Improving malaria knowledge and practices in rural Myanmar through a village health worker intervention: a cross-sectional study

Understanding psychosocial determinants of malaria behaviours in low-transmission settings: a scoping review

BACKGROUND

Recent estimates show progress toward malaria elimination is slowing in many settings, underscoring the need for tailored approaches to fight the disease. In addition to essential structural changes, human behaviour plays an important role in elimination. Engagement in malaria behaviours depends in part on psychosocial determinants such as knowledge, perceived risk, and community norms. Understanding the state of research on psychosocial determinants in low malaria transmission settings is important to augment social and behaviour change practice. This review synthesizes research on psychosocial factors and malaria behaviours in low-transmission settings.

METHODS

A systematic search of peer-reviewed literature and supplemental manual search of grey literature was conducted using key terms and eligibility criteria defined a priori. Publications from 2000-2020 in the English language were identified, screened, and analysed using inductive methods to determine the relationship between the measured psychosocial factors and malaria behaviours.

RESULTS

Screening of 961 publications yielded 96 for inclusion. Nineteen articles collected data among subpopulations that are at increased risk of malaria exposure in low-transmission settings. Purposive and cluster randomized sampling were common sampling approaches. Quantitative, qualitative, and mixed-methods study designs were used. Knowledge, attitudes, and perceived risk were commonly measured psychosocial factors. Perceived response-efficacy, perceived self-efficacy, and community norms were rarely measured. Results indicate positive associations between malaria knowledge and attitudes, and preventive and care-seeking behaviour. Studies generally report high rates of correct knowledge, although it is comparatively lower among studies of high-risk groups. There does not appear to be sufficient extant evidence to determine the relationship between other psychosocial variables and behaviour.

CONCLUSIONS

The review highlights the need to deploy more consistent, comprehensive measures of psychosocial factors and the importance of reaching subpopulations at higher risk of transmission in low transmission contexts. Malaria-related knowledge is generally high, even in settings of low transmission. Programmes and research should work to better understand the psychosocial factors that have been positively associated with prevention and care-seeking behaviours, such as norms, perceived response efficacy, perceived self-efficacy, and interpersonal communication. These factors are not necessarily distinct from that which research has shown are important in settings of high malaria transmission. However, the importance of each factor and application to malaria behaviour change programming in low-transmission settings is an area in need of further research. Existing instruments and approaches are available to support more systematic collection of psychosocial determinants and improved sampling approaches and should be applied more widely. Finally, while human behaviour is critical, health systems strengthening, and structural interventions are essential to achieve malaria elimination goals.

Choice of health providers and health-seeking behaviour among forest goer population in Myanmar: findings from a cross-sectional household survey

BACKGROUND

In Myanmar, malaria still poses a significant burden for vulnerable populations particularly forest goers even though impressive progress has been made over the past decade. Limited evidence existed related to forest goers' health-seeking behaviour and factors that drive decision making for providers' choice to support national malaria programmes towards elimination. In response to that, this research is conducted to identify who they preferred and what are the factors associated with providers' choice in malaria febrile illness and Rapid Diagnostic Testing (RDT).

METHODS

A cross-sectional study applying quantitative household survey was completed with 479 forest goer households in 20 malaria endemic townships across Myanmar. The household data was collected with the types of providers that they consulted for recent and previous febrile episodes. To identify the factors associated with providers' choices, univariate and multivariate multinomial logistic regressions were done using Stata version 14.1. Statistical significance was set as p = 0.05.

RESULTS

A total of 307 individuals experienced fever within one month and 72.3% sought care from providers. Also, a total of 509 forest goers reported that they had a previous febrile episode and 62.6% received care from a provider. Furthermore, 56.2% said that they had RDT testing during these previous febrile illnesses. They consulted public facilities and public health staff, private facilities, private and semi-private providers, community health volunteers or workers in their residing village and those located outside their villages but majority preferred those within their villages. On multivariate analyses, second richest quintile (public, RRR = 12.9) (semi-private, RRR = 17.9), (outside, RRR = 8.4) and access to 4 and above nearby providers (public, RRR = 30.3) (semi-private, RRR = 1.5) (outside, RRR = 0.5) were found to be significantly associated with provider choice for recent fever episode. Similar findings were also found for previous febrile illness and RDT testing among forest goers.

