Development of the Systems Tool for Readiness, Implementation anD malaria Elimination (STRIDE): an online Delphi study

In the lush, humid landscapes of the Greater Mekong Subregion, a quiet race is underway against a disease that has long plagued the area. Five nations—Cambodia, Laos, Myanmar, Thailand, and Vietnam—have made a solemn promise to the World Health Organization: they will eliminate malaria entirely by the year 2030. This is not merely a goal of stopping new infections; it is a commitment to eradicating the parasite from the region's ecosystems forever. To achieve this, these countries have already deployed powerful strategies, such as ensuring every sick person gets tested and treated immediately, and using specialized medicines to cure a stubborn form of the disease that hides in the liver. However, a strategy is only as strong as the system that carries it. Just as a ship cannot sail without a hull, a medical plan cannot succeed without a health system ready to support it. This system must have enough trained staff, reliable supplies of medicine and tests, a way to track every single case, and the money to keep everything running. If any part of this foundation is weak, the entire effort to wipe out the disease could crumble.

For years, experts have known that these health systems need to be strong, but they lacked a single, complete tool to measure exactly how ready they were. Existing checklists were like trying to fix a house by only checking the roof or only the plumbing; they missed the big picture. Some tools looked at the technical side of malaria but ignored the people and the money needed to run the program. Others looked at general health but were too broad to catch the specific needs of malaria elimination. Without a clear way to see where the cracks were, leaders were often guessing which parts of their system needed the most help. This uncertainty made it difficult to turn political promises into real, on-the-ground action.

To solve this problem, a team of researchers set out to build a new measuring stick, a comprehensive guide they named STRIDE. This tool was designed to act as a full-body scan for a country's health system, checking every vital organ from the top level of national policy down to the local village clinic. The researchers knew that creating such a tool required more than just writing questions; it needed the collective wisdom of the people who actually fight malaria every day. They gathered a panel of twenty-four experts, including leaders from national health programs, donors, and independent specialists, all with deep experience in the region. These experts were asked to review a draft of the tool, rating each question on whether it was truly relevant to measuring readiness.

The process was rigorous and iterative. In the first round of review, the experts found that while the draft was a good start, many of the questions were too vague. Terms like "high transmission areas" were open to interpretation, and some questions asked about two different things at once, which could confuse the people filling out the survey. The experts also felt that some of the ways to answer the questions were too subjective, relying on feelings rather than facts. For instance, instead of asking a manager to guess how often they provided feedback, the experts suggested asking for a specific schedule, like "weekly" or "monthly." Based on this feedback, the researchers rewrote the questions, added new ones that the experts felt were missing, and removed those that were redundant or irrelevant.

After refining the draft, the team sent it back to the experts for a second round of review. This time, the panel agreed that the tool had become much sharper and more useful. They endorsed the vast majority of the questions, confirming that the tool could now accurately assess the six critical building blocks of a health system: how services are delivered, how diseases are watched and tracked, the strength of the workforce, the availability of medicines and tools, the flow of money, and the leadership that guides it all. The final result was a two-part toolkit. The first part, the National Module, contains sixty-six questions designed for high-level officials to check the big-picture policies and strategies. The second part, the Sub-National Module, has fifty-five questions for field leaders to check the day-to-day operations, such as whether clinics have enough test kits or if the staff are trained properly.

The researchers tested the final tool to ensure it was scientifically sound. They calculated how well each question represented the concept of "readiness," and the results showed that the tool was excellent. Every single question was rated as highly relevant by the experts, and the tool as a whole was judged to be a very reliable way to measure what it was supposed to measure. This means that when a country uses STRIDE, they can trust the results to show them exactly where their health system is strong and where it is weak.

The value of this new tool lies in its ability to turn vague concerns into clear data. By using STRIDE, health leaders can stop guessing and start knowing. They can see, for example, that while their national policy is perfect, their local clinics are running out of essential medicines, or that their surveillance system is good at finding cases but bad at responding to them quickly. This clarity allows them to fix specific problems before they become crises. The researchers acknowledge that this tool is a starting point; it has been validated by experts, but it still needs to be tested in the real world to see how well it works in different countries and under different conditions. However, by providing a standardized way to measure readiness, STRIDE offers a crucial step forward. It gives the nations of the Greater Mekong Subregion a way to ensure their health systems are truly ready to keep their promise of a malaria-free future.