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)
Dominican Republic
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 (‘colmado’) owners and traditional healers (‘curanderos’). Perceived high-risk populations included people who live in rural areas, people who work in the fields or near stagnant bodies of water, people who herd cattle, residents of Dajabon Province, and males in general due to their outdoor working conditions. Haitian migrants were also reported to be at high risk. One key informant said:
“Most of our cases are from our neighbor, Haiti, because we live in a border region… The Healthcare system in Haiti is very weak, and when someone has malaria in Haiti, they think of witchcraft. And those who don’t believe in that [witchcraft] only use chloroquine for treatment.” (Key informant, Pedernales Province).
Trajectory of care-seeking behaviour
The majority of patients interviewed reported self-medicating with acetaminophen at the first sign of a fever, prior to seeking care in a formal health facility. A patient at a pharmacy explained his decision-making process, saying:
“Well, I decided to buy acetaminophen because you generally take it until you know if it is a virus or malaria – until you determine that it is malaria, you take acetaminophen” (Patient at a pharmacy, Pedernales Province).
Many patients chose to purchase medication at colmados due to accessibility and the reliable availability of medications. A few patients believed that doctors would recommend acetaminophen anyway, so it is easier to buy it at a colmado instead of making a trip to the hospital.
“You rarely go to the hospital because whenever you go to the hospital they just give you an acetaminophen when you have a fever, so, if I have fever and I know that the hospital will just give me an acetaminophen, I come to the pharmacy, buy it myself, and take it myself” (Patient at pharmacy, Dajabon Province).
If symptoms persisted after self-medicating, most patients reported going to a formal health sector facility. Overall, programme-level key informants felt that public facilities were widely attended by the general population, with one key informant estimating that only 2% of people in Pedernales Province seek care at private facilities. Indeed, patients reported that they sought care at the local public sector primary care centre [Primary Care Units of the Ministry of Public Health (Spanish acronym UNAP)] if their symptoms do not resolve after self-medicating with acetaminophen. However, some patients sought care at private for-profit clinics after self-medicating. One patient explained her care trajectory, saying:
“I went to a colmado and bought a pill, then I came to this doctor because I took the pills, but I felt the same. I went to the colmado when the fever began, 4 days ago” (Patient at a for-profit clinic, Pedernales Province).
The clientele of private clinics was reported by key informants to be middle- to high-income individuals, since private clinics typically require insurance. However, all five private clinic providers interviewed highlighted the large number of Haitian migrants who seek care in their clinics, and reported seeing patients coming from the public sector seeking a second opinion.
The perceived importance of traditional healers in the care-seeking trajectory of febrile individuals was low. One patient said:
“Well, I have never seen anyone go to a traditional healer…there are no traditional healers that people go to, and I think that [going] would be a mistake. In the hospital, I think, is the only place where there is medication to cure the disease” (Patient at a for-profit clinic, Dajabon Province).
Key informants and patients agreed that that those who seek care from traditional healers do so mainly out of cultural or spiritual beliefs, and that it is relatively uncommon.
Case management in private health sector facilities
Informal private providers
None of the informal private providers reported having RDTs or chloroquine-PQ bi-therapy, nor were they aware of the nationally recommended malaria treatment. While unaware of the recommended treatment, pharmacy owners were aware that treatment is available to patients within the public sector. Colmado owners reported selling analgesics (acetaminophen, Winasorb); nonsteroidal anti-inflammatory drugs (diclofenac, diclofex, ibuprofen, mefenamic acid, and aspirin); resfridol, a flu antiviral; ranitidine, an antacid and antihistamine; and omeprazole, a proton-pump inhibitor. The majority of traditional healers interviewed said they would refer a suspected case of malaria to a public health sector facility for testing, but first they would treat the patient with traditional medicine, such as herbal tea, homemade oral concoction, or a massage with oil.
Formal private providers
Formal private clinics ranged in perceived quality and services depending on their location. For example, private facilities in larger cities, such as Santo Domingo and Santiago, were perceived as high-quality facilities and as a prominent provider of health care delivery. However, the private sector plays a small role in malaria case management. A key informant explained how this service difference delays proper malaria case management:
“Generally, in the cases of [malaria] mortality that we’ve had, people go to the private sector and after the private sector they go to the public and from there they determine that it is malaria” (Key informant, Dajabon Province).
Private clinic providers reported seeing many patients with undiagnosed fevers, but perceived malaria cases to be very rare. None of the private clinic providers reported diagnosing a malaria case within the past year. However, four out of five private for-profit clinics had blood smear test supplies and reported sending samples to CENCET for malaria testing.
Barriers and facilitators to engaging the private sector
Key informants emphasized the need for increased case reporting from private health sector facilities, and suggested the following means of engaging the private health sector: (1) sending a malaria technician from CENCET to visit private facilities to test patients with fevers for malaria and treat if positive; (2) campaigning/messaging to encourage private providers to help eliminate malaria; (3) workshops for private providers; and (4) promoting awareness of malaria elimination to the general population through television, radio, church networks, or neighborhood committees.
The majority of traditional healers and all pharmacy staff said they would be willing to report cases to the NMCP and would be motivated by participating in a workshop led by the NMCP. However, the lack of record keeping and lack of access to diagnostics were listed as significant barriers to case reporting.