CONCLUSIONS

It was highlighted in this study that in forest goer households, they preferred nearby providers and the decision to choose providers seemed to be influenced by their access to number of nearby providers and socio-economic status when they sought care from a provider regardless of fever occurrence location. It was important that the national programmes considere involving these nearby providers in elimination efforts.

Association between biological sex and insecticide-treated net use among household members in ethnic minority and internally displaced populations in eastern Myanmar

Malaria prevalence in Myanmar is highest among remote and ethnic minority populations living near forest fringes along the country’s international borders. Insecticide-treated nets (ITNs) are a key intervention used to prevent malaria transmission, but insufficient ITN availability and low use can hinder effectiveness. This study assessed age and sex disparities in ITN possession, access, and use among household members of ethnic minority and internally displaced populations in eastern Myanmar. Cross-sectional data from the 2013 Eastern Burma Retrospective Mortality Survey were used to describe prevalence of ITN possession, access, and use. The association between a household member’s biological sex and their ITN use was assessed using multilevel log binomial regression. Age and household ITN supply were tested as potential effect modifiers. Of 37927 household members, 89.8% (95% CI: 89.5, 90.1) of people lived in households with at least one ITN. Approximately half belonged to households with sufficient ITN supply and used an ITN. Pregnant women and children under five had the highest proportion of ITN use regardless of sufficient household ITN status. Female adults aged 15 to 49 years old (Risk ratio or RR: 1.4, 95% CI: 1.29, 1.52) were more likely to use ITNs. This relationship did not differ by sufficient household ITN status. The findings suggest that among ethnic minority populations in areas where ITN use is indicated, many households do not have adequate ITN supply, and many individuals are not using ITNs. Children under five and pregnant women appear to be prioritized for ITN use and overall, women are slightly more likely to use ITNs than men. This study’s findings can support efforts ensuring that all household members belonging to ethnic minority and displaced populations in Eastern Myanmar benefit from sufficient ITN access and use for malaria prevention.

Estimating malaria disease burden in the Asia-Pacific

Background: The Asia-Pacific aims to eliminate malaria by 2030. Many of the 22 endemic countries have earlier targets. To track progress towards elimination and predict timelines and funding required it is essential to have an accurate picture of the true burden of malaria over time. Estimating this is a major challenge with most countries having incomplete data on numbers of cases and wide variation between health system access and performance. Regular estimates are published by the World Health Organization (WHO), but these are not split by species, can have a wide range of uncertainty, change over time and are not available for every year. Methods: For the Asia Pacific Leaders Malaria Alliance, the burden of malaria for the 22 malaria-endemic countries in the Asia-Pacific from 2000 to 2015 was estimated by combining data submitted by countries to WHO with a systematic review to estimate the proportion of cases recorded. Due to a lack of suitable data, it was only possible to apply this method to 2013-2015. A simplified method was then derived to estimate the annual burden of falciparum and vivax malaria as inputs to a mathematical model to predict the cost of elimination, which is described elsewhere. Results: The total number of estimated cases was around double the number of confirmed cases reported in the Asia Pacific with a broad range of uncertainty around these estimates due primarily to sparsity of data with which to estimate proportions of cases reported. The ranges of estimated burdens were mostly like those published for countries by WHO, with some exceptions. Conclusions: The accuracy and precision of malaria burden estimates could be greatly improved by having more regular large surveys on access to healthcare in malaria-endemic areas and making subnational data on malaria incidence and reporting completeness publicly available.

Introducing post-discharge malaria chemoprevention (PMC) for management of severe anemia in Malawian children: a qualitative study of community health workers' perceptions and motivation

Background

Severe malarial anaemia is one of the leading causes of paediatric hospital admissions in Malawi. Post-discharge malaria chemoprevention (PMC) is the intermittent administration of full treatment courses of antimalarial to children recovering from severe anaemia and findings suggest that this intervention significantly reduces readmissions and deaths in these children. Community delivery of health interventions utilizing community health workers (CHWs) has been successful in some programmes and not very positive in others. In Malawi, there is an on-going cluster randomised trial that aims to find the optimum strategy for delivery of dihydroartemesinin-piperaquine (DHP) for PMC in children with severe anaemia. Our qualitative study aimed to explore the feasibility of utilizing CHWs also known as health surveillance assistants (HSAs) to remind caregivers to administer PMC medication in the existing Malawian health system.

