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Malaria Community Health Workers (CHWs) in the Greater Mekong Subregion (GMS) are an important component of malaria elimination efforts. As malaria declines with intensified efforts to eliminate by 2030, expanding their roles beyond malaria could help to sustain funding and provision of malaria services at the community level. Evidence of how programmes have implemented and managed CHWs performing both malaria and non-malaria roles across the Asia-Pacific region can provide insight into the viability of this strategy. A short survey was distributed to national malaria programmes and implementing organizations in the Asia-Pacific region in 2021-2022. The survey identified CHW programmes in the region, and collected information on malaria and non-malarial services provided by CHWs, characteristics of each identified programme, and the impact of COVID-19 on these programmes. 35 survey responses identified 28 programmes in 14 countries. The most frequently reported services provided by malaria CHWs were health promotion and education for malaria (13/14 countries) and other diseases (11/14); and COVID-19 related activities (10/14). Most programmes were financed wholly through donor funding (18/28 programmes), or donor plus government funding (6/28). Of 21 programmes which performed programme evaluation, only 2 evaluated their impacts on diseases beyond malaria. Declining donor funding, and COVID-19 related travel and activity restrictions were identified as implementation challenges. CHWs across the Asia Pacific provide a range of health services with malaria and are resilient under changing public health landscapes such as the COVID-19 pandemic. Further investigation into the impact of additional roles on malaria CHW performance and targeted health outcomes is needed to verify the benefits and feasibility of role expansion. As the GMS approaches elimination, and funding declines, verifying the cost effectiveness of malaria CHW programmes will be vital to persuade donors and countries to invest in malaria CHWs to sustain malaria services, and strengthen community-based health care.

BackgroundIn Vietnam, multiple types of community-based malaria workers are recruited to promote access to malaria testing and treatment for at-risk mobile and migrant populations. However, as the country approaches elimination, these roles are at risk from declining investment. This article characterises the different types of workers and relevant health policy in Vietnam, and explores stakeholder perspectives on sustaining and expanding the roles of these workers in the malaria elimination context.MethodsWe conducted a rapid policy document review to describe the policy background of community-based health care in Vietnam and identify key informants. In-depth interviews were conducted with policymakers and implementers (n = 11) in different government sectors, international, and civil society organizations. We also conducted interviews (n = 8) and two focus group discussions with community members (n = 12), and interviews with health workers (n = 9) in 18 communities in Phu Yen and Binh Thuan provinces in the central region.ResultsOur study identified three main types of malaria workers: village health workers (VHWs), malaria post workers (MPWs) and other groups of workers supported by civil society organisations (CSO). Workers reported being willing to maintain their current roles and potentially provide additional services that respond to community needs, although they were concerned about excess workload and inadequate income. Besides working in a variety of jobs to secure their incomes, mainly in agriculture, VHWs in particular were primarily tasked with supporting the delivery of a wide range of health services from commune health stations. Faced with reduced patients, MPWs and CSO-supported workers could be tasked with the following potential roles: case notification for infectious diseases, real-time data collection and reporting, and screening for non-malaria illnesses using other rapid test kits. There was agreement that the community-based health network is crucial to health care delivery in remote communities and to ensure comprehensive access to care among vulnerable populations. However, policymakers and implementers stressed concerns about their limited skillsets, the inadequate budget to support these workers, and the regulation constraining them from performing diagnosis and treatment activities, highlighting the priority to maintain the capacity of workers and funding allocation through provincial advocacy and multi-programme collaboration.ConclusionsThis study highlights the crucial role of community-based health workers in eliminating malaria in Vietnam. Sustained efforts are needed to maintain accessible case detection and treatment while addressing local health concerns beyond malaria. Implementing these strategies requires prioritizing the mapping of groups most in need and developing enablers to raise community awareness and maintain the capacity of these workers. Ensuring political advocacy, financial resources, and coordination between multiple groups are key to maximizing impact and integrating malaria activities into the broader health system.

