Assessing the role of the private sector in surveillance for malaria elimination in Haiti and the Dominican Republic: a qualitative study

Abigail Sidibe; Alysse Maglior; Carmen Cueto; Ingrid Chen; Arnaud Le Menach; Michelle A. Chang; Thomas P. Eisele; Katherine Andrinopolous; Joseph Cherubin; Jean Frantz Lemoine; Adam Bennett

doi:10.1186/s12936-019-3024-3

Research
Open Access
Published: 05 December 2019

Assessing the role of the private sector in surveillance for malaria elimination in Haiti and the Dominican Republic: a qualitative study

Malaria Journal volume 18, Article number: 408 (2019) Cite this article

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Abstract

Background

Haiti and the Dominican Republic (DR) are targeting malaria elimination by 2022. The private health sector has been relatively unengaged in these efforts, 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 efforts 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 efforts.

Methods

In-depth interviews with 26 key informants (e.g. government officials), 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 definitions of the private health sector and identified 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 first 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 efforts 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 efforts 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 refining 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.

Background

Haiti and the Dominican Republic (DR) are the only remaining countries in the Caribbean with endemic malaria transmission [1]. Although elimination of Plasmodium falciparum was almost achieved in the 1960s, malaria resurged in the 1970s following reductions in funding. In the past decade, a new wave of funding and ambition has reinvigorated global goals of malaria eradication. Recognizing that elimination on the island of Hispaniola will require a coordinated approach, the Haitian and Dominican National Malaria Control Programmes (NMCPs) developed a bi-national plan to eliminate malaria by the year 2020, which now has been extended to 2022 [2, 3]. However, malaria transmission and health care systems differ considerably between the two countries which posess unique challenges to elimination efforts. In 2017, the island of Hispaniola reported 19,476 cases, 98% (19,135 cases) of which were reported in Haiti and only 2% (341 cases) were reported in the DR [4]. Actual case burden is likely much higher, as many cases are not reported through the national surveillance systems.

In order to achieve malaria elimination on the island of Hispaniola, all malaria cases must be detected, documented, and treated. However, due to accessibility and preference, populations at high risk of malaria often seek malaria treatment in the private health sector which has remained largely unengaged in these efforts [2, 5]. Engaging private providers is critical for effective case management and reporting, especially in settings where the private health sector plays a large role [6].

The private health sector consists of formal institutions, such as pharmacies, clinics, and hospitals, as well as informal institutions, such as shops, itinerant drug vendors, and traditional healers. Informal private providers might not have received formal training and their clinical practice might not be registered or licensed by any governing body. Prior research has shown that private health sector involvement in malaria surveillance, diagnosis and treatment efforts has strengthened national malaria elimination programmes [7,8,9,10,11,12]. However, the participation of the private health sector in malaria surveillance and elimination efforts in Haiti and the DR is largely unexplored, as are the care-seeking behaviours of individuals at high risk of malaria (either for behavioural reasons—e.g. migrant agricultural workers; or more immunological reasons—e.g. pregnant women). This study describes the role of private providers in case management and surveillance, explores care-seeking behaviour of individuals at high risk of malaria, and investigates possible means of engaging the private health sector in Hispaniola’s malaria elimination efforts.

Methods

National health system context

Haiti

The provision of healthcare in Haiti is highly fragmented, which has resulted in limited services and poor quality [13]. The formal health sector is comprised of public, private non-profit (e.g. non-governmental organizations and religious organizations), “mixed” non-profit [private management with staff paid for by the Ministry of Public Health and Population (French acronym MSPP)] and private for-profit organizations [5, 14]. Of more than 900 health institutions, roughly 38% are public, 42% are private, and 20% are mixed [15]. Informal private health sector providers, such as traditional medicine practitioners, play a major role as well. An estimated 50–80% of the population use traditional medicine services, due to spiritual beliefs as well as lower cost and greater accessibility [5, 14, 16]. A 2017 census found that only 23% of Haitian households live within 5 kilometres of a primary care facility of good quality in the formal health sector (a “good quality” facility was defined as having a high overall score on four service delivery domains: accessible care, effective service delivery, management and organization, and primary care functions) [17].

