Bhutan and East Timor were on the path to malaria elimination when the COVID-19 pandemic struck in 2020, disrupting their response. As the two countries adjust their timelines and set their sights to eliminate malaria by 2025, experts identify critical actions to get them back on track.
East Timor reported three new indigenous cases — or cases contracted locally with no evidence that they came from an imported case — of malaria in 2020, after having reported no such cases since 2018. Indigenous cases in Bhutan also increased to 22 in the same year, after reporting just two such cases in 2019, according to a new paper published in The Lancet’s regional health journal for Western Pacific, co-authored by health ministers of both countries.
The authors attribute the increase in cases to the COVID-19 pandemic. Movement restrictions and reassignment of malaria health workers to the COVID-19 response disrupted key malaria interventions such as border surveillance, and case investigation and management, according to the paper.
That set back the two countries toward malaria elimination in 2020. Countries need to have zero indigenous cases for three consecutive years to achieve that certification. Now experts are hoping the countries will be able to achieve this by 2025, with both recommitting to the goal of elimination. Last year, the World Health Organization announced a new initiative called the E-2025 that listed 25 countries, including Bhutan and East Timor, that could reach this milestone in five years.
“These countries are going to be a treasure for the region. Because if they are successful, and I think they will be in this renewed push for E-2025 in malaria elimination, they will have done so in a circumstance that … no one could have anticipated and that required them to really actualize a whole-of-government approach,” Sarthak Das, CEO at the Asia Pacific Leaders Malaria Alliance, told Devex.
Experts say reaching this milestone will require cross-government and cross-border collaboration, and sustained political commitment and visibility for malaria in the region.
Getting back on track
APLMA’s Das identified three things that should happen to get Bhutan and East Timor on track to eliminating malaria by 2025. First is having a joint cross-border elimination plan that links and allows district-level officials and health workers on both sides of the border to manage malaria.
Cross-border malaria transmission continues to pose challenges for elimination in East Timor and Bhutan. Of the 14 total confirmed cases of malaria in East Timor in 2020, half were imported cases. In Bhutan, nine of the 54 confirmed cases of malaria in the same year were imported cases, according to the World Malaria Report 2021. The rest are introduced cases, defined by WHO as cases that are contracted locally, but with “strong epidemiological evidence linking it directly to a known imported case.”
East Timor shares borders with Indonesia, where malaria continues to be a serious public health threat, and Bhutan with India, a malaria high-burden country. In 2019, efforts were made to develop a joint action plan for malaria elimination across Bhutan and India’s borders. A social application was also created to allow malaria workers to exchange information across the borders. However, efforts to formalize this system have faced delays amid the pandemic. Meanwhile, a memorandum of understanding for cross-border collaboration signed by officials from East Timor and Indonesia expired in 2020, according to the Lancet paper.
“When it comes to cross-border malaria transmission for Bhutan and Timor-Leste — it is of the utmost importance and a prime strategy, as the bordering areas are the ones with active foci and it is where the majority of cases are found (both indigenous and imported). This presents a huge risk of resurgence and continued local transmission of cases given the vector continues to be present in these areas,” Das said.
Second is ensuring the work involves government agencies other than health, such as finance ministries. But the third, and “most important” according to Das, is ensuring there’s high-level political commitment to cross-border elimination.
There has been good progress to get all these things in place, he said, including on the development of cross-border elimination plans. But “where the rubber hits the road is how those plans can be actionable,” he said.
The Lancet paper also identified the need to empower communities to be part of malaria prevention and control efforts, and in integrating anti-malaria work with other disease interventions. In Bhutan’s border towns for example, foreign workers undergo medical screenings for malaria, HIV, tuberculosis, and COVID-19.
Meanwhile, multilateral organizations can help keep the visibility on malaria and its elimination in their discussions with government authorities. They can also help incentivize cooperation between governments to address the problem, Das said.
“The near elimination countries and the issue of cross border malaria … [is] a niche topic, if we think about, let's say, the full … remit of an organization like the Global Fund [to Fight AIDS, Tuberculosis and Malaria], or the World Bank. But I think that just by making mention of it in our region, in these specific geographies, helps drive visibility and attention from the governments themselves,” he said.
About the author
Jenny Lei Ravelo@JennyLeiRavelo
Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.