Abstract Background Malaria transmission in Southeast Asia is increasingly confined to forests, where marginalized groups are exposed primarily through their work. Anti-malarial chemoprophylaxis may help to protect these people. This article examines the effectiveness and practical challenges of engaging forest-goers to participate in a randomized controlled clinical trial of anti-malarial chemoprophylaxis with artemether-lumefantrine (AL) versus a control (multivitamin, MV) for malaria in northeast Cambodia. Methods The impact of engagement in terms of uptake was assessed as the proportion of people who participated during each stage of the trial: enrolment, compliance with trial procedures, and drug intake. During the trial, staff recorded the details of engagement meetings, including the views and opinions of participants and community representatives, the decision-making processes, and the challenges addressed during implementation. Results In total, 1613 participants were assessed for eligibility and 1480 (92%) joined the trial, 1242 (84%) completed the trial and received prophylaxis (AL: 82% vs MV: 86%, p = 0.08); 157 (11%) were lost to follow-up (AL: 11% vs MV: 11%, p = 0.79); and 73 (5%) discontinued the drug (AL-7% vs MV-3%, p = 0.005). The AL arm was associated with discontinuation of the study drug (AL: 48/738, 7% vs 25/742, 3%; p = 0.01). Females (31/345, 9%) were more likely (42/1135, 4%) to discontinue taking drugs at some point in the trial (p = 0.005). Those (45/644, 7%) who had no previous history of malaria infection were more likely to discontinue the study drug than those (28/836, 3%) who had a history of malaria (p = 0.02). Engagement with the trial population was demanding because many types of forest work are illegal; and the involvement of an engagement team consisting of representatives from the local administration, health authorities, community leaders and community health workers played a significant role in building trust. Responsiveness to the needs and concerns of the community promoted acceptability and increased confidence in taking prophylaxis among participants. Recruitment of forest-goer volunteers to peer-supervise drug administration resulted in high compliance with drug intake. The development of locally-appropriate tools and messaging for the different linguistic and low-literacy groups was useful to ensure participants understood and adhered to the trial procedures. It was important to consider forest-goers` habits and social characteristics when planning the various trial activities. Conclusions The comprehensive, participatory engagement strategy mobilized a wide range of stakeholders including study participants, helped build trust, and overcame potential ethical and practical challenges. This locally-adapted approach was highly effective as evidenced by high levels of trial enrolment, compliance with trial procedures and drug intake.

Abstract Background Across the Greater Mekong Subregion, malaria remains a dangerous infectious disease, particularly for people who visit forested areas where residual transmission continues. Because vector control measures offer incomplete protection to forest goers, chemoprophylaxis has been suggested as a potential supplementary measure for malaria prevention and control. To implement prophylaxis effectively, additional information is needed to understand forest goers’ activities and their willingness to use malaria prevention measures, including prophylaxis, and how it could be delivered in communities. Drawing on in-depth interviews with forest goers and stakeholders, this article examines the potential acceptability and implementation challenges of malaria prophylaxis for forest goers in northeast Thailand. Methods In-depth interviews were conducted with forest goers (n = 11) and stakeholders (n = 16) including healthcare workers, community leaders, and policymakers. Interviews were audio-recorded, transcribed and coded using NVivo, employing an inductive and deductive approach, for thematic analysis. Results Forest goers were well aware of their (elevated) malaria risk and reported seeking care for malaria from local health care providers. Forest goers and community members have a close relationship with the forest but are not a homogenous group: their place and time-at-risk varied according to their activities and length of stay in the forest. Among stakeholders, the choice and cost of anti-malarial prophylactic regimen—its efficacy, length and complexity, number of tablets, potential side effects, and long-term impact on users—were key considerations for its feasibility. They also expressed concern about adherence to the preventive therapy and potential difficulty treating malaria patients with the same regimen. Prophylaxis was considered a low priority in areas with perceived accessible health system and approaching malaria elimination. Conclusions In the context of multi-drug resistance, there are several considerations for implementing malaria prophylaxis: the need to target forest goers who are at-risk with a clear period of exposure, to ensure continued use of vector control measures and adherence to prophylactic anti-malarials, and to adopt an evidence-based approach to determine an appropriate regimen. Beyond addressing current intervention challenges and managing malaria incidence in low-transmission setting, it is crucial to keep malaria services available and accessible at the village level especially in areas home to highly mobile populations.

