Effectiveness of an expanded role for community health workers on malaria blood examination rates in malaria elimination settings in Myanmar: an open stepped-wedge, cluster-randomised controlled trial

Background: As Greater Mekong Subregion countries approach malaria elimination, the motivation and social role of community health workers (CHWs), and malaria blood examination rates, have declined in parallel with decreasing malaria burden. To address this issue, a health system model which expanded the role for CHWs was co-designed with communities and health stakeholders in the Mekong Subregion and field-tested in Myanmar.

Methods: An open stepped-wedge cluster-randomised (at the village-level) controlled trial (ClinicalTrials.govNCT04695886) was conducted in 72 villages in Myanmar from Nov 1, 2021 to April 17, 2022 to evaluate the effectiveness and cost-effectiveness of the expanded CHW model. One-off and continuous implementation costs of the models were calculated.

Findings: A total of 2886 malaria rapid diagnostic tests (RDTs) (control period: 1365; intervention period: 1521) were undertaken across 72 villages during the 24-week study period. Compared to the existing CHW model, the introduction of an expanded role for CHWs resulted in a 23% relative increase in village weekly malaria blood examination rates by RDT, the primary outcome, (adjusted incidence rate ratio (AIRR) = 1.23, 95% CI = 1.01, 1.50, p = 0.036), adjusting for time and season. A 3.3-fold relative increase in village weekly referral rate of dengue, tuberculosis, diarrhoea, or RDT-negative fever cases after the introduction of the expanded CHW model (AIRR = 3.17, 95% CI = 1.23, 8.18, p = 0.017), was also observed. The total cost per CHW per five-year period was US$14,794 for the expanded CHW model and $5816 for the existing CHW model.

Interpretation: An expanded CHW model, co-designed with communities and health stakeholders, can increase malaria blood examination rates in malaria elimination settings and referral rates for other infectious diseases. Expanded CHW models will facilitate maintaining annual blood examination rates required for malaria elimination accreditation by the WHO.

Funding: An International Multilateral Donor (QSE-M-UNOPS-BI-20864-007-40).