Malaria Endgame: Can engagement of the for-profit private sector help the country reach the last mile of malaria elimination in Bangladesh?

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Mohammad Shafiul Alam, Md Jahangir Alam, Mohammad Sharif Hossain, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4699450/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Oct, 2024 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Among 13 endemic districts, the Chittagong Hill Tracts bear more than 90% of Bangladesh's malaria burden. Despite the private sector's prominence in rural healthcare, its role in malaria management remains underutilized. This study aimed to strategize leveraging the for-profit private sector, such as diagnostic and treatment centers, to bolster national malaria surveillance and control, advancing Bangladesh toward malaria elimination by 2030. Methods This mixed-method study commenced with a questionnaire-based cross-sectional survey followed by selected focused group discussions (FGDs) among the participants. Based on the endemicity and strategic priorities, a comprehensive mapping of private for-profit facilities from the regions comprising 15 sub-districts across 8 chosen districts (7 malaria endemic districts and the rest non-endemic districts) was created. For the non-endemic zone, the sub-districts were selected based on their proximity to an area with high malaria transmission. Results Among the 104 representative participants, majority were male (n=92, 88.5%), had a diploma in their respective fields (n=53, 51%) and were involved either in laboratory work (n=49, 47.1%) or as owners/managers of health centers (n=41, 39.4%). The selected health facilities were close to the corresponding UHC (mean distance 2.8 km), but were distantly located from the designated district hospitals (mean distance 48.9 km). The main sources of RDT kits (62.3%) and anti-malarial drugs (63.2%) were local wholesale markets. A large share of the corresponding facilities neither provided malaria treatment services (81.7%) nor worked with the NMEP (93.3%). Three FGDs were held with the for-profit service providers so that further insights and qualitative viewpoints of them can be utilized in situation analysis. Conclusions This study highlights challenges and recommendations for engaging private for-profit health facilities in Bangladesh's malaria elimination efforts. The identified challenges include low-quality RDTs, staff shortages, and inadequate capacity building. Recommendations emphasize effective training, stakeholder interaction, and enhanced oversight for successful malaria control efforts. Malaria malaria elimination for-profit private sector Bangladesh Figures Figure 1 Introduction Globally, 249 million cases of malaria were reported in 2022, and an estimated 608 000 people died due to the disease from 85 endemic countries. Between 2000 and 2022, the number of malaria cases in the Southeast Asia Region of the World Health Organization (WHO) Southeast Asia Region have declined by 76%, accounting for only 2% of the global cases in 2022 [ 1 ]. Similarly, Bangladesh has made significant strides in reducing the burden of malaria in the country. Between 2000 and 2022, malaria cases in Bangladesh decreased by 93% from 2008 to 2020 [ 2 ]. Currently, out of the 64 districts in the country, only 13 districts have reported malaria cases, and one district, Bandarban alone has reported 76% of the total cases in Bangladesh in 2022 according to the National Malaria Elimination Programme (NMEP) (unpublished data). To achieve the ambitious goal of achieving a malaria free world by 2030, the WHO emphasizes the first pillar of its strategy: ‘Ensure access to malaria prevention, diagnosis and treatment as part of universal health coverage’ [ 3 ]. Acknowledging this imperative, the NMEP in Bangladesh has actively coordinated with private graduate practitioners. Building upon this success, the NSP 2021-25 plans to further strengthen collaboration with private diagnostic centres and practitioners. This enhanced engagement with the private sector is crucial to expanding access to crucial malaria services and accelerating progress towards a malaria-free Bangladesh [ 4 ]. Bangladesh has achieved remarkable progress in health-related Millennium Development Goals (MDGs)[ 5 ]. Over the past few decades, both public and private healthcare facilities have experienced a significant surge, in contributing substantially to healthcare services. By 2019, the Directorate General of Health Services (DGHS) listed 255 public hospitals, 5,054 private hospitals and clinics, and 9,529 diagnostic centres with public hospitals offering 54,660 beds, while private hospitals contributed 91,537[ 6 ]. Despite this infrastructure expansion, ensuring quality, equitable access, and optimal utilization of healthcare services remains a challenge. The current physician-to-population ratio in Bangladesh is 1:1487, which falls short of established standards [ 7 ]. Moreover, the healthcare workforce exhibits imbalanced skill composition and uneven geographic distribution and is predominantly concentrated in urban areas [ 8 ]. This presents a significant hurdle in realizing the concept of universal healthcare, where comprehensive health services are accessible to all. In response, Bangladesh's pluralistic healthcare system, comprising four key stakeholders – the government, for-profit private sector, not-for-profit private sector (primarily NGOs), and international development organizations– is evolving [ 9 ]. For-profit private facilities are expanding into rural areas, while NGOs and international organizations continue to serve underserved communities. More regulated and concerted efforts among these stakeholders are crucial to ensure wider access to quality healthcare for the masses. Despite these advancements, the private healthcare system often serves as the initial point of contact for malaria case management. The sector is characterized by a lack of regulation, supervision, and low utilization of diagnostics in informal treatment. A consultation meeting held at the WHO headquarters in Geneva in October 2018 highlighted that private health services were not adequately incorporated into national strategies or plans and lacked clear guidance and policies for collaboration with private medicine retail outlets [ 10 ]. Surveys conducted in sub-Saharan Africa between 2014 and 2016 revealed that more than 50% of children affected by febrile illnesses sought initial treatment in the private sector in six countries, including Nigeria, Chad, Tanzania, Uganda, the Democratic Republic of the Congo, and Ghana [ 10 ]. In Bangladesh, for malaria case diagnosis and management, the public health care system and its partner NGOs are formally responsible. However, febrile patients and their attendees still prefer to seek health care at their nearest facility, whether public or private. There is also a gap in the reporting of malaria patients managed at for-profit private health facilities. Despite being a notifiable disease, private facilities have failed to report malaria to the National Malaria Health Management Information System (HMIS) due to a lack of an appropriate coordination system. As progress toward malaria elimination continues, understanding the load of cases managed by for-profit private health facilities, assessing their capacity, and leveraging their access following standardized procedures could prove invaluable in addressing each and every case effectively. Materials and Methods A mixed-method study was undertaken, beginning with a cross-sectional survey followed by focused group discussions (FGDs), aimed at evaluating the prevailing practices and comprehension of malaria diagnosis and case management among for-profit private sector providers. Study Area and Sample Size The National Malaria Elimination Programme (NMEP) categorizes Bangladesh into three regions based on malaria transmission status: Control (high transmission, 3 districts), Endemic (low transmission, 10 districts), and Non-Endemic (51 potential districts)[ 4 ]. Following NMEP recommendations, a purposive sampling strategy ensured representative samples from these regions comprising 15 upazilas (sub-districts) across eight districts: eight from the control region, six from the endemic region, and one from the non-Endemic region (Table 1 ). Upazila selection prioritized malaria incidence, with the non-Endemic region chosen based on proximity to high-transmission areas. Table 1 List of study areas Sl. District Malaria Transmission Level (API/1000 pop) Total Upazila covered by NMEP Upazila based on incidence Remarks 1 Bandarban High; API > 1 7 Alikadam, Lama, and Thanchi Control region 2 Rangamati High; API > 1 10 Belaichhari, Bagaichhari, and Juraichhari 3 Khagrachori High; API > 1 9 Lakshmichhari, and Matiranga 4 Netrokona Low; API < 1 2 Kalmakanda Endemic region 5 Kurigram Low; API < 1 2 Raomari 6 Moulvibazar Low; API < 1 7 Kamalganj, and Srimangal 7 Cox’s Bazar Low; API < 1 6 Chakaria, and Ramu 8 Feni Potential; API = 0 0 Chhagalnaiya Non-endemic region To ensure comprehensive coverage within each upazila, all private health service providers were surveyed. Initial expectations of 3–10 providers per upazila resulted in a projected sample size of 90. However, during field visits, 104 providers were identified, and all were included to maximize data capture (Fig. 1 ). Data Collection A cross-sectional survey was conducted using a semi-structured questionnaire administered between September 18th and 27th, 2022, to comprehensively gather data. The questionnaire underwent pretesting and rigorous review by experts from the NMEP, Communicable Disease Control (CDC) of the DGHS, WHO, and icddr,b, ensuring its validity and reliability. To streamline the data collection, an online application utilizing open data kits (ODK) was developed and installed on eight tablets for direct field data entry. The application captured the geographical location of each service provider, facilitating subsequent mapping. The study staff underwent comprehensive training on the application's functionality and usage, followed by a meticulous field test to ensure smooth operation. In addition to interviews, relevant document reviews were conducted to verify recent malaria detection and treatment at the surveyed health centres. A total of three FGDs were conducted among for-profit service providers. The participants, purposively selected for diversity, represented various healthcare professionals from the selected upazilas. For the control region, an FGD was held at Alikadam upazila on October 16, 2022, with 8 participants from three upazilas: Thanchi, Alikadam, and Lama of Bandarban district, the district with the highest reported malaria cases. The second FGD took place at Chakaria upazila on October 18, 2022, encompassing both endemic and non-endemic regions, with 7 participants from two upazilas: Chakaria and Ramu of Cox's Bazar district, the district with the highest reported malaria cases among the endemic regions. Despite the invitations, participants from non-endemic region did not participate in the second FGD. The third and final FGD occurred at Sreemangal upazila on October 23, 2022, focusing on endemic areas, with 11 participants from Kamalganj in Sreemangal upazila of Moulvibazar district and Raomari upazila of the Kurigram district. During interactive sessions, participants shared their perspectives on essential strategies for strengthening the malaria elimination program under the supervision of the NMEP. The FGDs were facilitated by one of the study investigators and involved a qualitative researcher within the team following standard guidelines. Health professionals from various working areas, including districts and upazilas, participated in the FGDs, with each session lasting between 100 and 157 minutes. Data Analysis For the questionnaire-based survey, data were imported from the ODK server. Data cleaning and analysis were conducted using Stata version 15.1 (Stata Corporations, College Station, TX, USA). All discussions during the FGDs were audio recorded, and verbatim transcriptions in Bengali were prepared to capture local terminology and nuances. The qualitative data collected were subsequently analysed using ATLAS.ti version 7.5.7 (ATLAS.ti Scientific Software Development GmbH), facilitating the coding of the data based on the research objectives. Qualitative data are presented as numbers and percentages, while normally distributed quantitative data are expressed as the mean ± standard deviation (SD); and non-normally distributed data are represented as medians (IQRs). Participants were categorized into three groups: control, endemic, and non-endemic regions. Subsequently, a comparative analysis was performed across various factors, including demographic characteristics, health facility characteristics, practices of malaria diagnostic and treatment services, malaria case reporting and referral systems, and involvement with the NMEP. To assess the differences between these groups, the chi-square test was utilized for categorical variables. For comparisons between two groups, the unpaired t-test was used, and for comparisons among more than two groups, ANOVA was employed for normally distributed quantitative data. A nonparametric k-sample test was used to test the equality of medians for non-normally distributed data. A significance level of p < 0.05 was adopted to determine statistical significance. All related costs and expenditures are described here