Malaria cases are almost exclusively diagnosed by passive detection, as there is little active surveillance in the country. Rapid diagnostic tests (RDTs) were introduced in 2010, became national policy shortly thereafter, and are currently used to confirm cases in the national surveillance system at a ratio of 3:1 compared to microscopy [18]. In 2011, chloroquine-primaquine bi-therapy was adopted as first-line treatment [2]. Primaquine (PQ) is incorporated into bi-therapy for its gametocytocidal effect, although the absence of PQ during treatment with chloroquine does not render the treatment ineffective. Despite high utilization of the private health sector, only the public and mixed institutions have access to PQ to satisfy the bi-therapy strategy. However, even among these institutions the availability of PQ is low; only 31% of these formal institutions stocked PQ according to a 2013 government report [15].

Dominican Republic

Prior to 2001, the majority of the population in the Dominican Republic was theoretically covered by a public system financed by general taxes. This system encouraged growth of the formal private health sector financed by voluntary reimbursement insurance, prepaid payment plans, and out-of-pocket expenditures. In 2001, the private health sector’s importance increased following adoption of a new healthcare framework, consisting of a complex system of public, private, and non-profit institutions. As of 2012, there were 1853 public sector facilities (1703 primary care units and 150 s- and third-level treatment centres) [19], and an estimated 7121 private sector facilities (6818 for-profit facilities and 283 non-profit facilities) [20].

Malaria diagnosis is primarily done by microscopy. RDTs have been introduced in the past 5 years but are mainly used for active case detection and are not universally used in health facilities. First-line treatment is chloroquine-PQ bi-therapy, which is freely available in the public sector only [2]. As in Haiti, there is limited information on private health sector adherence to malaria case reporting and surveillance, despite the presence of a central-level database managed by the National Center for the Control of Tropical Diseases (Spanish acronym CENCET) where both passively and actively detected cases are supposed to be reported [19, 20].

Selection of study sites and participants

Study sites

Study sites were selected due to their relatively high burden of malaria, reputation as high traffic areas for cross border migration, and/or presence of government and non-governmental organizations (Fig. 1). Study sites in Haiti were: Port-Au Prince (in the Ouest Department), Artibonite Department, Grande’Anse Department, and Nord/Nord-Est Departments. The Nord and Nord-Est Departments were combined into one effective study site at the recommendation of the local research assistants. Study sites in the DR were Dajabon Province, Monte Cristi Province, and Pedernales Province. A combination of purposive and snowball sampling methods were used to recruit community members for focus group discussions (FGDs), and key informants, private providers, and patients of private providers for in-depth interviews. All participants must have been 18 years of age or older.

Key informant interviews

Key informants were selected based on their involvement in malaria activities, such as NMCP staff, non-governmental organization staff, departmental government leaders. Key informants were recruited using purposive sampling through the following networks: Sociocultural Movement for Haitian Workers (Spanish acronym MOSCTHA), a private non-profit organization in the DR dedicated to advancing human rights of Haitian immigrants; staff at the International Training and Education Center for Health (I-TECH), a non-governmental organization in Haiti providing specialized healthcare services; and any colleagues suggested by members of those organizations. Inclusion criteria for key informant interviews required that selected individuals had experience working on malaria activities.

Focus group discussions

Key informants identified specific urban and rural areas with the selected study sites for FGD locations and facilitated contact with local community leaders. The community leaders guided recruitment of community member participants for FGDs. Community members must not have participated in a FGD in another district in order to be included in the FGD.

Private provider interviews

FGDs obtained a local definition of the private health sector and mapped locations of local private providers to recruit for interviews (Fig. 2). Following the FGDs, community leaders guided recruitment of private providers. In order to be included, private providers must have fit the definition of “any outlet, facility, or person that provides clinical or diagnostic services and is not managed by a national or local government, including traditional healers” [6].

Patients of private provider interviews

The private providers interviewed assisted the study team by inviting patients seeking care at their facility to participate in an interview. All patients interviewed were currently seeking care for a fever from a provider interviewed on the day of the provider’s interview.

Data collection

Data collection took place between December 2015 and February 2016 and was coordinated by staff at MOSCTHA in the DR, independent medical researchers in Haiti, and the University of California San Francisco (UCSF). Research assistants participated in a 3-day training in Port-au-Prince in Haiti and in Santo Domingo in the DR. The training covered the study protocol and qualitative methods in-depth. Following the main three-day training, research assistants participated in a 1-day refresher training conducted in each department. Research assistants conducted all research activities under the supervision of a local field manager and senior scientist in each country (JFL, JC). Interviews and FGDs followed semi-structured guides (topics in Fig. 3), lasted around 1 h, and were conducted in Spanish, French, or Creole depending on the location/participant. The interviews were audio-recorded, while the FGDs had a research assistant taking detailed notes.