Abstract Background Despite significant decline in malarial incidence and mortality in countries across the Greater Mekong Subregion, the disease remains a public health challenge in the region; transmission continues mainly among people who visit forests in remote areas, often along international borders, where access to primary healthcare is limited. In the absence of effective vector-control measures and limited exposure periods, malaria chemoprophylaxis has been proposed as a strategy to protect forest goers. As a rarely used approach for indigenous populations, questions remain about its feasibility and acceptability. Drawing on in-depth interviews with forest goers and stakeholders, this article examines opportunities and challenges for implementation of anti-malarial chemoprophylaxis for forest goers in Lao PDR. Methods In-depth interviews were conducted with 16 forest goers and 15 stakeholders in Savannakhet province, Lao PDR. Interview topics included experience of malaria prevention and health services, and perceptions of prophylaxis as a potential component of malaria elimination strategy. The interviews were transcribed and coded using inductive and deductive approaches for qualitative thematic analysis. Results In ethnically and geographically diverse villages, awareness of malaria risk prompts forest goers to protect themselves, albeit sub-optimally using available preventive measures. Stakeholders highlighted challenges for targeting at-risk populations and approaches to address forest malaria in southern Lao PDR. Among policymakers, choice and cost of anti-malarials, particularly their efficacy and source of funding, were key considerations for the feasibility of malaria prophylaxis. Acceptability of prophylaxis among forest goers was also influenced by the complexity of the regimen, including the number of tablets and timing of doses. Implementation of prophylaxis may be affected by a lack of transportation and communication barriers in remote communities. Conclusion Adding prophylaxis to existing malaria control activities requires strengthening the capacity of local health workers in Lao PDR. Ideally, this would be part of an integrated approach that includes strategies to address the other febrile illnesses that forest goers describe as priority health concerns. The prophylactic regimen also requires careful consideration in terms of effectiveness and simplicity of dosing.

Abstract Background In the Greater Mekong Subregion, adults are at highest risk for malaria, particularly those who visit forests. The absence of effective vector control strategies and limited periods of exposure during forest visits suggest that chemoprophylaxis could be an appropriate strategy to protect forest goers against malaria. Methods Alongside a clinical trial of anti-malarial chemoprophylaxis in northern Cambodia, qualitative research was conducted, including in-depth interviews and observation, to explore the acceptability of malaria prophylaxis for forest goers, the implementation opportunities, and challenges of this strategy. Results Prophylaxis with artemether–lumefantrine for forest goers was found to be acceptable under trial conditions. Three factors played a major role: the community’s awareness and perception of the effectiveness of prophylaxis, their trust in the provider, and malaria as a local health concern. The findings highlight how uptake and adherence to prophylaxis are influenced by the perceived balance between benefits and burden of anti-malarials which are modulated by the seasonality of forest visits and its influence on malaria risk. Conclusions The implementation of anti-malarial prophylaxis needs to consider how the preventive medication can be incorporated into existing vector-control measures, malaria testing and treatment services. The next step in the roll out of anti-malarial prophylaxis for forest visitors will require support from local health workers.

Substandard and falsified (SF) antimalarials have devastating consequences including increased morbidity, mortality and economic losses. Portable medicine quality screening devices are increasingly available, but whether their use for the detection of SF antimalarials is cost-effective is not known. We evaluated the cost-effectiveness of introducing such devices in post-market surveillance in pharmacies in Laos, conservatively focusing on their outcome in detecting SF artemisinin-based combination therapies (ACTs). We simulated the deployment of six portable screening devices: two handheld near-infrared [MicroPHAZIR RX, NIR-S-G1], two handheld Raman [Progeny, TruScan RM]; one portable mid-infrared [4500a FTIR] spectrometers, and single-use disposable paper analytical devices [PADs]. We considered two scenarios with high and low levels of SF ACTs. Different sampling strategies in which medicine inspectors would test 1, 2, or 3 sample(s) of each brand of ACT were evaluated. Costs of inspection including device procurement, inspector time, reagents, reference testing, and replacement with genuine ACTs were estimated. Outcomes were measured as disability adjusted life years (DALYs) and incremental cost-effectiveness ratios were estimated for each device compared with a baseline of visual inspections alone. In the scenario with high levels of SF ACTs, all devices were cost-effective with a 1-sample strategy. In the scenario of low levels of SF ACTs, only four devices (MicroPHAZIR RX, 4500a FTIR, NIR-S-G1, and PADs) were cost-effective with a 1-sample strategy. In the multi-way comparative analysis, in both scenarios the NIR-S-G1 testing 2 samples was the most cost-effective option. Routine inspection of ACT quality using portable screening devices is likely to be cost-effective in the Laos context. This work should encourage policy-makers or regulators to further investigate investment in portable screening devices to detect SF medicines and reduce their associated undesired health and economic burdens.