in dual currency, i.e., Bangladeshi Taka (BDT) and US Dollar (USD), applying the average exchange rate (USD 1 = 99.46 BDT) during the mid-point of the data collection year (2022), according to the Annual Report (July 2022 – June 2023) of Bangladesh Bank [ 11 ]. Researcher Reflexivity The process by which the corresponding moderators/facilitators in FGDs acknowledged and critically examined their neutral and non-judgemental perspectives that might impact the research process and findings and limit potential biases. The moderator’s point of view on private sector engagement in malaria elimination might have influenced the discussion, data collection, and results analysis. To the level best of their ability, they practised and kept their neutrality before, during and after each FGD. Moreover, the corresponding moderators were neither colleagues nor friends/neighbours of any of the 26 participants. Moreover, the supervising researcher with a specialization in qualitative research independently scrutinized every discussion in order to improve data reliability and ensure quality assurance. Results Demographic characteristics of the participants Of the 104 participants recruited in this study, 30.8% were from the control region, 63.4% were from the endemic region, and 5.8% were from the non-endemic region. The overall mean age of the respondents was 36.3 ± 11.3 years. The majority of respondents were male (88.5%). Educational qualifications varied among the respondents. In the study, there was no illiterate participants. Almost half of the participants (n = 53, 51%) had a diploma degree in a related profession. In the endemic region, most of the participants (n = 40, 60.6%) were involved in laboratory work, whereas the majority of the owners/managers (n = 21, 65.6%) of health facilities lived in the control areas (Table 2 ). The p-value indicated a statistically significant difference in education level (p = 0.002) and their role at the health centre (p = 0.003) among the regions. Table 2 Summary of the baseline characteristics of the participants Indicators Control Regions N = 32 n (%) Endemic Regions N = 66 n (%) Non-Endemic Regions N = 6 n (%) Total N = 104 n(%) P-value Age Mean ± SD 36.5 ± 12.1 36.3 ± 11.1 35.7 ± 9.8 36.3 ± 11.3 0.988 Sex Male 28 (87.5) 58 (87.9) 6 (100.0) 92 (88.5) 0.659 Female 4 (12.5) 8 (12.1) 0 (0.0) 12 (11.5) Education level Class 1–10 8 (25.0) 2 (3.0) 0 (0.0) 10 (9.6) 0.002 Class 11–12 12 (37.5) 16 (24.2) 1 (16.7) 29 (27.9) Diploma 9 (28.1) 41 (62.1) 3 (50.0) 53 (51.0) Under graduation 3 (9.4) 2 (3.0) 1 (16.7) 6 (5.8) Graduation 0 (0.0) 5 (7.6) 1 (16.7) 6 (5.8) Role at the health centre Owner/Manager 21 (65.6) 18 (27.3) 2 (33.3) 41 (39.4) 0.003 Consultant/Doctor/ Paramedics/ Pharmacist/ Nurse/ Employee 5 (15.6) 8 (12.1) 1 (16.7) 14 (13.5) Med tech/ Lab tech/ Lab in charge/ SACMO 6 (18.8) 40 (60.6) 3 (50.0) 49 (47.1) A total of 26 providers participated in the FGDs. Among them 88.5% were male and 50.0% of them were medical technologists employed in diagnostic services (Table 3 ). Table 3 Summary of the focus group participants FGD Study areas District Upazila (Sub-district) Gender & Participants $ Total M F 1 2 3 4 5 1 Control district Bandarban Thanchi 0 0 0 1 0 1 Alikadam 0 1 0 4 0 5 Lama 0 0 1 1 0 2 2 Endemic district Cox’s Bazar Chakaria 0 0 4 0 1 5 Ramu 0 0 1 0 1 2 Non-Endemic district Feni Chhagalnaiya 0 0 0 0 0 0 3 Endemic district Moulvibazar Kamalganj 0 0 2 0 0 2 Sreemangal 1 1 5 0 0 7 Endemic district Kurigram Raomari 0 0 0 0 2 2 Total 23 3 1 2 13 6 4 26 $ 1 = Nurse; 2 = Paramedic/medical assistant; 3 = Medical technologist (Lab); 4 = Pharmacy owner; 5 = Diagnostic centre owner; & M = Male ; F = Female Table 4 Characteristics of the health facilities included in the study Indicators Control Regions N = 32 n (%) Endemic Regions N = 66 n (%) Non-Endemic Regions N = 6 n (%) Total N = 104 n (%) P-value Type of health center Private clinic 1 (3.1) 15 (22.7) 3 (50.0) 19 (18.3) < 0.001 Consultancy & diagnostic centre 8 (28.1) 45 (68.2) 3 (50.0) 57 (54.8) Private chamber with graduate practitioner 7 (21.9) 3 (4.6) 0 (0.0) 10 (9.6) Drug store with malaria diagnostic facilities 12 (37.5) 2 (3.0) 0 (0.0) 14 (13.5) NGO clinic/hospital 3 (9.4) 1 (1.5) 0 (0.0) 4 (3.8) Distance from the UHC (km) Mean (Range) 3 (0–19) 2.8 (0–30) 0.4 (0–1) 2.8 (0–30) < 0.001 Distance from the district hospital (km) Mean (Range) 85.4 (19–120) 35.1 (7–63) 11.8 (11–12) 48.9 (7–120) < 0.001 Table 5 Information on malaria diagnostic services in for-profit private health care facilities Indicators Control Region N = 32 n (%) Endemic Region N = 66 n (%) Non-Endemic Region N = 6 n (%) Total N = 104 n (%) P-value Provision of malaria testing service by the health centers Yes 18 (56.2) 60 (90.9) 6 (100.0) 84 (80.8) < 0.001 No 14 (43.8) 6 (9.1) 0 (0.0) 20 (19.2) If "Yes", available method(s), n = 84 Only RDT 8 (44.4) 18 (30.0) 3 (50.0) 29 (34.5) 0.055 Only Microscopy 4 (22.2) 3 (5.0) 0 (0.0) 7 (8.3) Both 6 (33.3) 39 (65.0) 3 (50.0) 48 (57.1) If "Yes", primary test performed, n = 84 RDT 12 (66.7) 40 (66.7) 6 (100.0) 58 (69.0) 0.235 Microscopy 6 (33.3) 20 (33.3) 0 (0.0) 26 (31.0) Usage of malaria RDT brand (Multiple answer), n = 58 Non-WHO PQ RDT 4 (33.3) 16 (40.0) 1 (16.7) 21 (36.2) 0.107 WHO PQ RDT 8 (66.7) 13 (32.5) 4 (66.7) 25 (43.1) Both types 0 (0.0) 11 (11.5) 1 (16.7) 12 (20.7) Sources of RDT supply, n = 58 Market 10 (83.3) 38 (95.0) 6 (100.0) 54 (93.1) 0.293 BRAC/BRAC Lead NGOs 2 (16.7) 2 (5.0) 0 (0.0) 4 (6.9) Approximate number of malaria RDT conducted per month, Median (IQR), n = 77 Off Season 8 (5–23) 10 (5–20) 5 (2–5) 10 (5–20) 0.169 Peak Season 30 (25–65) 25 (10–40) 14 (5–20) 25 (13–45) 0.249 Approximate number of malaria microscopy done per month, Median (IQR), n = 55 Off Season 16 (7–25) 11 (5–20) 12 (3–40) 12 (5–23) 0.876 Peak Season 60 (40–65) 30 (20–50) 20 (6–50) 35 (20–50) 0.052 Cost of malaria diagnosis in range (BDT), Median (IQR) RDT (n = 73) 150 (80–200) 250 (200–300) 600 (500–600) 250 (200–300) 0.001 Microscopy (n = 53) 40 (30–100) 100 (50–100) 100 (100–100) 100 (50–100) 0.544 Characteristics of the health facilities Five types of for-profit private health facilities have been listed and mapped. Among them more than half were consultancy and diagnostic centres (54.8%), followed by private clinics (18.3%), and drug stores (13.5%). Private for-profit health facilities were positioned in proximity to the corresponding Upazila Health Complexes (UHCs) but were situated at a distance from the nearest district hospitals. Health facilities in non-endemic region were located significantly (p < 0.001) closer to the UHCs and district hospitals, than were those in control and endemic regions (Table-4). Availability of malaria diagnostic and treatment services In total, 80.8% of the listed facilities provided malaria testing services. However, a comparison revealed that the availability of testing services, both by rapid diagnostic test (RDT) and microscopy, was highest in the endemic region (65.0%), followed by the non-endemic region (50%), and the control region (33.3%). Nevertheless, this difference was not deemed statistically significant. Of the 84 facilities, 66.7% in both control and endemic regions, and 100% in non-endemic regions, utilized RDT as the primary testing method. Among them, 66.7% of both the control and non-endemic regions exclusively used WHO pre-qualified RDTs, while in the endemic regions, this percentage was only 32.5%. The cost of RDT varied across regions; in the control and endemic regions, the average cost per RDT was 150 BDT (1.5 USD) and 250 BDT (2.5 USD), respectively. However, in non-endemic regions, the cost was notably higher at 600 BDT (6 USD), and this difference was statistically significant (Table-5). However, during FGDs, it was noted that most of the participants emphasized the blood slide method as the preferred approach for diagnosing malaria parasites. The ratio of microscopic diagnoses varies depending on weather conditions and seasonal fluctuations, ranging from 10–15 cases or sometimes even more. “ I have noticed that the practice of malaria diagnosis reporting is successful because it is positive or negative in Sreemongol. I may not find malaria parasites in certain cases, while it could be positive, it may be missed by me; thus, a malaria blood slide test report should be delivered mentioning ‘found’ or ‘not found’.” ( Participant: FGD Sremongal, Male, Age 28 ) Drug store owners and dispensers rely on RDT kits obtained from various sources such as local suppliers and third-party suppliers. In some instances, private health centres receive RDT kits from BRAC consortium NGOs. Charges for microscopy and RDT vary based on management decisions, service capacity, and the reputation of the private facilities. In our study area, the cost of an RDT ranges from 60 BDT (0.6 USD) to 200 BDT (2 USD), while a blood slide microscopy test is relatively less expensive, costing only 40 BDT (< 0.5 USD) to 70/80 BDT (0.7/0.8 USD) for patients. With respect to malaria treatment services, the opposite scenario was found, where only 18.3% of the service providers provided malaria treatment services. Despite having such provisions, the health facilities in the three regions did not even start the malaria treatment before obtaining the test results. On the other hand, almost all health facilities selected in this study (n = 100, 96.1%) did not provide necessary treatment to severe malaria patients. “ Serological tests are conducted in our private laboratory along with RDT, but we do not provide treatment. We only tested patients for malaria if they were referred by our residential medical officer if malaria was suspected among attending patients who had fever with cold cough symptoms. We have a 24-hours doctor on duty in our health centre, so we will be able to provide treatment if anti-malarial medication is supplied at our health centre .” ( Participant: FGD Alikadam, Female, Age: 23 ) Moreover, similar to RDTs, local wholesalers were the main source of anti-malarial drugs. Among the treatment providers, only four claimed to treat severe malaria patients. However, only two of them followed specific treatment protocols (Table 6 ). Table 6 Information on malaria treatment services in for-profit private healthcare facilities Indicators Control Regions N = 32 n (%) Endemic Regions N = 66 n (%) Non-Endemic Regions N = 6 n (%) Total N = 104 n (%) P-value Provision of malaria treatment service by the health care centres Yes 10 (31.2) 8 (12.1) 1 (16.7) 19 (18.3) 0.071 No 22 (68.8) 58 (87.9) 5 (83.3) 85 (81.7) Source of anti-malarial drug supply, n = 19 Local wholesalers 10 (100.0) 7 (87.5) 1 (100.0) 18 (94.7) 0.484 NGOs 0 (0.0) 1 (12.5) 0 (0.0) 1 (5.3) Providing treatment to severe malaria patient Yes 0 (0.0) 3 (4.6) 1 (16.7) 4 (3.9) 0.133 No 32 (100.0) 63 (95.4) 5 (83.3) 100 (96.1) Availability of treatment protocol to treat severe malaria patient (n = 4) Yes 0 (0.0) 1 (33.3) 1 (100.0) 2 (50.0) 1.00 No 0 (0.0) 2 (66.7) 0 (0.0) 2 (50.0) What guidelines is your treatment protocol based on (n = 2) National guideline 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1.00 WHO guideline 0 (0.0) 0 (0.0) 1 (100.0) 1 (50.0) Don't Know 0 (0.0) 1 (100.0) 0 (0.0) 1 (50.0) Prices of the diagnostic services During a focus group discussion (FGD), participants mentioned that a patient has to pay 50 BDT (0.5 USD) to 1000 BDT (10 USD) to perform a malaria RDT while a blood slide microscopy test is relatively less expensive, costing 30–200 BDT (< 0.3–2 USD). An FGD participant mentioned borrowing RDT kits from a local NGO for diagnosing suspected malaria patients and subsequently referred them to the same organization for treatment as gratitude. Barriers to efficient malaria diagnosis and case management During the FGD, the participant mentioned several practical reasons to prevent efficient malaria diagnosis. Limited equipment, inconsistent power, and poor-quality rapid diagnostic tests exacerbate this issue. One participant expressed concern about false positives from these tests, highlighting the need for better solutions. " I believed that the RDTs used by local diagnostic centres and clinics were of poor quality and were unable to accurately diagnose malaria. Last year, there was a case where malaria was identified by an RDT, but I did not find any malaria parasites when examining the blood slide using microscopy in my laboratory. " ( Participant: FGD Sreemongol, Male, Age: 48 ). Another challenging issue in conducting malaria diagnosis by microscopy was the lack of an appropriate number of staffs in private health care centres. A laboratory technician had to perform different kinds of serological and haematological tests every day. They had to deliver malaria reports for commercial purposes within a short time frame. This was due to early reports requested by attending doctors and hospital management. According to the participants' statements, testing and interpreting malaria tests were also not easy for those who had recently attained a bachelor's degree in medical technology. This was also attributed to the curriculum and texts taught, where malaria was given less emphasis, and lab training sessions were lacking. Furthermore, they mentioned that most newcomers were unable to understand and conduct the blood slide examinations effectively to identify malaria parasites. Insufficient staffing is another barrier to quality diagnosis in the private health care centres. A laboratory technician must perform various serological and haematological tests daily, rushing to