Biregional Meeting on Healthy Borders in Greater Mekong Subregion, Bangkok, Thailand, 5-7 August 2013 : report

Meeting Report

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

5–7 August 2013 Bangkok, Thailand

WPR/DCC/DCC(01)/2013 RS/2013/GE/69(THA)

English only

REPORT

BIREGIONAL MEETING ON HEALTHY BORDERS IN THE GREATER MEKONG SUBREGION Bangkok, Thailand 5–7 August 2013

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines October 2015

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NOTE

The views expressed in this report are those of the participants of the Biregional Meeting on Healthy Borders in Greater Mekong Subregion and do not necessarily reflect the policies of the World Health Organization.

This report has been printed by the Regional Office for the Western Pacific of the World Health Organization for the participants of the Biregional Meeting on Healthy Borders in Greater Mekong Subregion, which was held in Bangkok, Thailand from 5 to 7 August 2013.

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CONTENTS ABBREVIATIONS ......................................................................................................................................... 4 SUMMARY ..................................................................................................................................................... 5 1. INTRODUCTION ....................................................................................................................................... 6 1.1 Objectives and meeting organization .............................................................................................. 6 2. PROCEEDINGS .......................................................................................................................................... 8 2.1 Multisectoral approaches to address the health needs of populations, including migrants, in border areas in the Greater Mekong Subregion ............................................................................... 8 2.2 Development, health systems and malaria in the Greater Mekong Subregion: the case for multisectoral action ....................................................................................................................... 10 2.3 Improving access to quality medicines in the Greater Mekong Subregion ................................... 12 2.4 Ensuring socially responsible infrastructure development in the Greater Mekong Subregion ..... 13 2.5 Increasing access to health services for people living in border areas in the Greater Mekong Subregion....................................................................................................................................... 15 2.6 Improving mechanisms for coordination across sectors and borders to better meet health needs .............................................................................................................................................. 17 3. CONCLUSIONS........................................................................................................................................ 19 ANNEXES ................................................................................................................................................... 21 Annex 1. Agenda.................................................................................................................................... 21 Annex 2. List of participants .................................................................................................................. 27 Annex 3. Background papers ................................................................................................................. 39

Keywords:

Delivery of Health Care / Health Services Accessibility / Transients and Migrants / Minority Groups / Mekong Valley

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ABBREVIATIONS ADB APSED ASEAN GMP HIA HIV/AIDS JUNIMA MDBS NGOs TB UN UNESCAP USA WHO Asian Development Bank Asia Pacific Strategy for Emerging Diseases Association of Southeast Asian Nations good manufacturing practices Health Impact Assessment Human immune deficiency syndrome/Acquired immune deficiency syndrome Joint United Nations Initiative on Migration, Health and HIV in Asia Mekong Border Disease Surveillance nongovernmental organizations tuberculosis United Nations United Nations Economic and Social Commission for Asia and the Pacific United States of America World Health Organization

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SUMMARY The WHO regional offices for South-East Asia and the Western Pacific jointly organized the Biregional Meeting on Healthy Borders in the Greater Mekong Sub-region from 5 to 7 August 2013 in Bangkok, Thailand. The meeting aim was to contribute to the improvement of the health of mobile and migrant populations and people living in border areas in the Greater Mekong Subregion through multisectoral collaboration. Complexities in the Greater Mekong Subregion directly and indirectly affect disease patterns in the Region and present challenges for tackling progressively complex health problems. In border areas, population movement, limited infrastructure and weak health systems constitute risks to population health. Some populations in border areas, including undocumented migrants, are often ineligible to receive services from host governments. These populations may have limited access to health services and necessary medicines. A systematic effort to strengthen health systems for all diseases in border areas will require investments in service delivery, human resources and surveillance, as well as broad national initiatives such as developing innovative financing mechanisms and enforcing drug regulations. Multisectoral involvement and collaboration is necessary to address these complex and interconnected issues. This meeting has set the stage for approaching health problems in new and innovative ways by focusing on border health. The meeting provided technical and policy updates through presentations and working group discussions and resulted in key recommendations for the way forward. Work must be done to include sectors beyond health, while strengthening health systems. Within health systems, technical collaboration in border areas could increase geographic coverage and provide more detailed technical information. It was recommended that both short and medium agendas and action points be developed with areas of work prioritized in both. Following prioritization of the issues, mechanisms can be researched to act on these priority issues, with a corresponding timeline for when the issues will receive attention by appropriate agencies. It was also suggested that a mapping exercise of all organizations working in border areas could be useful, in instances where a current map does not already exist. Finally, capacity development is necessary for collaboration to meet health needs. It was recommended that capacity development for government systems for healthy borders – through harmonized training and initiatives from various governments and organizations – be established. As the Greater Mekong Subregion grows and develops, investing in these initiatives directly translates into investing in a common, healthy future together. Linkages between countries in the Greater Mekong Subregion continue to expand, requiring international collaboration to create holistic approaches to tackle these issues.

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1. INTRODUCTION The Greater Mekong Subregion encompassing Cambodia, the Lao People’s Democratic Republic, Myanmar, Thailand, Viet Nam and Yunnan Province, China, is characterized by extensive shared border areas. The subregion is currently undergoing enormous economic development, environmental and social changes. These processes will introduce changes including large infrastructure projects and employment in new industries in both urban and rural areas. Increasing economic integration, ease of transport, increased connectivity among populations in the subregion and major population movements through new economic corridors are having anticipated and unforeseen impacts on health and well-being. These dynamics directly and indirectly affect disease patterns in the subregion and present challenges for tackling progressively complex health problems. In border areas, population movement, limited infrastructure, and weak health systems constitute risks to population health. Some populations in border areas, including undocumented migrants, are often ineligible to receive services from host governments. They may also have limited access to health services and necessary medicines. Due to limited opportunities for quality care, border and migrant populations may resort to using counterfeit or substandard drugs. Failure to access timely care, poor compliance and use of substandard medicines can increase the health risks for individuals, as well as the spread of disease in the community and the rise of drug resistance. Emergence of artemisinin resistance in the Greater Mekong Subregion, in particular, raises public health concerns for border areas. This is one example of the ways in which health inequities and risks in border areas in the Greater Mekong Subregion can pose challenges to population health throughout the subregion and beyond. Multisectoral involvement and collaboration is necessary to address these complex and interconnected issues. The value of this kind of approach was recognized at the World Conference on the Social Determinants of Health in 2011, which supported the 2009 World Health Assembly resolution endorsing a “health in all policies” approach. To achieve concrete health outcomes in the Greater Mekong Subregion, multiple stakeholders from non-health fields must be engaged to systematically incorporate health issues into the myriad of national security, labour, migration and economic development policies. Additionally, corporations and donor agencies can be encouraged to incorporate health issues into their operating principles in recognition of this as an investment to reaching their own aims. 1.1 Objectives and meeting organization

To mobilize multisectoral discussion on the health impacts of expanded development in the Greater Mekong Subregion and to provide a platform to develop concrete proposals for collaborative activities to address challenges to healthy borders, WHO regional offices for South-East Asia and the Western Pacific jointly organized the Biregional Meeting on Healthy Borders in the Greater Mekong Subregion in Bangkok, Thailand, on 5–7 August 2013. The objective of the meeting was to contribute to the improvement of health of people living in border areas of, and mobile and migrant populations in, the Greater Mekong Subregion through multisectoral collaboration.

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The meeting objectives were: 1) to develop collaboration mechanisms that can improve the health of people living in the Greater Mekong Subregion border areas; 2) to develop a multisectoral framework for border/migrant health in the Greater Mekong Subregion; 3) to identify best practices for development projects to improve the health of populations in the Greater Mekong Subregion; 4) to provide high-level commitment to implement the emergency response to artemisininresistant malaria in the Greater Mekong Subregion action plan; and 5) to support strengthening of access to quality health services and disease prevention in Greater Mekong Subregion border areas. Each session had a background paper (see Annex 3), a plenary panel discussion, and a designated working group (see Annex 1 for the agenda). The working groups were designed to identify the key issues, map stakeholders, summarize the status and provide a way forward in addressing the challenges involved in promoting and achieving healthy borders in the Greater Mekong Subregion. The meeting was attended by 180 participants, with representatives from six Member States, 22 development partners, academic institutions, donor agencies, nongovernmental organizations, intergovernmental organizations and United Nations (UN) agencies. There was multisectoral participation from government ministries including transport, economic, planning, agriculture, labour, social welfare, finance, immigration and foreign affairs, as well as health (see Annex 2 for the list of participants). The meeting was organized around themes for the six sessions: i. Multisectoral approaches to address the health needs of populations, including migrants, in border areas in the Greater Mekong Subregion;

ii. Development, health systems and malaria in the Greater Mekong Subregion: the case for multisectoral action; iii. Improving access to quality medicines in the Greater Mekong Subregion; iv. Ensuring socially responsible infrastructure development in the Greater Mekong Subregion; v. Increasing access to health services for people living in border areas in the Greater Mekong Subregion; and vi. Improving mechanisms for coordination across sectors and borders to better meet health needs.

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2. PROCEEDINGS 2.1 Multisectoral approaches to address the health needs of populations, including migrants, in border areas in the Greater Mekong Subregion

Introduction and outline of key themes The background paper, “Border Health: Concepts, Models and Applications for the Greater Mekong Subregion,” provided an introduction to the concept of border health, as distinct from migrant health, and an overview of models and frameworks that can be used to discuss and address border health issues. Border health has been defined as “a broad term that is characterized by the health care markets, regulatory environments, health laws, environmental factors, and health care consumer and individual behaviors both risk and protective that shape the health of immigrant and other populations 1 living in the region intersected by the geopolitical boundaries of two or more nations. ” In this approach, the definition of border goes beyond a strictly geographic definition of boundaries, and includes population or environmental health in border counties or municipalities, border provinces and even border countries. “Border health,” thus, can be distinguished from “migrant health” in that it focuses more broadly on populations who live on both sides of the boundary line, who are neither internal nor external migrants, as well as populations moving through border areas. Concerns in border areas include marginalization of border areas and communities, lack of data on these areas, communicable diseases, lack of access to quality health-services, and population movement due to conflict and violence. Adopting social determinants of health approach to border health entails understanding the environmental, interpersonal and individual factors that impact border health. This approach captures factors that inside and outside of the health system (i.e. immigration, labour, housing, social networks etc.) that influence individual physical, mental and social well-being in border areas. The components of the World Health Assembly 2008 migrant health framework can form the basis of a framework for border health, combined with the health-in-all-policies approach. This is an approach that ensures that public policies across sectors take into account health implications; combined with an approach to address social exclusion of migrants. To more comprehensively address health needs of vulnerable populations, and move towards healthy borders in the Greater Mekong Subregion, a healthy borders framework for the Greater Mekong Subregion should incorporate social determinants of health components, including specific aspects of border health. This includes considerations such as cross-border trade and development, working conditions, accessibility and quality of health services for migrants, and border control, detention and deportation laws and policies. The keynote address on the first day of the meeting, provided by Dr Supang Chantavanich, Professor Emeritus, Asian Research Center for Migration, Institute of Asian Studies, Chulalongkorn University, also touched on these themes. The presentation identified key challenges for border health in the Greater Mekong Subregion, exploring economic, political, social and cultural factors driving migration in the subregion, and various health risks present for vulnerable migrant populations, including workplace and environmental conditions that can increase risks for communicable diseases, injury and poor maternal and child health, and finally, made the case for a well-coordinated multisectoral and multi-country approach and response.

1

Zuñiga M. (2012). Border Health. In: Sajatovic M., Loue S. Encyclopaedia of Immigrant Health

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Plenary presentations Multisectoral approaches are unlikely to be successful without addressing migrant workers’ social exclusion, which is created by official agencies, laws and policies that impact migrants’ daily lives, security and livelihoods. Migrants are accepted into the economic spheres of society, but often rejected from social and cultural integration. Service provision needs to address the vulnerability that labour and immigration policies often cause migrants. Access to social protection is recognized as a right in international labour and human rights standards and instruments, and is particularly important for migrants who often lack health insurance and basic protections in the workplace. There are significant gaps in social protection for migrants in the Greater Mekong Subregion, and a multisectoral approach – including advocacy and political will, stakeholder engagement, and multicountry legal frameworks – will be necessary to address this. The Association of Southeast Asian Nations (ASEAN) has identified migrant health as a key concern within one of its three pillars, social-cultural community. Health concerns are also incorporated into other non-health discussions within ASEAN, including social welfare, labour and policy. The ASEAN Strategic Framework on Health Development (2010–2015) includes migrants’ health plans of action and other activities relevant to migrant health. In addition to international organizations and governmental actors, companies can be involved in this conversation as shown by successful efforts to engage the private sector in HIV control. Best practices include the Japan Bank for International Construction, which requires that all sub-contractors have HIV prevention programmes. Key topics, stakeholders, status quo and way forward The central purpose of a healthy border framework is to provide guidance for action to policy and decision-makers and stakeholders in all sectors (public and private), enabling selection of priority determinants to be addressed by each sector and highlighting linkages between sectors. In their discussion on developing a border health framework, participants identified multiple issues that should be incorporated, including concerns of both migrant and non-migrant populations, quality and access to services, and the social exclusion of migrants. Underlying all these issues, is the core question of financing for health programs, and mechanisms to ensure access to health care for migrants. Key stakeholders in developing a healthy borders framework are government agencies ranging from national level ministries to local government units in border areas, as well as multiple United Nations agencies, international organizations, civil society groups, employment and labour agencies, donors, religious organizations and temples, and the migrant and border populations themselves. The proposed framework can be fostered through political mechanisms, such as ASEAN or ASEAN +3 (China, Japan and the Republic of Korea. Additionally, health-specific collaborations in the Greater Mekong Subregion, including the Mekong Border Disease Surveillance (MBDS) system and the Asia Pacific Strategy for Emerging Diseases (APSED), can provide models for consideration. However, there is a need to engage with frameworks that go beyond communicable diseases. The World Health Assembly 2008 resolution on the Health of Migrants in 2008 (WHA61.17) and the operational framework developed during the WHO/International Organization for Migration (IOM) 2 Global Consultation on the Health of Migrants – the Way Forward (2010) can provide the basis for concerted action on migrant health, which overlaps with healthy border initiatives. 2

WHO (2010). Health Migrants – the way forward. Report of a global consultation. Geneva.

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Participants identified concrete ways forward to address these issues. The first is to establish a highlevel task force, with a technical working group, to oversee policies, programmes and activities in border health in the Greater Mekong Subregion, with a focal point to coordinate the process. Member States should develop an action plan endorsed by relevant departments that addresses complex issues, including national security, definition and determination of legal status of migrants and mechanisms to increase public and private partnerships. Engagement of a wide range of actors requires strong, high-level government commitment to conduct, coordinate and promote multisectoral and interdepartmental work. Data collection and analysis must also be improved. Data should be collected to establish baseline health needs and to identify existing and potential interventions. The recommendations outlined in WHO's Health of Migrants – the Way Forward (2010) to develop migrant sensitive indicators for health information and monitoring systems could be applied throughout the Greater Mekong Subregion. In combination, these actions will occur at different levels and in different sectors, and should be implemented through piloting and employing best practices. 2.2 Development, health systems and malaria in the Greater Mekong Subregion: the case for multisectoral action

Introduction and outline of key themes The concept paper, “Development, Health Systems and Malaria in the Greater Mekong Subregion: the case for multisectoral action”, framed the central concerns in malaria prevention and control, proposing that malaria is not only a health problem but also a development issue, requiring coordinated multisectoral efforts in the Greater Mekong Subregion. Despite immense gains in malaria control, and reduced incidence and mortality rates throughout the subregion, vulnerability remains for artemisinin-resistant malaria, particularly for migrant populations and ethnic groups. Despite global and regional action plans, large-scale development projects in the Greater Mekong Subregion also pose a threat in the form of changes in vector ecology, displacement of populations and increased population movement. Disparities in incidence and malaria mortality between countries, subregions and districts in the Greater Mekong Subregion exist, with patterns indicating the importance of focusing on border areas and mobile populations. Discussion of high-risk groups indicates that recognition of the challenges to providing high-quality diagnosis and treatment to these populations is a critical challenge in malaria elimination. The emergence of artemisinin-resistant malaria in the border areas of Cambodia, Myanmar, Thailand and Viet Nam is of serious concern as this is the first line treatment for malaria in most endemic countries. In addition, poor treatment practices and availability of substandard and counterfeit drugs in the Greater Mekong Subregion demonstrates that prevention and control of artemisinin-resistant malaria necessitates focus on migrant and mobile populations in border areas in the Greater Mekong Subregion. Plenary presentations In the presentations on this theme, the impact of development projects on malaria patterns and incidence in the Greater Mekong Subregion were discussed. Infrastructure development can increase migration along economic corridors, where there is already an overlap between incidence of malaria and increased burden of disease. Roadways, railways and hydro dams each impact malaria, indicating that malaria prevention and control programmes should receive more attention in economic planning,

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agriculture, environment and other sectors, and should be considered when planning and implementing development projects. Components of the 15 actions across four pillars in the WHO’s Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion: a regional framework for action (2013) demonstrate the role of non-health sector actors. High-level political support, including within ASEAN and through other regional fora, exists. However, that support must be translated to multisectoral actions, including efforts to ensure quality, availability and rational use of artemisinin-combination therapies and scaling-up key interventions for malaria elimination. Key topics, stakeholders, status quo and way forward The key challenges in controlling malaria and containing artemisinin resistance in the Greater Mekong Subregion, are to increase coverage of programmes and harmonize malaria treatment protocols. WHO’s Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion: a regional framework for action forms the basis of increased collaboration on containing resistance, identifying priority areas for action, including reaching all at-risk groups with full coverage of quality interventions. In addition to full coverage, closing the funding gap for these activities is a central issue. Stakeholders include populations and communities at risk, ministries of health, drug regulatory authorities, media, medicine manufacturers and traders, pharmaceutical associations, donors and large-scale development projects, as well as regional actors, such as ASEAN. The following objectives and actions were suggested: a) To achieve full population coverage of interventions through prevention, diagnosis and treatment, behaviour change communication, pre-migration education and health exams at border points, as well as inclusion of malaria-focused activities in development projects to reduce the risk of large scale development projects increasing malaria risk; b) To improve information by developing a standardized health information package on artemisinin resistance and disseminate throughout the Greater Mekong Subregion, expanding monitoring of drug resistance, and addressing knowledge gaps on artemisinin resistance through operations research; c) To close the funding gap through continuous advocacy at national and regional levels, and mobilization of resources through national ministries, private sector and regional bodies, including mechanisms for cross-border treatment; d) To address pharmaceutical issues by intensifying monitoring of drug quality, acting decisively in the case of substandard or counterfeit drugs and establishing and enforcing marketing and use of oral artemisinin monotherapy; and e) To improve multisectoral cooperation and cross-border collaboration through existing multisectoral bodies in the Greater Mekong Subregion, as well as establishing high-level national and provincial coordination mechanisms that focus on artemisinin resistance. Finally, state-owned and private companies should be engaged to provide a minimum package of health services in cross-border investment projects.

