (NSP) 2021–2025 advocates the need to have the collaboration of the private sector [4, 5]. The country has a huge potential in the private healthcare sector with over 5000 hospitals and clinics with a total number of over 90,000 beds, as well as 9529 diagnostic centers, that can help in eradicating malaria in the nation [3]. Nevertheless, such difficulties as the inconsistent quality, inadequate training and inability to become part of the National Malaria Elimination Program (NMEP) remain. It is important to make partnerships with the private sector stronger to increase access to quality malaria services and seal gaps currently present in surveillance and treatment.

Despite this policy direction, the for-profit private sector has bot yet been fully integrated into the NMEP platform. This may be due to the absence of routine mechanisms for formal reporting and coordination, limited opportunities for standardized training and supervision, and the lack of clear incentive or reimbursement structures for private providers. In addition, concerns about consistency in service quality and data completeness may have contributed to the slow integration of the private sector into the national malaria program [5].

The role that non-governmental organizations (NGOs) have in the context of malaria eradication in the Bangladesh country is significant in the context of the private sector. Since 2007, a consortium led by BRAC, the world’s largest NGO, has been at the forefront of these efforts [6]. Community health workers, such as Swasthya Shebika and Swasthya Kormi, have been tirelessly working under this platform to help achieve the goal of a malaria-free Bangladesh by 2030. Their dedication has resulted in a significant reduction in malaria cases in recent years [2, 4]. At the same time, many for-profit private healthcare providers operating in malaria-endemic regions have also been actively diagnosing and managing malaria cases. Their contributions deserve recognition and should be integrated into the NMEP platform to ensure a sustainable and collaborative approach to eradicating malaria in the country [3].

To engage this for-profit private sector providers under the platform of NMEP, a strategy has been drafted and a pilot implementation of that strategy was conducted and evaluated. By piloting a private sector engagement (PSE) strategy in Bandarban- a high-endemic regions, the study examines providers' adherence to strategy, their role in malaria detection and referral, and patient satisfaction with their services. The findings aim to address operational challenges, enhance surveillance systems, and offer scalable solutions for improving the private sector’s contribution to achieving a malaria-free Bangladesh by 2030.

Methods

Strategy to engage for-profit private sector in NMEP platform

Before developing a strategy to engage the for-profit private sector in the NMEP platform, a baseline situation analysis was conducted. The analysis revealed that over 80% of for-profit private sector providers performed malaria diagnostic tests. However, most did not report to the NMEP or provide treatment, primarily due to the unavailability of anti-malarial drugs in the local market [3].

According to the field-informed strategy for private sector engagement in malaria elimination and the country’s policy, the NMEP will provide WHO-prequalified malaria RDTs to for-profit private service providers free of charge [7]. In return, these providers will refer positive cases to the nearest Upazila Health Complex with a referral slip. While providers may charge a service fee as per their policies, they will not be permitted to treat patients directly (Unpublished document).

Study setting and participants

The pilot implementation of the strategy was carried out in Alikadam Upazila, situated in the Bandarban district of Chattagram Division, Bangladesh. Covering an area of 885.78 km², Alikadam lies at 21.6667°N and 92.3056°E. It is bordered by Lama Upazila to the north, Myanmar (Arakan) to the south, Thanchi Upazila to the east, and Naikkhongchhari Upazila to the west. The region is part of the relatively flat terrain within the hilly landscape of Bandarban. According to the population and housing census 2022, Alikadam had a population of 63,799, comprising 33,315 males and 30,484 females [8] (Fig. 1). The region is also a rich combination of various ethnic groups, such as Bengali, Murung/Mro, Marma, Tripura, Tongchangya, and Chakma, with Bengalis being the larger population [9].

Fig. 1.

Map of Bandarban district showing the study area (Alikadam Upazila)

The pilot study was conducted in the form of a single-group quasi-experimental study aimed at evaluating the effectiveness of a draft strategy that should engage for-profit and the private sector organizations, in the national malaria surveillance system. The research assessed the effectiveness of the implementation of the suggested PSE strategy-based toolkit, collected feedback with the help of surveys and interviews and provided recommendations regarding the optimization of the strategy. An area survey determined 10 for-profit private health service providers in Alikadam Upazila who were selected to take part in the pilot study. The pilot study was conducted over a one-month period, from March 1 to March 31, 2023.