deliver commercial malaria reports reasons, prompted by early requests from attending doctors and hospital management. Due to a lack of proper training, laboratory technicians and nurses in the private sector had very limited or no knowledge of malaria case management. “ Training and monthly medical camp arranged to conduct malaria diagnosis and treatment during a campaign will be fruitful for the people living in remote places intea garden area. ” ( Participant: FGD Sreemongol, Male, Age: 45 ) Service providers during FGDs mentioned that they usually refer patients to government health centres for treatment. Nevertheless, in some instances, a small number of individuals selling drugs would occasionally offer treatment for mild or uncomplicated cases, provided that they had anti-malarial medication in their store. Malaria case reporting and referral The median number of fever patients who experienced fever in the last two months was greater in the control region than in the endemic and non-endemic regions. However, the median number of fever patients tested for malaria was relatively low across all regions. In non-endemic regions, not a single patient with fever was tested for malaria in the past two months. Among the 23 facilities that claimed to have been diagnosed with malaria in the past two months, only 4 out of 23 reported it to the NMEP. The main reasons for not reporting to the NMEP included a lack of knowledge and uncertainty about reporting procedures. Malaria patients were primarily referred to UHC and NGO labs/healthcare workers, with limited referrals to district hospitals (Table 7 ). Table 7 Information on malaria case reporting and referral Indicators Control Regions N = 32 n (%) Endemic Regions N = 66 n (%) Non-Endemic Regions N = 6 n (%) Total N = 104 n (%) Number of fever patient received in last two months Median (IQR) 65 (36–110) 40 (15–80) 50 (35–60) 48 (20–90) Number of the received fever patient tested for malaria by RDT and/or Microscopy Median (IQR) 3 (0–35) 3 (0–16) 15 (10–30) 15 (0–35) Among them how many patients were malaria positive by RDT and/or Microscopy Range 0–15 0–7 0–0 0–15 Reporting to the NMEP (n = 23) Yes 1 (11.1) 3 (21.4) - 4 (17.4) No 8 (88.9) 11 (78.6) - 19 (82.6) Reasons for not reporting to NMEP Don’t work with the NMEP 1 (12.5) 2 (18.2) - 3 (15.8) Don't think It's necessary 1 (12.5) 0 (0.0) - 1 (5.3) Don't know what and how to report to NMEP 5 (62.5) 9 (81.8) - 14 (73.6) No Comments 1 (12.5) 0 (0.0) - 1 (5.3) Referring malaria patient to NGO Lab/HW 17 (53.1) 24 (36.4) 0 (0.0) 41 (39.4) UHC 13 (40.6) 14 (21.2) 5 (83.3) 32 (30.8) District Hospital 0 (0.0) 7 (10.6) 1 (16.7) 8 (7.7) During the FDGs, the participants preferred to report and refer malaria patients to the Govt. health facilities or NGOs working under the NMEP umbrella and suggest to establishing routine case reporting and incorporating a system with the national database of the NMEP platform. A recommendation arose from a participant from the Chakaria FGD. “ The Civil Surgeon office should play a lead role in monitoring malaria cases reported to the NMEP in due time. It was suggested that the directon be provided through paper-based reporting. However, a monthly online-based reporting format would be convenient for private profit sectors, clinics, and diagnostic centres. In addition, the continuous monitoring from the NMEP should be needed so that sincerity in duly report writing and submission can be achieved .” ( Participant: FGD Chakaria, Male ) Involvement with NMEP The collaboration between health facilities and the NMEP was found limited, with only a small percentage (6.7%) of facilities reporting their work with the program. The reporting of malaria positive results to higher facilities varied across regions with higher reporting rates in the endemic areas ( 56.1%) than in the control areas (21.9%), while non-endemic areas had no reporting during the study. Mobile phones were the primary method of reporting (78.4%) in both the control and endemic regions. Most of the health facilities (62.9%) expressed their willingness to work with the NMEP. In contrast, concern regarding additional workload (61.1%) was the main reason behind the opposite attitude toward the NMEP collaboration. One-third of the participants wanted to be trained through the NMEP training module. Moreover, training on malaria in the past three years was received by a very small fraction of respondents (12.5%) (Supplementary Table 1). Private for-profit healthcare centres are primarily driven by business interests, seeking to profit from each visiting patient, including those with suspected malaria cases. Furthermore, drug sellers anticipate receiving an honorarium as a service charge if RDTs are supplied to their outlets. The FGD participants expressed concerns about engaging with the NMEP for elimination efforts, emphasizing the need to implement service charges to compensate for low wages and the long, stressful working hours that often overburdened them. Consequently, expecting private for-profit facilities to provide free-of-cost services might not be feasible. Implementing additional service charges could enhance willingness and dedication in malaria case management, aligning with the business interests of these facilities. Discussion A proper and accurate diagnosis is the key for the proper management of a malaria patient. As recommended by the WHO, before providing any anti-malarial treatment all suspected malaria cases should be confirmed by quality-assured microscopy or RDT[ 12 ]. As evident in this study, malaria diagnosis by means of microscopy and RDT was readily available in 80% of the surveyed facilities, but the lack of a quality assurance system for microscopy was evident and also mentioned by the FGD participants. In many sub-Saharan African countries, microscopy has been used extensively in private for-profit healthcare facilities [ 13 , 14 ]. However, conducting microscopy in private clinics and drug stores is not always feasible. Barriers such as business interests, doctor preferences, and interruptions in electricity supply were considered obstacles for not conducting blood slide examinations for malaria diagnosis [ 15 , 16 ]. Another challenging issue in conducting malaria diagnosis by microscopy is the lack of an appropriate number of staff in the private health care centres [ 17 ]. A laboratory technician had to perform different kinds of serological and haematological tests every day. They had to deliver malaria reports for commercial purposes within a short time frame. This was due to early reports requested by attending doctors and hospital management. The affordability of services is an important consideration for care receivers. Charges for microscopy and RDT vary based on management decisions, service capacity, and the reputation of the private facilities [ 13 ]. Unlike other studies conducted elsewhere [ 18 , 19 ], the cost of a blood slide microscopy is relatively lower than that of a single RDT. In the past, it was recognized that a dedicated expert medical technologist was needed, if possible, to conduct malaria case diagnosis. If he/she was solely responsible for handling multiple lab tests simultaneously, there was a risk of missing malaria parasite detection [ 20 ]. Therefore, a trained technician specifically focused on diagnosing malaria cases and, if feasible, managing related issues was deemed necessary. Additionally, the involvement of trained staff enhances the precision of the diagnostic reports [ 21 ]. Sometimes, untrained private providers have been shown not to facilitate effective management of malaria cases, thus threatening to increase both mortality and lack of adherence to anti-malarial treatment [ 22 , 23 ]. Participants from the FGDs also emphasized the importance of local training held every three months, as a single session was deemed insufficient. Weekday training was preferred due to the greater workload during weekends in private facilities. The training curriculum focused on developing knowledge of slide test methods, with a specific request for incorporating reference positive slides to aid in understanding parasite types. Participants also highlighted the lack of slide cross-check tests and requested feedback from different locations where referral cross-checks were conducted. Additionally, they proposed conducting training sessions alongside monthly medical camps during campaigns, especially in remote areas such as tea garden regions, to improve malaria diagnosis and treatment for underserved populations. Overall, these enhanced training initiatives played a crucial role in improving the competence and accuracy of newly graduated medical technologists in diagnosing malaria cases [ 24 – 26 ]. The interactions among three core service delivery channels-public, private and community, must be taken into consideration in order to achieve universal health coverage with quality-assured diagnostics and anti-malarial treatment [ 27 ]. The interactive involvement of doctors and health centre owners is also essential. Laboratory technicians depend on doctors' recommendations for conducting various laboratory tests, including malaria diagnosis. Therefore, it is necessary to convince the doctors to engagement in the proposed project with the goal of eliminating malaria. They should take the initiative to recommend malaria parasite tests for all suspected patients. Awareness and support from local diagnostic centres and clinic owners are also vital. The support of private for-profit sector owners is crucial. They should remain aware of the project and be flexible with the time required to conduct laboratory tests, especially for malaria tests where accuracy and correct interpretation are unavoidable [ 28 ]. Private providers are often excluded from routine disease reporting systems because they often fail to report duly into national level HMIS, mirroring related studies [ 17 , 29 , 30 ]. For establishing routine case reporting and incorporating it into the national database through the NMEP platform, a recommendation arose from respondents, stating that the Civil Surgeon office should play a pivotal role in monitoring malaria cases and reporting to the NMEP in due time. It was suggested that direction to be provided through paper-based reporting. Lab technologists were proposed to lead the supervision process. A monthly reporting format was considered convenient for private profit sectors, clinics, and diagnostic centres. To guarantee proper case management and a periodical reporting system in the private health sector, regulation through the establishment of policies, rules and standards is inevitable [ 17 ]. A lack of proper oversight causes many for-profit health facilities to fall short achieving operational standards [ 16 ]. The issue of circulating an authorization letter arose from the realization that the initial efforts of private for-profit healthcare sectors in malaria case management were being overlooked by formal hospital staff. To prevent patients from seeking treatment from informal practitioners or drug sellers, it became crucial to address this issue. However, there was a concern regarding the capacity of selected and trained drug sellers and private clinic personnel, as their capabilities might remain unrecognized in the future. To mitigate this risk, the implementation of an authorization notice became necessary, which would be circulated to grant these healthcare providers the permission to treat malaria patients. The Civil Surgeon office could play a key role by issuing the notice to the relevant private clinics, diagnostic centres, and drug outlets. Additionally, to ensure effective monitoring of the project activities, the involvement of a reputable and efficient organization as a third-party monitor was recommended. The availability of antimalarial drugs at healthcare centres, where doctors are present to provide treatment instead of referring patients to government health facilities or partner NGOs, can create opportunities for more efficient malaria case management. This approach not only reduces time delays and hassles in delivering treatment to patients but also enhances overall effectiveness. A participant from the FGDs emphasized this strategy, stating that their private lab conducts serological tests alongside RDT but lacks the provision of treatment. However, with the presence of a 24-hour doctor at their health centre, they expressed the capability to provide treatment if anti-malarial medication is supplied. To implement this approach successfully, these doctors would require malaria case management training based on national guidelines. Additionally, it is crucial to inform relevant health authorities about diagnostic details to ensure treatment synchronization. According to other relevant studies, subsidies for RDTs and corresponding equipment purchases can strengthen complementary activities such as strategic behaviour change communication processes, community awareness and supervision of providers with integrated financial mechanisms, according to other relevant studies [ 17 , 31 , 32 ]. Private for-profit healthcare centres are primarily driven by business interests, seeking to profit from each visiting patient, including those with suspected malaria cases. Furthermore, drug sellers anticipate receiving an honorarium as a service charge if RDTs are supplied to their outlets [ 17 ]. During discussions, a participant highlighted that only 30% of suspected malaria cases were referred by doctors for MP