Questions/Answers

Malaria is an important public health issue of Thailand due to the increasing threat of multi-drug resistance malaria in the GMS. Malaria is largely confined to forest-fringe, border and remote and hard to reach areas with poor access to routine public health interventions; affecting largely indigenous populations, ethnic minorities and migrants. These populations, when suspected to be infected with malaria, have to travel long-hours, often with no road access, to the hospital or nearest public health facility. This can result in not just delayed diagnosis and treatment for malaria but also possibly death. Migrant workers, non-registered migrants, and those that cross the borders daily from neighboring countries contributed 47% of cases (over 2012-2017) detected from Malaria Posts. Apart from social and legal barriers to accessing health services at public hospitals, these migrants also face financial barriers for those without health insurance coverage. The malaria post (MP) was established at the community level to reduce the malaria burden and improve coverage and accessibility to early diagnosis and prompt treatment among all populations at risk of malaria by providing malaria services without cost to patients. MP worker is selected by the community members to ensure acceptance and works from their home to provide malaria diagnosis and treatment services. They are supervised by district/provincial health offices who also provide training using standardized operating procedures. The challenge of this initiative is ensuring and maintaining the quality of malaria services of MPs according to Ministry of Public Health standards for community health workers. A key success of this initiative is improving accessibility to community-based malaria services for vulnerable populations through strong partnership among communities, government offices and other stakeholders, making this a sustainable intervention towards achieving malaria elimination in Thailand.

Malaria is a curable disease, therefore, having the access to timely diagnosis and prompt treatment can save lives. Malaria is still an important public health issue in Thailand due to the increasing threat of multi-drug resistance malaria in the GMS. Malaria is largely confined to forest-fringe, remote and hard to reach area with poor infrastructure and insufficient health services, and along the border affecting vulnerable populations at risk for malaria, indigenous populations, ethnic minorities, occupational migrants. The objectives of the MP were: 1. To reduce the malaria burden (malaria morbidity and mortality rates) among the target population in the high malarious areas by working through home and community based provision of early diagnosis and prompt treatment for malaria under the support of the local health sector and local administrative organizations 2. To ensure maximum coverage and improved access to malaria services for of both Thai and migrants’ (registered and unregistered) and daily border crossers from neighboring countries. The MPs reduced travel time and transportation cost for these populations, provided diagnosis and treatment without cost, and for the migrant populations, was a measure to overcome additional social and legal barriers in accessing health services at public hospitals.

Inclusiveness. At its initiation in 2004, MPs were operating in 300 villages in 9 provinces. This expanded over time to cover 501 villages in 27 provinces by 2017. Between 2012-2017, MP workers screened (tested) a total of 434,675 people and diagnosed 27,013 with malaria (47% of cases among migrants). In comparison, public health hospitals throughout the country detected 20% of malaria among migrants over the same period. MPs also distributed free of charge, one Long lasting insecticide treated bed net (LLIN) to each unregistered migrant diagnosed with malaria (27% of migrant cases were provided with this service over 2012-2017). Partnerships. The programme has shown that community-based malaria posts increases access among target populations and also raise awareness to help people protect themselves from infection. MPs also raised awareness and built relationships between the official system and the migrant community through networks of Migrant Liaison Officers (MLO) and Migrant Volunteers (MV). In some areas of conflict-affected in southern Thailand, community-based malaria activities through MP have managed to deliver malaria services in conflict-effected villages encouraging community ownership and partnership in malaria prevention and control at grass roots level, promoting sustainability of the program and self-reliance of the community.

