European Union
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Providing diagnosis, treatment and prevention measures against malaria and other infectious diseases in the uprooted Burmese population of Tak Province, Thailand |
The Thai-Burma border has seen important changes in the composition of its population in the last 20 years. Besides the relatively stable Thai population (itself composed of Thai and other ethnic groups) a growing population originating from Burma has converged on the border. This "uprooted" population is mainly concentrated in refugee camps, the adjacent rural areas and nearby towns.
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In the border districts of Thailand's Tak Province the uprooted population from Burma is estimated at 300,000; this includes 100,000 living in refugee camps with the remaining 200,000 being a combination of "migrant workers" (who are registered with the Royal Thai Government and benefit from Thai governmental healthcare services), and relatively mobile "displaced persons" whose lack of legal status in Thailand means that they have little or no access to healthcare. There is estimated to be a ratio of two Burmese "displaced" persons for every registered Burmese "migrant worker" in Thailand.
In the refugee camps health care is provided by NGOs and other international groups and the health situation is usually considered satisfactory and sometimes better than in the surrounding rural areas. Particularly for the “ displaced” population living in the areas around the camps and the borderline, access to health is extremely limited or simply non-existent due to Thai government restrictions on movements of individuals and the lack of assistance and structures adapted to their culture and languages. The Thai public hospitals in the districts are over-stretched by the non-Thai patients who manage to reach them (55% of all malaria cases treated in Thailand by the Ministry of Public Health in 2006 were from the displaced population). For the displaced population this means that they live in an area where the world’s most drug-resist malaria is endemic, and they carry a disproportionately massive burden of malaria infection, but they are rarely able to access treatment and normally only do so once they are seriously ill.
The burden on the existing health structures is worsened by the quasi absence of health care in Burma, forcing patients to travel long distances to try to get treatment in Thailand. This situation creates ideal conditions for the transmission of infectious diseases such as malaria, tuberculosis, HIV/AIDS and others. The problem is so severe that the UN Security Council declared in 2007 that Burma presented a security threat to the region because of the spread of infectious diseases. On the Thai-Burma border, infectious diseases are the main cause of mortality and morbidity in the uprooted population and threaten the health of the host (Thai) population. This is aggravated by the high levels or resistance to antimicrobial and other anti-infective drugs, in particular in respiratory pathogens (including tuberculosis) and malaria parasites.
Since 1986, the Shoklo Malaria Research Unit (SMRU-MORU) attached to the Faculty of Tropical Medicine, Mahidol University in Bangkok, and the University of Oxford, UK, has worked among the uprooted population to reduce the impact of multi-drug resistant malaria and other infectious diseases. SMRU-MORU’s focus has always been on the groups at most risk from malaria: children and pregnant women, with one of the most effective ways of detecting the disease being through the operation of antenatal clinics. Until 1995 this work was focused only in the refugee camps and a strong collaboration was established with the NGO community to control malaria in the refugee population through the operation of “the Malaria Task Force” (MFT), supported by ECHO for several years. This was largely successful and malaria is now a minor problem within the camps. The vast majority of malaria cases treated in the camps is in people with a recent history of travel outside the camp perimeter, usually to rural areas along the border or in Burma. In Maela camp (Mae Ramat district) SMRU-MORU remains responsible for antenatal and obstetric care and the treatment of malaria patients.
Since 1995 SMRU-MORU has extended its activity to reach out to the displaced population who have no alternative access to malaria diagnosis and treatment or antenatal care. This is done in collaboration with the Thai Ministry of Public Health (MOPH) and in close collaboration with the district hospitals and the Tak provincial health authorities. In 2001-2003 the Tak Malaria Initiative, supported by the Bill & Melinda Gates Foundation deployed the malaria control strategy developed by SMRU-MORU in the refugee camps to all 200 affected villages in the province’s border districts with substantial success. When the funding from the Gates Foundation came to an end, the MOPH took over the program. This project uses the same strategy that was successful in rural villages in Thailand.
Beyond the serious impact that malaria has in the Burmese “displaced” population, there is also a global dimension to malaria on the Thai-Burma border because the malaria parasites found in this part of Asia are some of the most drug-resistant on earth and their expansion and spread is a very real threat (research has already demonstrated that the most drug-resistant malaria parasites found in Africa originated in South East Asia) and must be stopped. This is particularly urgent and important in the “displaced” population living along the border since we have seen worrying signs that the malaria parasites may become tolerant even to the artemisinin combination therapies (ACTs) now at the forefront of global malaria treatment.
In 2007 SMRU-MORU successfully applied, alongside the Thai Ministry of Public Health, to the 7th round of the Global Fund for AIDS, TB and Malaria (GFATM) to support the purchase of antimalarials, rapid diagnostic tests and bed nets for the uprooted population (excluding refugee camps) on the Thai-Burma border (project period 2008-2013). This current application to the European Commission is aimed at complementing the support from GFATM by providing resources for a comprehensive malaria control program with a focus on maternal and child health care, specifically targeting the “displaced” population living along the border in Tak province and extending these services to a larger proportion of this population.