Data analysis

As the FGDs were used primarily to inform sampling of private providers, the notes were not formally analyzed. For the interviews, audio recordings were transcribed and then translated from Creole, French, and Spanish into English by staff at MOSCTHA, I-TECH, and an independent consultant. The transcriptions were uploaded into ATLAS.ti (Scientific Software Development GmbH, ATLAS.ti. version 8.1) for management and coding. Two researchers independently read a sampling of transcripts and developed preliminary codebooks for each participant group type (key informants, private providers, and patients). The researchers then compared codebooks, maintained open dialogue for all instances of discrepancy, and created a final codebook. The codebook was then applied to all transcripts, remaining flexible to allow for new codes as needed. Themes were generated by grouping codes within each participant type, noting both common threads and divergent opinions, and then were compared between participant types and countries. The themes were organized into areas of discovery, which, along with verbatim quotes, were used to produce the summary of findings.

Ethical considerations

Ethical approval was obtained from the Institutional Review Boards of the Haitian Ministry of Public Health and Population, the Dominican Ministry of Public Health and Social Assistance, and University of California, San Francisco. Prior to all study activities, written informed consent was obtained from all participants in their native language.

Results

The results are organized by country, with subheadings that correspond to four areas of discovery: (1) characterizing private sector providers and high-risk populations, (2) care-seeking behaviour of febrile individuals; (3) case management in private health sector facilities; and (4) barriers to and facilitators of private health sector engagement in malaria elimination efforts. Across both Haiti and the DR, there were 12 FGDs with 7–11 participants in each (98 participants total), 26 key informant interviews, 62 provider interviews, and 63 patient interviews (Tables 1, 2 and 3).

Table 1 Focus group discussions

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Table 2 Key informant interviews

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Table 3 Private provider and patient interviews

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Haiti

Characterizing private sector providers and high-risk populations

Six FGDs elicited the following categories of private health sector providers: private for-profit clinic providers, and private non-profit clinic and hospital providers, pharmacy owners, shop owners, itinerant drug vendors and traditional healers. Traditional healers include (but are not limited to): herbal doctors (‘dokte feyes’), Vodou priests (female ‘mambos’ and male ‘houngans’), senior Vodou priests (‘badjikans’), charlatans (spiritual healers that pose as doctors) and traditional birth attendants (‘matrones’).

Participants perceived migrants who travel for work to the DR or within Haiti to be at high risk for malaria. The majority of patients reported that there is a significant mobile population who work and live in different areas and that these migrants may contribute to malaria transmission. One patient from the Grande’Anse Department said that the people who are at highest risk of suffering from malaria are “people who come from far away from this community, because they don’t protect themselves” (Patient at non-profit private hospital, Grande’Anse Department). Other perceived high-risk populations included: slum populations, pregnant women, children, mountain-dwelling populations, agricultural/farm workers, fish farmers (in general and specifically noted in Grand Saline, a commune in the Artibonite Department), and populations living around rice paddies.

Care-seeking behaviour

Self-medication

Self-medication, defined as taking medication without direction from a physician, with chloroquine, acetaminophen, paracetamol, or cotrimoxazole for an undiagnosed fever or suspected malaria was the most common first step in the care trajectory as reported by key informants, providers, and patients alike. One key informant said:

“I think that there’s this tendency, as soon as the person has fever, they will go buy chloroquine…that’s what people do…there is an abuse of chloroquine because in general people take that for fever (Key informant, Port-au-Prince).

Lack of accessibility to health sector facilities was reported as a barrier to seeking care and a facilitator of self-medication. One patient said:

“If the person is not able to go to the hospital, his first reaction will be to seek a drugstore to buy medicines to help him feel better” (Patient of traditional healer, Nord/Nord-Est Departments).

