A step above volunteerism – Providing malaria services in Myanmar during COVID-19

Myanmar is a country with a population of approximately 54 million, and has one of the lowest reported infection rates for COVID-19 in Southeast Asia, with its first confirmed case on 23 March 2020. As of 4th August 2020, Myanmar reported 355 confirmed cases and 6 reported deaths.

On the 24th March, after its first confirmed case, the Government of Myanmar launched a community lockdown in one village of the Chin State to control the spread of COVID-19. In Yangon, the health ministry designated ten of the city’s 33 townships as “high-risk” areas in April after finding more confirmed cases. Authorities also implemented other strict containment measures including travel restrictions, the closure of land borders, and bans on mass public gatherings.

COVID-19 has undoubtedly exerted immense pressure on the health systems of Myanmar, even though it shows steady improvements against SDG health indicators – including on TB and HIV.  The Sustainable Development Report 2020 ranks Myanmar 104 out of 166 countries in the SDG Global Rank, with SDG 3 on “Good Health and Well-Being” assessed with major challenges.

While the low number of confirmed COVID-19 cases can be attributed to the low numbers of tests conducted, the challenges faced by Myanmar in confronting the COVID-19 call attention to the wider and systemic issues developing countries face in addressing pandemic preparedness. In these situations, communities and civil society play an even greater and crucial role in overcoming challenges and ensuring the health needs of communities are met.

Mya Wai is one of the community actors that strive hard to ensure communities affected by malaria in hard to reach areas of Myanmar have access to malaria testing and treatment despite the restrictions implemented during the COVID-19 pandemic. The 42-year old is from Alekyun Ian-khwe Village, Katha Township, Sagaing Division – a popular destination for internal migrants for work because of the agriculture industry. Mya Wai works with Population Services International (PSI) Myanmar as a Malaria Community Volunteer. She migrated from Homalin Township, Sagaing Division in 2010 looking for better employment opportunities in the health care sector, and soon found herself as a community health practitioner operating a village health clinic in her home.

Even though the burden of malaria has declined dramatically over the last six years with an 82% reduction of malaria cases between 2012 and 2017, and 93% reduction in malaria deaths, Myanmar sees 291 out of 330 townships malaria endemic (i.e. malaria is normally occurring there).

“There was a time when malaria was so common, that everyone had a close relative affected by or passed away due to malaria,” says Mya Wai, who saw many malaria cases occurring in her village, especially among migrant workers who do not visit hospitals or health centres for testing and/or treatment due to financial constraints, which could include paying for  transportation costs needed to get to the local hospitals or health centres.

“With the COVID-19 pandemic, migrant workers hesitate even more to visit hospitals even though they show symptoms of malaria – including fever, because they cannot afford to lose one day of work. Having to be quarantined if suspected of COVID-19 means a loss of income for them,” Mya Wai reflected and emphasised upon the harsh realities of poverty on communities affected by malaria.

Mya Wai was an auxiliary midwife in the village, which made her a first point of contact for many people, including pregnant women and their family members. Recognising her unique position, PSI Myanmar approached her to join PSI as a malaria community volunteer in 2018. Joining PSI as a malaria community volunteer thus provided her training and built her capacity on administering Rapid Diagnostic Tests (RTDs) and malaria treatment, and since then, she has tested over 650 people in her township for malaria.

“Even though our township has not been as affected as others by COVID-19, many people who come to my home clinic during this time present symptoms of fever. I was initially scared, but had to overcome my fear as I knew those that came to me trusted me,” revealed Mya Wai. Many who sought Mya Wai’s support feared mandatory quarantine if they visited hospitals or government health centres as they presented fever symptoms. For the migrant workers and villagers in her township, COVID-19 appeared as a virus infecting only those that had travelled outside the country, and the general population was not aware of the threats of community spread of the virus.

“I had surgical gloves on as I conducted RDT, and masks were often used in the village as it was dusty and so often used them. In addition, PSI provided us with additional personal protective materials such as gloves, make, hand sanitisers, and face shields, and therefore I was ready and continued to provide services to those who visited me,” noted Mya Wai.

Although significant progress has been made towards malaria elimination in the Greater Mekong subregion (GMS), the threat of drug and insecticide resistance is real as Myanmar has seen the presence of molecular markers of artemisinin resistance with seven different validated mutations reported, which poses significant threats in how Myanmar along with its neighbouring countries of the Greater Mekong subregion (GMS) respond towards malaria interventions.

PSI Myanmar has been at the forefront of Malaria, HIV and TB responses for more than two decades. The organisation was founded in 1995 and focused on HIV prevention, but quickly expanded into services including reproductive health and treatment for sexually transmitted infections. In 2001 malaria prevention was added to its portfolio followed by malaria treatment in 2003, and it has since grown to include pneumonia, diarrhoea and malaria treatment.