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2.3

Improving access to quality medicines in the Greater Mekong Subregion

Introduction and outline of key themes The background paper for this topic, “Improving access to good quality medicines in the Greater Mekong Subregion”, highlighted medicines and vaccines as essential elements for health services. Lack of access to good quality medicines can lead individuals to use sub-standard or counterfeit medical products. Low availability of essential medicines in public facilities means patients have to buy them in private outlets, where the price may not be affordable for most people. Even when essential medicines are available in health facilities, either public or private, their quality cannot always be assured. Unfortunately, poor quality and counterfeit medicines have been detected in the 3 markets of Greater Mekong countries for many years. The production, distribution and sale of poor quality medicines, especially in remote and border areas of the Greater Mekong Subregion, remain as serious threats to public health. The underlying causes of poor quality and counterfeit medicines are complex, and include poor compliance or capacity for good manufacturing practices (GMP), weak regulatory enforcement from production to distribution, weak quality surveillance and lack of consumer awareness on the aspect of quality. Dealing with substandard medicines requires improved compliance and capacity for GMP. Dealing with counterfeit medicines requires forensic investigation and legal action against the counterfeiter. Both efforts are dependent on strengthening regulatory capacity and enforcement. Functioning medicine regulatory authorities – mandated to ensure safety, quality and efficacy of medical products already – exist in all Greater Mekong Subregion countries. However, the capacity to implement and to enforce regulation, especially in remote and border areas, varies greatly from country to country. Except for China and Thailand, lack of human resources is a serious problem for regulatory authorities in Greater Mekong Subregion countries, leading to inefficient implementation of medicines regulation. Plenary presentations The panel of this session focused on three issues: 1) access to quality-assured medicines; 2) challenges of building regulatory capacity for effective monitoring of quality medicines in border areas and; 3) examples of successful collaboration between enforcement agencies and regulatory authority to reduce counterfeit and substandard medicines. The four pillars required for quality medicines are: geographic accessibility, acceptability, availability and affordability. Other factors such as rational selection of products, sustainable financing, reliable health and pharmaceutical supply systems, and affordable prices also play a role. However, compliance gaps exist at all levels: central, provincial and peripheral and can be found in public and private sectors. For border areas in particular, weak regulatory presence and enforcement jeopardizes the assurance of product quality and safety in the market. In addition, very limited access to good quality medicines in 3

Wondemagegnehu E. Counterfeit and Substandard in Myanmar and Viet Nam. A report of study carried out in cooperation with the Government of Myanmar and Viet Nam. Wolrd Health Organization, Depertment of Essential Drugs and Other Medicines. WHO/EDM/QSM/99.3; Newton PN, Dondorp A, Green M, Mayxay M and White NJ. Counterfeit artesunate antimalarials in Southeast Asia. The Lancet, vol 362: 169, 2003.

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remote and border areas can lead people to purchase and use expired, substandard, fake and counterfeit medicines. Cambodia provides a case study of a successful collaboration between enforcement agencies and regulatory authority to reduce counterfeit and substandard medicines. Through a joint provincial and central-level committee for counteracting counterfeits, Cambodia is strengthening regulatory authority at border check- points. In addition, post-marketing surveillance is improving with the involvement of partners such as WHO and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The process still faces challenges including lack of uniformity in regulations of neighbouring countries and lack of awareness about harmful effects of substandard and counterfeit medicine. Opportunities to strengthen regional collaboration to improve medicine quality need to consider several interconnected domains from individual care-seeking behaviours to health system delivery mechanisms and national resource allocations. Key topics, stakeholders, status quo and way forward The key issues related to this topic are geographic accessibility, availability, acceptability and affordability. To address this, a system should include pre-marketing quality assessment, regulatory elements, technical elements and post-marketing surveillance. It is in the interest of countries to invest in this problem because of the negative economic impacts if limited resources are wasted for purchasing poor quality and counterfeit medicines. Consumers are key stakeholders in this discussion and, although many are in need of new and updated information on counterfeit medicine and proper use of medicine, they can also be collaboratively involved in programmes. Regulatory authorities of the Greater Mekong Subregion and partner organizations have taken actions to cope with poor quality and counterfeit medicines – survey/monitoring of substandard and counterfeit medicines, training on combating counterfeit medicines and sharing of information. However, to address this issue the capacity of regulatory authorities to implement medicine regulation, particularly in remote and border areas, should be strengthened. In addition, sustaining and improving cross-border collaboration between regulatory authorities has immense value. Countries should also aim to have quality surveillance programmes in place because adoption of GMP alone does not automatically assure the quality of products on the market. For a collaborative approach, both in-country and intercountry trainings on GMP, improving regulatory systems and regulation, quality monitoring of products, and surveillance of medicines on the market are suggested. This, along with multi-country advocacy for proper use of medicines in border areas, could greatly improve the impact of outreach programmes. 2.4 Ensuring socially responsible infrastructure development in the Greater Mekong Subregion

Introduction and outline of key themes The background paper for this theme, “Health Impact Assessment and Socially Responsible Infrastructure Development”, stated that governments, private sector and partners recognize the need for greater emphasis on health impact of development plans, programmes and projects in other sectors including agriculture, education, power, transport, and water and sanitation. The health impact of plans, programmes and projects can be assessed in terms of both positive and negative effects of

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investments, and changes can be made to enhance positive health impacts and mitigate negative health impacts. Health Impact Assessment (HIA) refers to a suite of methods ranging from participatory planning to economic analysis to evaluate the health impacts of policies, plans and projects. A HIA is broadly defined as "a combination of procedures or methods by which a policy, programme or project may be judged as to the effects it may have on the health of a population". The approach aims to enhance the use of data and participatory approaches to improve quality and transparency of decision-making for investment. HIA is not only to benefit health, but can help governments, private corporations and partners reaching other goals as well. Yet adoption of the approach is not widespread across the Region. Many of the required actions to mitigate negative health impacts or enhance positive impacts require engagement of other sectors, consistent with a health-in-all-policies approach. To achieve concrete health outcomes, stakeholders from non-health fields must be engaged to systematically incorporate health issues into the myriad of relevant policies. Infrastructural development can also generate health benefits and the use of HIA as a tool to maximize social wellbeing should be explored. Plenary presentations During the plenary session, speakers reiterated the importance of ensuring socially responsible infrastructure development. While transportation and hydropower programmes bring positive benefits such as improved access to specific geographic areas, increased mobility for both people and goods, and access to electricity, negative impacts may results as well. Potential negative impacts of transport projects include the spread of communicable diseases like HIV/AIDS due to increased population mobility. Development projects can be designed to consider these potential impacts. HIAs are key to creating socially responsible projects. HIAs can help identify potential negative impacts and trigger mechanisms for projects to be modified, thus mitigating negative impacts and enhancing the benefits of the project. Key topics, stakeholders, status quo and way forward Key issues related to socially responsible infrastructure development in the Greater Mekong Subregion include limited awareness of health implications from infrastructure development, lack of strong health indicators to better track specific health outcomes, insufficient guidance on and capacity for use of HIA, and a weak monitoring and evaluation mechanism during and after project completion. In addition, not all infrastructure development will have significant health implications and, thus, an issue is how to identify priority sectors for HIA. Individuals living in and around areas of infrastructure development are the main stakeholders. However, other stakeholders include investors and funders of development projects, the private sector, health-service providers, data management personnel and development project workers. It is recommended that HIA-specific legislation be enacted, as has occurred in some countries (e.g. Cambodia’s Environmental Protection Act, Article 5). This would aid in standardized use of this method. Established HIA teams and focal points to carry out HIA using practical guidelines are also recommended.

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Countries need to develop their own systems for delivering safeguards. This objective is in line with the Paris Declaration on Aid Effectiveness. In the case of the Asian Development Bank (ADB), borrower countries conduct a large number of impact assessments. A review of country-led and ADBsupported assessments is required to identify whether health impacts are covered in sufficient detail. Training activities and education should be pursued to improve HIA practice and augment the body of health professionals able to conduct HIA. WHO Regional Office for the Western Pacific, ASEAN, the Regional Forum on Environment and Health in Southeast and East Asian Countries and others have been active in developing HIA capacity and networking across the Region. An interest in enhancing health impacts and minimizing negative impacts needs to be fostered. Efforts to pilot HIAs in sectors currently lacking these assessments need to be supported. 2.5 Increasing access to health services for people living in border areas in the Greater Mekong Subregion

Introduction and outline of key themes The concept paper for this session, “Health Situation and Health Systems Analysis: Cambodia, the Lao People's Democratic Republic, Myanmar, Thailand and Viet Nam” provided an overview of national and border-area health status and health systems issues, including analysis of migrant and border area specific health challenges and health systems concerns. The papers provide an overview 4 of each countries health systems using WHO’s six building blocks framework. Recommendations based on these analyses included that governments and stakeholders should establish and support cross-sector (labour, migration and health) programmes that support a continuum-of-care model for individuals throughout the migration process, that coordination between countries in the Region to promote health, disease prevention, care and treatment should continue and expand in border areas, that these activities expand beyond the current primary focus on communicable diseases, and that community-based organizations working along border areas should be included in programme development and data collection. These five country reviews illustrate that border health is closely linked with socioeconomic determinants, along with geographic distribution of populations, risk areas for communicable diseases, and location and density of health services. As a result, actions and policies should be conducted in a multi-disciplinary way to account for sectors that influence border health. Issues such as poor migrant monitoring systems, key and hard-to-reach populations, under-resourced health systems in border areas, and ineffective border collaboration, are common to all countries in the Greater Mekong Subregion. Some issues – such as complex migration patterns and limited surveillance systems – are specific to certain countries. A number of key priorities were presented within the operational framework developed during the WHO /IOM Global Consultation on the Health of Migrants in 2010 including: • Monitoring of migrant health: data standardization across the Greater Mekong Subregion; disaggregated data for migrant health in border areas; monitoring migrants’ health-seeking behaviours especially those in trans-border movements; and analyses of data to assist in policy formulation.

WHO (2007). Everybody's Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action

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•

Promote conducive policies and legal frameworks on migrant health: adopt international standards on migrants’ right to health; health-in-all-policies approach particularly with a focus on migrants in border areas; monitor policy implementation; and extend social protection and health and improve social security for all migrants. Migrant-sensitive health systems: migrant appropriate health services; improve service quality for migrant focused programming; improve continuity-of-care provision from nongovernmental organizations and private providers; and advocate a multi-stakeholder approach towards health and migration. Partnerships, networks and multi-country frameworks in migrant health: multisectoral migration health dialogue; promote migrant health in multi-country networks; and address migrant health in global and regional processes.

•

•

Plenary presentations The ASEAN Strategic Framework on Health Development (2010–2015) operationalizes the 55 action points of the ASEAN Social and Cultural Community in terms of health. Discussion of the structure and organization of ASEAN’s work on improving health, highlighted best practices in providing primary health care to marginalized and at-risk populations. Multisectoral collaboration for elimination of malaria is of key importance. In the case of China, large-scale health education has been provided to increase compliance with malaria control activities, alongside capacity-building at local medical facilities in border areas to increase service accessibility and quality. Tuberculosis is also a significant concern in border areas, given migrant populations are often at higher risk for TB infection, and, specifically, multidrug-resistant TB. WHO has recently developed a framework on TB and migration in the Western Pacific Region, emphasizing the need for migrants to be able to receive quality diagnosis and treatment, or access proper referral mechanisms to treatment in their own country. Regional collaboration to address emerging public health threats is taking place in the Greater Mekong Subregion through a range of institutional arrangements. However, an enabling environment to improve access to health services requires increased political cooperation and attention to issues of financing. There may be a role for a regional financing mechanism, however, there are several unanswered questions, including how to ensure political commitment, sustainability, and implementation in line with country-specific financing. Key topics, stakeholders, status quo and way forward Key issues for people living in border areas in the Greater Mekong Subregion include inequities in access to and availability of services. These include the quality of services, attraction and retention of trained health providers to border areas, provision of information to local populations, and implementation of migrant-sensitive health services (which consider linguistic and cultural differences). Lack of insurance coverage for migrants and insufficient data to inform service provision in border areas are central issues. The question of quality health services is also tied to the question of resources, including infrastructure such as facilities, transport and equipment. In addition to stakeholders identified in other topic areas, providers of border area health services (including village health volunteers and medical personnel), and local government officials play important roles.

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To improve access to health services in border areas in the Greater Mekong Subregion, an ASEANlevel formal collaborative mechanism should be developed, as a step towards identifying the core responsibilities of regional and international organizations, including donors, to monitor and support action plans to improve border health. Activities to strengthen health systems in border areas should include professional and social incentives to attract and retain human resources for health in border areas, increase capacity of primary health care facilities, and expand universal health care coverage to include migrant workers. Other recommendations include strengthening intercountry and regional cooperation to share health information and disease surveillance, improved laboratory capacity and enforcement to ensure availability of quality assured medicines and reduce counterfeits, and increased capacity of drug regulatory agencies. The question of financing and resources is central – participants discussed efforts to increase funding for these activities through increased taxes and other revenues, as well as increased support from the private sector. 2.6 Improving mechanisms for coordination across sectors and borders to better meet health needs

Introduction and outline of key themes The background paper, “Improving mechanisms for coordination across sectors and borders to better meet health needs,” states that to ensure health needs of border populations are met potential problems and benefits arising from rapid economic development need to be anticipated and managed, in addition to addressing health-care access. Complexities in addressing this include the diversity of populations and health issues associated with population mobility, differences in health systems and health-care entitlements across borders and the influence of social determinants of health. Health needs for migrants and residents of border areas are met through access to formal and informal health-care providers, with traditional and western medicines procured through a variety of means. While their health needs may not be the same, migrants and residents share similar problems in terms of limited access to good quality health care, especially in rural and remote border areas. Health systems are designed as national entities. However, communicable diseases have no borders, while management of noncommunicable diseases may be limited when people traverse borders. Health needs of migrants (and ethnic minority groups in border areas) may be given less priority by the health sector despite their high vulnerability. Multisectoral responses (involving agriculture, education, forestry, transportation, social protection, etc.) are required at national and regional levels to address health hazards and risks, many of which arise from environmental, social, economic and occupational conditions. For border communities, health system financing and regulation issues become bilateral if not multilateral issues. Efforts on universal health coverage are focused on national health systems and may or may not include coverage for migrants. Furthermore, coordination mechanisms can evolve over time. Sharing information to manage matters of mutual interest helps to achieve common understanding, which can lead to sharing of resources if not greater alignment of work. For some issues, an enhanced and formalized information and communication system (such as disease reporting or reporting of counterfeit medicines) could help resolve bottlenecks in implementation.

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Plenary presentations During the plenary session, issues of risk governance and stewardship were presented, as well as examples of subregional and regional coordination. As countries in the Greater Mekong Subregion continue to build coordination mechanisms, there are models of cross-border collaboration (e.g. United States of America (USA)-Mexico and USA-Canada) to draw from. However, these arrangements are between governments and may not provide specific examples of cross-sector collaboration. To fill in gaps in knowledge, countries can look at other sectors, such as departments of forestry, fisheries, and customs. A strong approach to collaboration for countries in the Greater Mekong Subregion is likely to look build on synergies in existing networks. While a new network may be needed, countries should first look at existing memoranda of understanding, and networks such as Joint United Nations Initiative on Migration, Health and HIV in Asia (JUNIMA) and APSED. While thinking regionally is important, actions must be local. Without strengthening national and local capacities, large coordination mechanisms may falter. To improve capacities, more resources are needed. This includes having a sustainable, multi-donor regional fund for programmes. Key topics, stakeholders, status quo and way forward There are common needs across borders to protect health and reduce risks. However, networks and committees are often unlinked and have separate plans. Key needs include harmonizing policies, laws and regulatory frameworks, and strengthening political commitment. Multifaceted and complex issues require collaborative governance and involvement across sectors to meet the health needs of border populations. Work must be done to include other sectors, while strengthening health systems. Within health systems, technical collaboration in border areas could increase geographic coverage and provide more detailed technical information. Stakeholders include governments, the private sector (e.g. associations, chambers of commerce), nongovernmental organizations (health, social welfare, development), international nongovernmental organizations, and United Nations agencies. It was recommended that short- and medium-term agendas and action points be developed with areas of work prioritized in both. Following prioritization, existing mechanisms can be researched for action on priority issues, with a corresponding timeline for when the issues will receive attention by appropriate agencies. It was also suggested that a mapping exercise of all organizations working in border areas could be useful, in instances where a current map does not already exist. In addition, having a broad spectrum of agencies involved across public and private sectors will most likely be beneficial for coordination. In line with this, however, it is suggested that high-level authorities in countries take the lead in coordination and then identify focal points from specific sectors (e.g. WHO for health issues). Information management mechanisms and monitoring and evaluations frameworks that are standardized in the Greater Mekong Subregion could facilitate communication and information sharing, with a particular focus on including information from border areas. By providing a platform for dialogue and regular information exchange, such as regular biregional meetings, collaborative efforts will likely be strengthened. Regular information exchange and dialogue will also support and strengthen communication and coordination for alert of and timely action on key issues such as

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disease outbreaks. Although there are several networks, there are areas and specific health issues without a network supporting them – an important one being health sector development. Issues such as malaria control may be important entry points to enhance collaboration and build health systems components. Finally, capacity development is necessary for collaboration to meet health needs. It is recommended that capacity development for government systems for healthy borders – through harmonized training and initiatives from governments and organizations – be established. In addition, focusing on improving capacities at the local level in border areas, specifically on governance and leadership of subnational authorities at border areas, is a key step. 3. CONCLUSIONS With increasing trade, travel and development in the Greater Mekong Subregion comes increased risks to the health of people living in border areas, including migrants and ethnic minority groups. Unprecedented population movement in the subregion is likely to increase, placing further demands on programmes and initiatives. Due to the complex nature of the issues involved in border health, multisectoral approaches are required. Through this meeting, examples of public health threats, success stories and challenges were discussed. From the Greater Mekong Subregion, examples such as the UN ESCAP healthy highways project to combat HIV/AIDS and Thailand’s Business Coalition on AIDS, which uses private sector resources in delivering health services, illustrate the benefits of a multi-stakeholder and multisectoral response. Aiming to increase coordination should also be combined with efforts to strengthen systems, such as data collection, responses to disease outbreaks and standardized protocols. Countries in the Greater Mekong Subregion experience disparities and gaps in programmes, despite progress on some health topics and in some areas. For example, improved access for people in rural areas and border areas to health services are still needed. Supported by statements from ASEAN, participants at this meeting also recognize the need for more collaboration and synergy for both health and non-health issues. This collaboration should add value to initiatives and aim to involve stakeholders ranging from government officials to community members. This meeting has set the stage for approaching health problems in new and innovative ways. As the Greater Mekong Subregion grows and develops, investing in these initiatives directly translates into investing in a common, healthy future together. Links between countries in the Greater Mekong Subregion continue to expand, requiring international collaboration to create holistic approaches to tackle these issues.

