**3. Establish mission leadership with enough authority, respect, expertise and functional funding**

We urge Bill & Melinda Gates Foundation, the US government and the Asian Development Bank to fill the leadership vaccuum at the operational level, as the newly resistant parasites, if they reach Africa, will make the goal of malaria eradication very much more challenging. We believe these are the only organizations with the authority, resources, and respect to make this happen. Local governmental personnel with the responsibility for the mission must be empowered. Future, on-the-ground non-govermental leadership must be carefully selected to ensure they have the needed commitment, authority, respect, and expertise to be effective [41]. The WHO Emergency Response to Artemisinin Resistance (ERAR) in the GMS hub was established in 2013 [59] to strengthen the response to artemisinin resistant malaria by coordinating action, technical leadership and catalyzing resource mobilization. The ERAR hub was "transitioned" to the Mekong Malaria Elimination program in 2016 [60]. Why containment failed must be objectively evaluated to insure that the new leadership is effective. Public Health Emergency Operations Centers could be a good solution [61].

The elimination of malaria is not as difficult as it appears on the surface. It boils down to prevention and effective treatment of malaria patients in or traveling from the actual transmission foci. GMS original forest areas are now shrinking, which is making the mission easier. Bill Gates himself and others have effectively outlined the actions needed [41, 55]. Cambodia is the epicenter of emerging incurable malaria; the needed policies and guidelines are now in place in this country [24, 62]. What is needed now is quality implementation of relatively straightforward interventions in the field. In 2013, the RAI, a three-year \$100 million grant, was launched by the Global Fund (GF) to contain artemisinin-resistant malaria (http://www.raifund.org/). Many of the key impediments were clearly outlined in the 2015 RAI mid-term report [3]. Unfortunately, we were denied permission by Global Fund leadership to publish the conclusions and recommendations from their report in this chapter (A Joubert, personal communication). We were allowed to publish only the map, which revealed Pf was going up at that time (**Figure 3**).

essential to achieve elimination targets. Our new "Red-to-Green, Keep-It-Green" Information System is an example of the ability to provide near real-time feedback to leadership with image and video documentation of what is really happening in the field (see Section 5.1.1) for

**Figure 3.** Pf caseload increase between July 2014–June 2015 [3]. Malaria was again rising in 2017–2018 in several

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GF is by far the largest investor in malaria in the region; their funding, however, is not nearly as effective as it could be for malaria in the GMS, especially in Cambodia. GF has evolved to be a mega-donor. As with all large organizations, this brings bureaucracy; in addition, it has the added challenge of accountabilty for very large sums of money. Malaria in the GMS represents only a small part of the overall portofolio, but has the same rules that apply to all funding, impacting timely and effective intervention implementation. For example, a sub-contractor receiving Presidential Malaria Initiative (PMI) funding reports PMI funds are hard to use, but

both independent quality monitoring and supportive supervision.

provinces of Cambodia.

With a new leadership team, given a passion for the mission, along with authority, expertise and sufficient/effective funding, we strongly believe that Pf elimination goals can be achieved near to the WHO targets in the GMS [24]. Determining if the RAI mid-term review results have been effectively addressed should be top priority [3]. The results of routine, truly independent quality monitoring from the field must be a key component. Quality monitoring must focus on what is most important (e.g., effective prevention and treatment in actual transmission foci). Targeted supportive supervision for partners experiencing implementation challenges is also Preparing for the Next Global Threat: A Call for Targeted, Immediate Decisive Action… http://dx.doi.org/10.5772/intechopen.78261 49

numbers of their troops in Northeast India and Eastern Bangladesh, where these parasites will first arrive, and are currently the 2nd and 3rd largest contributors to international peacekeeping missions [58]. Third, a coordinated international response is absolutely required to manage this risk. In SEA, there are now fortunately few deaths from malaria. Leadership here has other pressing health issues to address, with malaria now becoming a low priority. Both international leadership and assistance for the countries involved, especially with security forces, is