Conceptual framework

All the work was conducted in consultation with the Communicable Diseases Act 2018 [10] and the draft strategy of involving the for-profit private sector in the malaria surveillance led by the NMEP (Fig. 2). The main aspects, including the identification or mapping of service providers, diagnostic tools, referral systems, and plans of oversight, were taken into account. It was important to have high level expectations of service delivery by providers to ensure the successful coverage of the service. The final aim was to increase the resilience of the health system and guarantee effective and enhanced health outcomes in addition to safeguarding equity and human rights. This was through accessing the marginalized communities, high-risk occupational groups, and vulnerable ethnic groups, which were the majority of the malaria incidences.

Fig. 2.

Conceptual framework for engaging for-profit private sectors in malaria surveillance

Alikadam Upazila consistently reports the highest malaria incidence in Bandarban district, with 4025 cases recorded in 2022 alone, transmitted throughout the year, marking an exception to its usual trend [1]. Apart from government and partner NGO health service facilities scattered across Upazila, for-profit private medical facilities are primarily concentrated in the Upazila Sadar. For the pilot study, 10 for-profit private health service providers were selected after discussing the draft survey results and methodology with stakeholders and experts from the WHO Bangladesh Country office, icddr,b and NMEP followed by incorporating their input, comments, and suggestions. The 10 facilities comprised two consultancy and diagnostic centers, five private clinics run by graduate doctors, two drugstores equipped with malaria diagnostic services, and one clinic operated by an NGO.

During stakeholder and expert meetings, it was decided that for the pilot study, for-profit private healthcare providers would be encouraged to use rapid diagnostic tests (RDTs) for suspected malaria cases and refer positive cases to the nearest government or partner NGO facilities. The NMEP supplied RDT kits to these providers free of charge; however, no financial incentives were offered for successful referrals, and the intervention did not cover any fees or service charges set by the providers.

Step-by-step procedures of engaging private sector providers in malaria surveillance

To ensure the successful implementation of the pilot study, several preparatory steps were undertaken. The team developed essential documents, including a training manual, supervision and monitoring tools, report forms, referral forms, and pre- and post-test questionnaires, through expert consultations. The NMEP purchased WHO-prequalified RDTs to be used during the training and pilot phases. Before the launch, local health authorities were oriented and a planning meeting held with the Civil Surgeon of Bandarban district, the UHFPO of Alikadam Upazila and the SMO Malaria of Bandarban to smooth the objectives and guarantee they were well coordinated.

Data collection

During the one-month pilot period, all participating private for-profit health facilities used standardized registers and reporting forms developed by NMEP and partners to document suspected malaria cases tested by RDT, corresponding results, and referral decisions. Supervisors used structured supervision and monitoring checklists during their visits to review records, verify the storage and use of RDTs, and track adherence to the pilot procedures. A brief patient satisfaction module was administered to a subset of RDT-positive patients to capture their perceptions of the testing and referral process. All completed registers, reporting forms, referral slips, and supervision checklists were collected at the end of the pilot and compiled for data entry and analysis.

Training and implementation

The pilot phase consisted of training the for-profit private healthcare providers according to the NMEP recommendations. The in-service training was done in day-long sessions by the local professionals who had received training-of-trainers (TOT) training. The participants were trained to conduct RDTs on suspected cases and, in the event of a positive result, the suspected cases were referred to government or partner NGO facilities. Pre-tests were carried out to determine the baseline knowledge. After the training, the providers received a month of RDT kits, reporting forms and referral forms, and a surveillance assistant was appointed to keep track of the stock and usage.

Quality assurance and monitoring

In order to ensure quality assurance, every test record, supply chain, and referral status was checked, and cross-checked where necessary. Bimonthly and weekly monitoring and supervision were used to maintain consistency. Data and reports were assessed after the piloting phase which took one month to develop a strategic action plan that would cater to the needs and gaps in the private sector. The end result of this plan, discussed among the stakeholders, included a budget and monitoring structure to support integration of private providers into the national malaria program.