Medications, including chloroquine, were reported to be widely available in informal health sector facilities, including shops and itinerant drug vendors. Self-medication is very common across socioeconomic groups, but key informants believed migrant workers to be especially susceptible to self-medication due to the large presence of itinerant drug vendors positioned around bus stops and transit centres. When asked what type of person buys medication from itinerant drug vendors to self-medicate, a key informant explained:

“People who travel [self-medicate], because they are getting in the bus to travel, and they [itinerant drug vendors] are persuasive. So voila, automatically people are going to buy that, [people] in bus stations who are going to travel out of the country to sell their products.” (Key informant, Port-au-Prince)

Informal vs. formal health sector facilities

If symptoms persist after self-medicating, participants described a few different pathways of care-seeking behaviour. This decision depended on multiple factors, including quality of care and reputation of health facilities, socioeconomic factors, education, and personal or spiritual beliefs. Accessibility of health care facilities, however, was the primary factor. One key informant said:

“It’s very easy [to get chloroquine] at the pharmacy. And the sellers even sometimes go buy chloroquine in a shop and sell it in the road. After [self-medicating], it depends on what care is offered in the zone. That can depend also on the education of the person. They can go look for traditional medicine, houngans. In the big cities, people prefer to go to private clinics.” (Key informant, Port-au-Prince).

Individuals living in rural areas frequent traditional healers and public or private non-profit health centres, while those who live in larger cities may choose to seek care in formal private clinics due to their accessibility. If they had access to all types of facilities, patients said their decision would be based on perceived quality of care, cost, and spiritual beliefs. Middle- and high-income individuals, who may have insurance and can afford care at for-profit private clinics, may choose to pay the user fee as opposed to obtaining free treatment in public or mixed facilities due to the perceived higher quality of care and shorter wait times. Non-profit hospitals were generally preferred over public hospitals if given a choice, also due to perceived higher quality of care and shorter wait times at non-profit facilities. For example, one patient explains their choice to seek care at a non-profit hospital: “

“The doctors acquire the ability to handle cases like malaria. They take care, they pay attention and they have medicines” (Patient at non-profit hospital, Grande’Anse Department).

Traditional medicine

Traditional medicine was reported to be used by people of all socioeconomic statuses due to its accessibility as well as its cultural and spiritual relevance, but was reported to be especially common among the rural population. One patient explained they sought care from a traditional healer “because I was in need to know my condition quickly” (Patient of houngan, Grande’Anse Department). The long and costly journey to formal sector facilities is a barrier to seeking care in a hospital and encourages seeking care from local traditional healers. There were also many patient reports of receiving free or gifted medications or treatments from traditional healers, making traditional medicine a more affordable method of treatment. When asked to describe the care-seeking trajectory should symptoms continue, a patient at a traditional healer said:

“If I’m in worse shape, I’ll see a doctor. The traditional healer is looking for a solution to get me a medical appointment, but I don’t have money. I haven’t seen a doctor since my sickness” (Patient of traditional healer, Artibonite Department).

If fever symptoms progressed after an initial visit to a traditional healer, some patients reported they would return to a traditional healer for additional treatment while others reported they would choose to seek care in a formal health sector facility. This decision again weighed largely on access to formal health sector facilities and spiritual beliefs. For example, one febrile patient said:

“I saw he [the traditional healer] provided an effective treatment for someone else…If I feel worse, I will go to a medical appointment or go to a church to pray” (Patient of traditional healer, Grande’Anse Department).

Some patients reported “spiritual diseases”, where patients attributed fever and other symptoms to spiritual imbalances or witchcraft: “This is not a common disease. It’s been thrown on me by humans” (Patient of traditional healer, Artibonite Department). One patient reported seeking care first at a hospital, yet felt that the treatment approach wasn’t correct “because I have a fetish disease” (Patient of traditional healer, Grande’Anse Department).

Interestingly, when patients were asked where they would seek care if they knew they had malaria, the large majority of patients said they would seek care in a formal health sector facility. However, many of these same patients who reported they would seek care in a formal health sector facility if they knew they had malaria were visiting traditional healers for an undiagnosed fever at the time of the interview.

Case management in private health sector facilities

Informal private providers

None of the informal private providers interviewed had RDTs or chloroquine-PQ bi-therapy. Some itinerant drug vendors and shop owners stocked chloroquine and reported selling it without a prescription. An itinerant drug vendor said:

“I give him [a febrile individual] chloroquine or paracetamol then I recommend this person to go to a health centre” (Itinerant drug vendor, Grande’Anse Department).

Traditional treatment methods for undiagnosed fevers included tea, roots, herbs, and bitter melon. Traditional healers explained that their knowledge is spiritually based. Nearly all traditional healers reported that they do not treat malaria and would refer a patient to a formal health facility if they suspected malaria. When asked if he would treat a case of suspected malaria, a traditional healer from the Nord/Nord-Est Departments said;

“No. In that case I can seek your expertise. I’m in contact with medical doctors and nurses… I sometimes see illnesses here for which I must seek a doctor to add to my treatment” (Houngan, Nord/Nord-Est Departments).