We urge Bill & Melinda Gates Foundation, the US government and the Asian Development Bank to fill the leadership vaccuum at the operational level, as the newly resistant parasites, if they reach Africa, will make the goal of malaria eradication very much more challenging. We believe these are the only organizations with the authority, resources, and respect to make this happen. Local governmental personnel with the responsibility for the mission must be empowered. Future, on-the-ground non-govermental leadership must be carefully selected to ensure they have the needed commitment, authority, respect, and expertise to be effective [41]. The WHO Emergency Response to Artemisinin Resistance (ERAR) in the GMS hub was established in 2013 [59] to strengthen the response to artemisinin resistant malaria by coordinating action, technical leadership and catalyzing resource mobilization. The ERAR hub was "transitioned" to the Mekong Malaria Elimination program in 2016 [60]. Why containment failed must be objectively evaluated to insure that the new leadership is effective. Public

The elimination of malaria is not as difficult as it appears on the surface. It boils down to prevention and effective treatment of malaria patients in or traveling from the actual transmission foci. GMS original forest areas are now shrinking, which is making the mission easier. Bill Gates himself and others have effectively outlined the actions needed [41, 55]. Cambodia is the epicenter of emerging incurable malaria; the needed policies and guidelines are now in place in this country [24, 62]. What is needed now is quality implementation of relatively straightforward interventions in the field. In 2013, the RAI, a three-year \$100 million grant, was launched by the Global Fund (GF) to contain artemisinin-resistant malaria (http://www.raifund.org/). Many of the key impediments were clearly outlined in the 2015 RAI mid-term report [3]. Unfortunately, we were denied permission by Global Fund leadership to publish the conclusions and recommendations from their report in this chapter (A Joubert, personal communication). We were allowed to publish only the map, which revealed Pf was going up at that time (**Figure 3**).

With a new leadership team, given a passion for the mission, along with authority, expertise and sufficient/effective funding, we strongly believe that Pf elimination goals can be achieved near to the WHO targets in the GMS [24]. Determining if the RAI mid-term review results have been effectively addressed should be top priority [3]. The results of routine, truly independent quality monitoring from the field must be a key component. Quality monitoring must focus on what is most important (e.g., effective prevention and treatment in actual transmission foci). Targeted supportive supervision for partners experiencing implementation challenges is also

needed to ensure proper response to this peril most directly threatening Africa.

**3. Establish mission leadership with enough authority, respect,** 

Health Emergency Operations Centers could be a good solution [61].

**expertise and functional funding**

48 Towards Malaria Elimination - A Leap Forward

**Figure 3.** Pf caseload increase between July 2014–June 2015 [3]. Malaria was again rising in 2017–2018 in several provinces of Cambodia.

essential to achieve elimination targets. Our new "Red-to-Green, Keep-It-Green" Information System is an example of the ability to provide near real-time feedback to leadership with image and video documentation of what is really happening in the field (see Section 5.1.1) for both independent quality monitoring and supportive supervision.

GF is by far the largest investor in malaria in the region; their funding, however, is not nearly as effective as it could be for malaria in the GMS, especially in Cambodia. GF has evolved to be a mega-donor. As with all large organizations, this brings bureaucracy; in addition, it has the added challenge of accountabilty for very large sums of money. Malaria in the GMS represents only a small part of the overall portofolio, but has the same rules that apply to all funding, impacting timely and effective intervention implementation. For example, a sub-contractor receiving Presidential Malaria Initiative (PMI) funding reports PMI funds are hard to use, but GF funds are 10 times worse (CO, person communication). GF funding is focused on process and financial accountability, not on timely, effective and quality implementation of interventions in transmission foci despite WHO's call for "urgent action" [24]. For example, in a province in Eastern Cambodia where malaria increased 2.5 fold in 2017, nets were first delivered to the lower risk villagers in early 2018 and the high risk mobile and migrant populations will not receive nets until at least mid-2018 following the set process. Furthermore, in the villages, a fixed number of treated nets are being provided, resulting in households with more than one forestgoer often not having enough nets. Response to new cases is in the village, which does not make sense with transmission being in the forest. Malaria in the region is an occupational disease for those working in the forest, while most programs have been designed around presumed household exposure. Lastly, Cambodia returned more GF funds unused than any other country in the region in the cycle that ended in December, 2017 (CO, unpublished observation).

