Report of the Programmatic Review of the National Malaria Control Programme in Thailand Bangkok, Thailand, 16–26 August 2011 Regional Office for South-East Asia SEA-MAL-269 Distribution: General Report of the Programmatic Review of the National Malaria Control Programme in Thailand Bangkok, Thailand, 16–26 August 2011 Regional Office for South-East Asia © World Health Organization 2012 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India Contents Page Executive summary ...................................................................................................................... v Acknowledgements .................................................................................................................. xiii Acronyms and abbreviations ...................................................................................................... xv 1. Background and rationale .................................................................................................. 1 1.1 Country situation ....................................................................................................... 3 1.2 Health care system ..................................................................................................... 7 1.3 Historical perspective of the Programme: from eradication to control, and back to elimination ............................................................................................. 8 2. External review ................................................................................................................. 10 2.1 Programme Management ......................................................................................... 12 2.2 Malaria case management ........................................................................................ 20 2.3 Vector control and entomology ................................................................................ 33 3. Surveillance system and artemisinin resistance containment activities in eastern provinces bording Cambodia as part of malaria control activities in Thailand .................... 40 Annexes 1. Summary of the 1995 External Review and 2009 Global Fund Report ............................. 48 2. Terms of Reference of four external reviewers and bio-data ............................................. 52 3. External Review of the Thai Malaria Control Programme, 18-23 August 2011 Teams 1 and 2. Field visit to Tak Province ........................................................................ 57 4. Briefing meeting on “Review of the Thai Malaria Control Programme” ............................. 60 5. Debriefing Meeting on “External Review of the Thai Malaria Control Programme” ........... 72 iii Executive summary The external review of the National Malaria Control Programme of Thailand was carried out at the request of the Ministry of Public Health (MoPH) by a team of four internationally recognized experts together with national staff from the Bureau of Vector Borne Diseases (BVBD), from selected national institutions, from nongovernmental organizations (NGOs) and WHO, from 15 to 26 August 2011. The general objective of the independent review was to assess the current policies, strategies, delivery mechanisms, monitoring and surveillance systems and general programmatic performance of the National Programme to reach malaria elimination goals, in order to provide advocacy for sustained support from political leaders and decision-makers for malaria elimination in Thailand, and to note any areas where a change in strategic direction is recommended. The review also focused attention on partnerships with stakeholders, NGOs and the private sector. It made recommendations to improve the cost– effectiveness of the national programme including programme management and health system strengthening towards malaria elimination. Field observations and analysis, and interviews were conducted with key stakeholders, NGOs and other Ministry of Health and government agencies directly or indirectly involved in malaria operations to identify strengths and weaknesses of the programme in the following areas: (1) programme management and policies; (2) use and flow of epidemiological information; (3) disease management (diagnosis, treatment and drug resistance monitoring); (4) vector control and entomology (ITNs– insecticide-treated mosquito nets and LLINS– long-lasting insecticide treated net, focal IRS– indoor residual spraying and vector bionomics); (5) IEC/BCC targeting migrant/mobile populations and ethnic minority communities; (6) malaria control operations at international border regions; and (7) financing. Programme funding for malaria control from national sources has been supplemented by several rounds of grants from the Global Fund to Fight AIDS, TB and Malaria (GFATM) in 2002 (R2), 2007 (R7) and 2011 (R10); national efforts to contain artemisinin resistance have been supported by grants from The Bill & Melinda Gates Foundation (BMGF) and the GFATM. Overall, the Bureau of Vector-Borne Diseases has made significant positive programme achievements based on recommendations made during the last external programme review in 1995, having shifted from a vertical to a semi-vertical programme in 1997. Nationally reported malaria cases and deaths in Thailand had decreased steadily since the late 1980s and early 1990s when the total numbers of malaria cases were in the range of 270 000–340 000. In 2010 malaria cases were down to 22 969. This steep decline has been accompanied by a reversal of the Plasmodium falciparum/P. vivax ratio to a current slight excess of P. vivax over Plasmodium falciparum. Similarly, malaria deaths decreased from over 4000 in 1965 to 80 in 2010, with the current case fatality rate being 0.8%. While in most parts of the country transmission rates have been reduced to extremely low levels or have been interrupted, several western districts bordering Myanmar and a few in the southern part bordering Malaysia with persisting civilian conflict and southeastern parts of the country bordering Cambodia, which experience major and intense population movement (e.g. migrant workers) across international borders, still experience high transmission rates. The considerable achievements made over the years are attributable to several positive socioeconomic factors as well as extensive deforestation alongside malaria programmatic performance including enhanced v Report of the Programmatic Review of the National Malaria Control Programme in Thailand malaria control activities as follows: (1) a change in treatment policies for Plasmodium falciparum to artemisinin-based combination therapy (ACT) – initially in parts of the country and eventually countrywide; (2) the adoption and implementation to scale of ITNs and later, LLINs supplemented in some areas by IRS; (3) more recently, expanding health services for malaria using microscopy and rapid diagnostic tests and provide effective medicines free-of-charge to treat malaria in remote communities through malaria clinics and malaria posts; (4) implementing behaviour change communication programmes and mobilizing endemic communities including cross border population; and (5) in highly endemic border areas of the country, providing health services to migrant mobile communities who move across international borders for short or longer- term periods, as a collaboration between the MoPH and a large network of NGOs and research partners. Following the achievements of recent years in reducing malaria incidence rates and deaths in Thailand, the national malaria control programme is now in transition from its previous national strategic plan (2006-2011) to a new strategic plan for 2011 to 2016. The major change is that the new strategy clearly enters into and adopts a dynamic elimination perspective, and sets as one of its three targets that the percentage of districts