Cambodia has set an ambitious goal of Plasmodium falciparum malaria elimination by 2020 and total Plasmodium malaria elimination by 2025. Figure 1 demonstrates the country’s impressive progress in reducing malaria trends from Jan 2018 – May 2020. This reduction, combined with the 2018 report of no malaria related deaths for the first time (WHO, 2019), puts Cambodia well on track to reaching its elimination goals. However, the novel coronavirus SARS-CoV-2 (COVID-19) pandemic presents a potential challenge to this goal. As observed in other countries around the world, COVID-19 can quickly overwhelm health system capacity and divert attention from other pre-existing health priorities.
Despite significant advancement towards malaria elimination, efforts over the last decade have been challenged by the spread of artemisinin- resistant (ART-R) P. falciparum malaria in Cambodia and neighbouring Greater Mekong Subregion (GMS) countries. In the GMS, malaria parasite reservoirs cluster along international borders and around forests, the same areas where ART-R malaria is also most prevalent (Kingdom of Cambodia MoH 2016, Bannister-Tyrrell et al 2019). Individuals known to frequent these remote forest locations remain a priority high-risk population group that fall outside the reach of village-centred interventions, presenting operational challenges for malaria programmes (Canavati et al 2020). These include forest-fringe village inhabitants who go into the forest regularly to hunt and gather and also includes mobile and migrant people who spend extended periods of time in the forest, for example, gem miners, loggers, or soldiers; and ethnic minorities who live in or next to the forest and practice subsistence agriculture in forest farms and fields (Bannister-Tyrrell et al 2019). Due to cultural and environmental barriers, as well as lack of adequate road infrastructure, these remote and often poor communities bear the greatest economic burden of ill health, and have limited access to health facilities or community-based health workers (CHWs) such as village malaria workers (VMWs) that operate in static village locations (Liverani et al 2017). In 2009, the national malaria control programme (CNM) introduced a new cadre of CHWs known as mobile malaria workers (MMWs) to actively target these remote populations (Canavati et al 2016).
Malaria Consortium is supporting the provision of early diagnostic and treatment (EDAT) services for malaria among remote populations through MMWs and mobile malaria posts (MPs) in three provinces in North East Cambodia. The approach was developed in alignment with the National Strategic Plan for Elimination of Malaria, in close collaboration with CNM and built on lessons learnt from earlier RAI projects (Malaria Consortium 2017).
Situated relatively close to China, Cambodia was quickly on high alert as international news first reported the outbreak of COVID-19 in Wuhan and the subsequent lockdown of the city. Cambodia’s first COVID-19 case was diagnosed on 27 January 2020 (WHO 2020), and the country responded swiftly by reducing international travel and setting up screening points at border crossings to provide health education and fever screening for returning Cambodian migrant workers. Travel within the country has been allowed to continue except for the holiday period of Khmer New Year (April). The Ministry of Health (MoH), World Health Organization (WHO), and other partners ramped up preparations for the health sector to accommodate a potential increase in COVID-19 cases and developed an Emergency Master Plan for COVID-19 response. The MoH updates the number and location of COVID-19 cases on a daily basis at https://covid19-map.cdcmoh.gov.kh/ and posts daily surveillance reports at http://cdcmoh.gov.kh/resource-documents/covid-19-documents. As of 20 July 2020 there have been a total of 171 confirmed cases and zero deaths reported in the country (https://covid19-map.cdcmoh.gov.kh/).
Literature review
There has been increasing global recognition of the important role CHWs play in helping to reduce inequities in access to essential health services. Renewed interest in these programmes can be traced, in part, to an increased focus on the achievement of universal health coverage (Naimoli et al, 2015). The WHO Global Strategy on Human Resources for Health: Workforce 2030, adopted by the World Health Assembly in 2016, encourages countries to adopt a diverse, sustainable skills mix, which includes harnessing the potential of CHWS in interprofessional primary care teams (WHO 2018). CHWs are now a component of many health systems, primarily in low- and middle-income countries, although in the context of COVID-19 there has been increased discussion about their usefulness in high income countries such as the United States (Water, 2020).
CHWs are broadly defined as members of a community, often chosen by the community and working within their own community, who are supported by the health system but have no professional training and are usually volunteers but may receive a stipend. Using CHWs to deliver health services in their source communities has been shown to be effective in improving coverage of interventions, leading to improvements in mortality. However, in some settings, high coverage of CHWs has not led to expected levels of improvement (Grant et al 2017). Because CHWs are recruited from within their own communities, they are likely to have both a personal and a service relationship with the people they visit (Grant et al 2017). Being a member of a community does not guarantee that CHWs will be trusted. To be successful, not only do specific efforts have to be made to ensure trust among the communities and CHWs, but between the CHWs, health facility staff and supervisors (Grant, 2017). Early community engagement, non- threatening home visits that enhance friendship and strong supportive supervision can improve the trust and acceptance of the CHWs within the communities, as well as the confidence of the CHWs themselves, increasing the willingness of community members to utilise CHW services (Singh 2015).
Successful CHW programmes require a strategic partnership between communities and health systems (and MoH partners). Successful partnerships, however, do not happen automatically. They require explicit mutual responsibilities and accountabilities, a demonstrated willingness to work in tandem toward a common objective and flexibility (Naimoli et al, 2015). To date, there have been limited studies to show how this collaborative, dynamic approach creates trust, which can help maximise the efficient use of available resources and build resilience.