I. EXECUTIVE SUMMARY
When it was launched in 2005, the goal of the President’s Malaria Initiative (PMI) was to reduce malaria-related mortality by 50% across 15 high-burden countries in sub-Saharan Africa through a rapid scale-up of four proven and highly effective malaria prevention and treatment measures: insecticide-treated mosquito nets (ITNs); indoor residual spraying (IRS); accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs); and intermittent preventive treatment of pregnant women (IPTp). With the passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act in 2008, PMI developed a U.S. Government Malaria Strategy for 2009–2014. This strategy included a longterm vision for malaria control in which sustained high coverage with malaria prevention and treatment interventions would progressively lead to malaria-free zones in Africa, with the ultimate goal of worldwide malaria eradication by 2040-2050. Consistent with this strategy and the increase in annual appropriations supporting PMI, four new sub-Saharan African countries and one regional program in the Greater Mekong Sub-region of Southeast Asia were added in 2011. The contributions of PMI, together with those of other partners, have led to dramatic improvements in the coverage of malaria control interventions in PMI-supported countries, and all 15 original countries have documented substantial declines in all-cause mortality rates among children less than five years of age.
In 2015, PMI launched the next six-year strategy, setting forth a bold and ambitious goal and objectives. The PMI Strategy for 2015-2020 takes into account the progress over the past decade and the new challenges that have arisen. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s Strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and ending extreme poverty. It is also in line with the goals articulated in the RBM Partnership’s second generation global malaria action plan,
Action and Investment to defeat Malaria (AIM) 2016-2030: for a Malaria-Free World and WHO’s updated Global Technical Strategy: 2016-2030. Under the PMI Strategy 2015-2020, the U.S. Government’s goal is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.
In 2011, PMI support extended to the Greater Mekong Sub-region (GMS), which is made up of six countries: Burma, Cambodia, China (Yunnan Province), Lao People’s Democratic Republic (PDR), Thailand, and Viet Nam. This FY 2017 GMS Malaria Operational Plan (MOP) presents detailed implementation plans for Burma, Cambodia, and Thailand/Regional which includes the Lao People’s Democratic Republic (Lao PDR) and Viet Nam.
Although considerable progress has been made in malaria control in the GMS during the past 10 years, malaria remains a major concern for the international community, ministries of health, and the people of the region. This is due primarily to the development and possible spread of resistance to artemisinin drugs, the principal component of the combination therapies for malaria that now are the first-line treatment for malaria throughout the GMS and the world. Plasmodium falciparum resistance to artemisinin drugs was first confirmed in western Cambodia; treatment failures to artemisinin-based combination therapy (ACT) have been reported from multiple sites on the Thai-Cambodian border; and an early warning sign of artemisinin resistance — prolongation of parasite clearance times — has been reported throughout the region.
The USG has supported malaria control efforts in the GMS since 2000. These regional efforts have focused on antimalarial drug resistance monitoring and drug quality surveillance. All GMS countries have received Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) support. The other major sources of funding for malaria in the region include the Three Millennium Development Goal Fund in Burma, Australia’s Department of Foreign Affairs and Trade, the United Kingdom’s Department for International Development, the Asian Development Bank, and the Bill & Melinda Gates Foundation. In addition, the Global Fund supports a 3-year $100 million Regional Artemisinin Initiative to reduce malaria transmission and respond to resistance in GMS countries.
The FY 2017 PMI MOP for the GMS was developed with the Regional Development Mission for Asia (RDMA), and Burma and Cambodia USAID Missions during a planning visit in March 2016 by representatives from USAID, the Centers for Disease Control and Prevention, and the national malaria control programs of Burma, Thailand, and Cambodia, with the participation of other major donors and partners working on malaria in the area.
The FY 2017 MOP supports regional/cross-cutting activities, such as surveillance for antimalarial drug resistance and antimalarial drug quality assurance, and malaria prevention and control activities to reduce malaria transmission in geographically targeted areas. PMI is also supporting a pilot package of elimination activities in one operational district in Cambodia for potential scale up to other areas. PMI will also consider emergency assistance, including commodity support and technical assistance for surveillance, case management, and social and behavior change communication (SBCC) in other GMS areas threatened by artemisinin resistance. The activities PMI is proposing to support with FY 2017 funding are in line with the national malaria control program strategies of the six countries and are intended to complement ongoing Global Fund malaria grants and contributions from other donors.
The proposed FY 2017 PMI budget for the GMS includes $9 million for Burma, $4.5 million for Cambodia, and $3 million to the Thailand/Regional program. PMI will support the following intervention areas with these funds:
Entomological monitoring and insecticide resistance management:
Malaria transmission in the GMS is closely associated with two malaria vectors that inhabit the forest and forest fringe, Anopheles dirus and An. minimus. Countries have made progress in monitoring vector distribution and insecticide resistance, which to date has not been a major problem in the GMS area. Entomological surveillance will focus geographically on targeted areas with an emphasis on improved insecticide resistance monitoring and foci investigations, where epidemiologically appropriate. PMI will also provide support for entomological training in the region, in response to the changing vector ecology.
Insecticide-treated nets (ITNs):
Most studies suggest that insecticide-treated nets (ITNs) provide protection even with significant outdoor and early evening biting. There is a strong culture of bed net use in the GMS and net ownership is quite high, especially in Burma and Cambodia, but many of those nets are untreated. Considerable numbers of long-lasting ITNs targeted for high-risk areas in Burma, Cambodia, and Thailand are included in their respective Global Fund grants. With FY 2014 and FY 2015 funding, PMI procured approximately 823,000 and 423,000 long-lasting insecticidetreated nets (LLINs) in Burma and Cambodia, respectively, to fill gaps in Global Fund grants in the PMI focus areas and developed innovative SBCC approaches to improve LLIN use among vulnerable migrant and mobile populations.