The National SDGs committee, chaired by the Prime Minister, has highlighted 30 priority goals of which Goal 3.3 addressed ending epidemics of AIDS, tuberculosis, malaria by 2030. This is reflected in the National Malaria Elimination Strategy 2017-2026: Strategy 1: To accelerate malaria elimination through quality and comprehensive case management service, where service delivery through MPs is a critical component. To minimize resources and maximize coverage, the criteria for setting up a malaria post are (1) the village has malaria transmission; and (2) there is no other health facility located in the village. Currently the 501 MPs in the country are serving populations at risk of malaria in 952 villages (52%) where malaria transmission is on-going. As an extension of public health facility, the MP allowed the national malaria program to extend the implementation of its standard guidelines for diagnosis and treatment for malaria provision of quality assured tools (malaria tests and drugs etc) as well as supervision tools. These tools and guidelines ensured comparable quality of services to the formal public health facilities. These guidelines are used by provincial and district health officers to ensure all malaria posts operating in their coverage areas meet these quality standard.

In term of health services delivery, Thailand has shortages of medical personal due limited annual turnover of new medical personnel, aging population, and increase burden of non-communicable diseases with a concentration of health/medical personnel in urban areas. This has resulted in increased workload of hospital staff and increased patient waiting time for services. Malaria post provides an extension of local health service infrastructures that specializes in providing comprehensive malaria services that directly address the issue of insufficient coverage of health facility and health staff. Security issues can prohibit delivery and access to health services, particularly for women and children. In 2017, there are 501 MPs in 27 provinces effectively serving 52% of malaria villages. For community benefit, over 2012-2017, 8% of malaria cases were among children under 5 years of age and 32% were among females. These rates were comparable to those in the public hospitals over the same period and demonstrates the utility of the MPs in its coverage of all ages and gender. The delivery of early diagnosis and prompt treatment services contributed to positive patient’s outcome and improved quality of life in the community by shortening the period of transmission/reducing exposure to malaria.

Malaria patients often experience economic, socio-cultural-linguistic, security and legal barriers that discouraged them from accessing malaria services at public health facility. The MP, as a mechanism for malaria service delivery, aims to achieve positive impact to the population most vulnerable to malaria, particularly informal workers, non-Thai residents, registered and non-registered migrant workers. A trip to the hospital would mean loss of income for patient and their care taker. Transportation cost and hospital fees added to the economic barriers. By operating malaria post from the home of malaria post worker, the familiar setting reduce fear and stigma that is associated with formal health facilities especially for non-registered migrant workers or those who earn their living from illegal activities such as logging. All patients who seek services at malaria post will receive comprehensive services free of charge. The package of services include malaria test and treatment, clinical case management for patients diagnosed with malaria, malaria education and information in their local languages, and tools for personal protection (e.g. long-lasting insecticidal nets and insect repellent). In the context of multi-drug resistance in GMS, malaria post in Thailand play critical role providing radical cure treatment and assure adherence through supervised treatment.

The roles of health volunteers in Thailand have been limited to health education and health promotion in their community. Under Thai law, a professional license is required for an individual to perform medical procedures, diagnose and treat. The MP was the first scalable community-based health initiative to allow community workers to engage in medical procedures, diagnosis and treatment of a diseases (in this case malaria) with the supervision of provincial and district health offices. With the emergence of multidrug resistant malaria in Thailand and in the GMS, the role of malaria posts have expanded to include delivery of comprehensive malaria service package that address the whole patient’s life course from prevention of malaria, management of uncomplicated malaria starting from diagnosis, treatment compliance and follow-up, to cure.

Malaria village volunteers (MVVs) was first introduced in 1960 to provide treatment to patients who display symptoms of uncomplicated malaria without parasite-based confirmation. With increasing threats of multi-drug resistant malaria, the national program had adopted parasite-based confirmation prior to treatment and the roles of MVVs became limited to malaria education. Other mechanisms had been implemented to improve the access to malaria testing and treatment at the community level. Notably, these were through mobile malaria clinic (MMCs) managed by malaria officers and pilot community-based malaria clinics (CMCs, in hill tribe areas) managed by community workers, both relied on microscope examination. Lessons learned from these prior efforts include (1) difficult and time consuming to manage quality control and quality assurance for microscopy examination; (2) lack of infrastructure to maintain of equipment; (3) high prevalence of presumptive treatment among MVVs. With the introduction of reliable and robust rapid diagnostic tests (RDT) for malaria, the MP initiative was conceived by adapting from the MMCs, CMCs and MVVs.