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ANNEXES

Annex 1. Agenda Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 5–7 August 2013; Bangkok, Thailand Meeting venue: Ballrooms 1 & 2, 2nd Floor, Royal Orchid Sheraton Hotel Day 1: Monday, 5 August 2013 07:30–08:15 08:15 – 09:30 Registration Opening Session Welcome address Opening remarks Dr Yonas Tegegn WHO Representative to Thailand Dr Samlee Plianbangchang WHO Regional Director for South-East Asia (on behalf of SEARO and WPRO) Mr Arkhom Termpittayapaisith Secretary-General of the Office of National Economic and Social Development Board, Thailand Dr Rajesh Bhatia, CDS/SEARO Dr John Ehrenberg, DCC/WPRO

Opening address

09:30–10:00 10:00–10:30

Session 1: 10:30–10:40

10:40–10:55 10:55–11:10

11:10–11:25

11:25–11:40

Dr Supang Chantavanich Professor Emeritus, Asian Research Center for Migration, Institute of Asian Studies, Chulalongkorn University, Bangkok Development, health systems and malaria in the Greater Mekong Subregion: the case for multisectoral action Chair: Rapporteurs: Dr Porntep Siriwanarangsun Dr Sandra Tempongko, Director-General, Department of Disease SEAMEO/TROPMED Control, Dr Maria Guevara, Médecins sans Ministry of Public Health, Thailand Frontières Presentations: (15 minutes) Speakers: Development projects, migration and malaria Dr Deyer Gopinath, WHO, in the Greater Mekong Subregion Lao People's Democratic Republic Cross-border collaboration in malaria Dr Wichai Sathimai control: Lessons from Thailand Department of Disease Control, Bureau of Vector Borne Disease, Thailand Successes and challenges of multisectoral Dr Char Meng Chuor collaboration for malaria control and National Center for Parasitology, elimination: Examples in Cambodia Entomology and Malaria Control, Cambodia Towards multisectoral actions to combat Dr Leonard Ortega, CDS/SEARO

Introduction of participants and secretariat Meeting objective, outcomes and mechanics Group photo and coffee/tea break Keynote presentation: Challenges for border health in the Greater Mekong Subregion - the need for multisectoral and cross-country actions

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11:40–12:00 12:00–13:30 Session 2: 13:30–13:35

13:35–13:55

13:55–14:40

malaria drug resistance in the Greater Mekong Subregion Discussion Lunch break Multisectoral approaches to address the health needs of populations, including migrants, in border areas in the Greater Mekong Subregion Chair: Rapporteurs: Dr Bounlay Phommasack Dr Nasir Hassan, DHP/WPRO Director, Communicable Diseases Control Ms Sarah Meyer, Johns Hopkins Department, Ministry of Health University Lao People's Democratic Republic Speaker: (20 minutes) Dr Catherine Lee Border health: Concepts, models, and Johns Hopkins University applications for the Greater Mekong Subregion Panel members: (5-6 minutes each) Initiative for ASEAN Integration: Narrowing H.E. Dr Alicia Dela Rosa Bala the Health Gap ASEAN Socio-Cultural Community Mekong Migration Network Ms Jackie Pollock, MAP Foundation Ideas for private sector involvement Dr Anthony Pramualratana Thailand Business Coalition on AIDS National resources and agricultural aspects of Dr Sununtar Setboonsarng healthy borders Natural Resources and Agriculture Economist, Asian Development Bank Social protection of population, including Ms Viennarat Chuangwiwat migrants, in border areas International Labour Organization Discussion Coffee / tea break Improving access to quality medicines in the Greater Mekong Subregion Chair: Rapporteur: Mr Srinivas Tata Dr Sudhansh Malhotra, SEARO Chief, Social Policy and Population Section Dr Catherine Lee, Johns Social Development Division Hopkins University UN Economic and Social Commission for Asia and the Pacific Speaker: Improving access to quality Dr Souly Phanouvong medicines in the Greater Mekong Subregion US Pharmacopeia Panel members: (5-6 minutes each) Challenges of building regulatory capacity for Dr Zaw Win effective monitoring of quality of Department of Food and Drug pharmaceuticals in border areas Administration, Myanmar Successes of collaboration between Dr Heng Bunkiet enforcement agencies and regulatory authority Drug Regulatory Authority, to reduce use of counterfeit/substandard Cambodia medicines in Cambodia Capacity development of key stakeholders for Ms Aline Plancon, Interpol investigation of pharmaceutical crime Strategies to strengthen procurement and Dr Lamphone Syhakhang supply chains for better access in hard to reach Food and Drug Department, Ministry

14:40–15:00 15:00–15:30 Session 3: 15:30–15:35

15:35–15:55 15:55–16:30

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areas in Lao People’s Democratic Republic

16:30 – 17:00 17:00 – 17:15 18:30 – 20:30

08:30 – 08:35 08:35 – 08:50

Session 4: 08:50 – 09:00

09:00 – 09:20

09:20 – 09:40

09:40 – 10:00 10:00 – 10:30 Session 5: 10:30 – 10:35

Opportunities for strengthening regional collaboration to improve access to medicines in the Greater Mekong Subregion Discussion Summary and closure of Day 1 Rapporteurs/Secretariat Reception dinner hosted by the Regional Directors of SEARO and WPRO (Riverside Ballroom, Royal Orchid Sheraton Hotel) Day 2: Tuesday, 6 August 2013 Introduction of Keynote Speaker Dr John Ehrenberg, DCC/WPRO Keynote Address Stephen P. Groff Vice President (Operations 2), Asian Development Bank Ensuring socially responsible infrastructure development in the Greater Mekong Subregion Chair: Rapporteurs: Dr Vincent De Wit Dr Beverly Lorraine Ho Lead Health Specialist Asian Development Bank Human and Social Development Division, Dr Richard Brown, SEARO Southeast Asia Department, Asian Development Bank Speaker: (20 minutes) Dr Genandrialine Peralta Health impact assessment and socially Senior Safeguards Specialist responsible infrastructure development Environment, Southeast Asia Department, Asian Development Bank Panel members: (5 minutes each) HIV/AIDS and transport projects in Dr Bounpheng Philavong Lao People’s Democratic Republic National Center for HIV/AIDS and STI, Ministry of Health, Lao People's Democratic Republic Challenges in mitigating health risks in Ms Khin Mar Aye. Ministry of development projects in Myanmar National Planning and Economic Development, Myanmar Health without borders: sharing experiences Mr Srinivas Tata, UNESCAP from the UNESCAP project on healthy highways Sustainable infrastructure and development for Dr Eun Jin Choi, Korea Institute for health and environment Health and Social Affairs Discussion Coffee /tea break Increasing access to health services for people living in border areas in the Greater Mekong Subregion Chair: Rapporteurs: Dr Supang Chantavanich Ms Sarah Meyer, Johns Hopkins Director, Asian Research Center for Migration, University Institute of Asian Studies, Chulalongkorn Dr Vason Pinyowiwat, SEARO University

of Health, Lao People’s Democratic Republic Dr Klara Tisocki, DHS/WPRO

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10:35 – 10:55

10:55 – 11:30

Speaker: Increasing access to health services for those living in border areas in the Greater Mekong Subregion Panel members: (5-6 minutes) ASEAN health cooperation in increasing access to health services among the ASEAN people

Dr Jaime Calderon Regional Migration Health Advisor, International Organization for Migration Dr Ferdinal Fernando ASEAN Socio-Cultural Community Department Professor Xiao Ning National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention Dr Catharina van Weezenbeek, DCC/WPRO Dr Benedict David Australian Agency for International Development Dr Maung Maung Than Htike International Health Division, Ministry of Health, Myanmar Dr Supakit Sirilak, Ministry of Public Health, Thailand

Tuberculosis in the context of healthy borders Regional collaboration to address emerging public health threats across the Asia Pacific: Our experience of a regional response to malaria and malaria drug resistance Health and development in border areas of Myanmar Border health programme in Thailand 11:30 – 12:00 12:00 – 13:30 Discussion Lunch Break Brown Bag Seminar: "Innovative, cross-sectoral approaches to surveillance and control of malaria and dengue”

Session 6: 13:30 – 13:35

13:35 – 13:50

13:50 – 14:30

Dr Susann Roth, Senior Social Development Specialist Regional and Sustainable Development Department, Asian Development Bank Improving mechanisms for coordination across sectors and borders to better meet health needs Chair: Rapporteurs: H.E. Dr Alicia Dela Rosa Bala Dr Catherine Lee, Johns Hopkins Deputy Secretary-General, University Association of Southeast Asian Nations Dr Roderico Ofrin, EHA(ASEAN) Socio-Cultural Community SDE/SEARO Speaker: Dr Vivian Lin, Director Risk governance and stewardship for a healthy Division of Health Sector setting: Improving coordination for health Development, WPRO across borders Panel members: (5-6 minutes each) Mekong Basin Disease Surveillance Dr Bounlay Phommasack Ministry of Public Health, Lao People's Democratic Republic Brokering commitments for migrants’ access Mr Clifton Cortez to health care – the role of JUNIMA Joint Initiative on Mobility & HIV/AIDS (JUNIMA) Regional public goods and cross border health Dr Myo Thant, Office of Regional

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challenges

APSED/International Health Regulations Perspective from the finance sector on coordination 14:30 – 14:50 Discussion 14:50 – 15:15 Coffee / tea break Session 7: Group Work: Five parallel sessions using world café method 15:15–15:25 Introduction to the group work dynamics Facilitators: Dr Katsunori Osuga, DCC/WPRO Dr Susann Roth, ADB 15:25–17:30 Topic 1: Strengthen high level multisectoral commitment to implement the emergency (20–25 response to artemisinin-resistant malaria in the Greater Mekong Subregion minutes for Moderators: Dr Eva Christophel / Dr Leonard Ortega each group) Rapporteurs: Dr Maria Guevara / Dr Sandra Tempongko Topic 2: Set the stage for a multisectoral framework for border/migrant health in Greater Mekong Subregion Moderators: Dr Brent Burkholder / Dr Luo Dapeng Rapporteurs: Dr Jaime Calderon / Dr Nasir Hassan Topic 3: Identify best practices for development projects to lessen negative impacts and improve the health of populations in the Greater Mekong Subregion Moderators: Dr Richard Brown / Dr Deyer Gopinath Rapporteurs: Ms Glenda Gonzales / Dr Beverly Ho Topic 4: Stress the need for access to quality health services and disease prevention in Greater Mekong Subregion border areas. Moderators: Dr Sudhansh Malhotra / Dr KlaraTisocki Rapporteurs: Ms Sarah Meyer / Dr Catherine Lee Topic 5: Identify collaboration mechanisms that can improve the health of people living in the Greater Mekong Subregion border areas Moderators: Dr Ferdinal Fernando / Dr Vivian Lin Rapporteurs: Dr Roderico Ofrin / Dr Najibullah Habib Day 3: Wednesday, 7 August 2013 Summary of discussions and the way forward Chair: Dr Shin Young-soo WHO Regional Director for the Western Pacific 08:50 – Opening Remarks H.E. Dr Pradit Sintavanarong 09:05 Minister of Public Health, Thailand 09:0–09:20 Keynote Address H. E. Dr Le Luong Minh Secretary-General, The Association of Southeast Asian Nations Secretariat (ASEAN) 09:20–09:25 Break 09:25–09:30 Chair: Rapporteurs: H.E. Professor Pe Thet Khin Dr Catherine Lee and Ms Sarah Union Minister of Health, Myanmar Meyer Co-chairs: Johns Hopkins University Dr Rajesh Bhatia, CDS/SEARO Dr John Ehrenberg, DCC/WPRO

Economic Integration, Asian Development Bank Dr Richard Brown, DSE/SEARO Ms Wang Min Ministry of Finance, China

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Introduction to the session

09:30–09:40

09:40–09:55 09:55–10:05

10:05–10:20 10:20–10:40 10:40–10:50

10:50–11:05 11:05–11:15

11:15–11:30 11:30–11:40

11:40–12:00 12:00–12:10 12:10–12:25

12:25–12:50

Strengthen high level multisectoral commitment to implement the emergency response to artemisinin-resistant malaria in the Greater Mekong Subregion Discussion Set the stage for a multisectoral framework for border/migrant health in Greater Mekong Subregion Discussion Coffee/tea break Identify best practices for development projects to lessen negative impacts and improve the health of populations in the Greater Mekong Subregion Discussion Stress the need for access to quality health services and disease prevention in Greater Mekong Subregion border areas Discussion Identify collaboration mechanisms that can improve the health of people living in the Greater Mekong Subregion border areas Discussion Overall summary Comments and feedback on meeting outcomes (1-2 minutes each) Closing session Call for Action

Chair: H.E. Professor Pe Thet Khin Union Minister of Health, Myanmar Presenter: Dr Eva Christophel, DCC/WPRO

Presenter: Representative from the Ministry of Health, Lao People's Democratic Republic

Presenter: Representative from the Ministry of Health, Myanmar

Presenter: Representative from the Ministry of Health, Viet Nam

Presenter: Representative from the Ministry of Health, Cambodia

Dr John Ehrenberg, DCC/WPRO Representatives from country delegations and partners H.E. Mr Sorawong Thienthong Deputy Health Minister, Thailand Dr Bounkong Syhavong Vice Minister of Health, Lao People’s Democratic Republic H.E. Professor Pe Thet Khin Union Minister of Health, Myanmar Mr Larry Maramis Director of the Cross-Sectoral Cooperation Directorate of the ASEAN Socio-Cultural Community Dr Shin Young-soo WHO Regional Director for the Western Pacific (on behalf of SEARO & WPRO)

12:50–13:00

Closing Remarks

13:00–14:00

Lunch / End of meeting

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Annex 2. List of participants 1. COUNTRY PARTICIPANTS

CAMBODIA

H.E. Professor SEA Huong, Under Secretary of State, Ministry of Health, 151-153 Kampuchea Krom Blvd, Phnom Penh, Tel: +855 23 722 933. E-mail: seahuong2@gmail.com Dr CHAR Meng Chuor, Director, National Center for Parasitology, Entomology and Malaria Control, 372 Monivong Blvd, Street No 322, Phnom Penh, Tel. +855 23 223442, E-mail: mengchuor@cnm.gov.kh Dr HENG Bunkiet, Director, Department of Drugs and Food, Ministry of Health, 151-153 Kampuchea Krom Blvd., Sangkat Mittapheap, Khan 7 Makara. Phnom Penh, Tel. +855 23 880 247, E-mail: hengbunkiet@yahoo.com Mr KIM Phalla. Director, Economic and Public Finance Policy Department, Ministry of Economy and Finance, St 92, Sangkat Wat, Phnom, khan Daun Penh, Phnom Penh, Tel.+855 23 724664, E-mail: kimphalla@hotmail.com Mr LENG Tong, Director of Occupational Safety and Health Department, Ministry of Labour and Vocational Training. #3, Russian Blvd., Sangkat Touek Laaki, Khan Toulkork, Phnom Penh, Tel. +855 23 884375; E-mail: lengtongpachem@gmail.com Mr SAM Saroeurn, Deputy Director, Statistical Standards and Analysis Department, Ministry of Planning, No 386, Monivong Blvd, Sangkat Boeng, Keng Kang I, Chamkarmon, Phnom Penh, Tel: +855 17 835118 E-mail: ssaroeurn18@hotmail.com Mr SOK Khorn, Deputy Chief of Macroeconomic Office, Economic and Public Finance Policy Department, Ministry of Economy and Finance, St 92, Sangkat Wat, Phnom, khan Daun Penh, Phnom Penh, Tel.:+855 23 724664, E-mail: khornsok@gmail.com Mr PHY Maly, Official, Department of Occupational Safety and Health, Ministry of Labour and Vocational Training, #3, Russian Federal Blvd, Tuek Laak I., Phnom Penh, Tel: +855 23 884375, E-mail: malyphy@gmail.com Mr CHAN Samrith, Chief of Bureau , National Institute of Statistics, Ministry of Planning, Building No 386, Monivong Blvd., Boeng Keng Kang 1, Chamkarmon, Phnom Penh, Tel.: +855 12 672728, E-mail: samrith82@yahoo.com

CHINA

Ms Jianli HAN, Deputy Division Director, Department of International Cooperation, National Health and Family Planning Commission, 1 Xi Zhi Men Wai Nan Lu, Xicheng District, Beijing 100044, Tel.: +86 68792292; E-mail: hanjl@moh.gov.cn Dr Jun LI, Deputy Director/Professor, Guangxi Institute of Parasitic Diseases, 18 Jinzhou Road, Nanning 530028, Tel. +86 7715 18845, E-mail: lijun-68@21cn.com Dr Feiyu MO, Senior Staff Member, Disease Control Office, Guangxi Province Health Department, 35 Taoyuan Rd, Nanning 530021, Tel.: +86 77 12635860; Email: 2569045815@qq.com Ms Meng SHAO, Program Officer, National Health and Family Planning Commission, No 1, Nanlu, Xizhimenwai, Beijing, Tel.: +86 10 68792297; E-mail: shaongmeng@moh.gov.cn

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Ms Min WANG, Principal Staff Member, Social Security Department, Ministry of Finance, No 3, Sanlihe Nansanxiang, Xicheng District, Beijing, Tel.: +86 77 12635860, E-mail: 2569045815@qq.com Dr Ning XIAO, Deputy Director/Professor, National Institute of Parasitic Diseases, China CDC, 207, Ruijin, No 2 Road, Shanghai 200025, Tel.: +86 20 54186399; Email: xiao.ning@yahoo.com Mr ShuiYuan XU, Director of General Office, Department of Services and Management of Migrant Population, National Health and Family Planning Commission, No 14, Zhichun Rd, Haidian District, Beijing 100141,Tel: +86 10 62030797, Email xshuiyuan@sina.com Dr Yichao YANG, Director, Guangxi Institute of Parasitic Diseases, 18 Jinzhou Road, Nanning 530028, Tel.: +86 771 2518845, E-mail: yylchao@sohu.com Mr Bingli ZHANG, Director, Rural Health Division of Primary Health Department, National Health and Family Planning Commission, No 1 Xi Zhi Men Wai Nan Lu, Beijing, Tel.: +86 10 62030878, E-mail: 18811080811@163.com Mr Qifa GAO, Consultant , National Health and Family Planning Commission, No 1, Nanlu Xizhimenwai, Beijing 100044, Tel.: +86 10 68792349, E-mail: gqifa@sina.com LAO PEOPLE’S DEMOCRATI C REPUBLIC H.E. Dr Bounkong SYHAVONG, Vice Minister of Health, Ministry of Health, Simeung Road, The Cabinet, Vientiane, Tel.:+85621 253017, E-mail: bounkongs@yahoo.com Mrs Vilaythone SUNTHONEXAYMONGKHON, Deputy Permanent Secretary, Ministry of Home Affairs, Nahaidiao Street, P.O. Box 6376, Vientiane, Tel.:+856 20 56994155, E-mail: vilaythonespx@gmail.com Dr Bounlay PHOMMASACK, Director General, Department of Disease Control, Ministry of Health, Simoung Rd., Sisatanak District, Vientiane, Tel.:+856 21 285 449, E-mail: bphommasack@gmail.com Mr Sychath BOUTSAKITIRATH, Deputy Director General, Ministry of Energy and Mines, Nongbon Road, Vientiane, Tel.: +856 020 9960 0004, E-mail: sychath@det.gov.la Mr Mahanakhone SOURIYA, Deputy Director-General, Department of Department of Livestock and Fisheries, Ministry of Agriculture and Forestry, Khounta Village, Sikhot District Vientiane, Tel.: +020 555 485 555, E-mail: m.souriya@yahoo.com Dr Bounpheng PHILAVONG, Director, Center for HIV/AIDS/STIs (CHAS), Ministry of Health, Km 3 Thadeua Road, Vientiane, Tel. +856-21-315500, E-mail: bounpheng.p@moh.gov Dr Chanthaly CHANSOMPHENG, Deputy Director, UN System Division, Department of International Cooperation, Ministry of Planning and Investment, Souphanouvong Avenue, Ban Sithanneua, Sikhottabong District, Vientiane, Tel.: +856 21 22214, E-mail: chansompheng@yahoo.com Ms Keo CHANTHAVIXAY, Deputy Director of Skill Development and Employment Department, Ministry of Labor and Social Welfare, P.O. Box 347, Pangkham Road, Chanthaboury District, Vientiane, Tel.: +856 21 217738, E-mail: k_chanthavixay@yahoo.com