testing, while 70% were avoided. This was attributed to the test being a time-consuming procedure and having limited profitability. The participants expressed concerns about engaging with the NMEP for elimination efforts, emphasizing the need to implement service charges to compensate for low wages and the long, stressful working hours that often overburdened them. Consequently, expecting private for-profit facilities to provide free-of-cost services might not be feasible. Implementing additional service charges could enhance willingness and dedication in malaria case management, aligning with the business interests of these facilities. Nevertheless, the for-profit service providers have shown interest in working with the NMEP. They have also expressed reservations about treating malaria patients. There is interest among the providers in working under the NMEP platform. However, they expressed a need for training to ensure a high-quality of services. They have also requested subsidies for diagnostic tools and incentives for their services. Moreover, they have desired a simple and user-friendly case referral system that is in line with phenomena seen in many countries [ 33 , 34 ] such as Yemen, where the usefulness of training intervention was found to be useful for the PHP in practicing national treatment guidelines [ 35 ]. Strengths and limitations: This study is the first to explore the willingness of for-profit private sectors in both malaria-endemic and non-endemic areas of Bangladesh to collaborate with the NMEP in eliminating malaria through a mixed-methods approach. However, the study's limitations include a short timeframe and a lack of comprehensive data from non-endemic regions. Since the data are only from one non-endemic area, they may not be generalizable to the entire non-endemic population. Conclusion The for-profit private sector in Bangladesh is somehow engaged in malaria case management but its contribution requires recognition. Their service can be streamlined with the NMEP and further enhanced by providing training, through innovative strategies, standard operating procedures, resource mobilization and surveillance tools. Declarations Author Contributions MSA, MSH,MJA and AH conceived and designed the study. MSH, CSP, and AM collected the data. MSA, MSH, AM and AH contributed to the data analysis and interpretation. MSA, MJA, MNH and AM supervised the study. MSA drafted the manuscript. All the authors have read and approved the final manuscript. Conflict of interest: The authors declare no conflicts of interest. Funding source: The WHO AC and VC (GF) fund have been used for this study. The authors did not receive any financial support for writing this manuscript. Disclaimer: The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Ethical clearance The study was approved by the Institutional Review Board (IRB) of icddr,b. Written informed consent was obtained from the study participants before data collection. Consent for publication Not applicable. Acknowledgement This research protocol was funded by the World Health Organization. icddr,b acknowledges with gratitude the commitment of the World Health Organization to its research efforts. icddr,b is also grateful to the Governments of Bangladesh and Canada, for providing core/unrestricted support. Data sharing The de-identified data underlying this research can be shared upon request from the corresponding author. References WHO: World malaria report 2023. 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McArdle RP, Phru CS, Hossain MS, Alam MS, Haldar K: Bangladesh Should Engage the Private Sector for Malaria Elimination by 2030. medRxiv 2024 : 2024.2004. 2010.24305490. Hossain MS, Matin MA, Ferdous N-EN, Hasan A, Sazed SA, Neogi AK, Chakma S, Islam MA, Khan AA, Haque ME: Adherence to Anti-Malarial Treatment in Malaria Endemic Areas of Bangladesh. Pathogens 2023, 12: 1392. Mbacham WF, Mangham-Jefferies L, Cundill B, Achonduh OA, Chandler CI, Ambebila JN, Nkwescheu A, Forsah-Achu D, Ndiforchu V, Tchekountouo O: Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon. The Lancet Global Health 2014, 2: e346-e358. Organization WH: Malaria microscopy quality assurance manual-version 2. World Health Organization; 2016. Sudhinaraset M, Briegleb C, Aung M, Khin HSS, Aung T: Motivation and challenges for use of malaria rapid diagnostic tests among informal providers in Myanmar: a qualitative study. Malaria Journal 2015, 14: 1-11. Phok S, Phanalasy S, Thein ST, Likhitsup A: Private sector opportunities and threats to achieving malaria elimination in the Greater Mekong Subregion: results from malaria outlet surveys in Cambodia, the Lao PDR, Myanmar, and Thailand. Malaria journal 2017, 16: 1-22. Awor P, Wamani H, Bwire G, Jagoe G, Peterson S: Private sector drug shops in integrated community case management of malaria, pneumonia, and diarrhea in children in Uganda. The American journal of tropical medicine and hygiene 2012, 87: 92. Ahmadi A, Nedjat S, Gholami J, Majdzadeh R: Disease surveillance and private sector in the metropolitans: a troublesome collaboration. International journal of preventive medicine 2013, 4: 1036. Phalkey RK, Kroll M, Dutta S, Shukla S, Butsch C, Bharucha E, Kraas F: Knowledge, attitude, and practices with respect to disease surveillance among urban private practitioners in Pune, India. Global health action 2015, 8: 28413. Willey BA, Tougher S, Ye Y, org Anp, Mann AG, Thomson R, Kourgueni IA, Amuasi JH, Ren R, Wamukoya M: Communicating the AMFm message: exploring the effect of communication and training interventions on private for-profit provider awareness and knowledge related to a multi-country anti-malarial subsidy intervention. Malaria Journal 2014, 13: 1-10. Lussiana C: Towards subsidized malaria rapid diagnostic tests. Lessons learned from programmes to subsidise artemisinin-based combination therapies in the private sector: a review. Health policy and planning 2016, 31: 928-939. Rao VB, Schellenberg D, Ghani AC: Overcoming health systems barriers to successful malaria treatment. Trends Parasitol 2013, 29: 164-180. Hill J, D'Mello-Guyett L, Hoyt J, van Eijk AM, ter Kuile FO, Webster J: Women's access and provider practices for the case management of malaria during pregnancy: a systematic review and meta-analysis. PLoS Med 2014, 11: e1001688. Bin Ghouth AS: Availability and prescription practice of anti-malaria drugs in the private health sector in Yemen. J Infect Dev Ctries 2013, 7: 404-412. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Supplementary Table 1: Distribution of responses on characteristics and engagement with NMEP Cite Share Download PDF Status: Published Journal Publication published 25 Oct, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 09 Jul, 2024 Editor assigned by journal 08 Jul, 2024 Submission checks completed at journal 08 Jul, 2024 First submitted to journal 07 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4699450","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":324634014,"identity":"10111524-d4bc-440c-9f79-71d5f26d87f9","order_by":0,"name":"Mohammad Shafiul Alam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYDACCQaGDwkMFnJsDAwGEowNxGlhnJHAIGFMohYgmdhAtBb52c0PGx62SaT3sR/eeLtyB4Ocef8C/FoM7hwzbEhsk8ht40krtjx7hsFY5sYDAlokEswfgLVI8JhJNrYxJM6QOEDAYTPSP4JsSWcjWgvDjRywwxIQWvgbCDjsRk5hQ8I5CUOwXxrPSBhLSBCwBOiwjY0/ymzk5dsPb7zZuMNGToKfkMPQANAKiQTStAABqbaMglEwCkbBsAcAa1pBR4aBrtQAAAAASUVORK5CYII=","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Shafiul","lastName":"Alam","suffix":""},{"id":324634015,"identity":"6bdab930-5164-465e-888a-27545fc650d5","order_by":1,"name":"Md Jahangir Alam","email":"","orcid":"","institution":"World Health Organization, Country Office for Bangladesh","correspondingAuthor":false,"prefix":"","firstName":"Md","middleName":"Jahangir","lastName":"Alam","suffix":""},{"id":324634016,"identity":"ebc7bb62-97cc-4840-8b83-2ce93c6ffcad","order_by":2,"name":"Mohammad Sharif Hossain","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Sharif","lastName":"Hossain","suffix":""},{"id":324634017,"identity":"85726fea-dac9-4264-aece-b513636442f7","order_by":3,"name":"Mohammad Abdul Matin","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Abdul","lastName":"Matin","suffix":""},{"id":324634018,"identity":"88217448-3cda-4781-93c8-a938c97ead53","order_by":4,"name":"Ching Swe Phru","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"Ching","middleName":"Swe","lastName":"Phru","suffix":""},{"id":324634019,"identity":"7d1210a3-81cd-42b6-81d8-fea9d222e261","order_by":5,"name":"Anamul Hasan","email":"","orcid":"","institution":"International Centre for Diarrhoeal Disease Research","correspondingAuthor":false,"prefix":"","firstName":"Anamul","middleName":"","lastName":"Hasan","suffix":""},{"id":324634020,"identity":"b56bcea8-1db9-415c-803b-796537d6312c","order_by":6,"name":"Md Mushfiqur Rahman","email":"","orcid":"","institution":"National Malaria Elimination Program","correspondingAuthor":false,"prefix":"","firstName":"Md","middleName":"Mushfiqur","lastName":"Rahman","suffix":""},{"id":324634021,"identity":"232b5b16-b3ad-4bbf-9616-507bb7caba54","order_by":7,"name":"Md Mosiqure Rahaman","email":"","orcid":"","institution":"National Malaria Elimination Program","correspondingAuthor":false,"prefix":"","firstName":"Md","middleName":"Mosiqure","lastName":"Rahaman","suffix":""},{"id":324634022,"identity":"42f3ec9c-efdd-400c-9589-6a64d0c66287","order_by":8,"name":"Md Nazrul Islam","email":"","orcid":"","institution":"National Malaria Elimination Program","correspondingAuthor":false,"prefix":"","firstName":"Md","middleName":"Nazrul","lastName":"Islam","suffix":""},{"id":324634023,"identity":"975717ac-9646-4c28-8497-44c550eea2bf","order_by":9,"name":"Shyamol Kumer Das","email":"","orcid":"","institution":"National Malaria Elimination Program","correspondingAuthor":false,"prefix":"","firstName":"Shyamol","middleName":"Kumer","lastName":"Das","suffix":""},{"id":324634024,"identity":"26ecc334-b88f-4894-a998-d655040000c7","order_by":10,"name":"M. 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Between 2000 and 2022, the number of malaria cases in the Southeast Asia Region of the World Health Organization (WHO) Southeast Asia Region have declined by 76%, accounting for only 2% of the global cases in 2022 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, Bangladesh has made significant strides in reducing the burden of malaria in the country. Between 2000 and 2022, malaria cases in Bangladesh decreased by 93% from 2008 to 2020 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Currently, out of the 64 districts in the country, only 13 districts have reported malaria cases, and one district, Bandarban alone has reported 76% of the total cases in Bangladesh in 2022 according to the National Malaria Elimination Programme (NMEP) (unpublished data).\u003c/p\u003e \u003cp\u003eTo achieve the ambitious goal of achieving a malaria free world by 2030, the WHO emphasizes the first pillar of its strategy: \u0026lsquo;Ensure access to malaria prevention, diagnosis and treatment as part of universal health coverage\u0026rsquo; [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Acknowledging this imperative, the NMEP in Bangladesh has actively coordinated with private graduate practitioners. Building upon this success, the NSP 2021-25 plans to further strengthen collaboration with private diagnostic centres and practitioners. This enhanced engagement with the private sector is crucial to expanding access to crucial malaria services and accelerating progress towards a malaria-free Bangladesh [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBangladesh has achieved remarkable progress in health-related Millennium Development Goals (MDGs)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Over the past few decades, both public and private healthcare facilities have experienced a significant surge, in contributing substantially to healthcare services. By 2019, the Directorate General of Health Services (DGHS) listed 255 public hospitals, 5,054 private hospitals and clinics, and 9,529 diagnostic centres with public hospitals offering 54,660 beds, while private hospitals contributed 91,537[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite this infrastructure expansion, ensuring quality, equitable access, and optimal utilization of healthcare services remains a challenge.\u003c/p\u003e \u003cp\u003eThe current physician-to-population ratio in Bangladesh is 1:1487, which falls short of established standards [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Moreover, the healthcare workforce exhibits imbalanced skill composition and uneven geographic distribution and is predominantly concentrated in urban areas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This presents a significant hurdle in realizing the concept of universal healthcare, where comprehensive health services are accessible to all. In response, Bangladesh's pluralistic healthcare system, comprising four key stakeholders \u0026ndash; the government, for-profit private sector, not-for-profit private sector (primarily NGOs), and international development organizations\u0026ndash; is evolving [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For-profit private facilities are expanding into rural areas, while NGOs and international organizations continue to serve underserved communities. More regulated and concerted efforts among these stakeholders are crucial to ensure wider access to quality healthcare for the masses.