With FY 2016 funding, PMI is procuring approximately 607,000 LLINs and hammock nets for migrant and vulnerable populations in targeted focus areas. With FY 2017 funds, PMI will procure approximately 686,000 LLINs for Burma, Cambodia, Thailand, and Lao PDR. Indoor residual spraying (IRS) is mostly limited to outbreak response and focal control and is not a key activity in national malaria control strategies in the GMS with the exception of Thailand. Therefore, PMI funds will not be targeted for IRS in the Sub-region.
Malaria in pregnancy: While intermittent preventive treatment for pregnant women (IPTp) is not part of national policies for any country in the Sub-region, given the low prevalence of malaria in the GMS, PMI will support promotion of universal LLIN coverage and prompt diagnosis and treatment of clinical cases of malaria in pregnant women as they remain a vulnerable group in the region. PMI supported a rapid assessment of malaria in pregnancy to identify programmatic areas for strengthening in Burma, Cambodia, Thailand, and Lao PDR in 2015. With FY 2016 funding, PMI is building on the assessment findings and recommendations to ensure all GMS national programs have updated policies and guidelines.
With FY 2017 resources, PMI will support procurement of LLINs, training and supervision of facility staff, and updating training materials and job aids to strengthen malaria case management and prevention activities provided through antenatal clinics in Burma and Cambodia.
Case management: In all countries making up the GMS, diagnosis of malaria is based on laboratory tests with microscopy or rapid diagnostic tests (RDTs). Although all countries in the GMS recommend ACTs as the first-line treatment of Plasmodium falciparum infections, artemisinin resistance has been confirmed throughout the Sub-region. Treatment failures to ACTs have now been documented in Western and Northern provinces of Cambodia. Case management of malaria in the GMS is further complicated by the fact that P. vivax and P. falciparum are co-endemic. With FY 2015 and FY 2016 funding, PMI has supported training of community health and malaria volunteers and health facility staff in Burma, Cambodia, and Thailand in malaria case management including diagnostic testing.
The majority of RDT and ACT needs in Burma, Cambodia, Lao PDR, and Thailand is anticipated to be met by those countries’ Global Fund grants through 2016 when the Global Fund malaria grants in Burma and Thailand will end; however, an anticipated extension of Thailand and Burma’s Global Fund malaria grant is expected through 2017. With FY 2017 funding, PMI will procure small quantities of RDTs to fill gaps and strengthen laboratory capacity in targeted areas. PMI will also procure ACT treatments to fill any gaps in Burma and Cambodia and respond to urgent needs in the region. Because of concerns about the quality of malaria diagnosis and treatment in targeted areas, PMI will support in-service training, accreditation of microscopy trainers, development of slide banks, and quality assurance of the parasitological diagnosis of malaria. In addition, PMI will continue to support drug quality assurance efforts by helping the national pharmaceutical reference laboratories in Burma, Cambodia, Lao PDR and Thailand achieve and maintain international accreditation. PMI will continue to support drug therapeutic efficacy and drug resistance monitoring at 45 sites (alternating every other year) in all six GMS countries.
Social and behavior change communication (SBCC): PMI will continue to provide technical support to national programs to facilitate development and use of effective communication strategies and appropriate SBCC approaches. As countries move from malaria control to elimination, SBCC interventions will need to be more tailored and targeted for hard-to-reach populations that remain at risk, including mobile and migrant populations. PMI supports integration of SBCC activities in the delivery of malaria services (e.g., distribution of LLINs and case management). A multi-pronged, comprehensive approach for SBCC interventions will be emphasized to sustain community involvement, support promotion of healthy behaviors, and reduce risk-taking in the context of malaria exposure. With FY 2017 funding, PMI will support development of effective SBCC approaches for elimination in targeted areas of Cambodia. In Burma, with FY 2017 funding, PMI will support efforts to standardize and harmonize key SBCC materials and messages at the community level.
Surveillance, monitoring and evaluation (SM&E): The quality of malaria case detection and reporting systems varies widely within the GMS. In the context of malaria elimination, accurate and timely data are essential to identify cases, mount a timely response, inform policy decisions, and focus resources to areas of ongoing malaria transmission. USG funding for SM&E during the past several years has focused on updating national M&E plans, providing technical assistance for surveys, and capacity development at the national level. With FY 2015 and FY 2016 funding, PMI is supporting strengthening and scale-up of surveillance systems in Burma,
Cambodia, and Lao PDR, providing technical assistance for national surveys in Cambodia and Burma, and supporting collection and reporting of routine surveillance and survey data in PMI target areas.
With FY 2017 funding, PMI will focus efforts on targeted areas to implement systems and practices to foster timely collection and use of quality surveillance data. At the national level, PMI will provide technical support to all national malaria control programs on their national M&E plans, through support for national/sub-national malaria surveys, and build SM&E capacity within their national programs and at state/province and district levels, including technical support for surveillance systems and databases. In Cambodia and Burma where many patients seek care in the private sector, PMI will continue to strengthen collection and integration of malaria data from private providers.
Operational research (OR): PMI has supported key operational research activities in the region in the past to address outdoor transmission by assessing the acceptability and entomological efficacy of insecticide-treated clothing and the safety of low-dose primaquine in those with glucose-6-phosphate dehydrogenase deficiency and infected with P. falciparum. No OR is currently planned with FY 2017 funding, but PMI will continue to keep abreast of key programmatic bottlenecks and plan for OR to address those gaps as necessary.