Results

All 10 private health facilities in Alikadam participated in the private sector engagement survey. Between March 1 and 31, 2023, a total of 440 participants (health care seekers/patients) were enrolled in the pilot study from each private sector health facility. The highest number of patients was screened at PS-01, accounting for 39.5% of the total screenings, followed by PS-03 (23.0%) and PS-05 (12.3%). In contrast, PS-09 and PS-10 screened the lowest, with only 4 (0.9%) and 5 (1.1%) patients, respectively (Table 1). As this was a feasibility-oriented pilot with a small number of facilities, the relevant findings were presented using descriptive statistics, focusing on counts and percentages across facilities and overtime.

Table 1.

Participant enrollment status in different private health facilities of Alikadam

Provider’s ID	Patient screened (N)	%
PS-01	174	39.5
PS-02	24	5.5
PS-03	101	23.0
PS-04	6	1.4
PS-05	54	12.3
PS-06	22	5.0
PS-07	15	3.4
PS-08	35	8.0
PS-09	4	0.9
PS-10	5	1.1

Characteristics of the enrolled participants

A total of 440 suspected and febrile individuals underwent RDT for malaria, and 1.8% tested positive. Among the positive patients, 50% had P. falciparum infection, and the other 50% had P. vivax infection. Among the enrolled participants, 2.5% were less than one year of age, and 12.0%, 22.1%, and 63.4% of participants were between 1–5 years, 6–15 years, and more than 15 years, respectively. The majority of participants were male (54.6%), and among the women, 4.0% were pregnant. Among the malaria-positive participants, 98.4% were referred to government health facilities, the BRAC, or BRAC-led NGO consortium for malaria program. Among the referrals, 28.6% were directed to the Upazila Health Complex (UHC) government health facilities, while 71.4% were referred to the BRAC or BRAC-led NGO consortiums. Only one participant was identified at a late hour and could not be referred (Table 2).

Table 2.

Demographic characteristics of the enrolled participants

Characteristics	N	%
Patient’s age
< 1 Year	11	2.5
1–5 Year	53	12.0
6–15 Year	97	22.1
> 15 Year	279	63.4
Patient’s gender
Male	240	54.6
Female	200	45.4
Number of pregnant women	8	1.8
Total number of RDT done	440
Distribution of RDT result
Negative	432	98.2
Positive	8	1.8
Pf	4	50.0
Pv	4	50.0
Mix	0	0.0
Patient referred
Yes	7	98.4
No	1	1.6
Patient referred to
UHC	2	28.6
BRAC and BRAC lead NGOs	5	71.4

Efficiency of the private service providers

Of the 10 private health facilities, 5 (50%) enrolled malaria-positive participants. Among these, PS-01 had the highest enrollment, contributing 3 out of 8 participants (37.5%), followed by PS-05 with 2 participants (25.0%). PS-03, PS-06, and PS-08 each enrolled 1 participant (12.5%) (Fig. 3).

Fig. 3.

Distribution of RDT and malaria detection results

Patient satisfaction and perception

Among the 8 participants who tested positive for malaria, 5 (62.5%) participated in the patient satisfaction survey (Table 3). All participants reported that a trained individual conducted the RDT, and they expressed satisfaction with the service provided by the private service provider. When asked about their satisfaction with being referred to Upazila Hospital/Community Clinic/Ekta/BRAC for malaria medication, 100% of the participants indicated that they were satisfied. Additionally, all (100%) of the participants expressed satisfaction with the services received at Upazila Hospital/Community Clinic/Ekta/BRAC and stated that they would visit there in the future for malaria testing and treatment. However, all (100%) participants believed that they should have initially visited Upazila Hospital/Community Clinic/Ekta/BRAC for malaria testing and treatment. When asked why they did not go there first, 4 out of 5 participants mentioned that they did not believe that their fever could be due to malaria, while one participant noted that on that particular day, BRAC/BRAC-led NGO staff was not available in their village.

Table 3.