\u003c/p\u003e \u003cp\u003eDespite these advancements, the private healthcare system often serves as the initial point of contact for malaria case management. The sector is characterized by a lack of regulation, supervision, and low utilization of diagnostics in informal treatment. A consultation meeting held at the WHO headquarters in Geneva in October 2018 highlighted that private health services were not adequately incorporated into national strategies or plans and lacked clear guidance and policies for collaboration with private medicine retail outlets [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurveys conducted in sub-Saharan Africa between 2014 and 2016 revealed that more than 50% of children affected by febrile illnesses sought initial treatment in the private sector in six countries, including Nigeria, Chad, Tanzania, Uganda, the Democratic Republic of the Congo, and Ghana [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Bangladesh, for malaria case diagnosis and management, the public health care system and its partner NGOs are formally responsible. However, febrile patients and their attendees still prefer to seek health care at their nearest facility, whether public or private. There is also a gap in the reporting of malaria patients managed at for-profit private health facilities. Despite being a notifiable disease, private facilities have failed to report malaria to the National Malaria Health Management Information System (HMIS) due to a lack of an appropriate coordination system.\u003c/p\u003e \u003cp\u003eAs progress toward malaria elimination continues, understanding the load of cases managed by for-profit private health facilities, assessing their capacity, and leveraging their access following standardized procedures could prove invaluable in addressing each and every case effectively.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA mixed-method study was undertaken, beginning with a cross-sectional survey followed by focused group discussions (FGDs), aimed at evaluating the prevailing practices and comprehension of malaria diagnosis and case management among for-profit private sector providers.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Area and Sample Size\u003c/h2\u003e \u003cp\u003eThe National Malaria Elimination Programme (NMEP) categorizes Bangladesh into three regions based on malaria transmission status: Control (high transmission, 3 districts), Endemic (low transmission, 10 districts), and Non-Endemic (51 potential districts)[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing NMEP recommendations, a purposive sampling strategy ensured representative samples from these regions comprising 15 upazilas (sub-districts) across eight districts: eight from the control region, six from the endemic region, and one from the non-Endemic region (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Upazila selection prioritized malaria incidence, with the non-Endemic region chosen based on proximity to high-transmission areas.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of study areas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSl.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalaria Transmission Level\u003c/p\u003e \u003cp\u003e(API/1000 pop)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal Upazila covered by NMEP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUpazila\u003c/p\u003e \u003cp\u003ebased on incidence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRemarks\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBandarban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh; API\u0026thinsp;\u0026gt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlikadam, Lama, and Thanchi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eControl region\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRangamati\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh; API\u0026thinsp;\u0026gt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBelaichhari, Bagaichhari, and Juraichhari\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKhagrachori\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh; API\u0026thinsp;\u0026gt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLakshmichhari, and Matiranga\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetrokona\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow; API\u0026thinsp;\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKalmakanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEndemic region\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKurigram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow; API\u0026thinsp;\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRaomari\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoulvibazar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow; API\u0026thinsp;\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKamalganj, and Srimangal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCox\u0026rsquo;s Bazar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow; API\u0026thinsp;\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChakaria, and Ramu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePotential; API\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChhagalnaiya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNon-endemic region\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo ensure comprehensive coverage within each upazila, all private health service providers were surveyed. Initial expectations of 3\u0026ndash;10 providers per upazila resulted in a projected sample size of 90. However, during field visits, 104 providers were identified, and all were included to maximize data capture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted using a semi-structured questionnaire administered between September 18th and 27th, 2022, to comprehensively gather data. The questionnaire underwent pretesting and rigorous review by experts from the NMEP, Communicable Disease Control (CDC) of the DGHS, WHO, and icddr,b, ensuring its validity and reliability.\u003c/p\u003e \u003cp\u003eTo streamline the data collection, an online application utilizing open data kits (ODK) was developed and installed on eight tablets for direct field data entry. The application captured the geographical location of each service provider, facilitating subsequent mapping. The study staff underwent comprehensive training on the application's functionality and usage, followed by a meticulous field test to ensure smooth operation.\u003c/p\u003e \u003cp\u003eIn addition to interviews, relevant document reviews were conducted to verify recent malaria detection and treatment at the surveyed health centres.\u003c/p\u003e \u003cp\u003eA total of three FGDs were conducted among for-profit service providers. The participants, purposively selected for diversity, represented various healthcare professionals from the selected upazilas. For the control region, an FGD was held at Alikadam upazila on October 16, 2022, with 8 participants from three upazilas: Thanchi, Alikadam, and Lama of Bandarban district, the district with the highest reported malaria cases. The second FGD took place at Chakaria upazila on October 18, 2022, encompassing both endemic and non-endemic regions, with 7 participants from two upazilas: Chakaria and Ramu of Cox's Bazar district, the district with the highest reported malaria cases among the endemic regions. Despite the invitations, participants from non-endemic region did not participate in the second FGD. The third and final FGD occurred at Sreemangal upazila on October 23, 2022, focusing on endemic areas, with 11 participants from Kamalganj in Sreemangal upazila of Moulvibazar district and Raomari upazila of the Kurigram district. During interactive sessions, participants shared their perspectives on essential strategies for strengthening the malaria elimination program under the supervision of the NMEP. The FGDs were facilitated by one of the study investigators and involved a qualitative researcher within the team following standard guidelines. Health professionals from various working areas, including districts and upazilas, participated in the FGDs, with each session lasting between 100 and 157 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eFor the questionnaire-based survey, data were imported from the ODK server. Data cleaning and analysis were conducted using Stata version 15.1 (Stata Corporations, College Station, TX, USA). All discussions during the FGDs were audio recorded, and verbatim transcriptions in Bengali were prepared to capture local terminology and nuances. The qualitative data collected were subsequently analysed using ATLAS.ti version 7.5.7 (ATLAS.ti Scientific Software Development GmbH), facilitating the coding of the data based on the research objectives.\u003c/p\u003e \u003cp\u003eQualitative data are presented as numbers and percentages, while normally distributed quantitative data are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD); and non-normally distributed data are represented as medians (IQRs).\u003c/p\u003e \u003cp\u003eParticipants were categorized into three groups: control, endemic, and non-endemic regions. Subsequently, a comparative analysis was performed across various factors, including demographic characteristics, health facility characteristics, practices of malaria diagnostic and treatment services, malaria case reporting and referral systems, and involvement with the NMEP. To assess the differences between these groups, the chi-square test was utilized for categorical variables. For comparisons between two groups, the unpaired t-test was used, and for comparisons among more than two groups, ANOVA was employed for normally distributed quantitative data. A nonparametric k-sample test was used to test the equality of medians for non-normally distributed data. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was adopted to determine statistical significance. All related costs and expenditures are described here in dual currency, i.e., Bangladeshi Taka (BDT) and US Dollar (USD), applying the average exchange rate (USD 1\u0026thinsp;=\u0026thinsp;99.46 BDT) during the mid-point of the data collection year (2022), according to the Annual Report (July 2022 \u0026ndash; June 2023) of Bangladesh Bank [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eResearcher Reflexivity\u003c/h2\u003e \u003cp\u003eThe process by which the corresponding moderators/facilitators in FGDs acknowledged and critically examined their neutral and non-judgemental perspectives that might impact the research process and findings and limit potential biases. The moderator\u0026rsquo;s point of view on private sector engagement in malaria elimination might have influenced the discussion, data collection, and results analysis. To the level best of their ability, they practised and kept their neutrality before, during and after each FGD. Moreover, the corresponding moderators were neither colleagues nor friends/neighbours of any of the 26 participants. Moreover, the supervising researcher with a specialization in qualitative research independently scrutinized every discussion in order to improve data reliability and ensure quality assurance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics of the participants\u003c/h2\u003e \u003cp\u003eOf the 104 participants recruited in this study, 30.8% were from the control region, 63.4% were from the endemic region, and 5.8% were from the non-endemic region. The overall mean age of the respondents was 36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 years. The majority of respondents were male (88.5%). Educational qualifications varied among the respondents. In the study, there was no illiterate participants. Almost half of the participants (n\u0026thinsp;=\u0026thinsp;53, 51%) had a diploma degree in a related profession. In the endemic region, most of the participants (n\u0026thinsp;=\u0026thinsp;40, 60.6%) were involved in laboratory work, whereas the majority of the owners/managers (n\u0026thinsp;=\u0026thinsp;21, 65.6%) of health facilities lived in the control areas (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The p-value indicated a statistically significant difference in education level (p\u0026thinsp;=\u0026thinsp;0.002) and their role at the health centre (p\u0026thinsp;=\u0026thinsp;0.003) among the regions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the baseline characteristics of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;32 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;66 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Endemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;104 n(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (87.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass 1\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass 11\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (27.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53 (51.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder graduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRole at the health centre\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOwner/Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41 (39.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant/Doctor/ Paramedics/ Pharmacist/ Nurse/ Employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMed tech/ Lab tech/ Lab in charge/ SACMO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 (47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 26 providers participated in the FGDs. Among them 88.5% were male and 50.0% of them were medical technologists employed in diagnostic services (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e ).