Greater Mekong Subregion multicountry grant to eliminate malaria focuses on artemisinin resistance

Shobha Shukla and Bobby Ramakant
(First published in Aidspan on April 16, 2019)

Civil society’s role is crucial in hard to reach areas, and needs strengthening

This year’s World Malaria Day theme, “Zero Malaria Starts With Me,” re-energizes the fight to eliminate malaria, which, though preventable and treatable, still kills more than half a million people every year.

While major progress has been made against the disease in the past 15 years (with over 7 million malaria deaths averted and about a 40% reduction in malaria cases globally), the fight against malaria is approaching a negative tipping point - progress has slowed down in some parts of the world and has reversed in a few. One major challenge impeding malaria elimination is the emergence of drug-resistant malaria in the Greater Mekong Subregion (GMS), especially in Thailand, Cambodia, Myanmar, Laos and Vietnam.

Second Southeast-Asian regional grant to accelerate progress on malaria elimination

In 2013, in response to the emergence of drug-resistant malaria in the GMS, the Global Fund launched the Regional Artemisinin-resistance Initiative (RAI), which spanned 2013 to 2017. From 2018, a second phase of RAI was launched, the Regional Artemisinin Resistance Initiative towards Elimination of Malaria (RAI2E), a $243-million multicountry grant to accelerate elimination of Plasmodium falciparum malaria in the GMS over a three-year period (2018-2020). Of this amount, Thailand received $23 million, Myanmar $97 million, Cambodia $43 million, Laos $13 million, Vietnam $33 million, with $34 million dedicated to a regional component that focuses on ensuring malaria service coverage for remote populations in border areas.

Alistair Shaw, Senior Program Officer of the Raks Thai Foundation, which is a sub-recipient of the Global Fund RAI2E grant, said that RAI2E is the biggest regional grant from the Global Fund across the five GMS countries, and may be the first time a Global Fund grant is split 50:50 between civil society and government. [Editor’s note: the Global Fund confirmed that RAI2E is the biggest multicountry grant in the Fund’s portfolio in terms of dollar value; the GFO was not able to confirm Shaw’s assertion about the grant ‘split’ by the time of publication.]

Thailand’s Minister of Public Health, Professor Piyasakol Sakolsatayadorn, said: “This area is the epicentre of drug-resistant malaria, which could become a global health threat if we cannot manage and eliminate drug-resistant malaria in Thailand and the GMS.”

Thailand’s National Malaria Elimination Strategy was endorsed in 2016 with the elimination goal of 2024. Since then, malaria morbidity and mortality have continued to decline in Thailand, with new malaria cases dropping by 39% from 2016 to 2017 and by 51% from 2017 to 2018.

Sakolsatayadorn reaffirmed the country's target date for ending local transmission (within Thai borders) by 2024, and Thailand’s commitment to the regional effort: In 2014, 23 Asia-Pacific heads of government committed to eliminate malaria in this region by 2030, which is in line with Sustainable Development Goal 3.

Thailand is chair of the Association of Southeast Asian Nations (ASEAN) and is hosting Malaria Week from 22 to 25 April 2019 in Bangkok. The Global Fund is among the partners of this year’s Malaria Week, which focuses on eliminating malaria in Asia and the Pacific by 2030.

Drug-resistant malaria: a threat?

Shaw says that this regional project is of global significance because if drug resistance spreads beyond the Greater Mekong Subregion, it will have a devastating impact on countries with a high malaria burden.

Historically, the GMS has been the epicentre of antimalarial drug resistance. Forty to forty-five years ago, chloroquine resistance started in this region and spread globally; now, fears about the resurgence of malaria are because of artemisinin resistance.

But science is inconclusive about whether the spread of drug resistance is a risk. “It is mostly the asymptomatic patients that carry gametocytes [cells in Plasmodium falciparum that specialize in the transition between the human and the mosquito host]. In Thailand, less than 5% of patients have gametocytes that can transmit to the next mosquito cycle. There is no strong evidence so far whether a person who has drug-resistant malaria can transmit it to the mosquito and the mosquito carrying that phenotype [could] transmit it to another person,” says Professor Jetsumon Sattabongkot Prachumsri, who is the Director of Mahidol Vivax Research Unit (MVRU), Faculty of Tropical Medicine, Mahidol University in Thailand.

Dr Tim France, a global health expert partly based in Thailand, said: “At present there is much that we do not understand about malarial drug resistance, and we do know we are in a very active learning period. But whether drug resistance is spreading or occurring de novo, the conclusions and essential actions [need to] remain the same.”