In 2014, PSI Myanmar became a sub-recipient (SR) organisation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) under the Regional Artemisinin-resistance Initiative (RAI), and in 2017 continued to serve as an SR under the Regional Artemisinin-resistance Initiative 2 Elimination (RAI2E) grant. With the expected approval of the RAI 3 grant from the Global Fund, PSI Myanmar is anticipated to continue its role as an SR for the next three years.

“With the first COVID-19 confirmed case in Myanmar in March, PSI Myanmar immediately took emergency measures to ensure that our staff and volunteers providing services across HIV, TB and malaria were safe so as to continue providing essential services to our communities without interruption,” said Dr Ohnmar Myint, the Head of Operations of the Community Health Services Business Unit of PSI Myanmar. “PSI had distributed three months’ worth of medical supplies including RDT kits, gloves, face masks, and hand sanitisers to all malaria community health volunteers to ensure that they are kept safe while continuing service provision.

A medical doctor by profession, Dr Myint joined PSI in 1999 after serving three years in a government hospital in Mandalay and was initially stationed in remote parts of Myanmar, which gave her an insight into the importance of public health, and working with communities. “As Myanmar is not going through a nation-wide lockdown, the daily lives of people in rural areas remain very much the same. This means that for those that are in hard to reach malaria endemic areas and engage in agriculture for their livelihoods, they continue to be at risk for malaria. Therefore our job at PSI is to ensure that they get malaria services without interruption,” explained Dr Myint.

The provision of three monthly worth malaria health supplies provided an invaluable opportunity for malaria community volunteers like Mya Wai to play a critical role in continuing to detect and treat malaria case during the times of COVID-19. Mya Wai continues to operate her home clinic, visits villagers with fever symptoms and conduct RDTs, and with the support of PSI provides referrals if the villagers require additional health services. With adequate malaria health products, she has become a stronghold for malaria prevention in her village even during the COVID-19 pandemic.

“Now, whenever they detect malaria symptoms, they approach me first rather than the other way around, which has made malaria detection and treatment very easy,” shared Mya Wai. She has tested for more than 100 people for malaria since March 2020 and has detected malaria cases amongst those that tested which allowed for timely treatment.

In 2018, through the comprehensive network of malaria health providers, PSI Myanmar tested more than 650,000 febrile cases and more than 11,500 confirmed cases were treated. PSI Myanmar currently operates with a malaria community volunteer pool of 1,310 volunteers supported through the Global Fund RAI2E grant and is supporting Myanmar in its efforts towards malaria elimination. In addition, PSI provides malaria services to communities through a private outlet pool consisting of 785 outlets which include small grocery shops, retail outlets and small pharmacies.

At the global level, PSI is taking emergency actions by adapting existing programmes to respond to urgent needs created by COVID-19, including campaigns on hand washing, advocacy around social distancing, creating and expanding programmes that address ongoing needs arising from COVID-19, and working with country offices to integrate relevant COVID-19 activities into their work. “In Myanmar, we are working closely with government authorities and other stakeholders to reprogram existing resources to address the pandemic, and one of our successes include being one of the first country to apply for the 5% Operational Flexibilities of the Global Fund. Through the 5% Operational Flexibilities, we were able to reprogram over US$6.1 million, and we have also accessed over US$10.5 million through the COVID-19 Response Mechanism to mitigate COVID-19 impacts on HIV, TB and malaria, reinforce national COVID-19 responses, and make the necessary urgent improvements to health and community systems. All this has enabled us to provide masks, gloves, PPEs, and hand sanitisers to our community volunteers and clinic staff” observed Dr Myint.

“The existing ethnic conflict situation in Myanmar is a major drawback in the national malaria response, and in achieving the 2030 targets. If COVID-19 is not contained in Myanmar, we will see devastating results in areas where there are ethnic tensions which will significantly impact HIV, TB and malaria responses and efforts,” explained Dr Myint. This is of concern especially since social distancing is inconceivable in internally displaced person (IDP) camps such as those in Rakhine State housing Muslim Rohingyas. Currently PSI operates and supports and provides services in IDP camps in Kachin and Shan districts.

Furthermore, the slowing economic growth globally due to the COVID-19 pandemic has not spared Myanmar, and threatens to partially reverse the recent progress in poverty reduction while reducing the incomes of households that are already poor. The social and economic effects of COVID-19 could be significant, given the externally oriented economy, uneven social safety nets, and the fragile healthcare system. Although it is anticipated that social spending, particularly on health, is expected to increase over the medium term, from a very low base compared to other countries, the health system remains at very real risk of being overwhelmed should COVID-19 cases grown exponentially.

Dr Myint highlighted that Myanmar is still in need of external financial aid and technical support to address crucial gaps in the health infrastructure for a resilient health system which encompasses a strong and robust community system. Looking forward, she further stressed the important need for the government to work closely with international health financing mechanisms such as the Global Fund to ensure increased and sustainable mobilisation of domestic resources for health, especially in the challenging times up ahead post the COVID-19 pandemic.