PARTIAL INTEGRATION OF MALARIA CONTROL IN THAILAND PROGRESS OF PARTIAL INTEGRATION OF MALARIA CONTROL WITH OTHER VECTOR BORNE DISEASES CONTROL IN NORTHERN THAILAND Wannapa Suwonkerd1, Robert Vryheid2 and Nantawan Suwannachote1 1Vector Borne Disease Section, Office of Disease Prevention and Control No.10, Chiang Mai, Thailand; 2Graduate School of Public Health, San Diego State University, California, USA Abstract. Thailand partially integrated the malaria program into the provincial and local Public Health system starting in 2003 by adding it to the control of other vector borne diseases and by transferring some activities to the Public Health Department. This study evaluates the results of this transfer on 8 high malaria incidence districts of Mae Hong Son and Chiang Mai Provinces. Indicators were measured for all community hospitals, Vector Borne Disease Control Units, (VBDU), health centers (HC), malaria clinics, and malaria posts in 2003 and 2004 during the first two years of partial integration. The number of Vector Borne Disease Control staff decreased 1.8 - 3%, and their operational budgets decreased 25%. The VBDU staff did all the indoor residual spraying (IRS), insecticide treated net (ITN) work and entomology surveys, they took 80.6% of the blood films, and treated 72% of the patients, while Public Health system did the remainder. The Annual Parasite Incidence (API) (1 - 10/1,000) and IRS coverage (88 - 100%) remained adequate in most areas during the first years after partial integration, but the API increased (to 31.6 - 57.6/1,000) in some populations. The percentage of insecticide treated bed net coverage was adequate in Mae Hong Son (95.4%), but inadequate in Chiang Mai (52.2%). Early diagnosis and prompt treatment (4 - 23 days), hospitals report- ing disruption of anti-malarial drugs (3 of 7), and health centers having all needed equipment, training, and drugs for malaria diagnosis (9%) remain inadequate. If the program is allowed to diminish, malaria could spread again among the popu- lation. Integration of antimalarial activities into the general Public Health system has only been partially successful. We recommend the integration process and results should be monitored and evaluated to find and mitigate problems as they occur, and modify the integration process if needed. Key words: malaria, vector borne disease, control program, partial integration INTRODUCTION Correspondence: Wannapa Suwonkerd, Vector The 1978 International Conference on Borne Disease Section, Office of Disease Pre- vention and Control No. 10, 18 Boonruangrit Primary Health Care (Trigg and Road, Chiang Mai 50200, Thailand. Kondrachine, 1998) recommended inte- Tel. +66 (0) 53 221529 ext 216; Fax: +66 (0) 53 gration of malaria control into primary 212389 health care systems (PHC). The 1986 E-mail: [email protected] WHO Expert Committee on Malaria, 18th Vol 41 No. 6 November 2010 1297 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH Report also recommended vertical malaria Despite successes in most malarious areas control be transferred to PHC, with train- of China, PHC systems were insufficient ing and supervision by malariologists to control malaria well in some areas (Li et (WHO Export Committee on Malaria, al, 1995). In some countries, high malaria 1986). The 1992 WHO Global Ministerial transmission occurred when using the Conference on Malaria in Amsterdam, is- control strategy, allowing a resurgence of sued the World Declaration on the Con- malaria, such as in India. Some experts trol of Malaria, that adopted control as the recommended continuing to have a core main strategy for malaria, with integration of specialized malaria staff, especially for into PHC (Kidson, 1992; Trigg and vector control (Rashid, 1987; Dhingra et al, Kondrachine, 1998; WHO Export Commit- 1997; Sharma, 1999; Kroeger et al, 2002). tee on Malaria, 2000). Even in countries experiencing sufficient The control strategies obtained good malaria control progress to potentially results in parts of several endemic coun- eliminate indigenous transmission in some tries, (Mabaso et al, 2004; Sharp et al, 2007; areas, the WHO recommended a core WHO, 2008). Control programs were group of malaria experts organize the ver- plagued with the same operational prob- tical program to eliminate malaria (WHO, lems as eradication programs (Sharma VP, 2007). 