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the focus group participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFGD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStudy areas\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUpazila\u003c/p\u003e \u003cp\u003e(Sub-district)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eGender\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eParticipants\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eControl district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eBandarban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThanchi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAlikadam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLama\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEndemic district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCox\u0026rsquo;s Bazar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChakaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRamu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Endemic district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFeni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChhagalnaiya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEndemic district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMoulvibazar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKamalganj\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSreemangal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndemic district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKurigram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRaomari\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e\u003csup\u003e$\u003c/sup\u003e 1\u0026thinsp;=\u0026thinsp;Nurse; 2\u0026thinsp;=\u0026thinsp;Paramedic/medical assistant; 3\u0026thinsp;=\u0026thinsp;Medical technologist (Lab); 4\u0026thinsp;=\u0026thinsp;Pharmacy owner; 5\u0026thinsp;=\u0026thinsp;Diagnostic centre owner;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003e M\u0026thinsp;=\u0026thinsp;Male ; F\u0026thinsp;=\u0026thinsp;Female\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the health facilities included in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;32 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndemic Regions N\u0026thinsp;=\u0026thinsp;66 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Endemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;104 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eType of health center\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultancy \u0026amp; diagnostic centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (68.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57 (54.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate chamber with graduate practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug store with malaria diagnostic facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGO clinic/hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistance from the UHC (km)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8 (0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8 (0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistance from the district hospital (km)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.4 (19\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.1 (7\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.8 (11\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.9 (7\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInformation on malaria diagnostic services in for-profit private health care facilities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e Indicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl Region\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;32 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndemic Region\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;66 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Endemic Region\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;104\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eProvision of malaria testing service by the health centers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84 (80.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIf \"Yes\", available method(s), n\u0026thinsp;=\u0026thinsp;84\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly RDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly Microscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIf \"Yes\", primary test performed, n\u0026thinsp;=\u0026thinsp;84\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMicroscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (31.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsage of malaria RDT brand (Multiple answer), n\u0026thinsp;=\u0026thinsp;58\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-WHO PQ RDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO PQ RDT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (43.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth types\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (20.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSources of RDT supply, n\u0026thinsp;=\u0026thinsp;58\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (95.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54 (93.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBRAC/BRAC Lead NGOs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (6.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproximate number of malaria RDT conducted per month, Median (IQR), n\u0026thinsp;=\u0026thinsp;77\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOff Season\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (5\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (2\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak Season\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (25\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (10\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (13\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproximate number of malaria microscopy done per month, Median (IQR), n\u0026thinsp;=\u0026thinsp;55\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOff Season\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (7\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (3\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (5\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak Season\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (40\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (20\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (6\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (20\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCost of malaria diagnosis in range (BDT), Median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRDT (n\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (80\u0026ndash;200)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e250 (200\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e600 (500\u0026ndash;600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e250 (200\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMicroscopy (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (30\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (50\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 (100\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100 (50\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.544\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the health facilities\u003c/h2\u003e \u003cp\u003eFive types of for-profit private health facilities have been listed and mapped. Among them more than half were consultancy and diagnostic centres (54.8%), followed by private clinics (18.3%), and drug stores (13.5%). Private for-profit health facilities were positioned in proximity to the corresponding Upazila Health Complexes (UHCs) but were situated at a distance from the nearest district hospitals. Health facilities in non-endemic region were located significantly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) closer to the UHCs and district hospitals, than were those in control and endemic regions (Table-4).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eAvailability of malaria diagnostic and treatment services\u003c/h2\u003e \u003cp\u003eIn total, 80.8% of the listed facilities provided malaria testing services. However, a comparison revealed that the availability of testing services, both by rapid diagnostic test (RDT) and microscopy, was highest in the endemic region (65.0%), followed by the non-endemic region (50%), and the control region (33.3%). Nevertheless, this difference was not deemed statistically significant. Of the 84 facilities, 66.7% in both control and endemic regions, and 100% in non-endemic regions, utilized RDT as the primary testing method. Among them, 66.7% of both the control and non-endemic regions exclusively used WHO pre-qualified RDTs, while in the endemic regions, this percentage was only 32.5%. The cost of RDT varied across regions; in the control and endemic regions, the average cost per RDT was 150 BDT (1.5 USD) and 250 BDT (2.5 USD), respectively. However, in non-endemic regions, the cost was notably higher at 600 BDT (6 USD), and this difference was statistically significant (Table-5).\u003c/p\u003e \u003cp\u003eHowever, during FGDs, it was noted that most of the participants emphasized the blood slide method as the preferred approach for diagnosing malaria parasites. The ratio of microscopic diagnoses varies depending on weather conditions and seasonal fluctuations, ranging from 10\u0026ndash;15 cases or sometimes even more.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI have noticed that the practice of malaria diagnosis reporting is successful because it is positive or negative in Sreemongol. I may not find malaria parasites in certain cases, while it could be positive, it may be missed by me; thus, a malaria blood slide test report should be delivered mentioning \u0026lsquo;found\u0026rsquo; or \u0026lsquo;not found\u0026rsquo;.\u0026rdquo;\u003c/em\u003e (\u003cb\u003eParticipant: FGD Sremongal, Male, Age 28\u003c/b\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDrug store owners and dispensers rely on RDT kits obtained from various sources such as local suppliers and third-party suppliers. In some instances, private health centres receive RDT kits from BRAC consortium NGOs. Charges for microscopy and RDT vary based on management decisions, service capacity, and the reputation of the private facilities. In our study area, the cost of an RDT ranges from 60 BDT (0.6 USD) to 200 BDT (2 USD), while a blood slide microscopy test is relatively less expensive, costing only 40 BDT (\u0026lt;\u0026thinsp;0.5 USD) to 70/80 BDT (0.7/0.8 USD) for patients.\u003c/p\u003e \u003cp\u003eWith respect to malaria treatment services, the opposite scenario was found, where only 18.3% of the service providers provided malaria treatment services. Despite having such provisions, the health facilities in the three regions did not even start the malaria treatment before obtaining the test results. On the other hand, almost all health facilities selected in this study (n\u0026thinsp;=\u0026thinsp;100, 96.1%) did not provide necessary treatment to severe malaria patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSerological tests are conducted in our private laboratory along with RDT, but we do not provide treatment. We only tested patients for malaria if they were referred by our residential medical officer if malaria was suspected among attending patients who had fever with cold cough symptoms. We have a 24-hours doctor on duty in our health centre, so we will be able to provide treatment if anti-malarial medication is supplied at our health centre\u003c/em\u003e.\u0026rdquo; (\u003cb\u003eParticipant: FGD Alikadam, Female, Age: 23\u003c/b\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMoreover, similar to RDTs, local wholesalers were the main source of anti-malarial drugs. Among the treatment providers, only four claimed to treat severe malaria patients. However, only two of them followed specific treatment protocols (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInformation on malaria treatment services in for-profit private healthcare facilities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003eRegions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;32 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;66 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Endemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;104\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eProvision of malaria treatment service by the health care centres\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (31.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (87.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85 (81.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSource of anti-malarial drug supply, n\u0026thinsp;=\u0026thinsp;19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal wholesalers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (94.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGOs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProviding treatment to severe malaria patient\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (95.