By Kemi Tesfazghi, GEMS Program Director, PSI
Even as the world grapples with a pandemic, malaria presents a threat that cannot be ignored: increasing resistance to treatment. Staying the course on malaria elimination today means preventing tomorrow’s global health crisis. And treating malaria effectively means going where the patients are.
In the Greater Mekong Subregion (GMS) 40-78% of the population first seek health care in the private sector. To achieve malaria elimination, we need sustained private sector engagement.
PSI witnessed this trend from 2015 to 2019 while leading the Bill & Melinda Gates Foundation-funded GMS Elimination of Malaria through Surveillance (GEMS) project across Cambodia, Laos, Myanmar and Vietnam. In those four years, a total of 3.4 million malaria tests were conducted and about 99,000 malaria cases were detected and treated in the private sector. In 2019 alone, the project supported over 5,000 private providers and detected up to 18% of the national caseloads across the four countries. Since 2015, the GEMS project has also supported increased access to quality case management in the private sector in Cambodia, Laos, Myanmar and Vietnam, where oversight of the private sector is limited.
Often, malaria cases identified in the private sector go unreported or unrecognized by the national health systems.
In a malaria elimination context, every case counts and every case must be tested and treated. And when transmission levels get low enough, cases must be investigated and receive follow up—irrespective of whether that case is detected in the public or private sector.
There is good news. Over the past decade, countries of the GMS have achieved reductions in malaria incidence. For example, Myanmar experienced a fall in cases from 182,000 cases in 2015 to approximately 75,000 cases in 2018. With the decline in cases and an increasingly focal pattern of transmission, there is now a unique window of opportunity for national malaria programs (NMPs) to take ownership of engaging the private sector to achieve malaria elimination.
PSI will be there to help make this happen. PSI has received a follow-on investment to GEMS from the Gates Foundation. The primary objective of “GEMS+” will be to support NMPs in the four aforementioned GMS countries to integrate private sector engagement into their malaria elimination strategy, surveillance systems, planning and management structures.
GEMS+ represents an ambitious, ground-breaking investment at the end of which implementing malaria private sector programs will be transitioned to government oversight. It is anticipated that at the end of GEMS+, NMPs will be equipped to manage a refined network of private providers who have been trained and supervised to provide quality malaria case management and report malaria cases into the national surveillance systems.
To transition this network to government ownership by 2023, GEMS+ will work with NMPs to refine the number of private providers. The sheer size of the PSI-supported private sector network (21,361 in four countries at its peak in 2017) makes oversight by the public sector unrealistic and reliance on external donor funding unsustainable. This will be accomplished by working with NMPs using epidemiological data reflected national malaria stratification and health-seeking behavior data to identify areas where it’s rational for private providers to operate. Furthermore, PSI will work with NMPs to adapt private sector support models to a level that is feasible for NMPs, while maintaining the quality of care provided.
Finally, PSI will work with NMPs in each country to develop comprehensive private sector engagement strategies. This will be achieved by reviewing evidence from GEMS, GEMS+ and other sources to identify opportunities that present the greatest likelihood of success. GEMS+ will work with NMPs to develop Standard Operating Procedures (SOPs) and tools that can be sustained through government activities, prioritized in domestic funding and future Global Fund applications, or by other third-party funders.
The ultimate measure of the project’s success will be the integration of private sector networks into government systems and structures. Beyond having approved policies, strategies, SOPs and tools, success will be measured by the level of resources that the government dedicates to the private sector and the percentage of the active private sector network that is routinely managed by the government.
We anticipate that the outcome of this investment will look different in each of the four countries, along a spectrum of possibilities. At one end of the spectrum is a restriction on the type of services provided, or the type of private provider able to offer malaria case management. The other extreme is the government adopting a detailed private sector strategy as part of their work plan and national budget, with SOPs and staff dedicated to supporting quality case management to the existing private sector network at the same level of support that PSI currently provides.
Wherever each of the four countries falls on the spectrum, the GEMS+ commitment is to ensure that the government recognizes the private sector. Private sector providers are an essential component of national health systems. We hope Ministries of Health will increasingly include and support private sector providers in an evidence-based way to achieve the national objective of malaria elimination. Now, more than ever, these partners are critical to success.