The health system’s deficiencies play an important role in the performance of the case management strategy of global malaria control. The political divarication between central government and local government led to the national health system (NHS) not being able to effectively cover the Wa State. Since cease-fire between the central government and local government in 1988, the central government has established three hospitals in main towns and the local government was trying to establish a health service network but is short of investment in human resources and basic facilities, and some international NGOs were running some health programmes, however all three efforts have not established an effective public health service system.
A large proportion of febrile patients sought advice or treatment, however most of them sought treatment from medical sellers, so a high proportion of the febrile was only diagnosed by clinical symptoms for malaria, and most of the microscopy or RDT were given by outreach service of NGOs. In the neighbouring region (Yunnan Province of China), 82% of malaria patients chose township community hospitals first . The literature regarding treatment seeking in Myanmar and other countries of Greater Mekong subregion is rare. The situation seems similar that in sub-Saharan Africa; medicine sellers are widely used for fever and malaria treatment . Despite the drug seller market being extremely informal, it is the most available and stable provider. The Roll Back Malaria (RBM) Partnership had set a target for 80% to receive appropriate treatment within 24 hours by 2010 . However, this study found it was far away from that target. WHO now advocates strategies to improve home-based management of malaria, with retailer interventions being seen as one possible channel [16, 17]. At present, this could be one of strategies addressing timely and appropriate treatment of malaria for the Wa people.
Wa State is an endemic area of falciparum malaria. Patients should seek treatment within 24 hours, however less than one third of patients to do so. Of 12.5% (46/369) of febrile patients who never sought treatment outside the home, 67.4% (31/46) of them sought help from supernatural spirit. In the culture of Wa ethnics, people believe in everything has its soul, so they might seek help from spirit when they are ill. A study done in Burkina Faso showed that literacy level of the heads of the households was the main factor to bring children within 24 hours to the health facility for the treatment of malaria . In this study, 96.7% (357/369) of respondents were illiterate. Studies carried out in Ethiopia  and southern Ghana  showed that knowledge of respondents is not associated with malaria treatment-seeking . Knowledge itself is not equal to behaviour. People’s perception, knowledge and awareness, assured material supply and enabling environment are necessary for behaviour development . Family income and distances from a health facility can solve accessibility in economics and geography respectively, so the two factors are associated with treatment seeking in the study. In Wa tradition, men are usually more respectable and powerful than women ; on the other hand, mothers are usually child carers and housework undertakers, so wife or co-decision can increase timely treatment seeking, and male patients and children are more likely to be assisted in seeking treatment.
In the study design, the hypothesis is no difference in treatment-seeking between households in which there was someone with fever in the last two weeks compared to households without. In order to reduce recall bias, the households without fever in the last two weeks were just interviewed for socio-demographic characteristics, but for treatment-seeking and other related factors. In true-life, there may be differences in fever frequency and treatment-seeking pattern between the two household groups. This limitation may affect the results of the study. However the population of the two districts is estimated at 18, 940, but 718 households with 19.4% (3, 678) of the total population was visited. This can reduce sample bias caused by the difference.