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100 (96.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAvailability of treatment protocol to treat severe malaria patient (n\u0026thinsp;=\u0026thinsp;4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat guidelines is your treatment protocol based on (n\u0026thinsp;=\u0026thinsp;2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon't Know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePrices of the diagnostic services\u003c/h2\u003e \u003cp\u003eDuring a focus group discussion (FGD), participants mentioned that a patient has to pay 50 BDT (0.5 USD) to 1000 BDT (10 USD) to perform a malaria RDT while a blood slide microscopy test is relatively less expensive, costing 30\u0026ndash;200 BDT (\u0026lt;\u0026thinsp;0.3\u0026ndash;2 USD). An FGD participant mentioned borrowing RDT kits from a local NGO for diagnosing suspected malaria patients and subsequently referred them to the same organization for treatment as gratitude.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to efficient malaria diagnosis and case management\u003c/h2\u003e \u003cp\u003eDuring the FGD, the participant mentioned several practical reasons to prevent efficient malaria diagnosis. Limited equipment, inconsistent power, and poor-quality rapid diagnostic tests exacerbate this issue. One participant expressed concern about false positives from these tests, highlighting the need for better solutions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eI believed that the RDTs used by local diagnostic centres and clinics were of poor quality and were unable to accurately diagnose malaria. Last year, there was a case where malaria was identified by an RDT, but I did not find any malaria parasites when examining the blood slide using microscopy in my laboratory.\u003c/em\u003e\" (\u003cb\u003eParticipant: FGD Sreemongol, Male, Age: 48\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother challenging issue in conducting malaria diagnosis by microscopy was the lack of an appropriate number of staffs in private health care centres. A laboratory technician had to perform different kinds of serological and haematological tests every day. They had to deliver malaria reports for commercial purposes within a short time frame. This was due to early reports requested by attending doctors and hospital management.\u003c/p\u003e \u003cp\u003eAccording to the participants' statements, testing and interpreting malaria tests were also not easy for those who had recently attained a bachelor's degree in medical technology. This was also attributed to the curriculum and texts taught, where malaria was given less emphasis, and lab training sessions were lacking. Furthermore, they mentioned that most newcomers were unable to understand and conduct the blood slide examinations effectively to identify malaria parasites.\u003c/p\u003e \u003cp\u003eInsufficient staffing is another barrier to quality diagnosis in the private health care centres. A laboratory technician must perform various serological and haematological tests daily, rushing to deliver commercial malaria reports reasons, prompted by early requests from attending doctors and hospital management.\u003c/p\u003e \u003cp\u003eDue to a lack of proper training, laboratory technicians and nurses in the private sector had very limited or no knowledge of malaria case management.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003e\u0026ldquo;\u003c/b\u003e \u003cem\u003eTraining and monthly medical camp arranged to conduct malaria diagnosis and treatment during a campaign will be fruitful for the people living in remote places intea garden area.\u003c/em\u003e \u003cb\u003e\u0026rdquo;\u003c/b\u003e (\u003cb\u003eParticipant: FGD Sreemongol, Male, Age: 45\u003c/b\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eService providers during FGDs mentioned that they usually refer patients to government health centres for treatment. Nevertheless, in some instances, a small number of individuals selling drugs would occasionally offer treatment for mild or uncomplicated cases, provided that they had anti-malarial medication in their store.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMalaria case reporting and referral\u003c/h2\u003e \u003cp\u003eThe median number of fever patients who experienced fever in the last two months was greater in the control region than in the endemic and non-endemic regions. However, the median number of fever patients tested for malaria was relatively low across all regions. In non-endemic regions, not a single patient with fever was tested for malaria in the past two months. Among the 23 facilities that claimed to have been diagnosed with malaria in the past two months, only 4 out of 23 reported it to the NMEP. The main reasons for not reporting to the NMEP included a lack of knowledge and uncertainty about reporting procedures. Malaria patients were primarily referred to UHC and NGO labs/healthcare workers, with limited referrals to district hospitals (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInformation on malaria case reporting and referral\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003eRegions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;32 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;66 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Endemic Regions\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6 n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;104\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eNumber of fever patient received in last two months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (36\u0026ndash;110)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (15\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (35\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (20\u0026ndash;90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of the received fever patient tested for malaria by RDT and/or Microscopy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (10\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (0\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmong them how many patients were malaria positive by RDT and/or Microscopy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReporting to the NMEP (n\u0026thinsp;=\u0026thinsp;23)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (17.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (82.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasons for not reporting to NMEP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon\u0026rsquo;t work with the NMEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon't think It's necessary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon't know what and how to report to NMEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (73.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Comments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReferring malaria patient to\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGO Lab/HW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (53.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41 (39.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the FDGs, the participants preferred to report and refer malaria patients to the Govt. health facilities or NGOs working under the NMEP umbrella and suggest to establishing routine case reporting and incorporating a system with the national database of the NMEP platform. A recommendation arose from a participant from the Chakaria FGD.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe Civil Surgeon office should play a lead role in monitoring malaria cases reported to the NMEP in due time. It was suggested that the directon be provided through paper-based reporting. However, a monthly online-based reporting format would be convenient for private profit sectors, clinics, and diagnostic centres. In addition, the continuous monitoring from the NMEP should be needed so that sincerity in duly report writing and submission can be achieved\u003c/em\u003e.\u0026rdquo; (\u003cb\u003eParticipant: FGD Chakaria, Male\u003c/b\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInvolvement with NMEP\u003c/h2\u003e \u003cp\u003eThe collaboration between health facilities and the NMEP was found limited, with only a small percentage (6.7%) of facilities reporting their work with the program. The reporting of malaria positive results to higher facilities varied across regions with higher reporting rates in the endemic areas ( 56.1%) than in the control areas (21.9%), while non-endemic areas had no reporting during the study. Mobile phones were the primary method of reporting (78.4%) in both the control and endemic regions.\u003c/p\u003e \u003cp\u003eMost of the health facilities (62.9%) expressed their willingness to work with the NMEP. In contrast, concern regarding additional workload (61.1%) was the main reason behind the opposite attitude toward the NMEP collaboration. One-third of the participants wanted to be trained through the NMEP training module. Moreover, training on malaria in the past three years was received by a very small fraction of respondents (12.5%) (Supplementary Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003ePrivate for-profit healthcare centres are primarily driven by business interests, seeking to profit from each visiting patient, including those with suspected malaria cases. Furthermore, drug sellers anticipate receiving an honorarium as a service charge if RDTs are supplied to their outlets. The FGD participants expressed concerns about engaging with the NMEP for elimination efforts, emphasizing the need to implement service charges to compensate for low wages and the long, stressful working hours that often overburdened them. Consequently, expecting private for-profit facilities to provide free-of-cost services might not be feasible. Implementing additional service charges could enhance willingness and dedication in malaria case management, aligning with the business interests of these facilities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eA proper and accurate diagnosis is the key for the proper management of a malaria patient. As recommended by the WHO, before providing any anti-malarial treatment all suspected malaria cases should be confirmed by quality-assured microscopy or RDT[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As evident in this study, malaria diagnosis by means of microscopy and RDT was readily available in 80% of the surveyed facilities, but the lack of a quality assurance system for microscopy was evident and also mentioned by the FGD participants. In many sub-Saharan African countries, microscopy has been used extensively in private for-profit healthcare facilities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, conducting microscopy in private clinics and drug stores is not always feasible. Barriers such as business interests, doctor preferences, and interruptions in electricity supply were considered obstacles for not conducting blood slide examinations for malaria diagnosis [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Another challenging issue in conducting malaria diagnosis by microscopy is the lack of an appropriate number of staff in the private health care centres [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A laboratory technician had to perform different kinds of serological and haematological tests every day. They had to deliver malaria reports for commercial purposes within a short time frame. This was due to early reports requested by attending doctors and hospital management.\u003c/p\u003e \u003cp\u003eThe affordability of services is an important consideration for care receivers. Charges for microscopy and RDT vary based on management decisions, service capacity, and the reputation of the private facilities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Unlike other studies conducted elsewhere [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], the cost of a blood slide microscopy is relatively lower than that of a single RDT.