Participants’ satisfaction level

Question	Yes	No
Is your malaria RDT test done by a trained service provider?	5 (100.0)	0 (0.0)
Are you satisfied with the service of the service provider?	5 (100.0)	0 (0.0)
Are you satisfied that the service provider is referring you to UHC/CC/Ekta/BRAC for malaria medication?	5 (100.0)	0 (0.0)
Are you satisfied with the service provider of Upazila Hospital/Community Clinic/Ekta/BRAC?	5 (100.0)	0 (0.0)
Will you consider visiting UHC/CC/Ekta/BRAC for Malaria test and treatment in future?	5 (100.0)	0 (0.0)
Do you think people should first visit UHC/CC/Ekta/BRAC for Malaria test and treatment?	5 (100.0)	0 (0.0)
Why did not you go first to UHC/CC/Ekta/BRAC for Malaria test and treatment?
Did not thinking of malaria	4 (80.0)
BRAC/BRAC lead NGOs staff was not available	1(20.0)

Monitoring and evaluation

During the study, a supervisor regularly monitored the patient register books in private health facilities to ensure accurate documentation of information and proper storage of used and unused RDTs. Over five visits per facility (50 total visits), patient enrolment did not occur in 7 visits across 3 facilities. Initially, at first week, only 37.5% of health facilities maintained error-free records, but this improved steadily, reaching 62.5% in week 2, 80% in week 3, 100% in week 4, and 87.5% in week 5 (Fig. 4).

Fig. 4.

Weekly performance of patient register book records

Most errors were related to RDT dates (16.3%) and patient contact numbers (16.3%), followed by patient names (9.3%), while RDT results, referral information, and locations were recorded accurately. Across health facilities, 88% of RDTs were performed by trained personnel with prior patient consent (Table 4). Additionally, 88.0% of the service providers followed correct protocols, waited 15 min to obtain the test results, and ensured appropriate patient referrals. All used RDTs were stored correctly, and 100% of results were marked accurately.

Table 4.

Weekly monitoring of private health facilities (N = 50)

Indicators	Yes n (%)	No n (%)
Was the RDT performed by a trained person?	44 (88.0)	6 (12.0)
Did the service provider maintain all the procedure to conduct RDT test?	44 (88.0)	6 (12.0)
Did the service provider wait for 15 min to get the RDT test?	44 (88.0)	6 (12.0)
Did the service provider refer malaria positive patient to the proper place with proper instruction?	44 (88.0)	6 (12.0)
Did the service provider stored used-RDT in proper place appropriately?	44 (88.0)	6 (12.0)
Did the RDT test result display sticker visible?	50 (100.0)	0 (0.0)

Effect of the intervention

In March 2023, private service providers made a significant contribution, accounting for 20% of the total reported malaria cases in Alikadam (Fig. 5). Without the implementation of the intervention, those patients would have been overlooked.

Fig. 5.

Contribution of private service providers to malaria case detection in Alikadam

During the pilot study, Alikadam Upazila recorded 35 malaria cases, surpassing Lama upazila, which had 33 cases. Excluding the 7 cases reported from PHSP, Lama upazila would have had a greater number of reported malaria cases than Alikadam upazila. These findings provide strong evidence for implementing the proposed strategy, which is expected to enhance malaria case reporting to the NMEP and contribute to the program's objective of eradicating malaria from the country (Fig. 6).

Fig. 6.

Malaria case detection in most endemic Upazilas of Bandarban (Jan-Mar 2023)

Discussion

The private sector often serves as the initial point of contact for primary healthcare services, a pattern that extends similarly to malaria treatment [11, 12]. The private health sector, with its extensive reach and diversity, serves as a critical partner for malaria surveillance and an underutilized asset in delivering effective healthcare to marginalized populations, particularly in high-risk or border areas, where it is well-positioned to provide case management for mobile and hard-to-reach communities [13–15], including high-risk occupational groups and ethnic minorities. So, engaging the private health sector in malaria surveillance is crucial for reducing transmission, particularly in areas where the private sectors are either the primary or easy-going healthcare providers [11]. The pilot work on our study to involve the for-profit private sectors in the national malaria surveillance system in the Alikadam Upazila has borne fruitful outcomes. Malaria case detection and reporting by the active involvement of the private health service providers have played an important role and recorded 20% of the total number of reported cases of malaria in March 2023. The pilot study proved that successful implementation can benefit the malaria surveillance system by having a role played by the private providers as other studies have been conducted in other settings [11, 16–18].