1996; WHO, 2008). Cost-saving in many In this international context of simi- control programs resulted in decreased lar problems occurring in several coun- indoor residual spraying (IRS), leading to tries, this study examines the progress to- increased malaria in the 1990s (Roberts ward transferring malaria activities into et al, 1997). the PHC system in areas of northern Thai- When the PHC integration policy was land. Malaria control in Thailand com- proposed, some doubted the feasibility of menced in 1950s with impressive reduc- transferring malaria control activities to tions in morbidity and mortality. Trans- general PHC, because in many countries mission, however, is still ongoing, particu- PHC was not yet strong enough to handle larly along international borders and in the malaria control (Bruce-Chwatt, 1983). forest and forest fringe where the local Countries with effective PHC had a de- vectors are present. Only slow progress crease in malaria when malaria control in malaria control has been achieved in was integrated with PHC, such as in China these core areas, in spite of continuous case (Tang et al, 1991; Luo et al, 1996). Several and vector management implemented for Southeast Asian countries have integrated decades. The ecology of the vectors, diffi- malaria vertical programs into PHC, with cult travel, language and ethnic diversity, treatment transferred to PHC, but malaria and genetic polymorphism of the people vector control teams continued their work compound these problems (Malikul, 1988; and combined it with other insect-borne Charoenviriyaphap, 2000). disease vector control, such as dengue Over its history, Thailand’s malaria (Rashid et al, 1987). program policies have been altered several As predicted, some PHC systems times to fit changes in the malaria situa- could not handle the malaria control in tion affecting control and reporting activi- addition to the other diseases they were ties. These paralleled international policy already having difficulties controlling. changes described above, since Thailand 1298 Vol 41 No. 6 November 2010 PARTIAL INTEGRATION OF MALARIA CONTROL IN THAILAND participates in international malaria infor- do this, we assessed malaria control pro- mation exchange, and made the strategy gram indicators of processes for a) vector changes simultaneously with other coun- control and prevention and b) malaria pas- tries. sive case detection activities, impacts, Thirty to fifty years ago the Malaria malaria prevention, disease management, Division provided almost all the malaria and health sector development. services in outlying rural areas. These in- cluded active case detection by malaria MATERIALS AND METHODS workers going to houses, passive case de- tection by Malaria Clinics and trained vol- Chiang Mai and Mae Hong Son prov- unteers, and vector control by malaria inces were selected because they have the workers doing IRS and helping people dis- highest reported malaria cases in northern tribute insecticide treated mosquito nets Thailand. Two of Mae Hong Son’s 7 dis- (ITN). Later, the general Public Health tricts (Mae Sariang and Sop Moei), and 6 system gradually expanded its operations of Chiang Mai’s 24 districts (Chiang Dao, into these areas, mainly by establishing Fang, Wiang Haeng, Mae Ai, Omkoi and hundreds of Health Centers offering pre- Chai Prakan) were selected because they ventive and therapeutic services for a wide had the highest malaria incidence of all the range of diseases. The Malaria Division, districts in the 2 provinces (Fig 1). All the Ministry of Public Health (MOPH), started community hospitals and VBDU were se- doing work to prevent dengue and filari- lected at the district level and all the health asis, and changed its name to the Bureau centers (HC), malaria clinics and malaria of Vector Borne Diseases (BVBD). In re- posts were included at the community cent years, hospital and health center staff, level. vector borne disease control staff and vol- unteers, have obtained blood films from Several indicators were studied retro- patients suspected of having malaria. One spectively or cross-sectionally at the com- of the main activities of Vector Borne Dis- munity, district and provincial levels. ease Control Unit (VBDU) staff is IRS and During the integration process of transfer- ITN work with villagers and Public Health ring work from the VBDU staff to the Pub- staff. The MOPH is gradually phasing out lic Health staff, both sets of agencies con- the VBDU staff, letting them retire one by tinued to record and report all activities, one, and not hiring replacements. Accord- so these indicators provided reliable data. ing to plan, general Public Health system 1) Work transfer indicators measured staff will eventually take responsibility for the activities conducted by the VBDU staff, IRS and ITN, but thus far, they have relied and the Public Health staff, including on VBDU staff to do this. blood films taken from suspected cases, Since this integration process is par- blood films microscopically examined, tially completed, its progress must be patients treated, entomology surveys evaluated. Therefore, the objectives of this done, houses and farm huts sprayed and study