aggressively target malaria elimination. As we've discussed, we see this ultimately as a host country responsibility…" (M. Fukuda, personal communication). Many in the region are being misled that researchers are actually helping to protect host country militaries from malaria, when in practice, only small research studies are being conducted to fund research staff and to generate publications, with no action being taken based on the results. Leadership must take corrective action as militaries are both a key malaria transmission reservoir and can direclty support elimination operations (see Section 4). Malaria is the largest infectious disease threat for the US DoD and action can be taken as exemplified by an HIV prevention program to support foreign militaries and a DoD directive [30]. The US Army should engage with an institution that is not researchfocused to rapidly help eliminate the emerging incurable parasites and ensure than any malaria research funding in the region is focused on rapidly stopping falciparum malaria transmission. Vietnam can serve as an example for effective leadership and health system strengthening leading to rapid reduction and preparation for elimination of malaria. With intensive implementation of malaria control measures over the past decades, the burden of malaria is decreasing rapidly, and the disease is becoming increasingly focal. Between 2000 and 2016, the number of malaria cases was reduced by 94.4% (74,316 down to 4161) and number of

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Key factors leading to the success of the program are as follows: (1) strong commitment and substantial investments by the Government of Vietnam and its international development partners, (2) a strong and comprehensive health network from central to community levels, (3) a vertical, well organized and functional program (e.g., health staff specialized in malaria control activities are working effectively at all levels down to village), (4) extensive vector control measures with high coverage of ITNs and indoor residual spraying (IRS), (5) availability of highly effective medicines for malaria treatment at all levels, (6) engagement of multisectoral partners (see Section 4.2). Although great success towards malaria elimination has been made, Vietnam is now faced with a critical window of opportunity to achieve the elimination of malaria as mandated in

deaths reduced by 97.9% (142 down to 3) [64] (**Figure 4**).

**Figure 4.** Decreasing malaria transmission trends in Vietnam between 2000 and 2016.

Available financial resources must be used much more effectively. Despite large amounts of funding in the region, basic intervention coverage in forest transmission foci is poor. There is markedly disproportionate financial support provided for partner organizations in the region. Each international support staff often costs hundreds of thousands of dollars per person per year, including overhead and allowances. Yet, incentives for good performance are not allowed for malaria-endemic country government staff who have salaries that are not enough for subsistence. For example, district-level health staff typically make \$200–\$300/month, while salaries for NMCEP staff at the national level are in the range of \$300–\$1200/month. While GF guidelines do allow for incentives to government employees [63], we have been informed that this policy does not apply in the GMS (CO, personal communications). Undoubtedly, this leads to resentment by those expected to execute malaria elimination operations, which are often beyond their normal duties and may put their own job security at risk. A main argument against incentives is "sustainability in the context of decreasing external financing for malaria" (The RAI-Regional Steering Committee, personal communication), despite 7+ million lives being at risk. Malaria "East of Bangkok" can be rapidly eliminated, making longterm sustainability a non-issue if the recommendations in this chapter are followed.

Leadership must also address many conflicts of interest, which are often subtle in this setting, especially with research. As per the former Pacific Command Surgeon, "[elimination of malaria] is an action problem, not a research problem" (Rear Admiral C. Chinn, personal communication), yet the US Army continues to do only research with substantial increases in funding for malaria. Researchers, to be successful, must enhance their own *curriculum vitae* and malaria research usually requires substantial disease transmission, resulting in disincentives to facilitate elimination. The lead author is most familiar with the malaria research being conducted by the US military, which is expensive, frequently wasteful, often duplicative, many times not impactful and sometimes actually counterproductive (CO, unpublished observations). A mechanism must be in place for research prioritization, independent review by experts who understand the needs and challenges, and for timely action based on important findings [20].

The lead author of this chapter helped to identify funding to protect security forces in the GMS from malaria. His intent was for this to be modeled after the DoD directive to prevent and treat HIV-AIDS [30]. Following the realization that new funding was more for research, the following feedback was received … "I am aware that you're in disagreement… want to see us more aggressively target malaria elimination. As we've discussed, we see this ultimately as a host country responsibility…" (M. Fukuda, personal communication). Many in the region are being misled that researchers are actually helping to protect host country militaries from malaria, when in practice, only small research studies are being conducted to fund research staff and to generate publications, with no action being taken based on the results. Leadership must take corrective action as militaries are both a key malaria transmission reservoir and can direclty support elimination operations (see Section 4). Malaria is the largest infectious disease threat for the US DoD and action can be taken as exemplified by an HIV prevention program to support foreign militaries and a DoD directive [30]. The US Army should engage with an institution that is not researchfocused to rapidly help eliminate the emerging incurable parasites and ensure than any malaria research funding in the region is focused on rapidly stopping falciparum malaria transmission.