MP is established in the MP worker’s (MPW) home. In order to ensure quality standard across all malaria posts as an extension of the primary health care system, a small set up fee is provided to the malaria post worker’s to improve the appearance of the designated space in the home to serve as patient’s service areas. Each malaria post is provided with office furniture for patient reception, cabinets for storage of medical consumables, LLINs and repellent, cool box for storage of medicines and RDTs, and display shelving for malaria education material. Every MP is also provided with designated sign to indicate the house as malaria post, as well as operational hours. A monthly incentive is provided to help off-set the utility cost and mobile phone services to allow malaria post workers to notify malaria cases, refer patients, and obtain consultation on the patients when needed. Travel cost and related per diem are provided for the annual training of MPWs. DHO staff provide monitoring and supervision through monthly visits to make sure MP and MPW met the standard of health service delivery point, to replenish medical consumables, and provide feedbacks on services and malaria surveillance information.

Yes

The setting up of malaria posts has been justified to address accessibility issue to malaria services for patients in remote communities. The initiative which currently include the set-up of border malaria post has also improved access to malaria services for border communities in Thailand and neighboring countries. This concept of community-led delivery of primary health care and intervention has inspired the expansion of community-led disease management in other diseases context. In Thailand, the roles of village health volunteers (VHVs) had been traditionally limited to health education and health promotion activities, but has since expanded to include vector-control activities and providing patient’s support in the management of blood sugar and blood pressure, supervised treatment for some diseases including Tuberculosis, and is an essential part of continued home care for chronic patients and home bound patients. Furthermore, the long experience of MPs in Thailand has inspired neighboring countries (Lao PDR and Myanmar) to establish similar malaria posts in hard to reach border areas in their respective countries.

MP can be rapidly set up to deliver low cost community-based primary healthcare services compared to health facility-based delivery mechanism. MPs are based on sound epidemiological malaria elimination strategies and are established in areas of on-going malaria transmission. Setting up or relocating malaria posts to respond to changing malaria epidemiology would have minimal environment footprints since they are placed in the malaria post worker’s homes. The use of epidemiological data can pinpoint the placement of MPs down to the village cluster level to better direct resources to address service gaps experienced by most vulnerable communities. MP is community initiated and implemented based on a perceived need for malaria services which help promote community ownership and community acceptance. For most malaria patients, their earning potential is based on their productivity, therefore, providing prompt testing and treatment can improve malaria patient’s clinical outcome, as well as protect their livelihood with potential savings from wage loss by patients and their caretakers, transportation costs, and additional hospital fees. On a national scale, malaria post is an important intervention in Thailand’s malaria elimination strategy. If successful, the estimated cost-benefit implication of malaria elimination in Thailand is 1:15 (1THB investment to 15THB in benefit).

Malaria posts were initiated in 2004 and were needed during the intensive malaria control phase to bring down the burden of malaria to preelimination phase. Their roles have been expanded in the context of multi-drug resistant malaria and malaria elimination to include supervised radical treatment and follow-up of patients. The current analysis of these trends informs the program that malaria posts will need to be retained for at least 3 years once malaria transmission is interrupted in an area, after which the area may be declared as a malaria-free area. The role and function of malaria posts will be sustained over the period of malaria elimination and to prevent reintroduction of malaria (in areas of high vulnerability and receptivity) with the engagement of local administrative organization (LAO). The concept of community-led delivery of primary health care services, demonstrated through malaria posts, has been an inspiration to other disease control programs and is in line with Thailand’s National Health in All (HiAP) policy.