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Dr Lamphone SYHAKHANG, Deputy Director, Food and Drug Department, Ministry of Health, Simeuang Road, Vientiane,Tel. No. +856 21 214001, Email:syhakhangl@yahoo.com Mrs Saykham THAMMANOSOUTH, Director, Advancement of Women Division Secretariat Office, Ministry of Public Works and Transport, Lanxang Avenue, Vientiane, Tel: +856 21 454721, E-mail: saykhamt@yahoo.com Dr Bouasy HONGVANHTHONG, Director of Center of Malariology, Parasitology and Entomology, Ministry of Health, Vientiane, Tel.: +856 21 214 040, E-mail: cmpelao@gmail.com Dr Bounlome KEOBOUAHOME, Deputy Director of Socio-Cultural Department, of the National Assembly, The National Assembly Building, That Luang Square, Vientiane, Tel. +856-21 413 501, E-mail: lomkbh@gmail.com Mrs Sommay PHOMMOUNIVONG, Head of Division, Promotion of Women's Development and Mother and Child Division, Ministry of Industry and Commerce, Phonxay Road, Vientiane, Tel. +856 021 415930, E-mail: sommay18@gmail.com Ms Philayvanh VIRAVOUTH, Technical Staff, The Lao National Mekong Committee Secretariat, Ministry of Natural Resources and Environment, Khunboulom Road, Chanthabouly District, Vientiane, Tel.: +856 21 260983, E-mail: vphilayvanh@yahoo.com Dr Phonesavanh VONGKHAMCHANH, Deputy Director of 5 Mesa Hospital, Ministry of Public Security, Khouvieng Road, Vientiane, Tel.: +856 21 970485, Email: pelenoiteuy@yahoo.com MYANMAR H.E. Professor Pe Thet Khin, Union Minister for Health, Myanmar, Tel + 95 67 411353, E-mail: ihdmoh@mptmail.net.mm Dr Soe Lwin Nyein, Deputy Director General (Disease Control), Department of Health, Ministry of Health, Tel:+09 500 1210, E-mail: drslnyein@gmail.com Dr Win Naing, State Health Director, Kayin State Health Department, Ministry of Health, Tel: + 95 058 21236 Mr La Yaung, Director, Ministry of Boarder Affairs, Tel No. :+95 9 49209445 Ms Khin Mar Aye, Director Planning, Ministry of National Planning and Economic Development, Tel: 067 407087, E-mail: elegantmyanmar@gmail.com Dr Zaw Win, Director of Administration, Department of Food and Drug Administration, Tel No.: 067 431134, Email: zawwinbago@gmail.com Dr Htike Su Aung, Senior Medical Officer, Social Security Board, Ministry of Labour, Employment & Social Security Board, Tel No. +9567 430281, E-mail: htikesuaung13@gmail.com Mr Win Bo, Assistant Director, Immigration and National Registration Department, Ministry of Immigration & Population, Tel: +95 067 431007, E-mail: phyomaungmg2g@gmail.com Dr Maung Maung Than Htike, Deputy Health Director, International Health Division, Ministry of Public Health, Tel + 09 458020902, E-mail: mmth74@gmail.com

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Mr Phyo Maung Maung, Staff Officer, Immigration & National Registration Department, Ministry of Immigration & Population, Tel: +00 95 09 20 38884, E-mail: phyomaungmg2g@gmail.com Dr Hla Moe, Medical Superintendent, Mandalay Worker’s Hospital Social Security Board, Ministry of Labour, Employment and Social Security Board, Tel: +95 92000202, E-mail: htikesuaung13@gmail.com Dr Ko Ko Naing, Assistant Director (AIDS/STD), Ministry of Health, Tel: +95 67 421203, E-mail: kknaing09@gmail.com Mr Thet Naung, Deputy Director, Regional Supervisory Officer, Hpa An Township, Progress of Border Areas & National Races Department, Ministry of Border Affairs, Tel: +95 058 22523 Dr Tin Htun Oo, Team Leader, Vector Borne disease Control, Ministry of Health, Dawei, Tanintharyi, Tel: +95 9 43035672, E-mail: docutormyjg@gmail.com Ms Mi Ni Oo, Police Major / Deputy Head of Branch, Anti-Human Trafficking Unit, Myanmar Police Force, Ministry of Home Affairs, Tel: +9567422288, E-mail: minioo2067@gmail.com Mr Thet Oo, Staff Officer, Department of Social Welfare, Ministry of Social Welfare, Relief and Resettlement, Tel: +959448534830, E-mail: captainnyeinooswe@gmail.com Mr Nyein Oo Swe, Staff Officer, Department of Social Welfare, Ministry of Social Welfare, Relief and Resettlement, Tel: +95 67 404177, E-mail: captainnyeinooswe@gmail.com Mr Kaung Myint Thu, Staff Officer, General Administration Department, Ministry of Home Affairs, Tel: +95 9 43106062, E-mail: linnkyae@gmail.com THAILAND H.E. Dr Pradit SINTAVANARONG, Minister of Public Health, Ministry of Public Health H.E. Mr Sorawong THIENTHONG, Deputy Minister, Ministry of Public Health Mr Arkhom TERMPITTAYAPAISITH, (GMS National Coordinator)/Secretary General, National Economic and Social Development Board, 962 Krung Kasem Road, Pom Prab, Bangkok 10100, Tel: +66 2 280 4085 extension 2309, E-mail: arkhom@nesdb.go.th Dr Porntep SIRIWANARANGSUN, Director – General, Department of Disease Control, Ministry of Public Health, Tel.: + 66 2590 3351, +66 2590 3369, E-mail: psiriwa@hotmail.com / psiriwa@gmail.com Dr Pasakorn AKARASEWI, Director, Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Tel. +66 2 590 1776, E-mail: pasakron@sewi@gmail.com Dr Wichai SATIMAI, Medical Officer, Advisory level, Department of Disease Control, Ministry of Public Health, Tiwanon Road, Muang , Nonthaburi, Tel: +66 2590 3131 / +66 2590 3141, E-mail: satimaiw@yahoo.com Dr Supakit SIRILAK, Medical Officer, Advisory level (Preventive Medicine), Health Technical Office, Ministry of Public Health , Tiwanon Road, Muang , Nonthaburi, Tel.: +66 8 1379 3039, E-mail: konc62@yahoo.com

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Dr Suwat KITTIDILOKKUL, Director, Bureau of Policy and Strategy, Office of the Permanent Secretary , Ministry of Public Health Dr Nipon CHINANONWAIT, Director, Bureau of Vector Borne Diseases, Department of Disease Control, Ministry of Public Health, Tel.: +66 2 590 3145, Email: chinnipon2011@gmail.com Dr Pongwit BUALOMBAI, Deputy Director, Bureau of Vector Borne Diseases, Department of Disease Control, Ministry of Public Health, Tel.: +66 2 590 3126, E-mail: pongwitb@yahoo.com Dr Pornpet PANJAPIYAKUL, Deputy Director, Bureau of Health Administration, Office of the Permanent Secretary, Ministry of Public Health, Tel:+662 590 1755, E-mail: pornpet@gmail.com Ms Suparaporn THANNACHART, Policy Analyst, Professional Level Bureau of Policy and Strategy, Ministry of Public Health, Tel: +6625901390 E-mail: thsukai@yahoo.com Mr Sakdisilpa TULADHORN, Acting Director, Occupational Safety and Health Strategy Group, Ministry of Labour, Tel:+662 4488338 ext. 606, + 668 1345 7765, E-mail: saksil.t@labour.mail.go.th Mr Wattanawit GOJASENI, Director, Countries Partnership Branch, Thailand International Development Cooperation Agency, Ministry of Foreign Affair, Tel: + 662 2035000 ext. 41018, E-mail: wattanawit@mfa.go.th Ms Hataichanok SIRIWATTANAKUL, Development Cooperation Officer, Professional Level, Thailand International Development Cooperation Agency, Ministry of Foreign Affair, Tel: 662 2035000 ext. 42003, E-mail: hataichanoks@mfa.go.th Mr Pawornwat SIMASKUL, Attache, Thailand International Development Cooperation Agency, Ministry of Foreign Affair, Government Complex, Building B, Chanegwattana Road,Bangkok 10210, Tel: 662 2035000 ext. 42415, E-mail: trongs01@gmail.com Mr Pakorn KUMPORNLUA, Attaché, Thailand International Development Cooperation Agency, Ministry of Foreign Affair, Government Complex, Building B, Chanegwattana Road, Bangkok 10210, Tel:+662 203 5000 ext. 41007, E-mail: pakornkthai@gmail.com VIET NAM Mr Duc Minh BUI, Official, Consular Department, Ministry of Foreign Affairs, 40 Tran Phu Street, Ba Dinh District, Hanoi, Tel: +844 3799 3119, E-mail: buiducminh33@gmail.com Mr Hoang Khoi KHONG, Official, International Organization Department, Ministry of Foreign Affairs, 6 Chu Van An Street, Ba Dinh District, Hanoi, Tel: +84 4 3799 3316, E-mail: hoangkhoi@mofa.gov.vn Dr Thanh Dong LE, Director, Institute of Malariology, Parasitology and Entomology, in Ho Chi Minh City, 699 Tran Hung Dao Street, District 5, Ho Chi Minh City, Tel.: +84 8 3923 0009, E-mail: lethanhdong@gmail.com Mr Trung Kien LE, Researcher, National Institute of Malariology, Parasitology, and Entomology, Ministry of Health, 245 Luong The Vinh Street, Tu Liem District , Hanoi,. Tel:+84 4 3553 0066, E-mail:ltkien@outlook.com Mr Duc Trung LE, Official, International Cooperation Department, Ministry of Transport, 80 Tran Hung Dao Street, Hoan Kiem District, Hanoi, Tel: +84 4 39423417, E-mail: ldtrung@mt.gov.vn

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Dr Duc Khoa NGUYEN, Deputy Head of Communicable Diseases Control Division, General Department of Preventive Medicine, Ministry of Health, 138A-Giang Vo Street, Ba Dinh District, Hanoi, Tel: +84 4 3845 6255, E-mail: ndk_vnn@yahoo.com Dr Thanh Lam PHAM, Vice-Director of Health Administration, Ministry of Transport, 73 Yen Ninh Street, Ba Dinh District, Hanoi, Tel: +84 4 3824 3524, E-mail: lampt.cyt@mt.gov.vn Mrs Thi Lan Huong PHAM, Official, International Cooperation Department, Ministry of Labour, Invalid and Social Affairs of Viet Nam, No 12 Ngo Quyen Street, Hoan Kiem District, Hanoi, Tel:+84 4 382 69532, E-mail: huongbow@gmail.com Mr Dinh Thu PHAN, Officer of Drug Treatment Policy Division, Department of Social Vice Prevention, Ministry of Labour, Invalid and Social Affairs, 12-Ngo Quyen, Hoan Kiem, Hanoi, Tel:+84 4 382 41697, E-mail: vnphanthu@yahoo.com Mr Dang Ky VAN, Chief of Epidemiology Division, Department of Animal Health, Ministry of Agriculture and Rural Development, 15 Lane 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, Tel.: +84 4 3868 5104, E-mail: vandangky@yahoo.com Dr Anh Duong VUONG, Deputy Chief of Hospital Quality Management Division, Department of Medical Service Administration, Ministry of Health, 138A Giang Vo Street, Ba Dinh District, Hanoi, Tel: +84 4 627 33028, E-mail: vuongad@gmail.com Ms Thi Hong Hanh VU, Official, International Cooperation Department, Ministry of Agriculture and Rural Development, 2 Ngoc Ha Street, Ba Dinh District, Hanoi, Tel:+84 4 3734 7081, E-mail: Hanhvth.htqt.mard@gmail.com 2. PARTNERS ASIAN DEVELOPMENT BANK Mr Stephen P. GROFF, Vice President (Operations 2), Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel: +63 2 632 4444, E-mail: sgroff@adb.org Ms Leah GUTIERREZ, Director, Human and Social Development Division, SERD, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel: +63 2 683 1000, E-mail: lcgutierrez@adb.org Dr Vincent DE WIT, Chair, Health Communities of Practice, Lead Health Specialist, Human and Social Development Division, Southeast Asia Regional Department, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel:+63 2 683 1000, E-mail: vdewit@adb.org Dr Susann ROTH, Senior Social Development Specialist (Social Protection), Poverty, Reduction, Gender and Social Development Division, Regional and Sustainable Development Department, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel.: +632 6326111, E-mail: roth@adb.org Mr Hiroyuki MIYAZAKI, Infrastructure Specialist (GIS), Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel: +63 2 636 2198, E-mail: miyazaki@adb.org Dr Genandrialine L. PERALTA, Senior Safeguards Specialist (Environment), Southeast Asia Energy Division, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel.:+6326331726, E-mail: gperalta@adb.org

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Dr Sununtar SETBOONSARNG, Principal Natural Resources and Agriculture Economist, Environment, Natural Resources and Agriculture Division, Southeast Asia Department, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel: +632 6325672, E-mail: ssetboonsarng@adb.org Dr Myo THANT, Principal Economist, Office of Regional Economic Integration, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel: +632 6325974, E-mail: mthant@adb.org Dr Beverly Lorraine Chua HO, Researcher, Asian Development Bank, 6 ADB Avenue, Mandaluyong City, Metro Manila, Philippines, Tel:+632 6324444 local 70872, E-mail: beverlylorraine@gmail.com Dr Ross MCLEOD, Consultant, Asian Development Bank, GPO Box 2482, Sydney NSW 2001, Australia, Tel: +61 2 9233 8183, E-mail: rmcleod@esys.com.au ASSOCIATION OF SOUTHEAST ASIAN NATIONS H.E. Dr Le Luong MINH, Secretary-General, The Association of Southeast Asian Nations Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia, Tel.: (6221) 7262991 H.E. Dr Alicia Dela Rosa BALA, Deputy Secretary-General, ASEAN SocioCultural Community Department, The Association of Southeast Asian Nations Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia Tel.: (6221) 7262991, 7243372, E-mail: alicia.bala@asean.org Director Larry MARAMIS, Cross-Sector Cooperation Directorate, The Association of Southeast Asian Nations Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia, Tel: (62-21) 726 2991 ext 423: Dr Ferdinal M. FERNANDO, Assistant Director/ Head, Health and Communicable Diseases Division, Cross-Sectoral Cooperation Directorate, ASEAN Socio-Cultural Community Department, The Association of Southeast Asian Nations Secretariat, 70A Jalan Sisingamangaraja, Jakarta 12110, Indonesia, Tel: (62-21) 726 2991 ext 423, E-mail: ferdinal.fernando@asean.org AUSTRALIAN AGENCY FOR INTERNATIONAL DEVELOPMENT Mr Benedict DAVID, Principal Health Adviser, Health and HIV Thematic Group, Australian Agency for International Development, 255 London Circuit, Canberra ACT 2601, Australia, Tel: +61 2 6178 4593, E-mail: benedict.david@ausaid.gov.au Dr Renee MARTIN, Office of the Principal Health Specialist, Australian Agency for International Development, 255 London Circuit, Canberra ACT 2601, Australia, Tel: +61 2 6178 5761, E-mail: Renee.Martin@ausaid.gov.au Dr Michael O'DWYER, Health Sector Specialist (Mekong and Regional), Australian Agency for International Development, c/o Australian Embassy, 37 Sathorn Road, Bangkok, Thailand, Tel: +66 84875 2624, E-mail: michael.o'dwyer@ausaid.gov.au Dr Thanh L, Advisor to the ADB on Malaria Initiative, Australian Agency for International Development, 255 London Circuit, Canberra ACT 2601, Australia, Tel: +61 2 6178 4670, E-mail: Thanh.le@ausaid.gov.au CHULALONGKORN UNIVERSITY Professor (Dr) Supang CHANTAVANICH, Professor Emeritus, Department of sociology and Anthropology, Faculty of Political Science, Director, Asian Research Center for Migration, Institute of Asian Studies, Chulalongkorn

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University, Bangkok, Thailand, E-mail: chansupang@gmail.com INTERNATIONAL LABOUR ORGANIZATION Ms Viennarat CHUANGWIWAT, Programme Officer on Social Security, International Labour Organization, Regional Office for Asia and the Pacific, 10th Floor, United Nations Building, Rajdamnern Nok Avenue, Bangkok 10200, Thailand, Tel: +66 2 288 2244, E-mail: g7bkkdwt@ilo.org; viennarat@gmail.com Dr Jaime F. CALDERON Jr., Regional Migration Health Adviser, International Organization for Migration, Regional Office for Asia and the Pacific, 18th Floor Rajanakarn Building, 183 South Sathorn Road, Sathorn, Bangkok 10120, Thailand, Tel:+66 2 343 9448, E-mail: jcalderon@iom.int Ms Warin Choomsai Na AYUDHAYA, Project Manager for Global Fund Malaria, International Organization for Migration, Regional Office for Asia and the Pacific, 18th Floor, Rajanakarn Building, 183 South Sathorn Road, Sathorn, Bangkok 10120, Thailand, Tel: +02 3439312, E-mail: wchomsainan@iom.int Dr Montira INKOCHASAN, Senior Regional Migration Health Programme Assistant, International Organization for Migration, Regional Office for Asia and the Pacific, 18th Floor Rajanakarn Building, 183 South Sathorn Road, Sathorn, Bangkok 10120, Thailand, Tel.: +66 2 343 9416, E-mail: minkochasan@iom.int Dr Olga GORBACHEVA, Chief Medical Officer, International Organization Migration, Regional Office for Asia and the Pacific, 18th Floor Rajanakarn Building, 183 South Sathorn Road, Sathorn, Bangkok 10120, Thailand, Tel.: +02 3439312, E-mail: ogorbacheva@iom.int Mr Iain MCLELLAN, Regional Migration Health Intern, International Organization for Migration, 18th Floor Rajanakarn Building, 183 South Sathorn Road, Sathorn, Bangkok 10120, Thailand, Tel: +66 2 343 9417 E-mail: imclellan@iom.int Dr Leul A MEKONNEN, Chief of Mission, a.i., International Organization for Migration, ST 71, No 31, Chamkar Morn, BKK I, Phonm Penh, Cambodia, Tel:+855 23 210 853, E-mail: mekonnen@iom.int Mr Greg IRVING, Programme Manager – Migration Health, Mission in Myanmar, International Organization for Migration, 318ª Alhone Road, Dagon Township, Yangon, Myanmar, Tel. No: +95 1 252 569 E-mail: girving@iom.int INTERPOL Ms Aline PLANÇON, Assistant Director of Interpol’s Medical Products Counterfeiting and Pharmaceutical Crime Sub-directorate, Interpol. 69006 Lyon – France, E-mail: a.plancon@interpol.int Dr Masatoshi NAKAMURA, Consultant on Malaria Control in Myanmar, Japan International Cooperation Agency, Ba Yont Naung XPBI Street, West Gyo Gone, Insein Township, Yangon, Myanmar, Tel:+95 1 644212 E-mail: mnakamura8823@gmail.com Dr Catherine LEE, Research Associate, John Hopkins Bloomberg School of Public Health, 21 Intarakiri Road, Mae Sot, Tak 63110, Thailand, Tel.: +66 0 871966439, E-mail: cilee@jhsph.edu

INTERNATIONAL ORGANIZATION FOR MIGRATION

JAPAN INTERNATIONAL COOPERATION AGENCY JOHN HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

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Ms Sarah MEYER, Researcher, John Hopkins Bloomberg School of Public Health, 21 Intarakiri Road, Mae Sot, Tak 63110, Thailand, Tel:+66 0 82 704 2010, E-mail: smeyer@jhsph.edu KOREA INSTITUTE FOR HEALTH AND SOCIAL AFFAIRS MAHIDOL UNIVERSITY Dr EUN JIN Choi, Research Fellow, Health Promotion Research Division, Korea Institute for Health and Social Affairs, Jinhungro 268, Bulgwang-dong, Eunpyueong-gu, Seoul 122-705, Republic of Korea Tel.: +82-2-380-8249, E-mail: eunjin@kihasa.re.kr Dr Sureeporn PUNPUING, Director, Institute for Population and Social Research, Mahidol University, Salaya, Phuttamonthon, Nakhonprathom 73170, Bangkok, Thailand, E-mail: sureeporn.pun@mahidol.ac.th Dr Chalermpol CHAMCHAN, Deputy Director for Academic Affairs, Institute for Population and Social Research, Mahidol University, Salaya, Phuttamonthon, Nakhonprathom 73170, Bangkok, Thailand Dr Pojjana HUNCHANGSITH, Associate Professor, Institute for Population and Social Research, Mahidol University, Salaya, Phuttamonthon, Nakhonprathom 73170, Bangkok, Thailand, Tel:+662 441 0201 -4 ext 605 E-mail: pojjana.huc@mahidol.ac.th Professor Arjen M DONDORP, Interim Chair, Regional Steering Committee for Artemisinin, Resistance Initiative, Mahidol Oxford, Mahidol University, 420/6 Rajvithi Rd, Rajthevee, Bangkok, Thailand, Tel: +662 203 6333, E-mail: arjen@tropmedres.ac MAP FOUNDATION Ms Jackie POLLOCK, Executive Director, Michele Angelo Petrone (MAP) Foundation, P.O. Box 7, Chiang Mai University, Chiang Mai 50202, Thailand, Tel: +66 5 381 1202, E-mail: jackie_pollock@yahoo.com Dr Maria S. Guevara, Regional Humanitarian Representative (ASEAN), Medecins Sans Frontieres / Doctors Without Borders, 22/F, Pacific Plaza, 410-418 Des Voeux Road West, Sai Wan, Hong Kong, Tel:(852) 2950 4229 E-mail: maria_guevara@msf.org.hk Professor Pratap SINGHASIVANON, Secretary General, SEAMEO TROPMED Network, 420/6 Rajvithi Road, Bangkok, Thailand, E-mail: pratap.sin@mahidol.ac.th Professor Sandra TEMPONGKO, SEAMEO TROPMED Network, 420/6 Rajvithi Road, Bangkok, Thailand THAILAND BUSINESS COALITION ON AIDS UNITED STATES CENTERS FOR DISEASES CONTROL AND PREVENTION, THAILAND Dr Anthony PRAMUALRATANA, Executive Director, Thailand Business Coalition on AIDS, 2nd Floor, Tanakul Building, 77 Rama 9 Road, Huaykwang, Bangkok 10310, Thailand, Tel: +66 2 643 8080-7, E-mail: info@tbca.or.th Mitchell WOLFE, Director, GAP Thailand Asia Regional Office, Thailand MOPH – US CDC Collaboration and CDC/Southeast Asia Regional Office, US Centers for Diseases Control and Prevention, Bangkok, Thailand, E-mail: msw6@th.cdc.gov Dr Luis ORTEGA, Program Director, Division of Global Migration and Quarantine, US Centers for Disease Control and Prevention, Southeast Asia Regional Office, DDC 7 – MOPH, Soi 4, Nonthaburi 11000, Thailand Tel.: 02 580 0669, E-mail : luiso@th.cdc.gov