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1. Description of the action and its effectiveness:
The very effective strategy developed by SMRU-MORU in the early 1990s for the control of malaria in the refugee camps and in villages in the border districts is based on the use of rapid diagnostic tests and artemisinin-combination therapies (ACTs) as well as vector control measures (impregnated bed nets). There is now a large body of evidence from this region to show that this approach is effective and it has been adopted by other countries in Asia and more recently (2007) has been the cornerstone of World Heath Organization recommendations for the deployment of ACTs worldwide. Being largely excluded from the formal health system, the “displaced” population constitutes a reservoir of the disease and therefore represents a risk to the rest of the people living in the region and elsewhere. In addition to the facilities in Maela camp SMRU-MORU operates four border clinics with the agreement of the MOPH to provide basic health care, with a focus on malaria and particular attention to pregnant women and young children (the most susceptible groups). In recent years the number of patients attending SMRU-MORU border clinics has risen sharply as a direct result of the increase in the size of the displaced population. Funding is needed to support the increasing workload of the existing clinics and to expand the geographical coverage.
The overall objective of the action is to reduce the malaria burden among the displaced Burmese population residing in four districts of Thailand’s Tak province that border Burma.
The specific objective (purpose) of the action will be to give access to a comprehensive malaria control program for the displaced Burmese population living in the border districts of Tak province, which does not benefit from the Thai public health services or refugee camps health care programs.
Outputs: the most visible output will be the provision of an adapted medical service dedicated to the needs of the displaced population: the network of clinics that will operate 24 hours a day, seven days a week will be staffed by trained local personnel working under the supervision of qualified physicians. These field clinics operate out-patient and basic in-patient facilities, laboratories and antenatal clinics. Training will also take place in these field clinics for the local personnel and this is also an important output.
Expected results: overall, we expect to have the same impact in this population as that observed in the refugee camps: a sharp decline in the malaria related morbidity and mortality and an improvement in maternal and child health. We also expect that local personnel trained in our clinics will become an important asset for future health programs in this population.
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Specifically the following results are expected from the action:
- Displaced people, particularly those from high-risk groups, will have improved access to early malaria diagnosis & treatment services.
- Pregnant women and young children will have improved access to health services targeting their specific needs.
- People will be more aware of the risks of malaria transmission and will be better able to protect themselves against malaria infection
- The uprooted population's capacity to provide healthcare will be strengthened
- Information regarding health in the displaced population will be shared between agencies to ensure that the most appropriate prevention measures and treatments can be deployed
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Activities and their effectiveness:
Currently all five existing SMRU-MORU operated clinics (4 border clinics and 1 in Maela camp) offer daily free-of-charge out-patient consultations using the most appropriate diagnostic tools and treatments similar to those offered in the Thai health services. Basic in-patient care is also available for patients who need to remain under observation, but more severe cases are transferred to the nearest Thai hospital (incurring a cost). Antenatal services are also offered as the only means to prevent malaria associated mortality. This is the only strategy with proven effectiveness to reduce the maternal mortality associated with malaria. This mortality was very high (1,000 women per 100,000 live birth before the start of the antenatal clinics in 1986). Malaria is also associated with a reduction of birth weight, an independent risk factor for infant mortality. Delivery facilities are already available in one clinic for displaced people (Wang Pa clinic) and in Maela camp. Difficult deliveries are referred to Maela Camp or to the local Thai hospital (also for a cost). As part of the antenatal “package” offered at Maela Camp, the detection of HIV is also offered following counselling and the prevention of maternal to child transmission (PMTCT) is also made available to the women who are HIV positive. At present this is only available to the women in Maela camp. Each clinic is staffed with medical assistants, nurses, laboratory technicians, midwives, home visitors, cleaners and drivers. A telephone line links the clinics with SMRU-MORU’s Mae Sot head quarters. Monthly reports detailing the activities of the clinics are sent to the Thai MOPH as well as to the medical NGOs working on the Thai-Myanmar border. The 2007 activities of SMRU-MORU clinics can be summarized as follows:
Site |
Total number of consultations |
Total number of malaria treated |
Total number of pregnant women in antenatal (deliveries) |
Total number of women in PMTCT (screening) |
Maela Refugee Camp |
16,471 |
3,208 |
1,753 |
1000 |
Wang Pa |
13,827 |
15,259 |
412 |
- |
Mae Kon Ken |
4,673 |
3,637 |
- |
- |
Murunchai |
7,359 |
3,014 |
180 |
- |
Mawker Tai |
11,226 |
7,033 |
352 |
- |
Total |
53,556 |
32,151 |
2,697 |
1,000 |
Activities that will be supported by the project:
Specifically the following activities, targeting the "displaced" population will be undertaken during this action:
- Provision of comprehensive malaria diagnosis and treatment services via SMRU-MORU's existing network of four clinics (excluding Maela refugee camp)
- Provision of comprehensive malaria diagnosis and treatment services via one new clinic
- Antenatal clinics at all SMRU-MORU clinics (excluding Maela refugee camp) to detect and treat malaria
- New antenatal clinics established at 2 existing clinics
- All antenatal clinics to provide measures for prevention of mother-to-child HIV transmission, as well as dietary supplements and child immunisation
- New delivery facilities will be established at two antenatal clinics
- Provision of bed nets to those most exposed to malaria infection
- Malaria prevention and treatment awareness raising
- Knowledge, Attitude & Practise surveys of target population
- Training of midwives in obstetrics, antenatal care and prevention of mother-to-child transmission of HIV
- Training of laboratory staff
- Bi-annual inter-agency technical meetings to share information
- Quality assessment for laboratory facilities managed by other organisations