Cross Learning Field Visit Salavan province, Lao PDR, 7-10 November 2018 American Refugee Committee (ARC) as a host of the Malaria CSO platform joined the field visit hosted by Ministry of Health, Lao PDR, Centre for Malariology, Parasitology & Entomology (CMPE), Laos CCM, together with local CSO partners Lao Positive Health Association (Lao PHA), PEDA and Health Poverty Action (HPA Laos) which met during 7-10 November 2018, in Salavan province of Lao PDR. The main objectives of the visit were 1) to interact with community people, malaria volunteers, community leaders, the malaria risk population, and service providers, 2) to identify the success and challenges at the field level, and document evidence of success and challenges in RAI2E implementation and shared with RAI RSC. The meeting and discussion with the RAI2E implementing CSOs, public health officers, village malaria worker, mobile malaria workers and community people were organized and the meeting was held during the visit. This report was developed as a part of a collaborative cross learning field visit activity coordinated by RAI RSC CSO platform in GMS. The activity enabled RAI RSC CSO representatives and other CSOs to interact with and learn from each other, allowing them to view and share practical experience of best practices, challenges and success in malaria response. This report is based on observations in the RAI implanting district of Salavan province during the visitation period and cannot be generalized for other areas. ARC on behalf of Malaria CSO platform would like to thanks all for the generosity of the individuals and partners for their support of this visit. About the platform The Reginal Malaria CSO platform in the Greater Mekong Sub-region (GMS) is a network of Civil Society Organization (CSO) from the Global Fund RAI implementing countries: Cambodia, Lao PDR, Myanmar, Thailand, and Vietnam. The Platform serves as the CSO constituency engagement mechanism for the RAI RSC. ARC is the host of the platform for 2018-2020. For more details, please visit www.malariafreemekong.org Report: Field visit, Lao PDR, 7-10 November 2018 1 | P a g e Visit Summary Salavan Province Salavan is a province of Lao PDR located in the south of the country. The province covers an area of 10,691 km2, shares its borders with Savannakhet province to the north, Vietnam to the east, Xekong province to the southeast, Champasak province to south and Thailand to the west. The population of the province as per 2008 census is 400,000 distributed over 8 districts. The ethnic groups in the province comprise the Ta-oy, Pako, Katang, Kado, Suay and Laven. Ta-Oy district and Samouay districts are located in mountainous areas and are two of the three of the poorest districts in the province according to the national program. The district is 84 km away from Salavan province, it has 4 main ethnic groups: Lao loum, T-Oy, Katang and Pakoh. Salavan Provincial Health Office The visiting team met with Dr Boualay Senekeonikor, the head of the provincial health office and officers to update the overall malaria situation and NGOs working in the province. Rapid diagnostic testing increased compared to the same period last year, targeting the volunteer health workers to be trained regularly. LaoPHA is a local NGO working in the area and responsible for the malaria cases information update in the dashboard using the DHIS2 system. The mobile workers is hard to control due to their The team met with Dr. Boualay Senekeonikor, the head of the provincial health office, Salavan province varied work locations. There are limited resources to facilitate the regular health promotion meetings at the district level according to the head. According to P. vivax cases, G6PD rapid test is not available at the health center, therefore, in case the P. vivax positive at the villages/health centers later confirmed cases had to transfer for the G6PD testing before prescribing PQ treatment at hospitals level. The last campaign LLINs distributed was on 2016. Report: Field visit, Lao PDR, 7-10 November 2018 2 | P a g e Samouy and Tieng-Samouay village The villages that are located in the mountain share their border with Vietnam in the east. Samouy village comprises of 12 households and Tieng-Samouy village comprises of 23 households. They share their villlageship due to the population and because they are within walking distacne with each other. Two main languages are Pa-Koh and Ka-Tor which are use regularly, most of these people cannot speak Lao. Samouay villagers, 100% of the villagers are ethnics groups and most of them cannot speak Lao. Ta-Oy district health office The team visited the office and met Dr Souksavath Phimbounyor, head of the health office together with officers. Ta-Oy is the ethnic district composed of Lao-lum, Ta-oy, Ka-dan/Ka, and Pa- kod. People are migrating around throughout the year according to their work which is one of the challenges to control malaria. The district shares