Working towards the elimination of malaria in the Greater Mekong Sub-Region (GMS) of Southeast Asia is the goal of the second phase of the Regional Artemisinin-resistance Initiative (RAI). Earlier this year, the RAI’s Regional Steering Committee (RSC) – which is composed of governments from the five countries, funders, multilateral agencies, technical partners, scientific researchers, communities, and the private sector – submitted a detailed funding request to cover Phase 2. Aidspan has obtained a copy of the funding request. The RAI, which is the Global Fund’s largest regional grant, was launched in 2014 in response to the emergence of drug-resistant malaria in the GMS, first noted in Cambodia and Thailand, and later in Myanmar, Lao and Viet Nam. These are the five countries that make up the RAI. When it was launched, the RAI had a budget of $100.0 million and covered the period from 1 January 2014 to 31 December 2016. In December 2016, the Global Fund extended the grant to 31 December 2017 and provided $15.5 million in additional funding. The Phase 2 funding request is for $242.4 million. The RSC is proposing that Phase 2 start in January 2018 and run for three years. The RSC also submitted a prioritized above-allocation request (PAAR) in the amount of $16.5 million. (One might be forgiven for thinking that Phase 2 has already been approved. On World Malaria Day, 25 April 2017, the Global Fund issued a news release announcing the RAI expansion into Phase 2 and indicating that the projected cost was $242.0 million. Obviously, the Secretariat needed something that it could trumpet on World Malaria Day. At that time, the Technical Review Panel had not yet completed its review of the Phase 2 funding request. It has now done so. The request is now entering the grant-making phase.) If the requested $242.4 million is approved, $119.0 million will come from the $272.0 million set aside for multi-country programs for 2017-2019. The remaining $123.4 million will come from the allocations to the five countries involved in the RAI. The funding request says that the initiative is being renamed “the RAI2 Elimination Program” or “RAI2E” in line with the malaria elimination goal adopted by all five GMS countries. The majority of the budget for the RAI2E grant ($208.4 million) will be allocated to national programs in the five countries, but $34.0 million will be dedicated to a regional component that focuses on ensuring malaria service coverage for remote populations in border areas. These are the people who face the highest risk and are least likely to have access to formal health centers. “With the RAI investment bolstering national funding and the commitment of partners from all sectors, elimination is possible,” said Izaskun Gaviria, the Global Fund’s senior fund portfolio manager for the RAI. “The threat of drug resistance going global means we absolutely must finish the job. Failing to do so would squander the opportunity in the Mekong and be a huge setback for health security globally.” In the balance of this article, we provide a summary of the funding request, with a particular focus on the regional component. Reviewing Phase 1 In the funding request, the RSC said that in Phase 1 the RAI contributed to a sharp decline in malaria transmission in the GMS. Between 2012 and 2015, malaria incidence has been reduced by more than 54% and mortality is down by 84%. There were many notable successes in Phase 1. The following examples were taken from information that the Secretariat provided Aidspan:

• Between 2014 and 2016, the percentage of the population covered by insecticide-treated bed nets increased from 30% to 92%.
• In Cambodia, in 2014-2016, almost three-quarters of a million people were tested for malaria using rapid diagnostic tests (RDTs) and slides. Over 65,000 confirmed cases were treated.
• In Myanmar, in 2014-2016, more than 81,000 confirmed cases of malaria were treated.
• In Vietnam, in 2014-2016, over two million insecticide-treated bed nets were distributed to at-risk populations.
• In Thailand, in 2014-2016, almost 4.3 million people were tested for malaria using RDTs and slides. Almost 60,000 confirmed cases were treated.
• The number of community malaria volunteers trained in remote areas increased from 435 in 2015 to 2,407 in 2016.

The number of confirmed cases of P. falciparum malaria in the Karen region of Thailand, along the border with Myanmar, was reduced to nearly zero. However, the RSC said in the funding request, the spread of antimalarial drug resistance threatens to undermine these gains. To date, resistance of malaria parasites to artemisinin – the core compound of the best available antimalarial medicines – has been detected in all five countries of the GMS. In some areas, resistance to artemisinin and its partner drugs has attained alarming levels, with treatment failure reaching up to 25% in Cambodia. While Phase 1 of the RAI was being implemented, there were some significant developments in the epidemiology of the resistant strain of malaria (P. falciparum) as well as some major scientific discoveries. The resistant strain was not only spreading in places where it already existed, but it was also emerging in new places. Experts came to the realization that it was not possible to contain resistance to the P. falciparum strain of malaria. The only strategy that effectively deals with resistance is to eliminate the spread of malaria. These developments pointed to the need for accelerated regional elimination strategies, the funding request explained. The World Health Organization (WHO) developed a “Strategy for Malaria Elimination in the GMS, 2015-2030.” The WHO Strategy is based on the following overarching goals:

• Eliminate malaria by 2030 in all GMS countries and, considering the urgent action required against multidrug resistance in the GMS, eliminate P. falciparum malaria by 2025.
• In areas where malaria transmission has been interrupted, maintain malaria-free status and prevent reintroduction.

