Expansion of a malaria control program in Eastern Burma's active-conflict area and the need for a community-based approach

The malaria control program of the Karen Department of Health and Welfare (KDHW) has striven to provide universal coverage in areas of active conflict in Eastern Burma. KDHW piloted a community-based malaria control program in 2003, shifting resources from the clinic to the community by actively seeking, testing and treating febrile patients with WHO recommended technologies, such as quality rapid diagnostics and Artesunate combination therapy. As the program scaled up and intensive active management and outreach grew taxing on small clinic-based teams, utility of traditional birth attendants for outreach allowed the program to reach vulnerable populations, including pregnant women and children. Eventually, training of lay community members established a more comprehensive community-based approach with expansion to remote areas and those more vulnerable to security threats. Consistent with WHO recommendations to combat emerging Artesunate resistance in South-East Asia and empowering communities to continue providing care when security risks might isolate villages from clinic-based services, lay community members conduct routine house visits to teach prevention and monitor use of long-lasting insecticide treated nets, promptly identify new cases, and treat using a simplified protocol. Health workers' roles have evolved to assume supervisory roles in training and monitoring lay community members. Following the example of Cambodia's national program utilizing Village Malaria Workers, KDHW's program has been able to expand its coverage from a population of 3,000 to over 50,000 and improve its health worker to community population ratio from 1:455 to 1:187 in just eight years.