Between 2012 and 2020, Myanmar (Burma) made extraordinary gains against malaria. The number of confirmed cases fell by almost 88% and the reported number of deaths fell by 98%. In 2020, only 10 deaths in Myanmar were officially attributed to malaria. This was the result of a coordinated multi-stakeholder prevention, control and elimination strategy supported by sustained local and international investment. But these gains are now under threat due to the impacts of the COVID-19 pandemic and the February 2021 coup.
Malaria prevention, control and elimination efforts in Myanmar have focused heavily on the southeast where the emergence of multidrug-resistant malaria strains threatens local, regional and global public health. These are contested borderlands where ethnic nationality movements have been engaged in armed conflict with the Myanmar military for decades. These movements have established parallel administrations, including health departments, to meet the essential needs of their communities. Trusted by the communities they serve, and uniquely able to deliver services in this remote, mountainous terrain, they are a crucial link in the chain of health.
Community Partners International (CPI) has helped ethnic and community-based health organizations (ECBHOs) in southeast Myanmar to prevent, control and eliminate malaria for more than two decades. In the early years, the intensity of armed conflict and chronic underinvestment in health made this hugely challenging. ECBHOs relied on mobile “backpack” medic teams traveling from village to village, and moving together with communities when they were displaced by conflict. In this emergency context, it was difficult to sustain strategic malaria initiatives at scale.
With the glimmer of democratization that emerged from the 2010 elections, things began to change. Ceasefire agreements brought greater stability to southeast Myanmar. Shared interests in health provided a platform for nascent cooperation between the central government and ethnic nationality movements, and one of the first areas of cooperation was malaria. Under these early agreements, the Myanmar Ministry of Health and Sports (MoHS) provided malaria medicine and training to ethnic health workers through the National Malaria Control Programme (NMCP). This cooperation continued to grow and create impact in the years that followed. Between 2013 and 2018, Community Partners International and partners observed a tenfold decrease in malaria cases detected as a percentage of the number of tests in project coverage areas.
With support from the Access to Health Fund and private donors, Community Partners International is supporting access to an integrated package of health services for more than 440 villages and 220,000 people in southeast Myanmar. Under this project, the organization is helping the Mon National Health Committee (MNHC) to deliver malaria prevention and control to 49 villages in Mon State, Karen State and Tanintharyi Region in southeast Myanmar. The first line of malaria prevention, testing and care is provided by village health workers and village-based clinics. In areas where high positivity rates are observed, MNHC sends in mobile clinic teams to conduct mass screening and treatment.
When COVID-19 reached Myanmar in late March 2020, the MoHS and ethnic and community-based health organizations pivoted much of their focus and resources to tackle the immediate pandemic threat. Lockdowns and travel restrictions disrupted regular health services and supply chains, making it more difficult to sustain malaria initiatives.
“During COVID-19, the entire mechanism for malaria was almost cut off,” explains Saw Hsar Khee Lar, an MNHC Program Manager. “People were fighting for their survival. Some knew they had malaria but had to continue working to pay for COVID-19 treatment for family members rather than seek treatment for themselves. So the infection rate increased rapidly.”
On February 1, 2021, the Myanmar military seized power in a coup. The aftermath has engulfed the country in a humanitarian crisis and widespread outbreaks of violence and armed conflict. The impact on public health has already been profound and the health system now stands at the brink of collapse. As armed conflict has escalated in southeast Myanmar, health service cooperation between government and ethnic nationality movements has largely broken down.
“Since 2021, the incidence of malaria has significantly increased in Yebyu Township in Tanintharyi Region,” confirms Saw Hsar Khee Lar. “Displacement and migration due to conflict have had a big impact on service delivery and placed communities at greater risk of malaria infection,” he continues. “We have challenges to reach people with medicine and treatment as they are on the move or sheltering in displacement camps.”
“We have also faced issues for procurement and medicine distribution due to lockdowns and travel restrictions,” Saw Hsar Khee Lar explains. “It can be difficult for our staff to travel to villages and report malaria cases in a timely fashion. Our staff are also subjected to a lot of inspections at checkpoints when delivering medicines and this slows the process down.”
MNHC has adopted strategies to mitigate the impact of these disruptions. “At the clinic level, we try to provide standby stocks of malaria medicines for at least five patients as a precaution for when supply chains are disrupted,” explains Sar Hsar Khee Lar. “If we see an increase in malaria cases in a particular area, we try to stockpile more medicines and supplies to meet the needs. In this way, we can ensure that every malaria case can receive proper treatment. So far, we have managed to treat all serious cases that we have identified. We have strong partnerships and good collaboration with other local organizations that help us solve procurement gaps.”
Despite their efforts, there is evidence that the prevalence and incidence of malaria is increasing. Community Partners International’s data shows a nearly 50% increase in positive malaria cases identified and treated between 2020 and 2021 in project coverage areas. The organization expects this to increase further in 2022 as health service and supply chain disruptions continue.
Further up the supply chain, shortages of rapid diagnostic tests, malaria medicines and long-lasting insecticidal nets (LLINs) due to customs clearance delays and other supply issues are putting additional pressure on efforts to defeat malaria. The shortage of LLINs is particularly concerning as they offer an effective method of malaria prevention (studies have shown that they reduce the risk of malaria transmission by 56%). If prevention and control efforts stall significantly, the rising number of malaria cases will make it more difficult for ethnic and community-based health organizations to keep multidrug-resistant malaria at bay in southeast Myanmar. A resurgence would present a grave threat to global public health.