Methods

Between December 2016 and March 2018, 20 individual in-depth-interviews (IDIs) and 2 focus group discussions (FGDs) were conducted with 39 HSAs who had the responsibility of conducting home visits to remind caregivers of children who were prescribed PMC medication in the trial. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were uploaded to NVIVO 11 and analysed using the thematic framework analysis method.

Results

Although intrinsic motivation was reportedly high, adherence to the required number of home visits was very poor with only 10 HSAs reporting full adherence. Positive factors for adherence were the knowledge and perception of the effectiveness of PMC and the recognition from the community as well as health system. Poor training, lack of supervision, high workload, as well as technical and structural difficulties; were reported barriers to adherence by the HSAs.

Conclusions

Post-discharge malaria chemoprevention with DHP is perceived as a positive approach to manage children recovering from severe anaemia by HSAs in Malawi. However, adherence to home visit reminders was very poor and the involvement of HSAs in a scale up of this intervention may pose a challenge in the existing Malawian health system.

Trial registration

ClinicalTrials.gov identifier NCT02721420. The trial was registered on 26 March 2016.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3791-5) contains supplementary material, which is available to authorized users.

Malaria elimination in remote communities requires integration of malaria control activities into general health care: an observational study and interrupted time series analysis in Myanmar

BACKGROUND

Community health workers (CHWs) can provide diagnosis and treatment of malaria in remote rural areas and are therefore key to the elimination of malaria. However, as incidence declines, uptake of their services could be compromised if they only treat malaria.

METHODS

We conducted a retrospective analysis of 571,286 malaria rapid diagnostic tests conducted between 2011 and 2016 by 1335 CHWs supported by Medical Action Myanmar. We assessed rates of decline in Plasmodium falciparum and Plasmodium vivax incidence and rapid diagnostic test (RDT) positivity rates using negative binomial mixed effects models. We investigated whether broadening the CHW remit to provide a basic health care (BHC) package was associated with a change in malaria blood examination rates.

RESULTS

Communities with CHWs providing malaria diagnosis and treatment experienced declines in P. falciparum and P. vivax malaria incidence of 70% (95% CI 66-73%) and 64% (59-68%) respectively each year of operation. RDT positivity rates declined similarly with declines of 70% (95% CI 66-73%) for P. falciparum and 65% (95% CI 61-69%) for P. vivax with each year of CHW operation. In four cohorts studied, adding a BHC package was associated with an immediate and sustained increase in blood examination rates (step-change rate ratios 2.3 (95% CI 2.0-2.6), 5.4 (95% CI 4.0-7.3), 1.7 (95% CI 1.4-2.1), and 1.1 (95% CI 1.0.1.3)).

CONCLUSIONS

CHWs have overseen dramatic declines in P. falciparum and P. vivax malaria in rural Myanmar. Expanding their remit to general health care has sustained community uptake of malaria services. In similar settings, expanding health services offered by CHWs beyond malaria testing and treatment can improve rural health care while ensuring continued progress towards the elimination of malaria.

Awareness of malaria and treatment-seeking behaviour among persons with acute undifferentiated fever in the endemic regions of Myanmar

Background

Myanmar has a high burden of malaria with two-third of the population at risk of malaria. One of the basic elements of the Roll Back Malaria Initiative to fight against malaria is early diagnosis and treatment within 24 h of fever. Public awareness about malaria is a key factor in malaria prevention and control and in improving treatment-seeking behaviour.

Methods

A large community-based survey was carried out in 27 townships of malaria endemic regions in Myanmar in 2015 which reported on the knowledge, behaviour and practices around malaria in the general population. We used the data already collected in this survey to assess (i) general public awareness of malaria and (ii) treatment-seeking behaviour and associated factors among persons with acute undifferentiated fever.

