Malaria elimination in the Asia-Pacific: Going the last mile

There has been good progress in the bid to eliminate malaria from the Asia-Pacific region by 2030. Malaria elimination has been certified by the World Health Organization in Sri Lanka and China, is expected to be certified in Malaysia, and is within reach in Bhutan and Timor-Leste. The countries in the Greater Mekong Subregion have also made good progress and reached many milestones of success. However, the COVID-19 pandemic has threatened derailment of these impressive gains as countries in the region divert their attention and resources to combating the pandemic.

Much of the success in malaria control can be attributed to the vertical nature of the malaria program both at the global level and national level. That is, a program with clear objectives, quantifiable targets, focused on a single condition, and implemented with centralised management and dedicated means (staff, funds, etc). The last mile to elimination, however, is posing new challenges and new approaches are needed.

First, we need to tackle the challenge of reaching the hardest to reach communities. For example, those living in remote, rural areas, ethnic minorities and other marginalised sections of the population tend to have access difficulties and therefore the most limited contact with health services, lower levels of education and health literacy, and suffer poorer health for many conditions.

Second, we need to go beyond rolling out standard technical, vertical approaches and carry out a review of all demand- and supply-side factors. We need to understand better the social and cultural factors shaping health behaviours in communities, the role of community organisations and networks in providing trusted advice, and community perceptions of the health system. We need to reflect on shortfalls in current program implementation, including reviewing important policy barriers.

Third, we need to mainstream public health services and integrate better with the rest of the health system in order to tackle the elimination task. This approach should emphasise integrated, people-centred services, delivered where people live. Primary health care is the pivotal point for individual and community services, where case identification and treatment can occur for individuals, health education can be done for patients and for the community, and population outreach and environmental interventions can be carried out.

Fourth, we need to keep our minds open to new innovations which can help us achieve the elimination goal, including the potentially important results of recent vaccine trials and new therapeutic agents.

Finally, and importantly, we need to sustain political will and commitment in the face of competing priorities and reduced resources as countries continue to grapple with the COVID-19 pandemic. In the initial period of the pandemic, many countries focused their scarce resources on COVID-19 services, even to the neglect of other health issues. With the prolonged pandemic, government and health sector leaders will need to recommit to the understanding that health and development are integral to each other and reconfigure resources to achieve the most efficiency, effectiveness and equity.

Health is influenced by environmental, behavioural and healthcare seeking factors. How to address both demand-side and supply-side influences need to be considered in order to tackle the last mile.

The interaction between health service providers and patients and communities is shaped by a range of forces, so strategies to reach the last mile need to be tailored to communities and populations, while being cognisant of health system resources and capabilities. We should not underestimate the importance of demand-side influences such as culture, traditions, gender, local knowledge, language, health literacy, and the role of community organisations. At the same time, health systems may also need to be strengthened. Availability of supply may be a factor related to disorganised logistics; accessibility of services may relate to social and cultural factors as well as finances and geography; quality of services may reflect both the technical and social/cultural competency of the health workforce; cost of services will play an important role as price signal.

Weak health systems are ultimately an impediment to community trust in government policies as well as health systems. Universal health coverage may be the most critical policy intervention for addressing the last mile.

First, appropriate, evidence-informed and feasible policies are needed, for example to ensure that core public health functions such as surveillance, laboratory capacity, information systems, and outreach/education strategies are strengthened. Such policies must also be seen in the context of universal health coverage (UHC) and a ‘whole of health sector’ approach. This would entail defining core program elements and service delivery arrangements, aligning finances to service delivery, including increased domestic financing, and strengthening institutions to monitor, manage and evaluate the delivery of services and its financing. The Regional Framework for Action on Transitioning to Integrated Financing of Priority Public Health Services in the Western Pacific1 provides guidance on how to support integration of vertical programs into UHC.

Second, policies must also be in place to ensure effective inter-sectoral and multi-stakeholder governance. Mechanisms that can bring together health with finance, planning, social development, agriculture and industry, etc. offer the opportunity to emphasise policy coherence and complementarity across sectors. By utilising community engagement to reflect the voices and role of civil society, policies and institutions can become more responsive to community needs and be more efficient in solving shared challenges.

Third, and at a higher regional level, the implementation of required/needed policies within countries will continue to need high-level advocacy by senior officials and ministers of health at regional bodies such as ASEAN. This is a key role and objective of APLMA that needs to be maintained and strengthened, while continuing to emphasise better APLMA/APMEN integration at the country level. Maintaining advocacy at the highest political levels will, in turn, facilitate regional cooperation between countries in the region and continued collaborative support from multilateral organisations, bilateral development agencies, philanthropic organisations and international NGOs.

The last mile should not be seen as a distant dream but a worthwhile, achievable goal where science, policies and political leadership will ultimately benefit the people suffering from malaria in the region. In the words of Henry David Thoreau (1817–1862), ‘All endeavour calls for the ability to tramp the last mile, shape the last plan, endure the last hours toil’. While the last mile can be the most strenuous, it can also be the most rewarding.