Total Health System Malaria Surveillance

By M. James Eliades, PSI Asia Malaria Elimination Director 2017  -2019

Malaria has evolved. In countries where malaria is prevalent, overuse of the most common malaria-combating drugs–artemisinin-based combination therapies–has resulted in a drug-resistant strain of plasmodium falciparum, the parasite that causes malaria. This strain threatens to reverse the progress that has been made to reduce malaria and hinders our ability to eliminate the parasite. From 2015 to 2019, PSI supported governments in the Greater Mekong Sub-region (GMS) to eliminate the parasite by engaging key players in the fight against malaria: private sector healthcare providers.

The threat posed by artemisinin resistance has prompted four countries in the GMS to take direct action. Cambodia, Laos, Myanmar, and Vietnam have set the goal of eliminating P. falciparum by 2025. However, elimination is impossible without tracking infections. PSI has been operating in the GMS since 1995 and has firsthand experience surrounding the need for sophisticated malaria surveillance. From 2015 to 2019, PSI led the Bill & Melinda Gates Foundation-funded “GMS Elimination of Malaria through Surveillance” (GEMS) project across all four countries mentioned above. As part of their strategy, PSI chose to engage a diverse cross-section of formal and non-formal private sector providers to deliver quality malaria case management and reporting to national surveillance systems. This effort supported the four national malaria programs (NMP) and all three core pillars of the WHO’s malaria elimination framework: 1) universal access to prevention, diagnosis and treatment, and 2) accelerating elimination efforts and 3) transforming malaria surveillance into a core intervention.

An estimated 40% to 70% of people in the GMS first seek private sector care when presenting with the tell-tale fever that can indicate a malarial infection — making private sector providers the first line of defense. However, engaging these key players has proved challenging in many countries because the private sector encompasses such a diverse range of operators, from registered clinic-based doctors, to traditional healers, to village grocery store clerks. There has been no singular effective channel of communication to support all of them at once.

Meanwhile, limitations on human and financial resources disincentivize Ministries of Health (MOH) in the GMS to actively engage in malaria surveillance. According to an unpublished report from HANSEP, there is also a fear that this kind of engagement will validate questionable private sector practices, rendering the MOH potentially accountable for their outcomes. It is considered beyond the reasonable scope of a MOH to enforce regulations and monitor quality among private providers. Therefore, resources for training, supportive supervision and supplying drugs and diagnostic tests are prioritized for the public sector. In addition, there are many pre-conceived notions about private sector providers, primarily that they are motivated by money, and are therefore not reliable partners as business from malaria declines.

Given the need for malaria surveillance resources and the challenges presented by these dynamics, PSI, through the GEMS project, set out to demonstrate private sector effectiveness and test preconceived notions about Ministries of Health. Thanks to PSI’s twelve collective years of experience working across Cambodia, Laos, Myanmar, and Vietnam when the project started in 2017, the project had a solid foundation upon which to develop trust for information gathering for private sector providers and host governments.

Project results showed that:

  • Private sector providers detected, treated, and reported between 5% to 40% of national caseloads annually, with many cases coming from poor, peripheral, high-risk communities
  • Reporting rates improved and the quality of case management increased throughout the project
  • A provider survey demonstrated that private sector providers were motivated by helping their communities and contributing to a larger goal—not just financial gain

In addition to gathering information, PSI gave direct support to the private sector to build capacity for malaria surveillance. The GEMS project worked with providers to demonstrate, then scale up, their capacity to:

For example, by 2017 PSI had supported over 22,000 private sector healthcare providers in Myanmar, largely composed of non-formal players such as itinerant drug vendors and drug shop owners. In Laos, public and private sector providers now report directly into the national DHIS2-based health management information system.

The GEMS project shows what strategies are possible when funding is provided to support private sector healthcare. Because of limitations on human resources at the national level, that funding is most likely to first come through international organizations. The outcomes discussed here offer a learning tool for NMPs, which can benefit from GEMS’ experience and adopt components from the project that fit their needs and available resources. It also empowers these programs to advocate for additional support to take the lead on such activities themselves. While GEMS’ work centered in elimination settings, the strategies therein can also serve as guidance for those working in high-burden countries (HBC), particularly those where a very high proportion of people seek care in the private sector, like Nigeria, the Democratic Republic of the Congo and India.

HBCs must increase private sector engagement now if they hope to eventually transition from control to elimination.  Early and strategic involvement will be crucial. In some countries, it may make sense to begin with private providers who are already accredited, while in others it may be better to target providers in hard-to-reach locations that lack public sector access. Private sector providers need regular support, just as public sector providers do. The best course of action may be to decentralize the elements of support to sub-national health teams. Whichever strategies are taken, a total health system approach will be needed to shorten the time it takes to move across the elimination continuum. Success is unlikely unless the public and private healthcare sectors effectively align resources and efforts to combat malaria as a combined force.

Banner image credit: (c)PSI/Emily Carter

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