Results

A total of 6597 respondents from 6625 households were interviewed (response rate of 99.5%). About 85% of the respondents were aware that mosquito bite was the mode of transmission of malaria and 90% mentioned that malaria was preventable. However, only 16% of the respondents knew about anti-malaria drug resistance. There were certain misconceptions about the transmission of malaria such as dirty water, same blood group, sharing shelter, sleeping/eating together and poor hygiene. Health facility staff were the most common source of information about malaria (80%). Nearly one-fourth (23%) of the respondents with fever resorted to self-medication. Around 28% of the respondents with fever underwent blood testing, less than half of whom (44%) were tested within 24 h. Elderly age group, females, those with poor knowledge about malaria and those residing in non-Regional Artemisinin Resistance Initiative townships were associated with poor treatment-seeking behaviour in case of fever.

Conclusion

Although there is fair knowledge on mosquito bite as a mode of transmission and prevention of malaria, there are some misconceptions about transmission of malaria. Those having poor knowledge about malaria have poor treatment-seeking behaviour. A considerable number of respondents seek care from informal care providers and seek care late. Thus, there is a need to promote awareness about the role of early diagnosis and appropriate treatment and address misconceptions about transmission of malaria.

Mass drug administration and the sustainable control of schistosomiasis: Community health workers are vital for global elimination efforts

OBJECTIVES

Schistosomiasis control is centred on preventive chemotherapy through mass drug administration (MDA). However, endemic countries continue to struggle to attain target coverage rates and patient compliance. In the Philippines, barangay health workers (BHWs) play a vital role in the coordination of MDA, acting as advocates, implementers, and educators. The aim of this study was to determine whether BHW knowledge and attitudes towards schistosomiasis and MDA is sufficient and correlated with resident knowledge and drug compliance.

METHODS

A cross-sectional survey was conducted in 2015 among 2186 residents and 224 BHWs in the province of Northern Samar, the Philippines using a structured survey questionnaire.

RESULTS

BHWs showed good familiarity on how schistosomiasis is acquired and diagnosed. Nevertheless, both BHWs and residents had poor awareness of the signs and symptoms of schistosomiasis, disease prevention, and treatment options. There was no correlation between the knowledge scores of the BHWs and the residents (r=0.080, p=0.722). Kruskal-Wallis analysis revealed significant differences in BHW knowledge scores between the low (3.29, 95% confidence interval 3.16-3.36), moderate (3.61, 95% confidence interval 3.49-3.69), and high (4.05, 95% confidence interval 3.77-4.13) compliance village groups (p=0.002), with the high compliance areas having the highest mean knowledge scores.

CONCLUSIONS

This study highlights the importance of community health workers in obtaining the World Health Organization drug coverage rate of 75% and improving compliance with MDA in the community. Investing in the education of community health workers with appropriate disease-specific training is crucial if disease elimination is ultimately to be achieved.

A spatial agent-based model of Anopheles vagus for malaria epidemiology: examining the impact of vector control interventions

BACKGROUND

Malaria, being a mosquito-borne infectious disease, is still one of the most devastating global health issues. The malaria vector Anopheles vagus is widely distributed in Asia and a dominant vector in Bandarban, Bangladesh. However, despite its wide distribution, no agent based model (ABM) of An. vagus has yet been developed. Additionally, its response to combined vector control interventions has not been examined.

METHODS

A spatial ABM, denoted as ABM[Formula: see text], was designed and implemented based on the biological attributes of An. vagus by modifying an established, existing ABM of Anopheles gambiae. Environmental factors such as temperature and rainfall were incorporated into ABM[Formula: see text] using daily weather profiles. Real-life field data of Bandarban were used to generate landscapes which were used in the simulations. ABM[Formula: see text] was verified and validated using several standard techniques and against real-life field data. Using artificial landscapes, the individual and combined efficacies of existing vector control interventions are modeled, applied, and examined.

RESULTS

Simulated female abundance curves generated by ABM[Formula: see text] closely follow the patterns observed in the field. Due to the use of daily temperature and rainfall data, ABM[Formula: see text] was able to generate seasonal patterns for a particular area. When two interventions were applied with parameters set to mid-ranges, ITNs/LLINs with IRS produced better results compared to the other cases. Moreover, any intervention combined with ITNs/LLINs yielded better results. Not surprisingly, three interventions applied in combination generate best results compared to any two interventions applied in combination.

