Introduction

Burma records the most malaria deaths of any country in Southeast Asia, but preventive and curative services remain unavailable to the most vulnerable populations living in ethnic areas along the borders of India, China and Thailand.

Since 2001 Planet Care/GHAP has increased the capacity of local ethnic health organizations to increase access for villagers to proven preventive and curative malaria interventions. Beginning with a modest pilot program among 1,800 Karen internally displaced peoples (IDPs) in four villages along the Thai-Burma border, effective malaria interventions now reach 60,000 villagers in about 140 villages along three of Burma's borders.

The details of the program along each border, described below, are modified according to local guidelines, but are based on over four years of experience reducing malaria transmission along the Thai border.

Thai-Burma Border

The Thai-Burma border is often described as an "epicenter" of drug resistant malaria. Malaria prevalence (the proportion of the population with the disease at any time) among IDPs in eastern Burma is up to twenty times higher than right across the border in Thailand.

Malaria is the leading cause of morbidity and mortality in eastern Burma, accounting for 23% of medical cases, and 42% of deaths, with a disproportionate impact on young children. Over 20% of children will die before their fifth birthday, nearly half from malaria.

KDHW Responds to the Malaria Crisis:

In 2003 indigenous health workers of the Karen Department of Health and Welfare (KDHW) initiated, with technical assistance from GHAP, a pilot malaria control program in conflict affected areas of eastern Burma. The program was based on the three primary principles of WHO's Roll Back Malaria Initiative: Early Diagnosis and Treatment, Vector Control, and Education. Because of extensive drug resistance the program used an artemisinin combination therapy (ACT) recommended by the regional Thai-Burma Border Guidelines. Vector Control is achieved by distributing Long-Lasting Insecticide Treated Nets (LLITNs) to each household. The program enlisted support from the local population by establishing Malaria Committees in each village, which assist with education and monitoring of LLITN use. In the first two years of the Pilot Malaria Control Program, the burden of malaria (as measured by prevalence) decreased by more than 90%.

The program provides a sustainable and affordable solution to malaria control because the substantial reduction in transmission results in savings that can be translated into further expansion, or shifted to alternative health promotion activities. Due to the dramatic ability to save lives, GHAP and local ethnic minority health organizations intend to expand this unique malaria intervention as rapidly as possible.

Scaling Up

Building upon the dramatic success of the Pilot Program, KDHW rapidly expanded its Malaria Control Program (MCP) to reach 40,000 IDPs in over 50 villages by January 2007. Malaria prevalence remains consistently lower in program villages compared to villages before implementing MCP interventions -- and no malaria-related deaths were recorded in the four years from 2003-2006.

The rapid scale-up of the MCP provides an exemplary model of capacity building and sustainability for other programs. The health workers of KDHW are particularly proud of the malaria control program not only because of its remarkable success in reducing the burden of malaria, but because the health workers themselves have taken full ownership of all program activities. Whereas initial trainings were organized by GHAP volunteers and translated from English, malaria workshops are now organized by experienced health workers and are conducted almost entirely in Burmese. This successful trainer-training, whereby participant trainees are empowered in turn to train their peers, facilitates what health educators refer to as "geometric human resource growth" and allows for a rapid increase in human resource capacity for health.

Improving Access

Improving Access with Ethnic Community Health Workers

In some areas of Burma, local ethnic health organizations have a relative advantage over large international organizations when navigating the constrained political landscape of humanitarian assistance under the military regime.

For example, the international humanitarian organization Medecins Sans Frontiers (MSF) attempted to respond to the malaria crisis in conflict areas of eastern Burma but was forced to cease its operations due to constraints on its movement imposed by the junta.

In contrast to the experience of MSF, KDHW is able to circumvent the restrictions of the junta, and continues to expand its malaria program.

Village Health Workers: Delivering Malaria Control Interventions to IDPs Without Access to a Health Worker

Malaria program health workers of the KDHW are extending the training-of-trainer model to the village level by training Village Health Workers (VHW). Villagers have participated from the beginning of the malaria program by delivering educational messages and conducting house visits to monitor utilization of mosquito nets; but starting in early 2007, lay villagers are learning from indigenous health workers how to diagnose and treat malaria. Village health workers will greatly enhance the ability of the MCP to rapidly diagnose and treat malaria, which is the key to preventing morbidity and mortality in remote areas.

