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Abstract
BackgroundDespite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most ‘hard-to-reach’, such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment. As such, regional malaria elimination strategies endeavour to incorporate the private sector and local communities in improving surveillance and detection of the last malaria cases in remote forested areas. The question remains, however, whether such strategies can reach these hard-to-reach populations and effectively reduce their disproportionate burden of malaria. This paper evaluates the strategy of community and private sector engagement in a malaria elimination project in Vietnam, Laos, and Cambodia.MethodsEthnographic research, incorporating in-depth interviews, participant observations with informal discussions, and group discussions were conducted in Bu Gia Map commune, Binh Phuc province of Vietnam; in Phouvong district, Attapeu province of Laos; and, in nine newly established and informal communities in the provinces of Mondul Kiri, Steung Treng, Kratie, Kampong Thom, and Prah Vihear of Cambodia.ResultsDifferent types of factors limited or enhanced the effectiveness of the participatory approaches in the different settings. In Vietnam, inter-ethnic tensions and sensitivity around forest-work negatively affected local population’s health-seeking behaviour and consequent uptake of malaria testing and treatment. In Laos, the location of the project collaborative pharmacies in the district-centre were a mismatch for reaching hard-to-reach populations in remote villages. In Cambodia, the strategy of recruiting community malaria-workers, elected by the community members, did manage to reach the remote forested areas where people visited or stayed.Conclusions‘Hard-to-reach’ populations remain hard to reach without proper research identifying the socio-economic-political environment and the key dynamics determining uptake in involved communities and populations. Solid implementation research with a strong ethnographic component is required to tailor malaria elimination strategies to local contexts.
Highlights
Despite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most ‘hard-to-reach’, such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment
As the World Health Organization (WHO) states that engaging community service providers, who are often volunteers from communities, is the best solution to provide services in remote areas [7], the Greater Mekong Subregion (GMS) strategy of placing greater emphasis on community engagement strives to further increase this access to malaria control measures for these hard-to-reach populations
Case study 1: inter‐ethnic relations, Bu Gia Map commune, Vietnam Study participants A total of 71 in-depth interviews and participant observations with 40 informal conversations were conducted with public/private health staff, village health workers (VHWs), Population Service International (PSI) malaria-worker, pharmacists, ex/current malaria patients, families of patients, forest plantation workers, forest security guards, pastors, and groceryshop and cafe owners
Summary
Despite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most ‘hard-to-reach’, such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment. As a high proportion of malaria cases are asymptomatic in the GMS [1, 3], and are unlikely to actively seek care [15], relying only on passive case detection at the public health facilities presents serious limitations for early diagnosis and treatment In this way, the public–private mix approach attempts to increase access to early diagnosis and treatment, to improve malaria case reporting from the private sector, and to ensure the quality of service at both public and private sectors by standardizing care and regular monitoring [7, 16]. As the WHO states that engaging community service providers, who are often volunteers from communities, is the best solution to provide services in remote areas [7], the GMS strategy of placing greater emphasis on community engagement strives to further increase this access to malaria control measures for these hard-to-reach populations
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