its borders with Nong district of Savannakhet province. They have a regular quarterly meeting, the The team met Dr Souksavath Phimbounyor, head of the health volunteers from health centers update their malaria office, Ta-Oy district situation. Kok-Bok health centre The health center is responsible for 13 villages in the area. According to malaria testing and confirmed cases, From January to November this year, the highest tested and confirmed positive cases was in May which recorded 27 cases confirmed P. falciparum positive, there was no malaria positive in August, September, and October from this health center. Report: Field visit, Lao PDR, 7-10 November 2018 3 | P a g e Challenges identified from the visit 1. Good collaboration between the government and CSOs in the delivery of malaria services to vulnerable communities accounts for the progressive success of Laos in reducing malaria burden over the period 2014 to 2018. Compared to the past 4 years (2014 to 2017) when local CSOs, LaoPHA and PEDA were only involved in IEC/BCC activities and referral of suspected malaria cases to trained health service providers. Only in 2018 that LaoPHA and PEDA were able to do testing and treating of suspected malaria cases, services are now increasing and readily available in the communities and health centers with better access, whilst in 2014-2017 when local CSOs were only involved in IEC/BCC activities and referred suspected malaria cases to trained health service providers. Especially in Ta-oy district during our visit, a significant impediment for further progress towards elimination as we observed was a recent increase in P. vivax cases, the need of better follow-up systems to ensure especially for patients residing in remote areas from the health center. From the interviewing with the health volunteers during the visit, there was a possibility of persistence of significant cases diagnosed as P. vivax failed to complete treatment due to the distances, travelling cost from their villages to the health centers for G6PD testing/prescribing as it's available only at the hospital levels, therefore, travel cost and distance are increasing. Because of this patients are not going for treatment and contribute to the further transmission of the parasite in the community. 2. Gaps in LLINs coverage – LLINs is one of effective tools to prevent malaria. Despite CMPE and CSOs partners' efforts to ensure universal coverage of LLINs among all at-risk populations, there are still gaps in coverage in the villages we visited. Households without bed nets, or with bed nets with insufficient quantities to let all family members sleep under the nets underscores the improvement needed in terms of vector control. 3. Promote multi-sectoral collaboration for integrated services and paving way for universal health coverage – the already existing good collaboration between the government and CSOs can be amplified to the next level to maximize the impact of malaria programs. We observed untapped potentials of malaria volunteers in the community, with proper training and supervision, providing integrated services in the community is possible. 4. Capacity building is needed in the villages level – during the visit, the team observed that the challenges around health centers to have timely and quality reports as they are critical to making data-informed decisions. Specific findings related to this are – stock shortages and no data system to capture the stock-out areas to trigger timely replenishment of stock, inconsistencies in reports, redundancies in recording/reporting, and lack of data and records that tracks how many P. vivax cases referred from communities have actually reached and received treatment as it measures the magnitude of the problem. Furthermore, in the eliminating setting, there are increasing needs of use of data at more granular levels and we observed their limited capacities health staff, especially at the health center and district levels, missing the opportunities to identify outbreaks, conducting the investigations and timely responding. Report: Field visit, Lao PDR, 7-10 November 2018 4 | P a g e Recommendations to RSC and the National program: 1. Collaboration between the government and CSOs in the delivery of malaria services to vulnerable communities - Recommended to the Government of Lao PDR with to work with CSOs to ensure all confirmed malaria cases get equal rights of access to appropriate and radical antimalarial treatments as per national guidelines, by taking into account for their social, behavioral, geographical barriers. - Advocated the GF ATM and CCM to create enabling environment to promote this change by strengthening the capacities of health staff and volunteers, providing (or reviewing) current support mechanisms to will ensure effective referral and follow-up of all confirmed cases. 2. LLINs coverage The visit team advocated for the universal coverage and use of LLINs in all malaria-affected communities.