GF funds are 10 times worse (CO, person communication). GF funding is focused on process and financial accountability, not on timely, effective and quality implementation of interventions in transmission foci despite WHO's call for "urgent action" [24]. For example, in a province in Eastern Cambodia where malaria increased 2.5 fold in 2017, nets were first delivered to the lower risk villagers in early 2018 and the high risk mobile and migrant populations will not receive nets until at least mid-2018 following the set process. Furthermore, in the villages, a fixed number of treated nets are being provided, resulting in households with more than one forestgoer often not having enough nets. Response to new cases is in the village, which does not make sense with transmission being in the forest. Malaria in the region is an occupational disease for those working in the forest, while most programs have been designed around presumed household exposure. Lastly, Cambodia returned more GF funds unused than any other country

50 Towards Malaria Elimination - A Leap Forward

in the region in the cycle that ended in December, 2017 (CO, unpublished observation).

term sustainability a non-issue if the recommendations in this chapter are followed.

Leadership must also address many conflicts of interest, which are often subtle in this setting, especially with research. As per the former Pacific Command Surgeon, "[elimination of malaria] is an action problem, not a research problem" (Rear Admiral C. Chinn, personal communication), yet the US Army continues to do only research with substantial increases in funding for malaria. Researchers, to be successful, must enhance their own *curriculum vitae* and malaria research usually requires substantial disease transmission, resulting in disincentives to facilitate elimination. The lead author is most familiar with the malaria research being conducted by the US military, which is expensive, frequently wasteful, often duplicative, many times not impactful and sometimes actually counterproductive (CO, unpublished observations). A mechanism must be in place for research prioritization, independent review by experts who understand the needs and challenges, and for timely action based on important findings [20]. The lead author of this chapter helped to identify funding to protect security forces in the GMS from malaria. His intent was for this to be modeled after the DoD directive to prevent and treat HIV-AIDS [30]. Following the realization that new funding was more for research, the following feedback was received … "I am aware that you're in disagreement… want to see us more

Available financial resources must be used much more effectively. Despite large amounts of funding in the region, basic intervention coverage in forest transmission foci is poor. There is markedly disproportionate financial support provided for partner organizations in the region. Each international support staff often costs hundreds of thousands of dollars per person per year, including overhead and allowances. Yet, incentives for good performance are not allowed for malaria-endemic country government staff who have salaries that are not enough for subsistence. For example, district-level health staff typically make \$200–\$300/month, while salaries for NMCEP staff at the national level are in the range of \$300–\$1200/month. While GF guidelines do allow for incentives to government employees [63], we have been informed that this policy does not apply in the GMS (CO, personal communications). Undoubtedly, this leads to resentment by those expected to execute malaria elimination operations, which are often beyond their normal duties and may put their own job security at risk. A main argument against incentives is "sustainability in the context of decreasing external financing for malaria" (The RAI-Regional Steering Committee, personal communication), despite 7+ million lives being at risk. Malaria "East of Bangkok" can be rapidly eliminated, making longVietnam can serve as an example for effective leadership and health system strengthening leading to rapid reduction and preparation for elimination of malaria. With intensive implementation of malaria control measures over the past decades, the burden of malaria is decreasing rapidly, and the disease is becoming increasingly focal. Between 2000 and 2016, the number of malaria cases was reduced by 94.4% (74,316 down to 4161) and number of deaths reduced by 97.9% (142 down to 3) [64] (**Figure 4**).

Key factors leading to the success of the program are as follows: (1) strong commitment and substantial investments by the Government of Vietnam and its international development partners, (2) a strong and comprehensive health network from central to community levels, (3) a vertical, well organized and functional program (e.g., health staff specialized in malaria control activities are working effectively at all levels down to village), (4) extensive vector control measures with high coverage of ITNs and indoor residual spraying (IRS), (5) availability of highly effective medicines for malaria treatment at all levels, (6) engagement of multisectoral partners (see Section 4.2).

