Priorities of China’s participation in global malaria elimination: the perspective of malaria endemic countries | Infectious Diseases of Poverty | #education | #technology | #training


Participants

A total of 18 key informants from different malaria-endemic countries were interviewed, including 16 males and 2 females, aged between 30 and 50 years. Types, professional affiliation and number of respondents were summarized in Table 3.

Table 3 Type and number of respondents

Major challenges in malaria elimination faced by the countries

Shortage of funding

The Global Fund to Fight AIDS, Tuberculosis and Malaria (hereinafter referred to as Global Fund) was the most important source of funding commonly mentioned by respondents. Respondents in Laos revealed that the Global Fund has reduced its budget and that “Global Fund played the dominant role 5 years ago, but now the government takes its place” (antimalarial programme manager). Bangladesh respondent said funding was relatively insufficient based on its large population. Malaysia respondent denoted that concerns and investments in malaria were limited due to the needs for other infectious diseases such as dengue fever, as well as chronic diseases. Many recipient countries of the Global Fund mentioned that once malaria burden fell or progress stalled, attention and focus would disappear, further investment would be difficult to obtain, therefore the sustainability of funding failed to be assured.

Insufficient technical personnel

In general, both quantity and quality of health workers in malaria-endemic countries are insufficient. Qualitatively, certain lack is identified in the ability of field workers. And in terms of quantity, there is no adequate high-level talents and laboratory technicians. In African and South-East Asian countries, field work is usually undertaken by volunteers, whose ability and motivation to work are relatively low. Besides, entomologists and senior experts of public health in these countries are deficient. Respondents of Ghana said that universities in Ghana were unable to provide such subjects education, while professionals trained abroad often chose to work in other countries for better working environment and salary. Many respondents also mentioned the lack of domestic training mechanism, and the challenge to attract and retain technical personnel who received foreign training.

Challenges on vector control

Insecticide-treated mosquito net/long-lasting insecticidal net (ITN/LLIN) and indoor residual insecticide spraying (IRS) are two core vector control interventions. However, in Africa, it is very common that the coverage rate of mosquito nets is high but utilization rate is low, for which reasons can be summarized as follows: no bed for hanging mosquito nets; no accompanying education and instruction; wide spread of rumors, superstition and other adverse factor due to low literacy rate in rural areas; poor user experience due to bad smell of new mosquito nets.

And as for insecticide spraying, volunteers must take along pesticides and tools to spray everywhere. It is hindered by unsuitable housing conditions, insufficient insecticides, insufficient health workers and poor transportation, et al. Respondents also noted that failure of project management to adapt to local conditions also reduced spraying effectiveness. For instance, in tropical Africa, spraying must be finished before rainy season, but the right time is often missed because of funding and supplies delay.

Lack of antimalarial products

Some respondents from Africa also mentioned that there were no adequate supplies of affordable and high-quality antimalarial products. Respondent from Sudan said that the domestic supply chain of diagnostic preparations, drugs, vaccines and vector control tools was imperfect, with varying degrees of invalidity and waste. In the production and supply of antimalarial products, insufficient involvement of private sectors, serious bureaucracy and corruption in public sectors and nonstandard product procurement have resulted in high price and difficult access. In African countries, drug research and development as well as local manufacturing capacity is weak, the antimalarials exposed to the respondents are all imported from different countries. The quality of antimalarial drugs from different sources varies greatly, and the therapeutic effect cannot be guaranteed.

Challenges on universal health coverage (UHC)

In malaria-endemic countries, unequal access to health education, products, and interventions poses a huge challenge to the elimination of malaria. Many African countries indicated that the distance between health facilities in rural areas and between facilities and hospitals made it difficult to ensure vector control coverage or timely transport of severe malaria patients. A large number of residents in South-East Asian countries live and work in remote mountainous areas, which makes interventions inaccessible to high-risk population. Border malaria due to population movements as cross border, migrants, abroad and uncontrolled seasonal workers is also a common challenge in this region. Imported malaria has gradually become a difficulty in malaria control.

Unsound malaria surveillance system

Malaria surveillance system in malaria-endemic countries is poorly developed, of which the weaknesses arisen from community level. Respondents of Ethiopia stated that “real-time surveillance must be carried out at the community level, but it has not been implemented properly” (officer in health ministry). The current lack of initiative and credibility in community case reporting is not confined to areas of high transmission. According to respondents of Myanmar, “most tests in low-transmission areas are negative, which negatively affect motivation of volunteers and diagnostic accuracy.” (manager of infectious disease project). Respondents of Bangladesh and Vietnam said they didn’t have essential network, computers and mobile phones in communities needed for real-time reporting. In Vietnam, 2-3-7 strategy instead of 1-3-7 norm is used, since it is not possible to complete a report by telephone or text message within 1 day without modern equipments. Active case detection (ACD) is required in areas or populations with limited access to health care to eliminate malaria, whereas respondents of Malawi stated “now we can only do passive case detection” (public health professional, male, 38). These countries also have difficulty in managing and using the surveillance data, as one respondent mentioned that “we just collect data, we’re not using it” (district health officer).

