Exploring sub-national health system readiness for malaria elimination in the Greater Mekong Subregion: a qualitative study

Technical Summary: Exploring Sub-National Health System Readiness for Malaria Elimination in the Greater Mekong Subregion

Problem Statement
Countries within the Greater Mekong Subregion (GMS)—Cambodia, Lao PDR, Myanmar, Thailand, and Vietnam—have committed to eliminating malaria by 2030. While national-level political commitment and strategic frameworks exist, the transition from malaria control to elimination requires robust health systems capable of rapid adaptation. A critical gap identified is that national-level readiness does not automatically translate to adequate preparedness at sub-national levels (provincial, district, and township). Without well-functioning sub-national systems, the implementation of elimination strategies—specifically reactive surveillance and response—may be hindered, risking a resurgence of cases and jeopardizing the 2030 certification goal. Previous research has addressed national-level needs, but the specific operational requirements and bottlenecks at the sub-national level remain under-explored.

Methodology
This study employed a qualitative approach to assess sub-national health system readiness across the GMS.

• Data Collection: Semi-structured interviews were conducted with 39 purposively recruited stakeholders between August 2023 and September 2024. Participants included national policymakers (n=5), Ministry of Health personnel (n=12), managers and field supervisors from malaria implementing partners (n=16), and representatives from technical agencies and research institutions (n=6). Recruitment ceased upon data saturation.
• Analysis: Audio recordings were transcribed verbatim and analyzed using reflexive thematic analysis in NVivo version 15. The analysis utilized a combined deductive-inductive approach. Deductive themes were derived from the World Health Organization's (WHO) six health system building blocks framework: service delivery, surveillance, elimination workforce, products and commodities, programme financing, and leadership and governance. Inductive themes emerged during the coding process to capture context-specific nuances.
• Reporting: The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Key Contributions and Results
The study identifies specific health system needs and existing challenges across the six WHO building blocks at the sub-national level:

1. Service Delivery:

   • Needs: Universal access to services for at-risk populations (e.g., mobile/migrant populations, forest goers) and sustained community participation.
   • Challenges: Service disruptions due to difficult terrain, weather, and migration patterns. As case loads decline, community interest wanes, leading to reduced health-seeking behavior for febrile illnesses.
   • Findings: Stakeholders emphasized the need for community-delivered models (e.g., village health volunteers) and innovative communication strategies using digital platforms to maintain engagement.

2. Surveillance:

   • Needs: Timely implementation of reactive surveillance and response (within 7 days of diagnosis) and proper documentation for WHO certification.
   • Challenges: Delays in response activities caused by staff shortages, lack of operational funds, and logistical barriers (poor roads, lack of telecom). Documentation is hindered by inadequate storage infrastructure (flood damage, lack of cabinets) and technical issues with electronic systems (power outages, server errors).
   • Findings: Evidence of interrupted transmission requires three years of complete documentation, which is currently compromised in some areas due to record loss.

3. Elimination Workforce:

   • Needs: A dedicated workforce with strong technical capacity (microscopy, entomology) and adequate staffing levels.
   • Challenges: Significant staff shortages, high turnover, and overburdening of existing staff who manage multiple disease programs. Technical capacity is often insufficient for complex elimination tasks.
   • Findings: Stakeholders suggested task-shifting certain activities to village health volunteers, though concerns remain regarding their technical literacy and supervision. Job satisfaction and non-monetary recognition were cited as crucial for retention.

4. Products and Commodities:

   • Needs: Uninterrupted supply of quality diagnostics, medicines, and vector control tools, along with proper storage conditions.
   • Challenges: Frequent stock-outs of rapid diagnostic tests, antimalarials, and insecticides. Storage conditions are often suboptimal due to irregular power supply and lack of climate control (temperature/humidity monitoring).
   • Findings: Relocation of commodities between facilities is a practical solution but is often hindered by administrative red tape.

5. Programme Financing:

   • Needs: Adequate budget for elimination activities and flexible funding mechanisms for emergencies.
   • Challenges: Lengthy approval processes and administrative red tape prevent timely responses to unexpected case surges.
   • Findings: Stakeholders called for responsive emergency funding to bypass bureaucratic delays during outbreaks.

6. Leadership and Governance:

   • Needs: Strong partnership and coordination between National Malaria Elimination Programmes (NMEPs) and other sectors (private clinics, military, industry).
   • Challenges: Coordination is often irregular or ad-hoc.
   • Findings: Establishing formal, regular coordination mechanisms (e.g., quarterly meetings) is recommended to improve data quality and resource sharing.

Significance and Claims
The paper claims that successful malaria elimination in the GMS is contingent upon translating national political commitment into effective action through well-prepared sub-national health systems. The study provides a comprehensive evaluation of sub-national readiness, highlighting that gaps in any of the six WHO building blocks can hinder progress toward the 2030 goal.

The authors assert that their findings offer policy recommendations to strengthen sub-national systems, specifically by addressing service disruptions, staffing gaps, supply chain inefficiencies, and coordination failures. They propose that these insights should inform the development of a standardized yet adaptable health system readiness assessment tool. Such a tool would enable policymakers and program managers to identify specific local gaps and design tailored interventions. The study concludes that without addressing these sub-national health system issues, the regional goal of malaria elimination by 2030 and subsequent WHO certification will be difficult to achieve.

Note: The study acknowledges limitations, including the absence of certain stakeholder groups (e.g., Cambodian stakeholders, military representatives, and frontline volunteers from specific countries) due to administrative constraints, which may introduce selection bias. Triangulation with policy documents and literature was used to mitigate this.