Although great success towards malaria elimination has been made, Vietnam is now faced with a critical window of opportunity to achieve the elimination of malaria as mandated in

**Figure 4.** Decreasing malaria transmission trends in Vietnam between 2000 and 2016.

the "National Strategy for Malaria Control and Elimination 2011-2020 and Vision for 2030" [65]. This critical window includes the following factors: (1) efficacious antimalarial combinations still exist but are failing fast; (2) potent tools for vector control are available but could be undermined quickly by the development of insecticide resistance; and (3) financial support from external funding partners continues to flow but is likely time bound. The Government of Vietnam will also need to take bold steps and intensify national malaria elimination efforts to ensure that malaria is eliminated from Vietnam for good before this window of opportunity closes.

In the 2016 intervention study, Pf transmission was stopped, providing direct evidence that the Cambodian army was the primary Pf transmission reservoir in the area of the study [20]. We believe there is sufficient evidence to scale the interventions that were proven to be effective (e.g., permethrin-treated uniforms, see **Table 2**). The impressive results from the study,

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Additional evidence of security forces being a transmission reservoir comes from the area where the most resistant parasites cross-border into Vietnam. Forest rangers in the Bu Gia Map National Park screened positive for Pf malaria at about ~11% for Pf (very similar to the Cambodian army in Northwestern Cambodia, see above) [66]. This population is probably a significant malaria transmission reservoir in this area. From the publication, the rangers appear neither to be receiving effective prevention measures nor routine screening and treatment. No funding in the GF 2018–2020 budget was allocated for such activities in this population. The only way it will be possible is to request unused GF year-end funding be reallocated, which is not an easy process (CO, personal communication). Furthermore, since permethrintreated uniforms are not yet WHO-prequalified (despite standard of care in Western militaries and recent impressive evidence in the Cambodian army), GF funding may not be able to

Permethrin is very inexpensive, well-tolerated, and widely used for uniform treatment by Western militaries for malaria prevention [69]. The evidence for efficacy of treated uniforms/ clothing is summarized in **Table 2**. Based on available evidence, and in light of emerging incurable parasites and pyrethroid sensitivity of the main transmitting mosquitoes (M. Macdonald, personal communication), we believe treated uniforms should be rapidly scaled up for all

In Cambodia, there are three types of government security personnel working in the forest army, forest rangers, and border police; each falling under different ministries. We are aware of a pilot project in Northwestern Cambodia where an ADB-funded project is working with all of these groups for malaria prevention and treatment (CO, personal communications). We

security forces in the GMS as one component of an integrated vector control package.

believe this initiative should be taken to scale as quickly as possible in the region.

**4.2. GMS security forces can provide direct support if given a mission and properly** 

The Vietnam People's Army, including the Vietnam Border Defense Force, provides an excellent model for security personnel supporting health interventions. From 2005 to 2015, the Combined Military Medical Program contributed to improve health, hunger elimination and poverty reduction [75]. Example accomplishments for health include: (1) vaccination of 5.1 million children with Ministry of Health-recommended vaccines, (2) family planning for more than 3.7 million people, (3) malaria prevention education for more than 1.8 million people, and (4) IRS of nearly 26 million square meters of housing with National Malaria Control

More than 1300 health stations were strengthened with military staffing, including 1044 health stations in remote and isolated areas (>10% of all nationwide; in locations where it is hard to recruit civilian staff). The system includes 152 border clinics, which also serves as a

however, have unfortunately not yet been acted upon.

be used for this intervention (CO, personal communications).

**resourced**

Program with provided pyrethroids.

border surveillance system for early detection of epidemics.

In summary, with a new leadership team, given a passion for the mission, along with authority, expertise and sufficient/effective funding, we believe WHO's Pf elimination goals can be achieved near the set target date of 2020. Vietnam is an example of a success story, which can serve as a model for other country programs. However, Vietnam cannot eliminate malaria until neighboring countries also do so. We urge BMGF, Asian Development Bank (ADB), PMI, the US military and other philanthropists to take action to address the challenges presented here in order to drive malaria elimination in the region.
