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In
spite of the significant success of national malaria programmes,
several challenges remain to be addressed to further consolidate results.
Many meetings, reports and publications; undertaken with representatives of
national malaria programmes and partners; have
acknowledged progress made in malaria control and have identified the
following remaining issues yet to be addressed in the GMS:
 The
continuous technical and financial support, provided to national programmes and research institutions to monitor
therapeutic efficacy of antimalarial drugs in
sentinel sites, has helped to map falciparum
resistance trends in the GMS (see Mekong
profile) and identify hot spots where falciparum is
less susceptible to, or tolerant of, ACTs and artemisinin derivatives.
The border area between Cambodia
and Thailand
remains the epicentre of emerging malaria drug
resistance, showing increasing failure rate of P. falciparum
to artemisinin-based combination therapies (ACT)
and artemisinins. That situation has recently triggered
Member States and partners to progressively
set up and implement a Mekong Malaria MDR (Multi-drug Resistance) Strategy,
starting at the Thai-Cambodian border, and includes immediate preventive and
curative measures and operational research projects.
Increasing attention has been paid to
quality malaria diagnosis either through the use of quality rapid tests in
villages or quality microscopy in health care facilities. With the support of
the WHO’s Western Pacific Regional Office (WPRO) and partners, quality
assurance systems have been set up to identify substandard Rapid Diagnostic
Tests (RDTs). Suitable solutions, like cooler
boxes, have also been validated for storing rapid tests in an un-degraded
state even in the most remote areas. An accreditation system of technicians
in microscopy, supported by WHO, is currently implemented in almost all Mekong countries. In the context of a declining malaria
burden, clinical algorithms to manage febrile diseases at the peripheral
level are under review.
The
increasing production, circulation and use of counterfeit and substandard
drugs have been systematically documented by various programmes
and partners, leading to recent international operations to shut down
counterfeiters and boost national efforts to track substandard drugs and
enforce regulations. Building evidence and advocating continuous high level
regional action to identify counterfeiters will continue, as will support to
increase the capacity of national departments like the Food and Drug
Administration (FDA), to systematically address the challenge in coordination
with neighboring countries. Network of laboratories and experts will assist
national authorities to set standards, provide training opportunities and
raise awareness in this critical domain.
Through
regular meetings, the MMP has encouraged the development of and support for
cross border initiatives and actions. The containment of malaria multi-drug
resistance in the GMS is making progress on the Thai-Cambodian border and
should be expanded in the whole subregion and
beyond.
The
Mekong Malaria Programme is also critically looking at cost-effective
preventive measures against malaria, especially in forested areas where
traditional tools like insecticide-treated bednets
(ITNs) or long-lasting insecticide treated nets (LLINs) seem to be inefficient or unsuitable. The growing
importance of secondary vectors and adaptation of existing vectors, like
Anopheles minimus, to a rapidly changing
environment has to be better investigated and supported by MMP. Innovative
preventive approaches should be explored and validated, including perhaps the
use of stand-by malaria diagnosis and treatment for those temporarily working
in remote, hard-to reach locations. Also to be considered by the Mekong
Malaria Programme is the monitoring and mapping of vector resistance to
insecticides used in the region. Since counterfeit and substandard
insecticides are also on the increase, the Mekong
framework should consider extra effort in this area.
MMP
has also contributed to adjust, implement and validate Behavioral Change
Communication (BCC) strategies in far remote or hard-to-reach populations and
in migrants who are the most at risk / neglected population in the GMS. These
strategies are now fully part of national malaria control strategies and
scaled up as part of the Global Fund to Fight AIDS, Tuberculosis and Malaria
(GFATM) grants. Cultural barriers are better addressed and advocacy for a
substantial increase of health care coverage in such remote populations is
under way.
The
Mekong Malaria Programme, together with the ministry of health and other
partners, fine-tune and strengthen the routine Mekong
malaria surveillance and monitoring indicators. This means the development
and use of standardized methodologies, including household surveys models, to
be implemented across countries by all concerned parties. That system is
eventually expected to reflect the actual disease burden by age groups,
gender and occupational categories of population at risk. In some countries
or areas, as a result of successful malaria control activities, a
pre-elimination programme could be envisaged to be
set up with increasing attention to consolidating or reorienting successful
operations and strengthening the national surveillance system across public
and private health care facilities. A strong building capacity component is
required in this critical area.
Capacity
building is an essential component of the Mekong Malaria Programme to ensure
ownership and sustainable actions and results. In consultation with the Asian
Collaborative Training Network for Malaria (ACTMal)
and national / regional academic institutions, MMP encourages the development
of revised training packages in light of new Mekong
malaria challenges and objectives.
Last
but not least, MMP is supporting the development and implementation of a
Mekong Operational field research agenda. Operational research activities are
essential to assess and monitor the impact of traditionally recognized
interventions against planned targets and to validate innovative preventive
and curative interventions in the Mekong
context. Particular attention is given to new diagnostic tools, new combinations
of antimalarials and innovative vector control
measures.
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