The business-as-usual approach to malaria control and elimination is no longer reaping gains in an environment of ‘flatlined’ funding and more complex, heterogeneous transmission patterns. There is recognition that one-size-fits-all strategies must be abandoned and replaced with demand-driven, problem-based solutions to local operational challenges. Stratification is one step towards this vision, however, stratification will not deal with broader health systems challenges that prevent delivery of chosen anti-malaria strategies, nor will stratification deal with specific community technical challenges, such as varied causes of residual transmission. The district-level approach can support stratification by describing the types of challenges that districts face and their solutions, thus building a more robust strata level toolkit. We suggest that programmes considering shifts towards a district-level approach; use Box 2 as a reference for the steps necessary to change their malaria programme structure, management processes and financing by starting in pilot districts and expanding with experience.
Despite challenges that may result from the programmatic re-orientation we propose, change is needed to overcome stalled progress. Investment in and empowerment of districts will increase their ability to target and deliver quality interventions based on local contextual knowledge. Thailand and The Phillippines demonstrate early successes in implementing district and community-led malaria programmes, a trend we expect to increase in the larger movement towards integrated and decentralized health systems prescribed by the Sustainable Development Goals and Universal Health Coverage (Box 3). This opinion piece raises three areas for further discussion and argument regarding implementation of the district-led approach to malaria control and elimination:
- 1.
How to build sustainable capacity at the district level.
- 2.
What structural changes need to be made at the national level.
- 3.
What changes in donor practices and global guidance need to be made.
If done carefully and deliberately, district decision-making can allow for massive advances in the quality, coverage and efficiency of the health system, particularly at the fringes where high-risk and under-served communities reside, fostering an enabling environment for malaria control and elimination, placing those closer to the front lines in the lead.
Box 2 Steps needed to make the shift to district-level management
-
1.
Provide NMCPs with:
- a.
Access to and training on a broad malaria control and elimination toolkit.
- b.
Capacity building in facilitation, listening to the issues at hand, and in problem solving.
- c.
Broad support from the Ministry of Health to access skills found in other departments such as community engagement.
-
2.
Identify areas suitable for the new approach:
- a.
Districts with stagnation in progress to malaria goals.
- b.
Districts where capacity exists or the Ministy of Health is willing to invest to make capacity exist in decision-making and leadership.
- c.
Flexible finances exist to empower districts.
-
3.
Provide selected districts with:
- a.
Advocacy to increase local political commitment to the goal.
- b.
Change/organization management support.
- c.
Support in data assessment, intervention choices, and monitoring and evaluation.
- d.
Collaborations between the health system and affected communities to understand malaria transmission and seek feasible solutions to interrupting it.
-
4.
Provide affected communities with a platform to share knowledge on malaria and human behaviour, and seek collaborative solutions to malaria.
-
5.
Hold annual planning meetings, probably at the provincial level, that involve all levels of those involved in the process: the NMCP, the implementation team, community representatives, and other relevant stakeholders.
Box 3 A shift towards decentralized health systems and successful examples in Thailand and The Philippines
In the past few years, there has been movement toward smaller, sub-national geographical and administrative areas (e.g., provinces, states) applying for malaria-free certification, a process endorsed by WHO but managed independently by each country. Countries with heterogeneous transmission and highly devolved health systems across Asia–Pacific and Latin America have been pursuing progressive sub-national elimination by achieving and certifying malaria elimination province by province. This can be a motivating factor for provinces to support their constituent districts to tackle pockets of ongoing transmission by tailoring interventions to suit the situation of the particular locality. While many countries have assigned sub-national responsibility for implementation of malaria control and elimination programmes, some countries are leading the way by also decentralizing funding and decision-making to the district level.In Thailand, the annual malaria elimination targets of the national strategy are set at the district level. Data from the national malaria information system is used to annually stratify malaria transmission down to the village level, classifying all endemic villages in the country based on the number of active foci. The data are shared with sub-district (Tambon) health staff who can appeal to decision-makers to allocate adequate resources from local funding sources to fund the necessary prevention, case management and vector control interventions.
In The Philippines, elected local chief executives (barangay captains and mayors) are being engaged to support and lead malaria elimination hand-in-hand with district malaria workers and health officers. Community trust funds have also been established to build a permanent and sustainable community source of funding to supplement the cost of critical malaria control programme activities at the provincial and municipal levels in eliminating provinces [15].