China-Burma Border

Based upon the success of the KDHW malaria control program, GHAP began a similar MCP in Kachin state along the China-Burma border. Partnering with the Kachin health department, GHAP is building the capacity of local health workers to screen target populations for Plasmodium falciparum, the deadliest strain of the malaria parasite, treat using ACT, and distribute insecticide treatment to impregnate regular bed nets. Starting with 2 pilot villages in 2006, the program has expanded to cover 9 villages in 2007, reaching over 5,000 people.

Fewer security and political constraints allow the health workers to implement the program in more stable settings, i.e. "rural health centers," which allows for the use of field microscopy. Despite the low cost of rapid diagnostic test kits used in less stable areas (less than $1 per kit), microscopy costs less in the long run, and is able to confirm the diagnosis of other malaria parasites such as Plasmodium vivax.

Like the program on the Thai-Burma border, health workers return bi-annually to report their screening and treatment cases, and take refresher courses in malaria diagnosis and treatment and program monitoring. Older, more experienced malaria health workers are invited and encouraged to train the newer trainees in various program aspects.

The local health department is also taking initiative to educate and discourage the villagers about the existence of fake anti-malarials, known to be sold in abundance throughout Burma.

So far, the malaria prevalence in the pilot areas dramatically decreased from 12% to about 1% in less than one year. The overall number of people coming to the rural health centers seeking malaria treatment has also fallen dramatically.

Unlike the less stable populations of Karen state, the Kachin have marketplace access to acquire untreated bednets. Rather than purchasing expensive, long-lasting ITNS, the MCP decided instead to emphasize treating used bednets that most families seem to have in abundance. To this end, village education campaigns were initiated to encourage communities to treat their existing nets with KO-Tab insecticide treatment.

India-Burma Border

In January 2007, GHAP brought together several different ethnic minority groups from the India-Burma border for a health workshop, during which a "border" malaria control program was initiated. Represented groups included the Chin, Rakhaing, Naga, Kuki, Zomi and Mara. This unique public health partnership was the first time that some of these groups had come together to forge any collaboration. The main objective of the health workshop was to define which areas to target as malaria control areas. All health workers were trained in village screening methodology, diagnoses and treatment, data collection, and distributing Vitamin A.

Malaria control is only one of several major health issues along this border, but we hope to leverage this partnership with local and state health departments to tackle other public health issues.

Advocacy

Cross-border health care delivery creates many barriers, not least of which is the complex web of international regulations governing the purchase of the materials that make for successful interventions. Planet Care/GHAP continues to advocate for cheaper high quality supplies and antimalarials for our partners on all borders. Falling per-treatment costs will enable PC/GHAP and our partners to further leverage donor support to expand effective malaria control interventions to the most vulnerable populations along Burma's borders.

GHAP volunteers and our partners are showing the world that malaria control run by and for indigenous people in the poorest and remotest areas of southeast Asia is possible, including among IDPs living in areas of active conflict.

The successes of the malaria control program have been presented at numerous conferences, including the Global Health Council, Johns Hopkins University, Emory University Conference on Health and Human Rights, and the conference on Infectious diseases in the border regions of southeast Asia co-sponsored by GHAP.

Presentations have also been made at numerous US medical schools, schools of public health, and professional organizations including but not limited to: University of Southern California, UCLA, Johns Hopkins, Montefiore Medical Center, George Washington University, Mount Sinai School of Medicine (New York), Physicians for Social Responsibility, MSF, and PATH.

Results from malaria surveys and the malaria program have also been accepted for publication in peer-reviewed journals, and have been included in briefing reports to the US Congress and UK House of Commons.

Planet Care/GHAP is also at the forefront of exploring associations between malaria and exposure to human rights violations, such as forced migration, forced labor, landmines, and food insecurity.

Next Steps

Since consolidating its position and assuring high quality of care in new program villages, the KDHW is once again scaling up its malaria program, with the goal of reaching its entire target population of 90,000 in the near future.

In addition, in 2007 GHAP began providing technical training and monitoring and evaluation expertise for malaria control programs organized by the Backpack Health Worker Team (BPHWT) and the Burma Medical Association (BMA). This will increase the combined target population of PC/GHAP affiliated malaria control programs in eastern Burma to over 250,000.

Planet Care/GHAP continues to evaluate with our local partners the most cost-effective way to reduce malaria transmission in the complex ecological and political environment of Burma. In addition to cheaper, high quality materials and antimalarials, PC/GHAP is exploring ways to bring our partners from each border together so that they might learn from each other and develop a network of Burma-border malaria control programs to share successes and leverage purchasing power and advocacy.

As in all our programs, we cover administrative expenses so that 100% of donations to the malaria program go directly to our partners and the implementation of effective life-saving interventions.

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