CONCLUSIONS

Output of ABM[Formula: see text] showed high sensitivity to real-life field data of the environmental factors and the landscape of a particular area. Hence, it is recommended to use the model for a given area in connection to its local field data. For applying combined interventions, three interventions altogether are highly recommended whenever possible. It is also suggested that ITNs/LLINs with IRS can be applied when three interventions are not available.

Increasing family planning in Myanmar: the role of the private sector and social franchise programs

Background

This study examines the influence of clinical social franchise program on modern contraceptive use.

Methods

This was a cross-sectional survey of contraceptive use among 2390 currently married women across 25 townships in Myanmar in 2014. Social franchise program measures were from programmatic records.

Results

Multivariable models show that women who lived in communities with at least 1-5 years of a clinical social franchise intrauterine device (IUD) program had 4.770 higher odds of using a modern contraceptive method compared to women living in communities with no IUD program [CI: 3.739-6.084]. Townships where the reproductive health program had existed for at least 10 years had 1.428 higher odds of reporting modern method use compared to women living in townships where the programs had existed for less than 10 years [CI: 1.016-2.008].

Conclusions

This study found consistent and robust evidence for an increase in family planning methods over program duration as well as intensity of social franchise programs.

Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review

BACKGROUND

Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM).

METHODS

This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review.

RESULTS

A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges.

CONCLUSIONS

Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.

Malaria incidence in Myanmar 2005-2014: steady but fragile progress towards elimination

Background

There has been an impressive recent reduction in the global incidence of malaria, but the development of artemisinin resistance in the Greater Mekong Region threatens this progress. Increasing artemisinin resistance is particularly important in Myanmar, as it is the country in the Greater Mekong Region with the greatest malaria burden. If malaria is to be eliminated in the region, it is essential to define the spatial and temporal epidemiology of the disease in Myanmar to inform control strategies optimally.

Results

Between the years 2005 and 2014 there was an 81.1 % decline in the reported annual incidence of malaria in Myanmar (1341.8 cases per 100,000 population to 253.3 cases per 100,000 population). In the same period, there was a 93.5 % decline in reported annual mortality from malaria (3.79 deaths per 100,000 population to 0.25 deaths per 100,000 population) and a 87.2 % decline in the proportion of hospitalizations due to malaria (7.8 to 1.0 %). Chin State had the highest reported malaria incidence and mortality at the end of the study period, although socio-economic and geographical factors appear a more likely explanation for this finding than artemisinin resistance. The reduced malaria burden coincided with significant upscaling of disease control measures by the national government with support from international partners. These programmes included the training and deployment of over 40,000 community health care workers, the coverage of over 60 % of the at-risk population with insecticide-treated bed nets and significant efforts to improve access to artemesinin-based combination treatment. Beyond these malaria-specific programmes, increased general investment in the health sector, changing population demographics and deforestation are also likely to have contributed to the decline in malaria incidence seen over this time.

Conclusions

There has been a dramatic fall in the burden of malaria in Myanmar since 2005. However, with the rise of artemisinin resistance, continued political, financial and scientific commitment is required if the ambitious goal of malaria elimination in the country is to be realized.

Rural and urban disparities in health-seeking for fever in Myanmar: findings from a probability-based household survey

Background

The World Health Organization (WHO) recognizes Myanmar as having the highest burden of malaria in the Greater Mekong Sub-region (GMS). Early diagnosis and proper treatment are critical in containing malaria. The objective of this study was to assess determinants of seeking treatment for fever from trained providers across rural and urban areas in Eastern Myanmar.

Methods

A cross-sectional survey was conducted during the high malaria seasons in the eastern part Myanmar between August and September 2014. Multi-staged cluster sampling was used to sample households. A series of questions related to treatment-seeking for fever were asked. Bivariate and multivariate logistic regressions were conducted to identify independent correlates of seeking treatment for fever from trained providers.