Civil society plays key role in creating malaria-resilient communities

Under the RAI2E grant, six civil society organizations (CSOs) are working in 14 provinces across Thailand, which also cover Thai border areas with Myanmar, Malaysia, Laos and Cambodia. In 2018, CSOs conducted health-education sessions for over 70,000 people in very hard-to-reach communities and worksites (formal and informal) - most of them on Thai borders. These sessions provided information on malaria prevention and support for testing and treatment. CSOs have also distributed 75-80% of all bed nets in Thailand.

Shaw explained: “Our role has been to create malaria-resilient communities that can themselves identify malaria, and can respond to it through different mechanisms that have been set up and links that have been made to health services. We have also made strong relationships with local government officers to conduct mobile testing and prevention education in vulnerable populations.”

These vulnerable populations mainly include mobile migrant populations (MMPs) from Cambodia, Vietnam, Laos and Myanmar, as well as Thai ethnic-minority communities who are mobile or traveling through forests or across borders for short-term work. MMPs are not accessing conventional health services, so CSOs, in partnership with the Thai government, are zeroing in on communities in malaria transmission sites.

“Our work is to extend the reach of the government services to communities that are located far from local government health services and do not feel comfortable, or are unable, to access a conventional health service,” Shaw says.

Ensuring access to malaria services for populations most in need

Shreehari Acharya, Project Manager with the Regional Malaria CSO Platform, rues that while in the first RAI grant there were many malaria test-and-treat posts within a kilometer or two from the border (most of which is forested), in RAI2E their number has been reduced. “This is fine for those areas where there is no malaria anymore. But the removal of some of these posts, especially in areas where government health centres are far from the community, has made access to health services difficult.” This is aggravated in some malaria high-risk border areas where there is no internet access, no mobile network, and/or no public transport.

Other barriers to healthcare that MMPs face include a language barrier and the absence of legal documents. “They are still not comfortable to go straight to a health facility,” Acharya says. “They need someone they can trust, and who speaks their language, to accompany them to the health facility.”

To help address these challenges, the Global Fund is encouraging countries to put their resources into high-risk zones and to focus on hard-to-reach populations. Acharya agrees: “Thailand needs to put extra resources in areas where there are high number of malaria cases and not assume that central health centres will provide services to all in their surrounding areas.”

As CSO volunteers are not allowed to test and treat malaria in Thailand, they depend on government staff to go with them to forests or farms to provide these services to high-risk populations. But government health facilities are at times understaffed, which poses a challenge. Both Alistair Shaw and Shreehari Acharya believe that this restriction on services provided by CSO volunteers should change, for hard-to-reach communities in Thailand, and that CSOs are perhaps best placed to provide malaria control within the reach of these communities.

“Either CSO volunteers or someone trained in their community should be able to test and treat malaria. Most malaria cases except those in pregnant women or severe advanced cases, can perhaps be tested and managed by trained community volunteers at village level,” said Acharya.

Shaw agrees: “What is missing is a strong community-based initiative as part of RAI2E. While the role of CSOs is to create resilient communities that can identify and respond to malaria as and when it occurs, if communities are not provided with the tools and are not empowered, they cannot become resilient.”

In addition, Acharya says, volunteers sometimes follow up malaria cases 20km or 30km away, yet “they are reimbursed [only] a flat incentive for their travel cost, which is not fair,” she says.

Risk of malaria re-emergence if surveillance goes down

On World Malaria Day 2018, Thailand declared 35 provinces (out of a total of 76) malaria-free. However, as Thailand moves towards malaria elimination, the perception of risk among the general population is decreasing. On the one hand, communities are being told that they are at risk of malaria, while on the other hand, they are seeing very few malaria cases.

Professor Prachumsri cautions: “As malaria cases decline, people’s awareness also declines, especially in areas that were malaria endemic in the past.”

As Thailand and other nations accelerate their efforts to end malaria, surveillance is the lynchpin in stopping malaria’s re-emergence, according to Shaw. “We need to maintain our presence in all areas where malaria has already been eliminated to prevent reintroduction,” he cautions.

Acharya agrees: “Surveillance becomes more important as we move towards elimination because we need to know where the case is, where it is coming from and what the history is of that case. The [importance of] civil society’s role in surveillance also needs to be recognized and outlined by the government, so that together we can end malaria.”

Shobha Shukla and Bobby Ramakant
Citizen News Service - CNS
23 April 2019