MEDECINS SANS FRONTIERES

SEAMEO TROPMED NETWORK

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UNITED NATIONS DEVELOPMENT PROGRAMME UNITED NATIONS ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC UNITED KINGDOM DEPARTMENT FOR INTERNATIONAL DEVELOPMENT UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT

Mr Clifton CORTEZ,Regional Manager, a.i., Asia-Pacific Regional Centre United Nations Development Programme, Regional Centre in Bangkok, 3rd Floor United Nations Service Building, Rajdamnern Nok Avenue, Phranakorn, Bangkok 10200, Thailand, Tel: +66 (0) 2304 9100, E-mail: clifton.cortez@undp.org Mr Srinivas TATA, Chief , Social Policy and Population Section, Social Development Division, United Nations Economic and Social Commission for Asia and the Pacific, The United Nations Building, 6F, UN Bldg, Rajdamnern Nok Avenue, Bangkok 10200, Thailand, Tel.:+66 2 288 1667, E-mail: tatas@un.org

Dr Jason LANE, Senior Health Adviser, Global Funds Department, Department for International Development, 22 Whitehall, London, United Kingdom, E-mail : jason-lane@dfid.gov.uk Dr Aye Aye THWIN, Director, Office of Public Health, United States Agency for International Development, Athenee Tower, 25th Floor. 63 Wireless Road, Lumpini, Patumwan, Bangkok 10330, Thailand, Tel.: +662 257 3000, E-mail: aathwin@usaid.gov Dr Wayne STINSON, Office of Public Health, United States Agency for International Development, Athenee Tower, 25th Floor, 63 Wireless Road, Lumpini, Patumwan, Bangkok 10330, Thailand, Tel: 662 257 3000 Dr Mark FUKUDA, Office of Public Health, United States Agency for International Development, Athenee Tower, 25th Floor, 63 Wireless Road, Lumpini, Patumwan, Bangkok 10330, Thailand, Tel: 662 257 3000 Ms Sharlene BAGGA-TAVES, Office of Public Health, United States Agency for International Development, Athenee Tower, 25th Floor, 63 Wireless Road, Lumpini, Patumwan, Bangkok 10330, Thailand, Tel: 662 257 3000

UNITED STATES PHARMACOPEIAL CONVENTION

Dr Souly PHANOUVONG, Manager, Asia Programs, Promoting the Quality Medicines Program (PQM), Global Health Impact Programs (GHIP) United States Pharmacopeial Convention (USP), 12601 Twinbrook Parkway, Rockville, Maryland 20852-1790, United States of America Tel.: +1 301 816 8582, E-mail: sxp@usp.org Dr Kheang Soy TY, Chief of Party / Regional Director, USAID-Control and Prevention of Malaria (CAP-Malaria), University Research Co., LLC, Myanmar, Tel: +668 979 81 737 (Thailand); E-mail: ksoyty@urc-chs.com

UNIVERSITY RESEARCH CO., LLC

3. WHO SECRETARIAT

REGIONAL OFFICE FOR SOUTH-EAST ASIA

Dr Samlee PLIANBANGCHANG, Regional Director, World Health Organization Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel.: (91 11) 2337 0804; 2337 0809-11, E-mail: samleep@who.int Dr Rajesh BHATIA, Director, Department of Communicable Diseases, World Health Organization Regional Office for South-East Asia, World Health House,

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Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel.: (91 11) 2337 0804, E-mail: bhatiaraj@who.int Dr Khalilur RAHMAN, Coordinator, ESCAP & Inter-Agency Coordination, World Health Organization, Liaison Office with the United Nations Economic and Social Commission for Asia and the Pacific, Bangkok, Thailand Dr Leonard ORTEGA, Regional Adviser, Malaria, Department of Communicable Diseases, World Health Organization Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel.: (+91-11) 233 70804 Ext 26118, E-mail: ortegal@who.int Dr Richard BROWN, Regional Adviser, Disease Surveillance and Epidemiology, World Health Organization Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel: +91 11 23370804 Ext 26637, E-mail: brownr@who.int Dr Sudhansh MALHOTRA, Regional Adviser, Primary and Community Health Care, World Health Organization Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel.: +91 11 23370804 Ext 26637, E-mail: malhotras@who.int Dr Vason PINYOWIWAT, Technical Officer, International Health Regulation, World Health Organization Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel:+91 11 23370804 Ext 26637, E-mail: pinyowiwatv@who.int Dr Roderico OFRIN, World Health Organization Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi – 110002, India, Tel:+91 11 23370804 Ext 26637, E-mail: ofrinr@who.int Mr Jatinder Pal Singh CHHATWAL, Assistant, World Health Organization Regional Office for South-East Asia, World Health House, Mahatma Gandhi Road, New Delhi – 110002, India, Tel: +91 1 1233 70804, E-mail: singhja@who.int Mr Rangaran EKKADU, Administrative Assistant, World Health Organization Regional Office for South-East Asia, World Health House, Mahatma Gandhi Road, New Delhi – 110002, India, Tel: +91 11 2337 0804, E-mail: rangarajane@who.int WHO REPRESENTATIVE OFFICE, MYANMAR WHO REPRESENTATIVE OFFICE, THAILAND Dr Krongthong Thimasarn, Medical Officer, Malaria, WHO Country Office, 12 A Traders Hotel, Yangoon, Myanmar, Tel: +95 1 250583, E-mail: thimasarnk@who.int Dr Yonas TEGEGN, WHO Representative to Thailand, WHO Thailand 88/20, Permanent Secretary Building, BLDG. 3, 4TH FLR., Ministry of Public Health, Tiwanond Rd., Nonthaburi 11000, Thailand, Tel: +6625918198, + 6681921 5642, E-mail: tegeny@who.int Dr Brenton BURKHOLDER, Border and Migrant Health Programme Coordinator, and Team Lead for Communicable Diseases, World Health Organization, Country Office for Thailand, 4th Fl., Permanent Secretary Bld 3, Ministry of Public Health, Nonthaburi 11000, Thailand, Tel: +66 259 01523; +66 (0) 2 580-7537, E-mail: burkholderb@who.int Dr Maria Dorina BUSTOS, Malaria Technical Officer, WHO-Mekong Malaria Programme, Office of the WHO Representative to Thailand, Permanent Secretary

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Building 3, 4th floor, Ministry of Public Health, Tiwanon Rd, Nonthaburi 11000, Thailand, Tel:(66) 2 591 8198, E-mail: bustosm@who.int Ms Aree MOUNGSOOKJAREOUN, Border and Migrant Health Officer,Office of the WHO Representative to Thailand, Permanent Secretary Bldg 3, 4th Flr., Ministry of Public Health, Tiwanon Road, Nonthaburi 11000, Thailand, Tel: +66 2590 1509, +66 81 810 6816, E-mail: areem@who.int Dr Robert SADANG, Office of the WHO Representative to Thailand, Permanent Secretary Building 3, 4th floor, Ministry of Public Health, Tiwanon Rd, Nonthaburi 11000, Thailand, Tel:(66) 2 591 8198, E-mail: sadangr@who.int REGIONAL OFFICE FOR THE WESTERN PACIFIC Dr SHIN Young-soo, Regional Director, World Health Organization Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel:+63 2 528 8001, E-mail: shiny@wpro.who.int Dr John EHRENBERG, Director, Division of Combating Communicable Diseases, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel:+632 528 9701, E-mail: ehrenbergj@wpro.who.int Dr Vivian LIN, Director, Division of Health Sector Development, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel: +63 2 528 8001, E-mail: linv@wpro.who.int Dr Corinne CAPUANO, Executive Officer, External Relations and Communications, Office of the Regional Director, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel:+63 2 528 9930, Email: capuanoc@wpro.who.int Dr Eva Maria CHRISTOPHEL, Team Leader, Malaria, Other Vectorborne and Parasitic Diseases, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel: +632 528 9723, E-mail: christophele@wpro.who.int Dr Catharina VAN WEEZENBEEK, Team Leader, Stop TB and Leprosy Elimination, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel. +632 528 9706, E-mail: vanweezenbeekc@wpro.who.int Dr Katsunori OSUGA, Medical Officer, Stop TB and Leprosy Elimination, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel: +63 2 528 9709, E-mail: osugak@wpro.who.int Dr Klara TISOCKI, Team Leader, Essential Medicines and Technology WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel:+632 528 9026, E-mail: tisockik@wpro.who.int Dr Nasir HASSAN, Team Leader, Environmental Health, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel.:+632 528 9886, E-mail: hassanm@wpro.who.int Mr Sjoerd POSTMA, Team Leader, Health Services Development, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel:+632 528 9806, E-mail: postmas@wpro.who.int Dr Najibullah HABIB, Programme Management Officer, Division of Combating Communicable Diseases, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel: +63 2 528 9717, E-mail: habibna@wpro.who.int

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Ms Glenda GONZALES, Consultant, Division of Combating Communicable Diseases, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel:+63 2 528 89721, E-mail: gonzalesg@wpro.who.int WHO REPRESENTATIVE OFFICE, CAMBODIA WHO REPRESENTATIVE OFFICE, LAO PEOPLE'S DEMOCRATIC REPUBLIC Dr Pieter VAN MAAREN, WHO Representative, World Health Organization, No. 177-179 corner Streets Pasteur(51) and 254, Sankat Chak Tomouk, Khan Daun Penh, Phnom Penh, Cambodia, Tel: + (855) 23-216610, E-mail: vanmaarenp@wpro.who.int Dr Lou DAPENG, ESR Team Leader, World Health Organization, 125 Saphanthong Road, Unit 5, Ban Saphangthongtai, Sisattanak District, Vientiane, Lao People's Democratic Republic, Tel: +856 21 353902, E-mail: loud@wpro.who.int Dr Deyer GOPINATH, Medical Officer, World Health Organization, 125 Saphanthong Road, Unit 5, Ban Saphangthongtai, Sisattanak District, Vientiane, Lao People's Democratic Republic, Tel: +856 21 351835, E-mail: gopinathd@wpro.who.int Dr Takeshi KASAI, WHO Representative, World Health Organization 63 Tran Hung Dao, Hanoi, Viet Nam, Tel: +844 3943 3743; +844 3943 3740, Email: kasait@wpro.who.int

WHO REPRESENTATIVE OFFICE, VIET NAM

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Annex 3. Background papers

SESSION

1

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions.

EXECUTIVE SUMMARY This paper presents a situational analysis of the GMS countries, including their sociodemographic-economic profile, the malaria situation, the response to the malaria problem, the critical challenges especially the problem of artemisinin resistance, as well as the current and planned development activities in the subregion and their impact on malaria. It presents and reemphasises the case for malaria to be considered not just a health problem but a development issue requiring harmonized and well-coordinated multi-sectoral and inter-country actions to effectively control and eliminate it. The GMS countries are very heterogeneous with respect to their socio-demographic, health and economic profile, with Cambodia, Lao PDR and Myanmar generally clustered together on the lower end of the spectrum for most indicators, and Vietnam and Thailand on the other end. Data for Yunnan province alone is not available for most indicators. Large differences between the literacy levels of males and females and the availability of water and sanitation facilities between urban and rural areas still exist at present, especially in Cambodia and Lao PDR. Myanmar has the highest rate among the GMS countries in terms of both incidence and mortality for malaria while Yunnan Province and Vietnam have the lowest rates for both indicators. There have been tremendous gains in decreasing the incidence of malaria in the GMS between 2000 and 2010, with Vietnam and Thailand having the largest drop in rates at 81% and 71% respectively, during the 10-year period. The decrease in mortality rates during the same period is even more dramatic, with the drop in rates in all countries, ranging from 76%-93% during the decade. However, inspite of tremendous gains achieved in decreasing malaria morbidity and mortality in the past decade, critical challenges still need to be overcome which include the remaining hotspots which are generally the remote, border and mobile populations composed mostly of ethnic groups and migrant workers; growing evidence of artemisininresistance; and increasing incidence of counterfeit/substandard drugs.

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 1

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The extent and nature of the response to address the malaria problem in the GMS have been wide and varied, including the adoption of malaria-specific WHO resolutions (WHA58.2; WHA60.18; WHA64.17) and high-level political support (ASEAN Health Ministerial Meeting; Declaration of the 7th East Asia Summit; Asia Pacific Leaders Malaria Alliance). Very specific action plans have been developed to address the problem of artemisinin at the global (GPARC) and regional (ERAR) levels. The malaria problem in the GMS has been compounded by the rapid pace of economic development in the area covering infrastructure, energy, telecommunication, tourism, agriculture, environment, and human resource development. While these development projects have increased integration, prosperity, and accelerated economic growth in the region, there are also negative effects like the displacement of large populations, migration of workers and changes in vector ecology which have implications to malaria. The unintended negative effects of development activities in the region highlights the complex relationships underlying development issues which point to the need to mainstream malaria prevention and control efforts in the various sectors, thereby implementing a multisectoral response in the region. This approach requires the need for strategic partnerships at national and sub-regional levels involving different ministries, civil society, the private sector, development partners and others. The health sector must be able to show the leadership to advocate and engage the different sectors to proactively and collectively address the malaria problem.

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 2

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

1.

Purpose of the paper

This paper is prepared as a background document for the Bi-regional Meeting on Healthy Borders in the Greater Mekong Sub-region organized by SEARO and WPRO on 5 to 7 August in Bangkok Thailand. It aims to provide the representatives from the GMS countries as well as the UN and development partners participating in the meeting with a situational analysis of the GMS countries, including an overview of the malaria situation in the region, the problem of drug resistance and the factors contributing to it, and the current response to the problem in the context of the health systems and the socio-economic development of the area. It presents and re-emphasizes the case for malaria to be considered not just a health problem but a development issue which requires harmonized and well-coordinated multi-sectoral and inter-country actions to effectively control and eliminate it, in the context of socio-economic development in the GMS.

2. The Greater Mekong Sub-region The Greater Mekong Subregion (GMS) is composed of Cambodia, the Yunnan Province of the People’s Republic of China, the Lao People’s Democratic Republic, Myanmar, Thailand and Viet Nam. All these six places are bound together by the Mekong River and have a combined total 2011 population of 2.75 million (Table 1), which accounts for 11.3% of the total population of Asia. A map of the GMS is shown in Figure 1. The six GMS countries represent a wide spectrum of economic capacity, economic change, population size, health services infrastructure, and human and material resources. Despite the diversity, there is a degree of interdependence with respect to development objectives and planning needs that makes it desirable to examine ways of collaboration in containing diseases like malaria [1]. This section presents a situational analysis of the six GMS countries in terms of the most recent available data on their demographic, social, health and economic indicators.

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 3

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

2.1.1 Socio-demographic and economic profile Of the 6 GMS countries, the largest population is that of Viet Nam at almost 90M in 2011, while Lao PDR is the smallest with a 2011 population of only 6.3M. However, Lao PDR has the fastest population growth rate at 1.3%. Viet Nam is the most crowded with a population density of 271 persons per square kilometre. This is 10x higher compared to Lao PDR with a population density of only 27 persons/km2. Cambodia is the least urbanized, with only a fifth of its population living in urban areas. For all the other countries (except for China where data for Yunnan province in not available), about a third of its population are in urban areas. These are shown in Table 1.

Source: O’ Shannassy, T. Greater Mekong Subregion (GMS): Context. The Southeast Asian Journal of Tropical Medicine and Public Health. Volume 44 (Supplement 1). 2013. Fig. 1, page 2. [2]

Figure 1. The Greater Mekong Subregion

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 4

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 1. Demographic Indicators for Countries in the GMS COUNTRY 2011 POPULATION SIZE 1

(in thousands) Cambodia China (YunnanProv) Lao PDR Myanmar Thailand Viet Nam TOTAL 1Source:

POPULATION GROWTH RATE (%)1 1.2 0.43

AREA2 (in km2) 181,035 394,000

POPULATION DENSITY (persons/km2) 79.97 117.54

% POPULATION IN URBAN AREAS1 20.2 NA4

14,478 46,310

6,374 48,724 69,892 89,730 275,508

1.3 0.8 0.5 1.0

237,000 677,000 513,000 331,691 2,333,726

26.89 71.97 136.24 270.52

35.4 33.3 34.5 31.7

2012 ESCAP Population Data Sheet [3] Source: Mekong Basin Disease Surveillance Website [4] 3This growth is that of the whole China and not just of YunnanProvince alone 4 Data solely for Yunnan province is not available 2

Among the social indicators, one of the most relevant in relation to the success of a country’s disease prevention programme is the adult literacy ratio. Since this indicator measures people’s ability to read and write, it has a bearing on the health workers’ ability to conduct health promotion activities, eventually affecting people’s knowledge about the disease. The adult literary ratios of the GMS countries for 2000 and 2010 are shown in Table 2. The results indicate the following:  Of the GMS countries, the adult literacy levels of Cambodia and Lao PDR are lower compared to the 4 other countries in the region. This situation is the same at the start of the millennium up to the present. There is still a big difference in the adult literacy ratios between the sexes in Cambodia and Lao PDR, with the adult literacy ratio among females being at least 20% lower in relative terms (20.4% for Cambodia; 23.4% for Lao PDR) compared to the males.



Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 5

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 2. Adult Literacy Ratio of GMS Countries by Sex: 2000 and 2010 Male Country Cambodia China Lao PDR Myanmar Thailand Viet Nam 2000 79.5 (1998) 95.1 81.4 93.9 94.9 93.9 2010 82.8 (2009) 97.1 82.5 94.8 95.6 (2005) 95.3 2000 57.0 (1998) 86.5 58.5 86.4 90.5 86.5 Female 2010 65.9 (2009) 91.3 63.2 (2005) 89.9 91.5 (2005) 91.1 Both Sexes 2000 67.3 (1998) 90.9 69.6 89.9 92.6 90.2 2010 73.9 (2009) 94.3 72.7 (2005) 92.3 93.5 (2005) 93.2

Source:Asian Development Bank. Key Indicators for Asia and the Pacific 2012 ( 43rd Edition) [5]

The differences between the GMS countries are very clearly evident in the levels of their health indicators, with Cambodia, Lao PDR and Myanmar generally clustered on the lower end of the spectrum for most indicators while Thailand and Viet Nam are on the other end. As with most other indicators, data for Yunnan province in China alone are not available. Selected health indicators for the GMS countries are presented in Table 3. Table 3. Selected Health Indicators in the GMS Countries: 2010 Maternal Mortality Ratio (per 100,000 LB) 250 NA1 470 200 48 59 213 Infant Mortality Rate (per 1000 LB) 43 NA1 42 50 11 19 25 Under-Five Mortality Rate (per 1000 LB) 51 NA1 54 66 13 23 32 % Births Attended by Skilled HW 71.0 NA1 20.3 (2006) 63.9 (2007) 99.5 (2009) 87.7 (2006) __ 2

Country

Coverage (%) of Measles Immunization Among ≤1 93 NA1 64 88 98 98 91

Prevalence of Malnutrition Among <5 19.6 (2007) NA1 31.6 (2006) 22.6 7.0 (2006) 20.2 (2008) __ 2

Cambodia China (Yunnan) Lao PDR Myanmar Thailand Viet Nam Southeast Asia

Source:Asian Development Bank. Key Indicators for Asia and the Pacific 2012 (43 rd Edition) [5] 1 Data solely for Yunnan province is not available 2 The value for the whole Southeast Asia region cannot be compute because of differences in reference year of the latest available data

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 6

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The 2010 maternal mortality ratio of Lao PDR is extremely high compared to the other GMS countries – it is 1.9x higher compared to that of Cambodia, 9.8x higher compared to Thailand which has the lowest MMR in the region, and 1.2x higher compared to the overall level for Southeast Asia where all the GMS countries belong, except for China. The differences between countries are relatively smaller in the case of infant mortality rate, with Cambodia, Lao PDR and Myanmar being clustered together on the upper end. Myanmar has the highest IMR in the region as of 2010 with at rate of 50 infant deaths per 1000 live births. This rate is 4.5x higher compared to Thailand and 2x higher compared to the overall level for Southeast Asia. The patterns observed in terms of the differences between the infant mortality rates among the GMS countries are the same as that of the under-five mortality rate. The 2010 values range from 13/1000 live births in Thailand, to 66/1000 live births in Myanmar. The GMS countries are not the same in terms of the year when the most recent data on the percentage of births attended by a skilled health worker is available. However, based on the data presented in Table 3, it is evident that the MCH services in Lao PDR is highly problematic compared to other countries in the GMS, with only 1 out of every 5 births (20.3%) being attended by a skilled health worker in 2006. This is much lower compared to 87.7% reported by Viet Nam in the same year, or that of Myanmar with a corresponding figure of 66.7% for this indicator in 2007. Lao PDR consistently has the lowest levels of the health service indicators. In terms of the coverage of measles immunization, its 2010 coverage of 64% is so much lower compared to that of Cambodia, Thailand and Viet Nam whose coverage are at least 90%. Myanmar’s 2010 measles immunization coverage is also higher than that of Lao PDR at 88%. The availability of nutrition data is likewise not the same for the GMS countries. In 2006 which is the year for the latest available nutrition data of Lao PDR, about 1 out of every 3 (31.6%) children <5 years old in this country were malnourished. This is 4.5x higher compared to Thailand whose 2006 malnutrition prevalence figure among children <5 is only 7%. A subset of the health indicators which have a lot of bearing on economic development projects in an area are those related to environmental health, specifically water and sanitation. A whole lot of economic development projects cover the improvement of the water system which affect the coverage of the population with potable water supply, and eventually affect the incidence of water-borne and related diseases. Table 4 shows the proportion of the population in the GMS countries using improved sanitation facilities and water sources. Both indicators are part of the MDG indicators. A comparison is made of the levels of these indicators within the 20-year interval between 1990 and 2010 to reflect the pace of development especially among countries in the lower end of the economic spectrum like Cambodia, Myanmar and Lao PDR.

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 7

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The data in Table 4 show the following: a. The proportion of the population in the rural areas using improved sanitation facilities and water sources increased tremendously between 1990 and 2010. The improvements over the 20 year period are greatest in Cambodia and Lao PDR. b. As of 2010, there is still a large proportion of households in Cambodia, Lao PDR and Myanmar which do not have improved sanitation facilities and water supply. The country with the biggest problem is Cambodia, with only 20% of its rural population in 2010 having improved sanitary facilities and 58% having improved water supply. c. As of 2010, there is still a big difference between the urban and rural areas of Cambodia, Lao PDR and Myanmar in terms of coverage of improved sanitary facilities and water supply. d. Thailand has the best levels of the environmental health indicators among the GMS countries, having attained almost universal coverage of improved sanitary facilities and water supply, in both urban and rural areas. Table 4. Indicators Related to Water and Sanitation by Type of Area: GMS Countries, 1990 and 2010 % Population Using Improved Sanitation Facilities Country Urban 1990 Cambodia China (Yunnan) Lao PDR Myanmar Thailand Viet Nam 36 NA1 58 (1994) 77 (1991) 94 63 2010 73 NA1 89 83 95 94 Rural 1990 5 NA1 8 (1994) 47 (1991) 80 30 2010 20 NA1 50 73 96 68 Total 1990 9 NA1 16 (1994) 54 (1991) 84 37 2010 31 NA1 63 76 96 76 % population Using Improved Water Sources Urban 1990 48 NA1 75 (1994) 80 96 88 2010 87 NA1 77 93 97 99 Rural 1990 29 NA1 32 (1994) 48 82 49 2010 58 NA1 62 78 95 93 1990 31 NA1 39 (1994) 56 86 57 Total 2010 64 NA1 67 83 96 95

Source: Asian Development Bank. Key Indicators for Asia and the Pacific 2012 (43 rd Edition) [5] 1 Data solely for Yunnan province is not available

To complete the situational analysis of the GMS countries, their levels for selected economic indicators are presented in Table 5. Unfortunately, the values for most indicators Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 8

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion presented in Table 5 are not directly comparable with one another across countries because of differences in the latest available year of the data. Hence, care must be taken in making comparisons of these values. Table 5. Levels of Selected Economic Indicators for the GMS Countries (latest year) 2011 International Tourist Arrivals (thousand)

Country

% of the Population <$1.25/day

Household Electrification Rate (%)

Road Density (km. of road/1000 km2 of land area)

Human Development Index Paved Roads (% of total roads) Rank (out of 187 countries

Value (for 2011)

Cambodia China Lao PDR Myanmar Thailand Viet Nam

22.8. (2008) NA1 33.9 (2008) -3 0.4 (2009) 16.9 (2008)

20.5 (2005) NA1 46.3 (2002) 47.0 (2002) -3 96.1 (2005)

2,882 NA1 1,670 (2010) 391 19.098 6,014

216.7 (2004) NA1 171.4 (2009) 41.3 (2005) 352.4 (2006) 516.3 (2007)

6.3 (2004) NA1 13.7 (2009) 11.9 (2005) 98.5 (2000) 47.6 (2007)

.523 .6872 .524 .483 .682 .593

139 1012 138 149 103 128

Source: Asian Development Bank. Key Indicators for Asia and the Pacific 2012 (43rd Edition) [5] 1 Data solely for Yunnan province is not available 2 This value refers to the whole China and not just Yunnan province 3 Data not available at cut-off date

The proportion of the population below the poverty line is one of the MDG indicators, under the first MDG goal of eradicating extreme poverty and hunger. The data presented in Table 5 show the percentage of the population in each of the GMS countries living on less than $1.25/day measured at 2005 international prices, adjusted for purchasing power parity (PPP). The data show huge discrepancies in the status of the GMS countries with respect to this indicator, with Thailand having less than 1% of its population below the poverty line as of 2009. In contrast, a third (33.9%) of the Lao population are below the poverty line just a year before (2008), while that of Cambodia was a bit lower at 22.8 % for the same year. One of the identified economic effects of a successful malaria control programme is on the tourism industry. Table 5 shows the number of international tourist arrivals in each of the GMS countries as of 2011. As expected, Thailand had the highest number of international tourists at 19 million. Three other countries in the region – Viet Nam, Cambodia and Lao PDR had tourists exceeding one million during the same year. Road construction brings about a lot of changes, including among others, changes in the environment and local ecology, people’s mobility and migration patterns, and disease transmission. The influence of roads impact health outcomes directly and indirectly through Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 9

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion mediation of human exposure to infectious diseases, altering nutritional status and health seeking behaviour. [6] Data on road density among the GMS countries show that Viet Nam had 516 km. of road per 1000 km2 of land area as of 2007. This is 1.5x higher than the corresponding road density of Thailand in 2006. However, in terms of paved roads, Thailand has the best situation, with 98.5% of its roads already paved as early as 2000. A composite measure of the overall level of development of a country is the Human Development Index (HDI). Of the 187 countries in the world for which the Human Development Index was computed in 2011, all the GMS countries belong to the lower 50%, with China (referring to the whole country, not just Yunnan province) having the highest rank at 101, followed closely by Thailand which was ranked 103rd. Myanmar had the lowest HDI rank among the six GMS countries with a rank of 149.

2.1.2 Developmental partners in the GMS The GMS Programme was established in 1992 with assistance from the Asian Development Bank. It is a of sub-regional economic cooperation among the 6 countries to enhance their economic relations covering nine priority sectors: agriculture, energy, environment, human resource development, investment, telecommunications, tourism, transport infrastructure, and transport and trade facilitation. The GMS Programme, with the support of ADB and other development partners, is helping the participating countries achieve the Millennium Development Goals through the three C’s -- increased connectivity, improved competitiveness, and a greater sense of community. [7] From the very start, the GMS Programme has been a product of multisectoral and intercountry collaboration. Bilateral donors include the governments of Australia, the PRC, Denmark, Finland, France, Germany, Japan, the Republic of Korea, the Netherlands, New Zealand, Spain, Sweden, Switzerland, the United Kingdom, and the United States. Among the multilateral partners are ADB; the European Commission; the European Investment Bank; the Food and Agriculture Organization of the United Nations; the International Fund for Agricultural Development; the International Labour Organization; the International Organization for Migration; the Nordic Development Fund; the OPEC Fund for International Development; the United Nations Development Programme; the United Nations Environment Programme; the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP); the United Nations Educational, Scientific and Cultural Organization; the World Bank; and the World Health Organization.[7] In the specific case of malaria control across the GMS, WHO leads the Mekong Malaria Programme (MMP) largely funded by USAID. Aside from national malaria control programmes, there are multiple partners implementing various aspects of the programme like training, BCC and social marketing, promotion of private sector partnership, operations research, monitoring of drug quality and combating counterfeit drugs. It started as Roll Back Malaria Mekong Initiative launched in Vietnam in 1999, it has evolved into Emergency Response to Artemisinin Resistance (ERAR) in the Greater Mekong Sub-region (please see section 4.1). Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 10

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

3. Malaria situation in the GMS 3.1 Epidemiologic profile The epidemiology of malaria in the GMS is highly complex and varies considerably from one population group to another. All four species of human plasmodia occur but the vast majority of malaria cases are caused by Plasmodium falciparum and P. vivax. [8] The epidemiology of the disease varies greatly between and within countries and from one population group, individual, or situation to another. In many cases, the different situations require different malaria control strategies, adapted to suit specific risk groups and vector behaviours, and adjusted to consider local infrastructure and health service coverage, as well as the rapidly evolving environmental conditions resulting from the large number of economic development projects being implemented. [9]

3.1.1 Incidence The overall incidence of malaria in the GMS as of 2010 is 2 per 1000 population. Myanmar has the highest incidence, with a level which is 2.4x higher compared to that of Lao PDR, which has the second highest incidence in the region, and 65x higher compared to that of Yunnan province in China, which has the lowest incidence in the GMS. About 2 out of every 3 persons (69%) in Myanmar live in malaria endemic areas. [9] For the whole region, 80.1% of the confirmed malaria cases in 2010 were P. falciparum. However, in the case of Lao PDR, almost all cases (97.9%) were P. falciparum. Table 7 shows selected statistics related in malaria incidence in the GMS for the year 2010. There have been tremendous gains in decreasing the incidence of malaria in the GMS countries between 2000 and 2010. Viet Nam and Thailand have been the most successful, having decreased their incidence rates by 81% and 71% respectively, during the 10-year period. This huge decrease is also very clearly evident in Figure 2 which shows a comparative picture of the Annual Parasite Index (number of confirmed malaria cases per 1000 population) of the GMS countries in 2002 and 2010. While about half of the provinces across the countries in the GMS had API levels in the >10and 1-10 per 1000 population categories in 2002, the picture changed drastically in 2010, with the API levels of most provinces having improved, and moved one level lower.

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 11

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 7. Selected Statistics Related to Malaria Incidence in the GMS: 2010 No. of Confirmed Malaria Cases1 Malaria Incidence Rate (per 1000)1 % Decrease in Malaria Incidence Rate (2000-2010)2 46,101 2,277 14,654 420,808 44,124 17,515 555,479 8,213 631 14,341 390,518 18,604 12,763 445,070 4,794 1,638 304 29,944 25,838 4,466 66,802 3.26 0.05 3.68 8.77 0.64 0.20 2.04 24 52 48 71 81 -

Country

Population Size1

P. falciparum Malaria Cases1

P. vivax Malaria Cases1

Cambodia China - Yunnan Lao PDR Myanmar Thailand Viet Nam TOTAL 1Source:

14,138,255 45,966,000 6,200,894 47,963,012 69,122,234 87,848,445 271,238,840

Hewitt, S et al. Malaria Situation in the Greater Mekong Subregion. The Southeast Journal of Tropical Medicine and Public Health Volume 44 (Supplement 1) 2013. page 54 (Table 1) [9] 2Source: Joint Assessment of the Response for Artemisinin Resistance in the Greater Mekong Sub-Region (Draft of Full Report) Table 2.1, page 2 [8]

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API in the GMS, 2002

API in the GMS, 2010

Source: Hewitt, S et al. Malaria Situation in the Greater Mekong Subregion. The Southeast Journal of Tropical Medicine and Public Health Volume 44 (Supplement 1) 2013. page 65 (Figure 4) [9]

Figure 2. Annual Parasitic Index in the General Mekong Subregion: 2002 and 2010

3.1.2 Mortality There were 1067 deaths due to malaria in the whole GMS in 2010, with a rate of 0.39 deaths per 100,000 population. In terms of countries, the mortality pattern is the same as that of malaria incidence, with Myanmar having the highest mortality rate in 2010, and Yunnan having the lowest. The extent of improvements in decreasing malaria mortality between 2000 and 2010 are a lot bigger than that of incidence, with all countries (except for Yunnan) being able to decrease malaria mortality by at least 76% during the 10-year period. These are shown in Table 8. A more dramatic picture of these improvements is also shown in Figure 3, which presents a comparative picture of malaria mortality in the GMS in 2002 and 2010. Whereas the 2002 picture is predominated by provinces with mortality rates in the ≥10 and <10 per 1,000,000 population categories, in the 2010 map, most provinces no longer have any deaths.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 8.Selected Statistics Related to Malaria Mortality in the GMS: 2010 Population Country Cambodia China - Yunnan Lao PDR Myanmar Thailand Viet Nam TOTAL 1Source:

Size1 14,138,255 45,966,000 6,200,894 47,963,012 69,122,234 87,848,445 271,238,840

Number of Deaths due to Malaria1

Malaria Mortality Rate (per 100,000)1

% Decrease in Malaria Deaths (2000-2010)2 83 39 93 763 87 86

151 3 24 788 80 21 1067

1.07 0.01 0.39 1.64 0.12 0.02 0.39

Hewitt, S. Malaria Situation in the Greater Mekong Subregion. The Southeast Journal of Tropical Medicine and Public Health Volume 44 (Supplement 1) 2013. page 54 (Table 1) [9] 2Source: Joint Assessment of the Response for Artemisinin Resistance in the Greater Mekong Sub-Region (Draft of Full Report) Table 2.1, page 2 [8] 3Refers to the reduction in mortality rates and not the reduction in the absolute number of malaria deaths between 2000 and 2010

1Source:

Hewitt, S. Malaria Situation in the Greater Mekong Subregion. The Southeast Journal of Tropical Medicine and Public Health Volume 44 (Supplement 1) 2013. page 66 (Figure 5) [9]

Figure 3. Malaria Deaths (per 1,000,000 population) in the GMS: 2002 and 2010 Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 14

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

3.1.2 High risk groups There are five broad categories of people affected by malaria in the GMS: ethnic minority groups; forest fringe inhabitants; rubber plantation workers; temporary migrants and seasonal workers; and new forest settlers. [9] Traditional forest inhabitants belong to over 50 ethnic groups most of whom have their own distinct language, making communication of health messages extremely problematic. Minority groups tend to be concentrated in remote areas usually along borders where health care services are often limited. Families generally spend months away from their communal villages to tend crops in small farms scattered throughout the nearby forest, making access to health care more difficult. [9] This combined residence pattern commonly practiced by ethnic minority groups wherein they sleep in their villages and in the field leads to complex mobility patterns affecting bed net use, one of the preventive measures for malaria. In a study conducted among the Rag-lai minority group in south-central Viet Nam, 84.6% of the respondents were using bed nets while staying in their villages. However, among Rag-lai farmers sleeping in the forests, only 52.9% reported sleeping under a bed net at the forest. A fifth (20.6%) slept unprotected while both in their villages and in the forest. [10] The most at-risk groups are migrant workers who work in the mines, forests or in agriculture. An assessment of an outbreak in Attapeu Province in Lao PDR in 2011 showed that migrant workers accounted for 70% of confirmed malaria cases [9]. In Thailand, a cross-sectional survey conducted in 3 provinces to determine the prevalence of Plasmodium infections among migrant workers showed a 6.2% total positivity rate. This result is much higher compared to the rate of 0.055% for the Thai population in general. The majority of positive cases were migrant workers from Myanmar. [11] In Cambodia, a large-scale survey in three areas of multi-drug resistant malaria involving 11,652 participants resulted in a malaria prevalence of 3.0%, 7.0% and 12.3% in Sampovluon, Koh Kong and PreahVihear areas, respectively. Multiple regression analysis applied to the data to determine risk factors identified adult males involved in forest activities and children living in foreign-fringe villages as high risk groups. [12]

3.2 Critical challenges While the statistics reveal an encouraging declining trend in both the morbidity and mortality due to malaria in the GMS especially in the past decade, there are critical challenges which need to be overcome before the ultimate goal of eliminating the disease can be achieved. These include the remaining hot spots in the more remote and inaccessible forested forest-fringe areas within the GMS mainly along international borders; growing evidence of resistance to artemisinin-based combination therapies; increased incidence of fake and/or substandard antimalarial drugs; and a complex of cultural, geographic, political, and legal impediments to health care access by minority, mobile, remote and border populations. [13]

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3.2.1

Focal hotspots: Remote, border and mobile populations

In the speech given by Dr. SamleePlianbangchang, Regional Director of WHO-SEARO on World Malaria Day this year, he mentioned that “those most vulnerable to malaria include tribal communities, migrant populations, subsistence farmers and those working in development projects such as agroforestry, hydropower dams, roads, irrigation projects, mining, and rubber plantations”. [14] These are the hot spots for malaria, with morbidity rates much higher than that of the general population. A more detailed description of these high-risk groups was given earlier in Section 3.1.2.

3.2.2 Drug resistance Resistance to a number of formerly effective malaria drugs originated along the Cambodia-Thailand border. It then spread west to South Asia and to Africa where most malaria deaths occur. [15] Artemisinin-resistant malaria has emerged in Cambodia, Myanmar, Thailand and Viet Nam in recent years. Artemisinin-based combination therapies (ACT) are the first line treatment for uncomplicated falciparum malaria in most endemic countries hence the emergence of artemisinin-resistant malaria is a serious concern. Resistance has occurred as a consequence of several factors: poor treatment practices, inadequate patient adherence to prescribed regimens, and the widespread availability of oral artemisinin-based monotherapies and substandard forms of the drug. The current WHO working definition of P falciparum resistance to artemisinin is as follows: “an increase in parasite clearance time, as evidenced by ≥ 10% of cases with parasites detectable on day 3 after treatment with an ACT (suspected resistance)” OR “treatment failure after treatment with an oral artemisinin-based monotherapy with adequate antimalarial blood concentration, as evidenced by the persistence of parasites for 7 days, or the presence of parasites at day 3 and recrudescence within 28/42 days (confirmed resistance)” Source: WHO 2010. Global Report on Antimalarial Drug Efficacy and Drug Resistance: 2000-2010. ISBN 978 92 4 1500470.