The results indicate that it is essential to prepare the private health service providers, proper RDT testing and referral practices, and record keeping. Other developing areas have found the use of ineffective treatment of malaria by untrained private healthcare providers who are generally difficult to control. This does not only add to the rising issues of antimalarial drug resistance, but also threatens to augment malaria-associated mortality rates [19]. The positive effects of involving the private sector in malaria surveillance as evidenced by these high satisfaction levels by the patients further underscore the importance of the decision-making process.

The results indicate that it is essential to train the providers of the private health services to enhance the malaria surveillance systems. A one-day training was sufficient for this pilot with close supervision, a more intensive training package, together with periodic refresher training, would likely be preferable for larger-scale implementation to ensure fidelity to the RDT procedure. With proper training, these providers are equipped to complete RDTs, act according to standard referral measures, and record cases and treatment in good detail. This is necessary so that the contributions of the private sector can be in line with the national health goals and national health surveillance systems [20, 21]. In addition, the level of satisfaction mentioned by patients is very high, which shows the success of using personal providers. This type of collaboration contributes to the increase of access to diagnostic and treatment services, as well as the development of trust and confidence in healthcare systems. The incorporation of the private providers also enhances the coverage and quality of surveillance activities especially in the regions where the public health infrastructures may be insufficient or overburdened [22]. All these strategies support the efforts of malaria control and elimination, which proves the importance of the involvement of the public in solving endemic diseases by supporting the efforts of the state [11].

The promising results of the incorporation of the use of the private health providers in malaria surveillance systems give a robust foundation of extending the strategies in other at-risk regions within Chittagong Hill Tracts and the surrounding areas with Myanmar and India [23, 24]. Such regions have been recording high cases of malaria although malaria prevalence in the country has declined in recent years [25]. The partnership with the NMEP, the private sector stakeholders, and the concerned authorities will be vital in achieving the objective of the program, that is, eliminating malaria in Bangladesh.

This research is unique in the sense that it is one of the pioneer studies in Bangladesh to test the inclusion of the involvement of the private healthcare providers in the national malaria surveillance framework to utilize a neglected resource to enhance malaria control. Its holistic nature involving training, provisioning of resources and monitoring meant that it met the national guidelines hence improving the quality and reliability of data collection. In addition, the high level of universal patient satisfaction of malaria-positive respondents demonstrates the suitability and efficiency of the activities of the private sector in the provision of diagnostic and referral services. The research is also informative in terms of evidence and a model of scaling the involvement of the private sector to other areas of high risks which have good data to support the implementation of the higher levels.

The study has minimal limitations even though it has contributed. The Alikadam Upazila geographic area might not be a complete covering of the Bangladesh malaria-prone areas. The pilot stage, which lasts only one month, restricts the evaluation of the long-term viability and overall effects. Also, the sample size (only 10 private health facilities) is not large enough to ascertain variation in provider performance in a larger or more heterogeneous population. Lastly, loopholes in the referral system, including the use of non-financial incentives and lack of financial support on providers may be problematic in terms of scalability and continued engagement.

Conclusion

Our pilot study showed that integrating for-profit private providers into the NMEP surveillance platform is feasible and effective, contributing 20% of reported malaria cases in Alikadam. Training, diagnostic tools, and a referral system improved adherence to guidelines and surveillance, with high patient satisfaction. Scaling this approach could support malaria elimination in Bangladesh.

Author contributions

MSA, MSH, MJA, MMuR, MMoR, MNI and AH conceived and designed the study. MSH, MAM, and CSP and AnH collected the data. MSA, MSH, AnH and AH contributed to the data analysis and interpretation. MSA, MJA, MMuR, MMoR, MNI, SKD, MK, MHR, and AH supervised the study. MSA drafted the manuscript. All the authors have read and approved the final manuscript.

Funding

The WHO Country Office fund has been used for this study. The authors did not receive any financial support for writing this manuscript.

Data availability

The de identified data and materials underlying this research are available upon reasonable request from the corresponding authors.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethical Review Committee (ERC) of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Written informed consent was obtained from the study participants before data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.