Patient interviews validated the traditional healers’ claim of referring patients to formal health facilities, with many patients reported being referred to formal sector hospitals by traditional healers in the past. Program-level key informants, however, generally did not seem aware of the willingness of traditional healers to interact with the formal health sector: “Houngans do not refer patients to hospitals” (Key informant, Port-au-Prince).

Formal private providers

Three of four formal private providers interviewed reported providing combination therapy to confirmed malaria cases. One private provider in the Grande’Anse Department did not have either chloroquine or combination therapy available. Only half of formal providers interviewed reported currently having RDTs in stock, which in turn made presumptive treatment relatively common in their practice. Accordingly, there were also a few patient reports of receiving presumptive treatment from formal private providers.

Key informants reported that non-profit facilities that have approval from the MSPP are provided RDTs and bi-therapy free of charge, in return for sending case and stock reports. One key informant explained this collaboration, saying:

“The formal private sector, which has approval from the MSPP, has free access to the tests and drugs against malaria…they just have to send back their reports. The informal private sector is being challenged. They do not have access to the tests and drugs against malaria. This restriction included the ambulatory drug vendors and pharmacies. The latter ones have access to chloroquine, but not to primaquine” (Key informant, Port-au-Prince).

One non-profit hospital provider reported collaborating with the MSPP, receiving training on malaria diagnosis and treatment as well as provision of RDTs and combination therapy. The other non-profit private hospital provider interviewed, however, reported no training from MSPP and no provision of RDTs and combination therapy. Key informants commented that the partnership between the MSPP and non-profit facilities is not as strong as it could be due to lack of finances, poor information dissemination from the government to the facilities, and logistical difficulties of returning case reports to the MSPP.

One non-profit private hospital and two for-profit private clinics reported that they commonly refer patients to receive malaria diagnosis with an RDT in a public hospital, with the instructions of returning with their test results to be treated.

“We send them to a public hospital to do the lab test, then they come back with their prescription for the medicine” (Non-profit private hospital provider, Grande’Anse Department).

However, other formal private facilities do not have access to anti-malarial medication and refer patients to the public sector for treatment.

“When we are in front of cases like malaria, we refer them to [Public Hospital] to seek medicine, because we do not have a stock house here” (For-profit private clinic provider, Grande’Anse Department).

Barriers and facilitators to engaging the private health sector

Key informants unanimously agreed that traditional healers must be engaged in national malaria strategies because they are important community and spiritual leaders. The majority of traditional healers interviewed wanted to be integrated into the formal health system and were interested in participating in malaria elimination efforts. One mambo commented on the coexistence of the informal and formal medical systems

“If we had a serious government we could do as some African countries do: traditional healers are part of the regular medical system, and are permitted to study cases at the hospital. I’ve been to many meetings that describe the existence of a combination health care system in African countries. Many cases at the hospital could be treated with herbs. Both systems are valuable. Your pills from the modern laboratories are effective but I can make some of the same remedies by pounding herbs. They can be just as effective and contain no chemically dead added elements. The remedy that has no chemical additives can have fewer negative effects and that is better for the patients” (Mambo, Nord/Nord-Est Departments).

Traditional healers agreed that they would be motivated to report malaria cases in exchange for respect and acknowledgement of their practice within the formal health sector:

“[I would like] that I be recognized as someone who helps them and who refers patients to them. They should value my work and be interested in my making a proper living” (Matrone, Grande’Anse Department).

Ongoing trainings and incentives, such as pre-paid calling cards or money, were also reported to be motivating by traditional healers. Feelings about participating in national malaria elimination efforts among itinerant drug vendors diverged; some expressed interest, while others felt ostracized from the formal health sector and would hesitate to participate.

All formal providers were interested in reporting cases to the NMCP, with one non-profit health centre provider and one private clinic provider already reporting cases. Providers wanted additional staff, provision of RDTs and bi-therapy, and trainings to help with the responsibility of reporting cases. A private clinic provider explained:

“We would have to afford employing and training the personnel necessary for such an endeavor, a Health Surveillance Officer to gather and analyze data for the ministry. Besides training, the element of human resource is fundamental, as are material resources all provided in a timely manner…I’m always interested to know how the health Ministry envisions malaria, what studies they have conducted to indicate the areas where it is most prevalent.” (Private clinic provider, Nord/Nord-Est Departments)