Challenges in existing forms of international assistance

Challenges in Global Fund’s support

Most respondents regard Global Fund as large-scale investment, which provides a great number of mosquito nets, insecticides, antimalarials, rapid diagnostic test agents and other products, but there are problems in the way of money distribution and management. Managers of malaria projects pointed out that there were gaps between planning and the actual needs due to inadequate research. They also pointed out that money from Global Fund usually specified the usage without meeting the real need. In addition, funding application process usually takes a long time, and cannot remain predictable and sustainable, resulting in delayed intervention or suspended programme. Zambia and other African countries complained about the internal management of the Global Fund, arguing that a large amount of money was consumed by unnecessary meetings and activities.

Problems in WHO’s technical assistance

Technical support in malaria-endemic countries is mainly provided by the WHO. According to respondents of African countries, the WHO’s documents were mechanically copied by most countries and there was a lack of coordination and guidance from WHO. They also indicated that frontline health workers were not involved in making national malaria strategic plan, so there was lack of practical feedback. One respondent said “Some of the challenges proposed by national malaria strategic plan are real, but some are hypothetical without evidence.” (district-level health officer). Moreover, project implementers in recipient countries lack ownership and are often forced to stop current work and quickly adopted the new instruction. Respondents of Sudan and Ghana also pointed out that WHO usually tended to focus on areas with high disease burden, but ignored areas with low disease burden, which was not conducive to achieving the goal of malaria elimination.

Priorities of China’s participation

Experience and technique sharing

Experience and technique sharing are what respondents of all countries expect most from China. In their opinion, China’s own successful experience in malaria control makes its advantage compared to other partners or leaders in global malaria elimination. Respondents stated that compared to funding support, “sharing your experience and techniques is more valuable to us” (manager of infectious disease programme). Many respondents believed that China’s success could be replicated in their countries since they are all developing countries with similar history of malaria epidemic. Many countries entering the stage of malaria elimination like Vietnam showed their interest in China’s “1-3-7” norm, while Malawi expect China to help the implementation of mass drug administration (MDA). Respondents said that current technical strategies fail to receive specific guidelines from WHO, and China could provide rich experience in developing and applying appropriate strategies.

Health human resource training

Capacity building is urgently needed in malaria-endemic countries and there is a great need for health human resources training. As for who should be trained, respondents who works as laboratory staffs said they needed to train more technicians to operate microscopes and PCR. District-level health officers indicated a need to train project executors to think in the context of public health and conduct epidemiological investigation to provide evidence for decision-making. Also, one respondent believed that to improve the efficiency of training, high-level officers should be trained first, for they had influence in policy making to promote the malaria control framework in the country. As for the form of training, respondents suggested both inviting Chinese experts to their countries and sending personnel to China were appropriate. But they also mentioned that providing lectures in their country would be more beneficial and cost-effective than sending personnel to China, especially for mass personnel training. In addition, some respondents mentioned that there were language barriers in the current training held by China, and they expected better communication in future trainings.

Public health system building

The needs of public health systems building in malaria-endemic countries mainly focused on disease control network, surveillance, emergency care and health information system. Respondent of Bangladesh said, “we want support from China on how we can develop this excellent CDC network from national level to township level” (surgeon). Respondents in Ethiopia said they needed China’s help with “community-based real-time surveillance and response systems”. Respondent from Sudan recommended the Chinese government to support them in emergency care so as to respond quickly to new cases (hospital director). Several respondents from Africa suggested that China help improve the utilization of health information because in their countries they have collected large amounts of data but had no the ability to analyze and use them properly.

Scientific research cooperation

There is a great need for malaria-endemic countries to collaborate with China in joint case diagnosis and research for difficult and complicated cases. Respondents mentioned that there are limited scientific research in their countries which makes it difficult to deal with complex and changing situation of the disease. One respondent stated that in his country, there was no specialized research institute for parasitic diseases, and China’s help for establishing such institute would increase their capacity to control and eliminate malaria. In the Greater Mekong Sub-region facing the challenge of artemisinin resistance, respondents of Cambodia, Vietnam and Laos mentioned they were willing to conduct relevant research in their countries which need additional support (deputy director of laboratory). Some respondents from African countries pointed out the limitations of the current vector control-based strategies, and expressed their hope to collaboratively carry out pilot projects to develop more localized strategies.



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