Results

The analysis was restricted to 637 participants who reported either themselves or their family members having had fever 2 weeks prior to the interview. In the multivariate analysis, rural residents were less likely to have sought treatment from trained providers (AOR = 0.60, 95 % CI 0.42–0.88; p = 0.01) while residents who had fever patients between the ages of 5 and 14 years (AOR = 1.60, 95 % CI 0.90–2.53; p = 0.05); and those who knew that sleeping under bed nets can prevent malaria (AOR = 2.08, 95 % CI 1.00–4.30; p = 0.05); were borderline more likely to have sought treatment.

Conclusion

This study suggests that rural populations need improved access to trained providers. Additionally, future programmes should focus on increasing knowledge around malaria prevention and treatment.

Tackling malaria, village by village: a report on a concerted information intervention by medical students and the community in Mifumi, Eastern Uganda

BACKGROUND

Can an information intervention facilitated by information technology and carried out by an interdisciplinary team comprising medical students, technical experts, and the community itself make a positive contribution in reducing the burden of malaria at the village level? In Mifumi village in Eastern Uganda, MIFUMI Project, Makerere University College of Health Sciences Community Based Education and Service program (COBES), and the U.S. National Library of Medicine carried out a series of activities between 2007 and 2010.

METHODS

The team surveyed the community's knowledge of malaria prevention and treatment; implemented a health information intervention using tutorials in a variety of media; and observed the community's use of previously distributed insecticide treated nets (ITNs) using a digital pen application.

RESULTS

As a result of concerted education and outreach, the village residents have a good understanding of malaria prevention and treatment seeking behaviors. Leveraging the power of information technology and interdisciplinary teamwork, medical students and the denizens of a rural community were able to engage in an interactive experience of health education and promotion.

CONCLUSION

Preliminary observations suggest that a health information intervention in concert with a collaborative community effort of education and prevention can build capacity within a community to take control of its own health.

Human resources for health: task shifting to promote basic health service delivery among internally displaced people in ethnic health program service areas in eastern Burma/Myanmar

Background

Burma/Myanmar was controlled by a military regime for over 50 years. Many basic social and protection services have been neglected, specifically in the ethnic areas. Development in these areas was led by the ethnic non-state actors to ensure care and the availability of health services for the communities living in the border ethnic-controlled areas. Political changes in Burma/Myanmar have been ongoing since the end of 2010. Given the ethnic diversity of Burma/Myanmar, many challenges in ensuring health service coverage among all ethnic groups lie ahead.

Methods

A case study method was used to document how existing human resources for health (HRH) reach the vulnerable population in the ethnic health organizations’ (EHOs) and community-based organizations’ (CBHOs) service areas, and their related information on training and services delivered. Mixed methods were used. Survey data on HRH, service provision, and training were collected from clinic-in-charges in 110 clinics in 14 Karen/Kayin townships through a rapid-mapping exercise. We also reviewed 7 organizational and policy documents and conducted 10 interviews and discussions with clinic-in-charges.

Findings

Despite the lack of skilled medical professionals, the EHOs and CBHOs have been serving the population along the border through task shifting to less specialized health workers. Clinics and mobile teams work in partnership, focusing on primary care with some aspects of secondary care. The rapid-mapping exercise showed that the aggregate HRH density in Karen/Kayin state is 2.8 per 1,000 population. Every mobile team has 1.8 health workers per 1,000 population, whereas each clinic has between 2.5 and 3.9 health workers per 1,000 population. By reorganizing and training the workforce with a rigorous and up-to-date curriculum, EHOs and CBHOs present a viable solution for improving health service coverage to the underserved population.

Conclusion

Despite the chronic conflict in Burma/Myanmar, this report provides evidence of the substantive system of health care provision and access in the Karen/Kayin State over the past 20 years. It underscores the climate of vulnerability of the EHOs and CBHOs due to lack of regional and international understanding of the political complexities in Burma/Myanmar. As Association of Southeast Asian Nations (ASEAN) integration gathers pace, this case study highlights potential issues relating to migration and health access. The case also documents the challenge of integrating indigenous and/or cross-border health systems, with the ongoing risk of deepening ethnic conflicts in Burma/Myanmar as the peace process is negotiated.