Note that the “hotspots” for artemisinin resistance are all in border areas, which are now the focus of control /elimination strategies. The varying topographies and drug policies of the countries in the GMS, systematic findings and reports of sub-standard and counterfeit drugs, injudicious use of medicines in the private sector, as well as the high degree of population mobility, justifies the need for more intensive inter-country cross-border collaboration. Countries and partners need to be pro-active against the emergence of artemisinin resistance from its initial foci on the Cambodia-Thailand border and now possibly spreading or emerging de novo in other sites of the Mekong region. Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 16

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Attempts to contain artemisinin-resistance first started in 2008 in the Thai-Cambodia border with the support mainly from Bill & and Melinda Gates Foundation and are still on-going until now, and this is further being pursued in other border areas where resistance has been documented. The response of the global community to this problem is further described in Section 4.4 of this paper.

Source:

Bustos MD et al. Monitoring antimalarial drug efficacy in the Greater Mekong Subregion: an overview of in vivo results from 2008 to 2010. The Southeast Journal of Tropical Medicine andPublic Health Volume 44 (Supplement 1) 2013. page 205 (Figure 2) [16]

Figure 4. Sentinel Sites for Drug Efficacy Monitoring in the GMS where Artemisinin Resistance has either been Confirmed or Suspected, 2008 to 2010

3.2.3 Counterfeit drugs A counterfeit or fake drug is one that has been deliberately mislabelled for identity and/or source. It can be a perfect imitation containing the same active ingredients, the same formulation and identical packaging. A substandard drug is a legally-branded or generic product but does not meet international standards for quality, purity, strength or packaging. [17] The prevalence of poor quality medicines in Southeast Asia, whether counterfeit or substandard, cannot be underestimated. Counterfeit drugs are produced with intent to deceive Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 17

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion and often contain little or no active pharmaceutical ingredient or possibly dangerous adulterants. On the other hand, substandard medicines are registered authorized products that fail to comply with Good Manufacturing Practices and are often of poor quality. In the GMS, the proliferation and circulation of counterfeit and substandard drugs are exacerbated by the limitations in reach and scope of regulatory authorities, budgetary constraints, human resources and laboratory capacity deficiencies. [18] In an article published in the Lancet in 2001 [19], Paul Newton of Oxford University reports about the results of a study conducted in five GMS countries to investigate the distribution and identify distinguishing characteristics of fake drugs. Of 104 “artesunate” samples bought from 104 shops in Cambodia, Lao PDR, Myanmar, Thailand and Viet Nam, 38% did not contain artesunate. However, characteristics such as cost and physical appearance reliably predicted authenticity. A succeeding study conducted in 2002-2003 in the same countries to assess the prevalence of counterfeit antimalarial drugs showed that of 188 “artesunate” blisterpacks purchased, 53% were counterfeit. This result shows a 15% increase over the prevalence of the previous study done two years before in the same areas. In addition, the packaging of the counterfeit drugs have improved, with refinements made on the fake blisterpacks making them difficult to distinguish from their original counterparts. [20] In response to the worsening fake artesunate situation in the GMS, an international multidisciplinary group under the auspices of WHO-WPRO and the International Police Organization (INTERPOL) collaborated in 2005 to conduct an epidemiologic investigation to determine the active ingredients and the source of the counterfeit drugs. From the total of 391 samples collected from the five countries, 49.9% contained none or only small quantities of artesunate. Chemical analysis on the fake samples showed a large variety of wrong active ingredients including banned pharmaceuticals, a carcinogen, and raw material needed to manufacture the illicit drug “ecstasy”. Another importance of this study was that it demonstrated the importance of conducting international cross-disciplinary collaboration which in this case prompted the Chinese government to take action, since the study also established that some of the drugs came from China. [21] The problem of counterfeit drug in the GMS continues up to the present. It is an issue which is difficult to address because it involves not only the health sector. A programme to control the proliferation of counterfeit drugs will not be successful without the cooperation of the drug regulatory agencies and police agencies to identify and catch the criminals and the justice departments/ministries to prosecute them. Hence this is a problem which requires multisectoral collaboration at all levels.

4. Current response The response to the malaria problem has been seen at various levels, from the countries which developed and implemented their national malaria control programme, to the regional and global levels coming from various forms of regional partnership and multisectoral collaborations as well as from the development agencies and the UN bodies. Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 18

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4.1 Global and regional initiatives At the global level, the World Health Organization has been at the core of the fight against malaria. To guide member countries on various aspects of their malaria control programme, WHO has adopted the following resolutions related to malaria: 1. WHA 58.2: Malaria Control (adopted during the 58th WHA, 23 May 2005) [22] – Among others, this resolution urged member states to:  Achieve community participation and multi-sectoral collaboration in vector control and other preventive actions  Develop or strengthen inter-country cooperation to control the spread of malaria across shared borders and migratory routes  Encourage inter-sectoral collaboration, both public and private, at all levels especially in education 2. WHA 60.18: Malaria, including proposal for establishment of World Malaria Day (adopted during the 60th WHA, 23 May 2007) [23] – Among the important articles of this resolution was to urge Member States to:  Aim at reducing or interrupting malaria transmission through integrated vector management, promoting improvement of local and environmental conditions and healthy settings, and increasing access to basic health services, antimalarial medicines, diagnostics and preventive technologies in order to reduce the disease burden; and  Implement integrated approaches to malaria prevention and control through multisectoral collaboration and community responsibility and participation. 3. WHA 64.17: Malaria (adopted during the 64th WHA, 24 May 2011) [24]  Urged Member States to use the expansion of interventions for malaria prevention and control as entry point to strengthening health systems, including laboratory services, maternal and child health services at peripheral health facilities, integrated management of illnesses at the community level, and timely and accurate surveillance. All national programmes and partners working on malaria in the GMS are brought together under the Mekong Malaria Programme (MMP). This was originally launched in Ho Chi Minh City in 1999 as the Mekong Roll Back Malaria Initiative.The MMP has prepared the “Strategic Plan to Strengthen Malaria Control and Elimination in the Greater Mekong Subregion: 2010-2014”which included health systems strengthening and increased integration of malaria, as well as regional and private sector engagement and coordination among its proposed strategies to reach its goals and objectives. [25] The MMP has evolved into the Emergency Response to Artemisinin Resistance (ERAR) in the Greater Mekong Subregion with a regional hub based in WHO-Cambodia. The ERAR Regional Framework for Action 2013 – 2015 proposes 15 actions in 4 action areas. These are presented in detail in Section 4.4. To emphasize the importance of combating the malaria problem in the region, the ASEAN Health Ministerial Meeting held on 4 July 2012 in Phuket, Thailand organized a high-level Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 19

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion consultation convened by the Government of Thailand and the Roll Back Malaria Partnership (RBM) to urge greater political support for on-going malaria control efforts in the region. [26] Within the same year, a big conference entitled “Malaria 2012: Saving Lives in the Asia Pacific” was held in Sydney, Australia from 31 October to 2 November 2012. It was attended by representatives of 30 countries and 130 organizations in the Asia Pacific Region and beyond. In the consensus document released after the meeting, the participants agreed to work together to achieve the long-term goal of eliminating malaria in the Asia Pacific region and aiming for the following targets by 2015: [27]    Reduce malaria cases and deaths by 75% Contribute to the UN Secretary General’s goal of near zero deaths worldwide Contain artemisinin-resistance

The consensus document also includes five priority actions to be taken: 1. Promote high-level regional political leadership and collaboration 2. Close the financing gap 3. Expand access to quality medicines and technologies 4. Achieve universal coverage of key malaria interventions in primary care 5. Accelerate highest priority research. Among the ideas discussed during the Sydney meeting is the establishment of an Asia Pacific Leaders Malaria Alliance which aims to strengthen regional collaboration to accelerate the fight against malaria and overcome the emergence of drug-resistant strains of the disease. This was followed through during the 7th East Asia Summit in Phnom Penh Cambodia on 21 November 2012. In the meeting, Prime Minister Julia Gillard of Australia committed $1M to support the establishment of the alliance. [28]

4.2 National control programmes The malaria burden in the GMS has been dramatically reduced over the last 20 years. During this period malaria control activities have been scaled-up very significantly as a result of increased political and financial support from both domestic and international sources. The Global Fund alone has provided USD353M for malaria control in the six countries of the GMS since 2002. The impact of this scale-up has been very pronounced with reductions in malaria mortality of more than 50% in most countries during the last 10 years. Interventions such as the provision of free insecticide treated bednets (ITNs) (and more recently long-lasting insecticide treated bednets (LLINs)) and the use of rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs) are generally considered to have played an important part in this success.Nevertheless, malaria remains an important public health issue throughout the region and national malaria control programmes (NMCPs) generally continue to receive strong political support. [30]

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Table 9 presents a summary of national programme priorities, impact level targets and elimination goals of the six GMS countries. Containment of artemisinin resistance is a priority of the 4 countries where this is a problem. In addition, 5 of the GMS countries – Cambodia, China, Lao PDR, Thailand and Viet Nam - have explicitly indicated the move towards elimination as a priority of their malaria control programme.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 9. Summary of National Programme Priorities and Elimination Goals in the GMS Priorities / Targets Priorities Cambodia Malaria control, containment of artemisinin resistance and province-wise move towards elimination. China (Yunnan) Prevention of importation of malaria by Chinese economic migrants returning from highly endemic areas of Myanmar and preventing local transmission in the few remaining endemic foci. The national goal is elimination. Lao PDR Malaria control with a gradual provincewise move towards elimination. Myanmar Massive rapid scale-up of malaria control effort and containment of artemisinin resistance. Thailand Containment of artemisinin resistant falciparum malaria along borders with Cambodia and Myanmar, and malaria control moving towards elimination elsewhere. Impact of malaria on tourism is a key concern. Malaria mortality rate down to 0.05 per 100,000 in 2016. Viet Nam Containment of artemisinin resistant falciparum malaria in affected provinces; malaria control moving towards elimination elsewhere.

Impact targets mortality

–

Impact targets morbidity

–

Annual probable and confirmed malaria deaths reported in public health facilities down to less than 1 per 100,000 by 2015 and down to zero by 2020. Annual probable and confirmed malaria cases reported in public

Annual malaria deaths(as reported by hospitals) down to 0.2 per 100,000 by 2015

To reduce malaria mortality by at least 50% by 2015 compared to baseline data in 2007.

Malaria mortality rate below 0.02 per 100,000 by 2020.

By 2015, zero malaria case in all 55 type 3 counties; by 2015, no locally

Annual parasite incidence down to 2 per 1,000 by 2015.

To reduce malaria morbidity at least 50% by

Annual parasite incidence down to 0.2 per 1,000 by 2016.

Annual parasite incidence below 0.15 per 1,000 by

Session 1: Development, Health Systems and Malaria in the GMS: The Case for Multi-sectoral Actions 22

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion health facilities down to less than 2 per 1,000 by 2015. transmitted malaria in all 55 type 2 counties and in 2 type 1 counties; by 2015, 17 type 1 counties are below 0.1/1000 API. All species by 2020 in Yunnan, by 2015 elsewhere. 2015 compared to baseline data in 2007. by 2020.

Elimination targets

By 2020 no hyperendemic provinces; 40 provinces with no local transmission; 15 provinces in elimination mode and 8 provinces in pre-elimination mode. Source: Hewill, S. and Delacollette C. Malaria Control in the Greater Mekong Subregion: An Overview of the Current Response and its Limitations, Table 1 [30]

Pf by 2020; all species by 2025.

No timeline yet formalized.

Elimination artemisinin resistant Pf.

of

Interruption of malaria transmission (no indigenous cases for 3 years) in 60% of districts by 2016 and 80% by 2020.

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4.3 Regional partnerships and multisectoral response Several funding agencies and technical partners have been involved in various aspects of the malaria programme in the GMS. Table 10 shows a mapping of the countries covered by each of these partners and the stage of the support – whether it is on-going, just phasing-in or in the process of phasing-out. The data in the table show that of the 7 funding agencies identified, 6 are supporting Myanmar. In contrast, it is mainly the Global Fund which is supporting Lao PDR. In terms of technical support, all technical partners identified are supporting Thailand while Lao PDR has once again the lowest number of partners supporting. Table 10. Major funding partners Global Fund USAID/PMI AusAID BMGF Clinton Foundation JICA DFID Major Partners WHO ACTMalaria Malaria Consortium APMEN Technical

Summary of Geographical Coverage of major Funding and Technical Partners involved in Malaria-related Efforts in the GMS Cambodia China (Yunnan) Lao PDR Myanmar Thailand Viet Nam GMS

LEGEND: Continuing support Support phasing-out Support phasing-in

Source: Hewitt, S. and Delacollette C. Malaria Control in the Greater Mekong Subregion: An Overview of the Current Response and its Limitations, Table 7 [30]

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4.4 Response to artemisinin resistance The response to the problem of artemisinin resistance has been provided at all levels. In the WHO resolution WHA64.17 adopted in 2011, one of the provisions urged Member States to take immediate action to combat major threats, namely resistance to artemisinin-based medicines, by strengthening regulatory services in the private and public sectors, working to halt the use of oral artemisinin-based monotherapies and substandard medicines not meeting WHO prequalification standards. [24] A more detailed plan of action was presented in the Global Plan for Artemisinin Resistant Containment (GPARC) which was developed by the WHO Global Malaria Programme through consultations with over 100 malaria experts. This was launched in January 2011 and is intended to mobilize global and local stakeholders for the containment and ultimate elimination of artemisinin resistance where it has emerged and for the prevention of its emergence/spread to new locations. [31] The GPARC stipulates the following goals and recommendations: 1. Stop the spread of resistant parasites 2. Increase monitoring and surveillance to evaluate the threat of artemisinin resistance 3. Improve access to diagnostics and rational treatment with ACTs 4. Invest in artemisinin resistance-related research 5. Motivate action and mobilize resources. At the regional level, the Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion (ERAR) was formulated. This Regional Framework for Action 2013–2015 highlights key action areas to further progress in the efforts to contain resistance. It identifies 15 actions in four areas of priority action to be implemented by a consortium of endemic countries, UN agencies, and country-based malaria partners. [32] These are shown in Table 11. Table 11. Key Action Areas and Corresponding Actions for the ERAR Key Action Area Full coverage of quality interventions in priority areas 1. 2. 3. Tighter coordination and management of field operations 4. 5. Actions Increase quality and coverage of key interventions in the private and public sector. Engage health and non-health sectors to reach high-risk populations Implement measures to ensure continuous and uninterrupted supply of essential commodities Strengthen coordination of field activities Monitor staff performance and increase supportive supervision 25

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 6. Better information for artemisinin resistance containment 7. 8. 9. Promote the integration of resistance containment, in malaria elimination and malaria control while maintaining the focus on resistance Improve collection and use of data to target operations Fast-track priority research and refine tools for containment and elimination Increase monitoring of antimalarial therapeutic efficacy and strengthen the therapeutic efficacy networks worldwide

10. Increase monitoring of insecticide resistance Regional support oversight and 11. Enhance accountability and exchange of information 12. Build political support at all levels 13. Facilitate progress and regional cooperation on pharmaceutical regulation, production, export and marketing 14. Create regional community of practice on approaches to high-risk and hardto-reach populations 15. Support cross-border coordination

The ERAR framework is focused on the GMS but recognizes that artemisinin resistance is an issue of global concern. It further recognizes that concerted and coordinated efforts at local, regional and global levels are needed to effectively address the problem. Another regional initiative to respond to the problem of artemisinin resistance is the “Declaration of the 7th East Asia Summit on Regional Responses to Malaria Control and Addressing Resistance to Anti-malarial Medicines”. This declaration was signed by Heads of State/Government of the 10 ASEAN member states plus Australia, China, India, Japan, Republic of Korea, the Russian Federation, New Zealand and the United States during the 7th East Asia Summit held in Phnom Penh Cambodia on 20 November 2012. It declared that signatories will strengthen the national and regional responses to contain resistance to antimalarial medicines through existing bilateral, regional, and multilateral channels. The declaration outlined 10 action points/strategies to meet their objectives including, among others: [33]   Agreeing that a regional commitment to malaria control and elimination requires a comprehensive approach by integrating cross-sectoral programmes; and Agreeing that strong national responses to malaria control and elimination require cross-sectoral approaches beyond the health ministries and that cross-sectoral approaches are critical in addressing resistance to anti-malarial medicines.

To contain and eliminate artemisinin resistance in the region, the implementation of the Mekong countries’ national strategic plans in line with the Global Plan for Artemisinin Resistance Containment (GPARC) and more recently the Emergency Response to 26

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Artemisinin Resistance in the Greater Mekong Subregion (ERAR) are being streamlined for targeted and better coordinated actions with support from international development partners. A major focus of the containment/elimination strategies in all five countries and the region will be mobile and migrant populations especially those in border areas. Migrants to rural areas where malaria is endemic in the GMS are the highest risk groups for malaria in general and also may spread artemisinin resistant malaria from place to place. Operationally the GPARC defines areas as tiers as follows: Tier 1: Areas where there is credible evidence of artemisinin resistance. Tier 2: Areas with significant inflows of people from tier 1 areas, including those immediately bordering tier 1. Tier 3: Areas with no evidence of artemisinin resistance and limited contact with tier 1 areas. Tier 4: The activities to be undertaken in each tier are as follows:

In late 2011 and early 2012, an assessment of the 2008-2011 response to artemisinin resistance in the GMS was carried out jointly by WHO, UK DFID, USAID/PMI and supported by the AusAID and BMGF. The assessment concluded that “…. a good, if delayed, start has been made to addressing artemisinin resistance in the GMS. In some areas the impact has already been impressive. In general, the approach outlined in the Global Plan for Artemisinin Resistance Containment (GPARC) and several associated national level strategies and plans was found to be appropriate”. The report went on to say: “However, overall the assessment is sobering. It is impossible to avoid the conclusion that not enough is yet being done, with enough intensity, coverage and quality, to respond to a problem that could not only slow future progress but also undo the gains already made in malaria control worldwide.” The report “calls for a very large increase in attention to this issue”. [8] 27

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Evidence of resistance has now been detected in several sites. Containment activities are now ongoing in all four affected countries:  Cambodia – The BMGF-supported Cambodia-Thailand Artemisinin Resistance Containment Project from 2008-2011 rolled out massive containment operations. The Global Fund Round 9 grant began in 2010, with the goal to contain artemisininresistant Plasmodium falciparum parasites by removing selection pressure and to move towards pre-elimination status. Myanmar – The Myanmar Artemisinin Resistance Containment Framework (MARC) began in April 2011 supported by the Three Diseases Fund. Thailand – Containment operations started in 2008, jointly with Cambodia. Global Fund Round 10 started in 2011 supporting the response to artemisinin resistance, focusing on the Myanmar-Thailand border areas. Viet Nam – Began containment operations in 2011 focusing on the two affected provinces, with limited government and WHO funding.







Artemisinin resistance is a regional problem requiring regional solutions with a medium to long-term multi-sectoral involvement to preserve and sustain whatever gains have been achieved in malaria control in the region. Failure to eliminate, or at least contain, artemisinin resistance in the GMS could compromise global efforts to control and eliminate malaria. In this context, the Global Fund recently allocated US$100 million for the Regional Artemisinin Initiative (RAI) in the GMS.