\u003c/p\u003e \u003cp\u003eIn the past, it was recognized that a dedicated expert medical technologist was needed, if possible, to conduct malaria case diagnosis. If he/she was solely responsible for handling multiple lab tests simultaneously, there was a risk of missing malaria parasite detection [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, a trained technician specifically focused on diagnosing malaria cases and, if feasible, managing related issues was deemed necessary. Additionally, the involvement of trained staff enhances the precision of the diagnostic reports [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSometimes, untrained private providers have been shown not to facilitate effective management of malaria cases, thus threatening to increase both mortality and lack of adherence to anti-malarial treatment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Participants from the FGDs also emphasized the importance of local training held every three months, as a single session was deemed insufficient. Weekday training was preferred due to the greater workload during weekends in private facilities. The training curriculum focused on developing knowledge of slide test methods, with a specific request for incorporating reference positive slides to aid in understanding parasite types. Participants also highlighted the lack of slide cross-check tests and requested feedback from different locations where referral cross-checks were conducted. Additionally, they proposed conducting training sessions alongside monthly medical camps during campaigns, especially in remote areas such as tea garden regions, to improve malaria diagnosis and treatment for underserved populations. Overall, these enhanced training initiatives played a crucial role in improving the competence and accuracy of newly graduated medical technologists in diagnosing malaria cases [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe interactions among three core service delivery channels-public, private and community, must be taken into consideration in order to achieve universal health coverage with quality-assured diagnostics and anti-malarial treatment [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The interactive involvement of doctors and health centre owners is also essential. Laboratory technicians depend on doctors' recommendations for conducting various laboratory tests, including malaria diagnosis. Therefore, it is necessary to convince the doctors to engagement in the proposed project with the goal of eliminating malaria. They should take the initiative to recommend malaria parasite tests for all suspected patients. Awareness and support from local diagnostic centres and clinic owners are also vital. The support of private for-profit sector owners is crucial. They should remain aware of the project and be flexible with the time required to conduct laboratory tests, especially for malaria tests where accuracy and correct interpretation are unavoidable [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrivate providers are often excluded from routine disease reporting systems because they often fail to report duly into national level HMIS, mirroring related studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. For establishing routine case reporting and incorporating it into the national database through the NMEP platform, a recommendation arose from respondents, stating that the Civil Surgeon office should play a pivotal role in monitoring malaria cases and reporting to the NMEP in due time. It was suggested that direction to be provided through paper-based reporting. Lab technologists were proposed to lead the supervision process. A monthly reporting format was considered convenient for private profit sectors, clinics, and diagnostic centres.\u003c/p\u003e \u003cp\u003eTo guarantee proper case management and a periodical reporting system in the private health sector, regulation through the establishment of policies, rules and standards is inevitable [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A lack of proper oversight causes many for-profit health facilities to fall short achieving operational standards [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The issue of circulating an authorization letter arose from the realization that the initial efforts of private for-profit healthcare sectors in malaria case management were being overlooked by formal hospital staff. To prevent patients from seeking treatment from informal practitioners or drug sellers, it became crucial to address this issue. However, there was a concern regarding the capacity of selected and trained drug sellers and private clinic personnel, as their capabilities might remain unrecognized in the future. To mitigate this risk, the implementation of an authorization notice became necessary, which would be circulated to grant these healthcare providers the permission to treat malaria patients. The Civil Surgeon office could play a key role by issuing the notice to the relevant private clinics, diagnostic centres, and drug outlets. Additionally, to ensure effective monitoring of the project activities, the involvement of a reputable and efficient organization as a third-party monitor was recommended.\u003c/p\u003e \u003cp\u003eThe availability of antimalarial drugs at healthcare centres, where doctors are present to provide treatment instead of referring patients to government health facilities or partner NGOs, can create opportunities for more efficient malaria case management. This approach not only reduces time delays and hassles in delivering treatment to patients but also enhances overall effectiveness. A participant from the FGDs emphasized this strategy, stating that their private lab conducts serological tests alongside RDT but lacks the provision of treatment. However, with the presence of a 24-hour doctor at their health centre, they expressed the capability to provide treatment if anti-malarial medication is supplied. To implement this approach successfully, these doctors would require malaria case management training based on national guidelines. Additionally, it is crucial to inform relevant health authorities about diagnostic details to ensure treatment synchronization. According to other relevant studies, subsidies for RDTs and corresponding equipment purchases can strengthen complementary activities such as strategic behaviour change communication processes, community awareness and supervision of providers with integrated financial mechanisms, according to other relevant studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrivate for-profit healthcare centres are primarily driven by business interests, seeking to profit from each visiting patient, including those with suspected malaria cases. Furthermore, drug sellers anticipate receiving an honorarium as a service charge if RDTs are supplied to their outlets [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. During discussions, a participant highlighted that only 30% of suspected malaria cases were referred by doctors for MP testing, while 70% were avoided. This was attributed to the test being a time-consuming procedure and having limited profitability. The participants expressed concerns about engaging with the NMEP for elimination efforts, emphasizing the need to implement service charges to compensate for low wages and the long, stressful working hours that often overburdened them. Consequently, expecting private for-profit facilities to provide free-of-cost services might not be feasible. Implementing additional service charges could enhance willingness and dedication in malaria case management, aligning with the business interests of these facilities.\u003c/p\u003e \u003cp\u003eNevertheless, the for-profit service providers have shown interest in working with the NMEP. They have also expressed reservations about treating malaria patients. There is interest among the providers in working under the NMEP platform. However, they expressed a need for training to ensure a high-quality of services. They have also requested subsidies for diagnostic tools and incentives for their services. Moreover, they have desired a simple and user-friendly case referral system that is in line with phenomena seen in many countries [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] such as Yemen, where the usefulness of training intervention was found to be useful for the PHP in practicing national treatment guidelines [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations:\u003c/h2\u003e \u003cp\u003eThis study is the first to explore the willingness of for-profit private sectors in both malaria-endemic and non-endemic areas of Bangladesh to collaborate with the NMEP in eliminating malaria through a mixed-methods approach. However, the study's limitations include a short timeframe and a lack of comprehensive data from non-endemic regions. Since the data are only from one non-endemic area, they may not be generalizable to the entire non-endemic population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe for-profit private sector in Bangladesh is somehow engaged in malaria case management but its contribution requires recognition. Their service can be streamlined with the NMEP and further enhanced by providing training, through innovative strategies, standard operating procedures, resource mobilization and surveillance tools.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMSA, MSH,MJA and AH conceived and designed the study. MSH, CSP, and AM collected the data. MSA, MSH, AM and AH contributed to the data analysis and interpretation. MSA, MJA, MNH and AM supervised the study. MSA drafted the manuscript. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding source:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe WHO AC and VC (GF) fund have been used for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any financial support for writing this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eEthical clearance\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board (IRB) of icddr,b.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the study participants before data collection.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research protocol was funded by the World Health Organization. icddr,b acknowledges with gratitude the commitment of the World Health Organization to its research efforts. icddr,b is also grateful to the Governments of Bangladesh and Canada, for providing core/unrestricted support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe de-identified data underlying this research can be shared upon request from the corresponding author.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO: \u003cstrong\u003eWorld malaria report 2023.\u003c/strong\u003e Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eHaldar K, Alam MS, Koepfli C, Lobo NF, Phru CS, Islam N, Faiz A, Khan WA, Haque R: \u003cstrong\u003eBangladesh in the era of malaria elimination.\u003c/strong\u003e \u003cem\u003eTrends in Parasitology \u003c/em\u003e2023.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization: \u003cstrong\u003eGlobal Technical Strategy for Malaria 2016\u0026ndash;2030.\u003c/strong\u003e Geneva, Swizerland2015.\u003c/li\u003e\n\u003cli\u003eNational Malarial Elimination Programme: \u003cstrong\u003eNational Strategic Plan for Malaria Elimination in Bangladesh: 2021-2025.\u003c/strong\u003e (Directorate General of Health Services ed. 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Despite the private sector's prominence in rural healthcare, its role in malaria management remains underutilized. This study aimed to strategize leveraging the for-profit private sector, such as diagnostic and treatment centers, to bolster national malaria surveillance and control, advancing Bangladesh toward malaria elimination by 2030.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis mixed-method study commenced with a questionnaire-based cross-sectional survey followed by selected focused group discussions (FGDs) among the participants. Based on the endemicity and strategic priorities, a comprehensive mapping of private for-profit facilities from the regions comprising 15 sub-districts across 8 chosen districts (7 malaria endemic districts and the rest non-endemic districts) was created. For the non-endemic zone, the sub-districts were selected based on their proximity to an area with high malaria transmission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 104 representative participants, majority were male (n=92, 88.5%), had a diploma in their respective fields (n=53, 51%) and were involved either in laboratory work (n=49, 47.1%) or as owners/managers of health centers (n=41, 39.4%). The selected health facilities were close to the corresponding UHC (mean distance 2.8 km), but were distantly located from the \u0026nbsp;designated district hospitals (mean distance 48.9 km). The main sources of RDT kits (62.3%) and anti-malarial drugs (63.2%) were local wholesale markets. A large share of the corresponding facilities neither provided \u0026nbsp;malaria treatment services (81.7%) nor worked with the NMEP (93.3%). Three FGDs were held with the for-profit service providers so that further insights and qualitative viewpoints of them can be utilized in situation analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlights challenges and recommendations for engaging private for-profit health facilities in Bangladesh's malaria elimination efforts. The identified challenges include low-quality RDTs, staff shortages, and inadequate capacity building. Recommendations emphasize effective training, stakeholder interaction, and enhanced oversight for successful malaria control efforts.\u003c/p\u003e","manuscriptTitle":"Malaria Endgame: Can engagement of the for-profit private sector help the country reach the last mile of malaria elimination in Bangladesh?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 18:07:05","doi":"10.21203/rs.3.rs-4699450/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-09T09:45:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-08T12:57:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-08T12:55:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-07-07T08:50:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6e8def4-94aa-46ca-9711-7bc705c1dab0","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:08:59+00:00","versionOfRecord":{"articleIdentity":"rs-4699450","link":"https://doi.org/10.1186/s12889-024-20448-2","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-10-25 15:58:00","publishedOnDateReadable":"October 25th, 2024"},"versionCreatedAt":"2024-08-09 18:07:05","video":"","vorDoi":"10.1186/s12889-024-20448-2","vorDoiUrl":"https://doi.org/10.1186/s12889-024-20448-2","workflowStages":[]},"version":"v1","identity":"rs-4699450","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4699450","identity":"rs-4699450","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}