Other new strategies were introduced, such as the decision to involve village malaria village workers in the response. Phase 2 (RAI2E) The funding request proposes significant changes to the implementation arrangements for RAI2E. In Phase 1, the RAI operated only at a regional level, with the U.N. Office for Project Services (UNOPS) serving as principal recipient (PR). Each country also had a separate malaria grant covering national activities with various agencies serving as PR. This arrangement was deemed to be inefficient. All of the national NFM grants end in 2017, so the Global Fund decided that in 2018 and beyond, all Global Fund malaria funding for the five countries will be in one grant, RAI2E, managed by UNOPS. As indicated above, the RSC proposes to invest $208.4 million in national programs in 2017-2019. See Table 1 for information on what each country will receive. The funds for national programs will be disbursed by UNOPS directly to governments and civil society organizations (CSOs) in each country.

Table 1: Breakdown by country of the funding awarded for national malaria programs in RAI2E in 2017-2019

Table 2 provides a list of the modules and high-level interventions for the national programs component of RAI2E.

Table 2: List of modules and high-level interventions for the national programs component

The funding request states that keeping the momentum from Phase 1 going will require a high-level commitment by governments and players across the region and at all levels. “This includes harmonizing the RAI2E with national program cycles, coordinating with the national country coordinating mechanisms (CCMs), taking part in high-level discussions with the ministries of health at Director General level (all of which has now begun, and will be intensified),” the request states. “In addition, the RSC must continue to engage with regional institutions and initiatives.” With the decrease of the malaria burden across the region, the disease is increasingly concentrated among certain populations that are often outside the reach of public health services. These key affected populations are described in Table 3. The funding request prioritizes the expansion of services to these populations.

Table 3: Key affected populations – Malaria in the Greater Mekong Sub-Region

The request said that as countries transition from malaria control to elimination, active community engagement in all aspects of the response will be increasingly critical to the success of the regional elimination goal. It said that the first phase of the RAI demonstrated the impact and effectiveness of a community-based and community-led response in reaching hard-to-reach populations. An important factor to this success, the request said, is the shifting of the community’s role from being a passive recipient of services to being an active participant and contributor to the response. Strengthening community ownership and engagement, in particular increasing and maximizing the roles of community stakeholders – e.g. malaria health workers, community health workers, outreach workers, and community- and civil society organizations (CSOs) – and providing them with adequate resources and political and policy support “will play a critical role in sustaining and achieving the elimination agenda,” the request stated. The funding request said that mobile and migrant populations (MMPs) face obstacles in accessing equitable and essential health care for a variety of reasons, including living and working conditions, education level, gender, irregular migration status, language and cultural barriers, legal status, and a lack of migrant-inclusive health policies. The request said that there is a need for more robust analysis of information on human rights and gender and that, to address this need, the regional component of the RAI2E will support a regional CSO platform (more on this below). Regional component of RAI2E The regional component focuses on maximizing malaria service coverage for remote populations in border areas, piloting innovative interventions to deal with residual malaria transmission, stimulating innovative ways to speed-up elimination, supporting countries to move from malaria control to malaria elimination, and building strong multi-sectorial partnerships. The regional component also aims to address overarching issues affecting national strategies, to enhance country components and to ensure regional coherence. The funding request described seven “packages” (i.e. strategies) for RAI2E, as follows:

1. Extend access to prevention tools and case management services amongst hard to reach populations through “Inter-Country Projects” (ICP) that go beyond what is described in country components.
2. Stimulate operational research and innovation to guide policy.
3. Ensure the availability of quality health products across the GMS.
4. Strengthen regional surveillance.
5. Monitor anti-malarial drug efficacy and treatment policy updates.
6. Support constituencies to improve and expand delivery in country components through regional multi-sectoral collaboration.
7. Support the enabling environment to ensure quality implementation of the RAI2E.