Yes

1. Malaria Program External Review 2015. Building on the recent East Asia Summit Declaration for a malaria free Asia Pacific by 2030, and given the pivotal role of Thailand in these multi-country efforts, an in-depth review of the Thai Malaria Programme was considered timely and appropriate to reorient the current control interventions in line with the Greater Mekong Subregion (GMS) malaria elimination (2016-2030) initiative. It was also considered helpful for the programme to explore increase domestic financing resources for malaria. Thematic papers, desk reviews were conducted of this review and interviews and field visits were carried out in provinces that included MPs. 2. Routine Programmatic Supervision reports by health officers. These supervision tools are programmatic forms and standardized for assessing quality of service provision – stocks, performance of MPW and quality checks. 3. Global Fund evaluations over 2012-2017 included On site Data Verification (OSDV) visits to the field and Country Coordinating Mechanism (CCM) visits to key affected areas.

Malaria Program Review 2015: The Malaria Posts and Border Malaria Posts should be continued as outreach activities of the health promotion hospitals (HPH) and to be closely linked to them. MPs may continue as long as malaria transmission was on-going in an area but also as outreach sites for HPH. Continuing NGO support to reach out to the vulnerable migrant remains a challenge but is essential as a link is still required through the service of Migrant Liaison Workers (MLO) and MHV - peer volunteers who can cross the international border, who freely associate and mingle in migrant aggregations and who therefore are able to promote timely referrals to MP for fever, adequate follow up on those out on treatment and promote the use of ITNs.

Key measurement indicators include the proportion of targeted villages where provision of early diagnosis and treatment is set up through MPs, an increasing proportion of migrants (through village surveys, MP records) accessing health care services. Routine indicators (monthly/quarterly) include surveillance indicators (disaggregated by MP, age, gender and other patient profiles): 1. Number of persons tested, positive by malaria species 2. Percentage of patients receiving correct treatment for malaria by national treatment guidelines 3. Percentage of stock out of RDTs and first-line antimalarial drugs 4. Number of insecticide treated nets distributed to migrants and through MPW 5. Number of MPWs trained annually

Since the inception of MPs in 2004, various stakeholders have been engaged as the geographic coverage and also roles of MPs expanded. Initially driven by communities and formal public health system, Public health office provided MP not only office materials, medical supplies and medicine but also training on malaria case management (diagnosis and treatment), vector control and close supervision. Additional USAID funding allowed provincial/district health offices to further expand MPs in Ranong, Tak, and Chanthaburi provinces. In 2009, formal collaborations with non-government organization (NGOs) further extended the MP network to engage directly with migrant communities through MLO and MHV. In 2013, NGO further established malaria corners in strategic areas very close to the international border check points to refer migrants with symptoms of malaria to the nearest MP or health facility. There are no formal evaluations of assessing this process of engagement or performance of this collaboration with NGO or with public health systems. Individual partners had assigned individual responsibilities according to the allocated resources – outcomes and impact and reported regularly to the national malaria program. Regular coordination meetings were also conducted at both provincial and central levels. Joint monitoring and supervision visits were conducted in respective partners implementing areas.

Key lessons learned: • Community members help to select MPWs which promote community trust, and reduce the socio-cultural-linguistic barriers that migrants may experience in formal health facility settings. • As a community-led health services delivery initiative, MP is integrated as part of the local health system. Provincial and district health offices provide training and supervision according to Ministry of Public Health (MoPH) standard for community health workers and monitor their performance to ensure that patients receive comparable quality of services without having to go to the health facility. • MP offers comprehensive malaria intervention package that include testing, treatment, follow-up, and prevention. • MP are best fit and are sustainable where there is a sound evidence based epidemiological need and are evaluated periodically. Further opportunities: • Robust evaluation of MPs contribution towards malaria declining trends and as a mechanism to deliver reliable malaria services in disenfranchised populations • Promotion of community resilience and integrate management (budgetary and administrative) of MPs from MoPH to LAOs in line with national malaria elimination strategy • Improvements in quality of routine monitoring and supervision of MP performance to identify shortfalls in service delivery and institute prompt corrective measures.