We provide additional information on each of these packages below. Inter-Country Projects RAI2E will expand prevention, testing and treatment coverage for hard-to-reach populations at risk, including through cross-border approaches. Proposed activities include establishing malaria posts, and deploying village malaria workers and mobile malaria workers in underserved areas, in areas considered a “source” for parasite migration, and along travel routes frequented by high-risk migrant populations. They also include distributing personal protection tools through innovative methods to mobile and migrant populations routinely exposed to malaria vectors. In addition, where supported by national programs, the RAI2E will implement mass treatment to dramatically reduce the malaria burden in settled populations not routinely accessing current prevention tools or diagnosis and treatment services. Operational research The plan is to continue a “learn-by-doing” approach that was successful in Phase 1, whereby research projects strive to have substantial impact, while at the same time collecting data for evaluation. The research will be designed to define optimal and sustainable approaches for prevention, diagnosis and treatment in response to a rapidly changing malaria epidemiology; and to accelerate the transition from control to elimination by piloting new tools and making surveillance a core intervention. The provision of case management services at community level has proven to be highly successful. Operational research will be conducted to explore extending the service package to address other health needs and tackle sustainability issues associated with elimination. An extended role for community health workers, including case investigation, focus investigation, active case detection, mass or focal screening, and treatment using highly-sensitive rapid diagnostic tests (RDTs), will be piloted. In addition, research will be conducted on, among other things, the effectiveness of the highly sensitive RDTs; and the materials used for bed nets. Phase 2 will also see the establishment of a regional Innovation Lab. Ensuring quality health commodities The goal of this package is to ensure improved access to quality-assured and appropriate combination antimalarial products and ensure their appropriate use in all GMS countries. Examples of the activities in this package are as follows:

• identify key national and cross-border regulatory and enforcement actions for stopping illegal activities;
• provide capacity building support on how to strengthen national legal frameworks to deal with substandard and falsified products;
• develop capacity to implement a risk-based market surveillance system; and
• support the national regulatory authorities to provide public information and education in local languages on the risks of using inappropriate medicines.

Strengthening regional surveillance In Phase I of the RAI, the initiative supported the development of a Regional Data Sharing Platform (RDSP) by the WHO. One of the goals of the regional surveillance package in Phase 2 is to transform the focus of the RDSP from “control” to “elimination.” Other goals are as follows:

• to facilitate regional data sharing while strengthening capacity of national programs to generate, analyze, store, share and use information to target interventions;
• to establish case-based surveillance to accelerate malaria elimination;
• to strengthen capacity of countries to generate timely quality data; and
• to complement RDSP efforts with strong and regular WHO technical assistance in surveillance and M&E, to provide hands-on support in each country as per their respective needs, and to lead efforts towards a harmonized regional approach.

Monitoring drug efficacy and treatment policy updates The main objective of this package is to inform policy makers on treatment efficacy and the drug resistance situation, and to provide evidence for appropriate treatment options to support malaria elimination. The recent rapid spread of antimalarial resistance has intensified the need for routine monitoring of drug efficacy. Therapeutic efficacy studies (TES) are the gold standard; they remain the main source of information on which to base selection of antimalarials. However, areas with low malaria transmission do not have enough patients to use the standard WHO TES protocol. Instead, the RAI2E proposes to incorporate into routine case management the collection of efficacy data during the 28-day follow-up of patients. In addition, filter paper blood spots will be collected for monitoring molecular markers (MMs). Supporting constituents to improve service delivery The RSC intends to enhance high-level regional, political and multi-sectoral engagement to support country-level elimination efforts. In line with the Roll Back Malaria multi-sectoral action framework, this package aims to enhance collaboration with CSOs, the corporate sector and defense ministries. As a principle, the RSC intends to allocate approximately 1% of the overall funding envelope to strengthen and build relationships to leverage political support in order to reinforce service delivery capacity at country level. One of the objectives of this package is to facilitate effective and meaningful collaborations between communities affected by malaria, CSOs, governments, private sector, donor agencies, technical partners and other stakeholders in the design, implementation and monitoring and evaluation of malaria programs and policies. Another objective is to ensure that the principles of communities, rights and gender are championed in the “last mile” response in national and regional elimination programs. A third objective is to strengthen and promote the capacity and engagements of affected malaria communities and civil society in critical health and development agendas. One of the activities of this package is supporting a regional CSO platform to address issues of access to service by vulnerable and affected communities. The funding request said that CSO participation can help to ensure that the communities are informed and empowered. Supporting the enabling environment The funding request states that a review of the RAI conducted in December 2015 emphasized the “vital importance” of providing a higher level of implementation visibility at the sub-national level in the GMS. To help track progress, RAI2E will establish a semi-permanent independent monitoring function. In addition, RAI2E will strengthen the oversight function of the RSC by, among other things, establishing a formal oversight committee and by recruiting additional staff for the RSC secretariat. Resilient and sustainable systems for health The funding request included RSSH initiatives. Several initiatives have been incorporated into the country components. They include the strengthening of national information systems and protocols for surveillance and response activities particularly at the provincial, district and commune levels. Activities include the training of peripheral health staff and village health workers to enable them to implement more effective malaria control interventions, including providing treatment. The funding request also includes separate modules on health management information systems; procurement and supply chain management systems; community responses and systems; human resources for health; and integrated service delivery and quality improvement. Prioritized above-allocation request The $16.5 million PAAR consists of additional activities in the national programs of four of the five countries: Lao, Cambodia, Viet Nam and Thailand.