Source: WHO/GMP Technical Expert Group Recommendations, June 2013

Figure 5. GMS map with Artemisinin Resistance Tiers (as of June 2013)

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4.5 Gaps Inspite of the enormous response at all levels and the major gains in the malaria programme, there is still a long way to go towards the achievement of the ultimate goal of elimination. Further work is needed to tailor existing tools and delivery mechanisms (taking advantage of potential synergies with other health programmes) and to develop new interventions to address the needs of populations not adequately served by existing approaches. In addition, continued efforts are needed to strengthen the management of national programmes and the coordination of multiple partners. Continued political support is key to securing adequate funding and ensuring that malaria control and elimination targets are achieved. [30] Among the gaps which need to be addressed are: a. Coverage of key services --The coverage of key interventions is critically low or suboptimal in some areas, threatening progress across the GMS as a whole. With the economic crisis now affecting financial support for malaria programmes in many countries, major gaps already exist in the immediate funding requirements for essential commodities. b. Addressing the problem of declining financial support -- The precarious nature of external financial support which provides a large proportion of overall funding in all GMS countries except China, is now a major issue in the region. In several countries, the situation is critical. c. Addressing the problem of artemisinin resistance-- Experts agree that there is a limited window of opportunity for containing or eliminating artemisinin resistant parasites before they spread, putting at risk recent progress in malaria control. The urgency is increased by the fact that no other antimalarial medicines are available that offer the same level of efficacy and tolerability as artemisinin-based combination therapies (ACTs), and few promising alternatives are available in the immediate research and development pipeline. While efforts to contain and prevent artemisinin resistance at global, regional, national and local levels have begun, they are not sufficient and must be expanded, intensified and better coordinated. d. Strengthening surveillance systems -- Epidemiological, parasitological, entomological and drug quality surveillance is a central and critical component of any functional malaria control programme. All six GMS countries have surveillance systems in place but their quality and coverage varies considerably from one to another. e. Strengthening health systems – National malaria control programmes are implemented in the context of local health systems and weaknesses in these health systems impact negatively on the effectiveness of malaria control efforts.One highly problematic area within the health system is human resources, where additional support is needed for its development, especially for programmes moving towards elimination. Adequate HR are crucial to achieving programmatic success.

29

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion f. Continued innovation -- There is still an ongoing need to conduct basic, applied and operational research and development activities to generate innovative ideas and approaches for key issues like effective ways of engaging the private sector to strengthen service delivery, protecting people from early biting and outdoor resting vectors through habitat management and barrier system, or developing interventions for those beyond the reach of facility-based and community-based case management services.

g. Transforming commitments into concrete actions – The earlier sections of this paper have shown that expressions of commitment to address various facets of the malaria problem have been given even at the highest levels by the heads of governments and the UN agencies. The bigger challenge is to sustain the interest, generate the political will, and produce the required resources to transform commitments into concrete actions.

5.

Economic development in the GMS

GMS economies have grown at some of the fastest rates in the world since the early 90s when the GMS Programme was first launched. Growth in the region as a whole has averaged close to 8% per year in the last 20 years, with growth in most countries being even more rapid in the second decade than in the first. The GMS Programme has aimed to enhance economic relations among the GMS countries by focusing on the design and implementation of high-priority subregional projects in transport, energy, telecommunications, tourism, agriculture, the environment and human resource development, as well as in the cross-cutting area of trade and investment. [34]

5.1

Development projects in the GMS

As of September 2011, the GMS Programme had implemented 55 investment projects with a total project cost of about $14 billion, involving sub-regional road, airport and railway improvements; hydropower projects for cross-border power supply; tourism infrastructure development; and communicable disease control [35]. Major projects implemented under each of the seven development sectors covered by the programme are listed in Table 12.

30

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 12. Development Projects Implemented and Planned in the GMS SECTOR Infrastructure development PROJECTS IMPLEMENTED1 STRATEGIC OBJECTIVES/PRIORITY ISSUES TO BE PURSUED: 2012-20222

Near-completion of the transport  encouraging multimodal systems, component of the 3 main GMS particularly road and rail; economic corridors:  improving road safety and addressing  East-west thebroader social dimensions of transport investments;  North-south  ensuring that climate change  Southern considerationsare considered in transport development (e.g., controlling greenhouse gas emissions through freight traffic management);addressing the nonphysical barriers to cross border transport; and  promoting the development of economic corridors.

Energy

Development of major hydropower  enhance access to energy for all sectors projects for cross-border power and communities, particularly the poor in supply, with private sector the GMS, through promotion of best participation energy practices in the subregion;  develop and utilize more efficiently indigenous, low carbon, and renewable resources, while reducing the subregion’s dependence on imported fossil fuels;  improve energy supply security through cross-border trade while optimizing use of subregional energy resources; and  promote PPP and private sector participation, particularly through SMEs for subregional energy development.

Telecommunication

Optical fiber interconnection of the  strengthen the institutional structure for telecommunication systems of the sector cooperation; GMS countries  identify and prioritize further information superhighway network (ISN) infrastructure needs;  build capacity for the use of advanced technology;  advance cooperation on new ICT;  promote ICT applications including ecommerce and e-learning;  channel human resources to ensure the sustainable development of the sector; 31

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion SECTOR PROJECTS IMPLEMENTED1 STRATEGIC OBJECTIVES/PRIORITY ISSUES TO BE PURSUED: 2012-20222  continue to develop pilot ICT projects In rural areas. Tourism Conduct of promotional campaigns and other subregional cooperation initiatives to put GMS on the world’s tourist map GMS national tourism offices, development partners, and the private sector will focus resources on implementing three consolidated programmes:  Tourism-Related Human Resource Development Programme. The programme focuses on capacity building and training of government= officials and tourism hospitality enterprises and upgrading of tourism training facilities. Pro-Poor Sustainable Tourism Development Programme. The programme focuses on safeguarding heritage and vulnerable groups from the negative impacts of tourism accelerating the development of propoortourism products and services, developing ecologically sensitive and socially responsible tourism infrastructure, promoting private sector investment in responsible tourism ventures, and promoting energy efficiency andenvironmentally friendly technologies. Sustainable Marketing and Product Development Programme. The programme focuses on improvements in quality standardsof tourism facilities and services, jointmarketing of priority Mekong River segments, further streamlining of cross-border travel (including visa) formalities, and harmonizing the collection, analysis, and dissemination of tourism statistics.





Agriculture

Expansion of sub-regional trade in agri-food products; promotion of climate change adaptation including use of climate friendly and genderresponsive bio-energy technologies

Implementation of the Core Agriculture Support Programme Phase II with three pillars:  Pillar 1: Building global competitiveness in food safety and modernizing agricultural trade.This pillar will be pursued by promoting agricultural trade and agribusiness investment in the GMS economic corridors through harmonized food safety standards based on 32

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion SECTOR PROJECTS IMPLEMENTED1 STRATEGIC OBJECTIVES/PRIORITY ISSUES TO BE PURSUED: 2012-20222 international standards, information technology-based traceability systems and e-commerce, and a communitybased participatory guarantee approach.  Pillar 2: Promoting climate-friendly agriculture and natural resource management.This pillar will be pursued by supporting climate-resilient farming systems; a weather-based insurance system; and control of transboundary invasive species, pests and animal diseases.  Pillar 3: Promoting agriculture as a leader in rural renewable energy technology and eco-friendly crossborder supply chains. This pillar will be pursued through a regional bioenergy regulatory framework and harmonized standards, biomass technologies and fertilizers for carbon credit, and ecolabel systems for market access. Environment Implementation of 1st phase of Core In considering the further development of Environment Programme and the Core Environment Programme and Biodiversity Corridors Initiative Biodiversity Conservation Corridors Initiative (CEP–BCI), the GMS countries  Improvement of land use have identified the following priority management and sustainable thematic issues: finance mechanisms in rural  Biodiversity conservation and poverty communities alleviation. With infrastructure and other  Mainstream environmental development being major drivers of issued into national planning ecosystem fragmentation and process destruction and as poverty alleviation remains at the core of the GMS countries developmental efforts, it will be important to expand the biodiversity conservation and pro-poor activities of theCEP–BCI, especially among the vulnerable upland communities and as a means of ensuring biodiversity conservation.  Climate change adaptation and mitigation.GMS countries are also concerned about the potential negative impacts of climate change on food and energy security. Increasing weather variability is also likely to increase the vulnerability of ecosystem services and amplify impacts on dependent poor 33

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion SECTOR PROJECTS IMPLEMENTED1 STRATEGIC OBJECTIVES/PRIORITY ISSUES TO BE PURSUED: 2012-20222 communities. Furthermore, major destruction of biomass in recent years from the subregion’s forests is frustrating efforts to control greenhouse gas emissions.  Capacity development. This will include increased activities under CEP–BCI projects and programmes involving the participation of young GMS national researchers through the environmental education network, thereby enhancing environmental awareness in the younger generation and increasing environmental management performance and nature conservation in the subregion. GMS universities and civil society will also support such targeted capacity development. Human resource  Prevention and development c9mmunicable including IV/AIDS control of  Promoting regional cooperation on diseases education and skills development, including building the capacity of GMS government officials in development  Pilot implementation of a management through further phases of framework for mutual recognition the Phnom Penh Plan for Development of skills and qualifications to Management and developing and address skills shortages and piloting a framework for the mutual enhance subregional recognition of technical and vocational competiveness skills in the GMS;  Efforts to support safe labour  Facilitating safe labor migration within migration and address human the subregion, including upgrading labor trafficking migration management systems, enhancing social protection for migrant  Implementation of first 4 phases workers, and improving labor market of Phnom Penh Plan for information systems; Development Management which builds needed skills and  Supporting communicable disease capacities in the GMS control (including HIV/AIDS, malaria, and dengue) in the subregion and improving food and drug safety;  Enhancing regional cooperation for social development, including strengthening subregional cooperation in anti-human-trafficking activities, improving the capacity of vulnerable groups including women, and conducting research on the social impacts of increased subregional connectivity; and enhancing the sense of community in GMS youth; and 34

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion SECTOR PROJECTS IMPLEMENTED1 STRATEGIC OBJECTIVES/PRIORITY ISSUES TO BE PURSUED: 2012-20222 strengthening regional institutional links and mechanisms for HRD cooperation in the GMS. 1Source: 2Source:

[36] [37]

35

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion A major component of the development projects implemented in the GMS are the economic corridors. The GMS countries adopted the economic corridor approach to development during the 8th GMS Ministerial Meeting held in Manila in 1998. This strategy aimed to improve and enhance investments in transport, energy, and telecommunications in the subregion. The three economic corridors – north-south, east-west, and south -- have linked various parts of the GMS to major markets, with certain places serving as centers for production, trade and enterprise development. These corridors extend the benefits of improved transport links to remote and landlocked locations in the GMS which have been disadvantaged by their lack of integration with more prosperous and better located neighbouring areas. [36] The three economic corridors increased trade volume in the region by a factor of more than ten over a decade and spurred rapid economic growth. They also facilitated the development of mines, hydropower, and agro-industrial concessions. [37] Figure 6 shows the areas linked by the 3 economic corridors.

Source: ADB. Greater Mekong Subregion Economic Cooperation Programme Overview. Asian Development Bank. 2012. page 11 [7].

Figure 6. The GMS Economic Corridors 36

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion In 2012, the GMS Programme began its third decade. A new strategic framework was developed for 2012 -2022 to define its priorities and directions for this period. The main strategic objectives and action points to be pursued under each of the seven development sectors covered by the programme is presented in the last column of Table 12.

5.2

Impact of development activities in the GMS on malaria

The GMS Programme no doubt contributed substantially to the increased integration and prosperity in the sub-region. Its success as evidenced by the accelerated economic growth reduction of poverty and improvement of social indicators is a testament of the quality of the GMS countries’ development strategies and policies. Infrastructure development is the core of the programme. [35] While better infrastructure brings increased trade, employment opportunities, improved access to health and better services, and greater access to high- quality goods, there is also a downside to this rapid growth. Infrastructure development also brings about displacement of large population, migration of workers and changes in vector ecology which have implications to malaria. [2] One of the downside of infrastructure development is migration/mobility of people. It has been postulated that greater risk to malaria is likely to result from the movement of people (density, exposure, behavior) associated with many infrastructure projects. [38] Mobility is a growing phenomenon in the GMS. Population mobility in the region is now economically driven. The infrastructure development in the GMS has been a major pull for “labor migration”. [39] Furthermore, the development context in the GMS influenced the composition of migrants as well as its flow and determined migrants’ identities and their rights. For the low skilled workers who make up most of the workers in the GMS, the channels for legal migration remain limited which results to large-scale “illegal migration”. At the same time, the improved road conditions facilitate in-country travelling that make it easier for undocumented migrants to reach unofficial entry points. Their illegal status and identities affect their rights and access to general health services and in particular to malaria services. Undocumented migrants are prone to be exploited in terms of salaries and benefits and are more often marginalized and harder to reach. [40] Their access to health services is limited for several reasons. One is that out of fear of discovery of their illegal status, they may refrain from seeking help from public health services; another reason is their inability to pay for services because of low salaries, which they may rather spend on their own basic needs or send home to their families in their country of origin. Moreover, as undocumented migrants they are disempowered to negotiate or fight for their rights, thus employers may not provide them with the necessary support for their own health concerns. Furthermore, there is a tendency for migrant workers to self-medicate which may make them more vulnerable to substandard antimalarials and oral artemisinin monotherapies which may not only negatively affect their own health but also contribute to drug resistance. [2] Population mobility discussions are often focused only on the migrant workers, However, it should be underscored that migrant workers move with extended families which may include other highly vulnerable groups like children and pregnant women. Evidence suggests that brain affliction as a consequence of cerebral malaria in early childhood may have an effect on a child's cognitive and learning ability; residual neurological sequelae may hinder the developmental progress of 1% -5% of children infected early in life. [41] Pregnant women are disproportionately affected by malaria and in most endemic areas of the world 37

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion constitute the main adult risk group for malaria. Pregnant women living in areas of low or unstable malaria transmission are at a two-or-threefold higher risk of developing severe disease as a result of malaria infection than are non-pregnant adults living in the same area. [42] Migrant workers coming from highland areas usually have low immunity to malaria. This lower immunity plus their working conditions and working behaviour in the lowlands, i.e. working in forests or plantations without protection where the risk of malaria transmission is high, may put them at greater risk of developing severe malaria. Development activities may also lead to changes in land use patterns. The rapid deforestation, illegal logging, and forest conversion such as development of large scale plantations for rubber, oil palm or cashew nuts can have an impact on mosquito density and disease incidence. [2] Large scale infrastructure development projects and changing land use patterns perhaps pose the most significant risk for increased transmission in the GMS. These development activities can result in changes in (i) vector ecology in particular the predominant species and biting times; (ii) result in spread of resistant strains; and (iii) increased vulnerability of populations with low immunity who seek work in malaria transmission areas. [2] The GMS is recognized as one of the most active regions for hydopower in the world. In the GMS, many hydropower projects have cross-boundary impacts. [2] Dams are considered to be one of the most important means of meeting the water and energy needs of the population. However, dams can also have negative implications for malaria. Dams can result in the creation or elimination of mosquito breeding sites which together with the changes in the demography of the population can alter human-vector-parasite contact patterns. [2]

6.

Multisectoral response for malaria prevention and control

The preceding sections in this paper discussed not only the epidemiology of malaria in the GMS but also the response as well as current and planned development activities in the region and their impact on malaria. It has been shown that development in the GMS aiming at improved socio-economic conditions of the region may have negative implications on the burden of malaria. On the other hand, studies have shown that malaria control interventions contribute to development through reducing poverty and improving the overall health of the population.

6.1. The need for a multi-sectoral response The impact of development activities on malaria is determined not only by factors within the health sector’s domain but also by factors outside of the realm of health. There is a need to underscore that the complex problem of malaria is best tackled not just through health policies but through policies that also address other factors that increase people’s vulnerability to infection and disease. These policies may involve sectors such as transportation, public works, education, migration, labor, agriculture. 38

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion In the context of the 8th WHO Global Conference on Health Promotion, “Health in All Policies” (HiAP) has been defined as "an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity”. A HiAP approach is founded on health-related rights and obligations. It emphasizes the consequences of public policies on health determinants, and aims to improve the accountability of policy-makers for health impacts at all levels of policy-making. [2]. There’s a need to put malaria high on the agenda of other relevant sectors in order to develop “healthy policies” in these sectors. [43]

6.2. Experience of the HIV/AIDS project portfolio within the ADB-financed infrastructure projects in the GMS The Asian Development Bank (ADB), as a regional bank, was concerned with the threat the HIV epidemic poses to the region’s progress in reducing poverty and its socioeconomic development. Commissioned studies of ADB had shown that HIV infection reduced the income-earning capacity of affected households and significantly increased their spending on health care. The studies highlighted the fact that HIV was markedly worse than other chronic diseases because it affects people in their prime productive years (15-49 years of age). Studies have also documented the economic impact on families and communities. Studies done in 2008 by ADB and UNAIDS showed that at current estimates of the epidemic’s growth, annual poverty reduction estimates and trends maybe reduced by as much as 60% in Cambodia and 23% in India. ADB has been involved in HIV/AIDS related activities for the last two decades. Its activities have evolved from a series of economic analyses, support for regional conferences and information-sharing to a selective prevention programme, most notably in the transport sector. ADB started incorporating HIV prevention in transport projects in the GMS in 1999. A systematic assessment of HIV risk and vulnerability is now part of all ADB-financed infrastructure projects. The approach has been implemented with support from ADB’s Transport Community of Practice and infrastructure mission leaders. [44] The HIV prevention component of ADB-financed infrastructure projects has been funded through one of the two funding mechanisms: (i) by allocating a portion of the actual project budgets (requiring investment from the Developing Member Countries); or (II) by using grant funds. HIV interventions utilizing grant funds are mainly focused on health education for workers during the construction phase of the infrastructure project. Whereas the more extensive interventions, such as implementing demonstration projects, executing efforts to effect broader transport sector policy change in a country, conducting more rigorous evaluation efforts, engaging in cross-border coordination and knowledge sharing activities, were funded using special technical assistance, financed by designated trust funds administered by ADB. The key approach to ADB’s HIV prevention programmes is mitigating the HIV risks and vulnerabilities linked to economic corridors of the GMS. 39

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

6.3. The way forward for a multi-sectoral response to malaria Much progress has been accomplished in the prevention and control of malaria in the GMS. However, it continues to be challenged by several factors outside of the domain of the health sector such as the unintended negative effects of development activities in the region. Understanding the complex relationship of these development issues and concerns related to malaria underscores the fact that there is a need to mainstream malaria prevention and control efforts in these sectors, thereby implementing a multi-sectoral response in the region. Migration is a development issue which has a very strong health dimension in general and malaria implications in particular. Given the high levels of internal and external migration in the GMS and the complexity of the mobility issue, there is a need to work more closely with the different stakeholders beyond the health sector to predict migration patterns and malaria hotspots. Information about migrants is a sensitive issue and often not readily available for malaria control programmes. Deforestation and forest conversion are two development issues that have implications to vector–human interactions. The mainstreaming of malaria prevention and control tackling deforestation should be underscored. Schools have an important role to play in the multi-sectoral approach to malaria prevention and control. School-based health education can be utilized to raise community understanding of malaria and the need for control, and can create a demand for health services to provide universal access to appropriate treatment. Skills-based health education can promote the prevention of malaria by encouraging adoption of healthy behaviors related to malaria like the use of impregnated bed nets and when to seek treatment. It can also adopt skills-based strategies for reducing specific risks of malaria that can be mainstreamed in existing reproductive health classes. Schools can also serve as venue for synchronized impregnation of bed nets and promotion of appropriate use of treated nets. An effective partnership between the health sector and the schools is needed to achieve its goal of prevention and control. [45] There should be strong advocacy to include malaria prevention and treatment in the social, economic and health impact assessments related to large scale infrastructure projects in the GMS. Experience of mainstreaming HIV/AIDS in development projects should be taken into account - the involvement of the transport, communication, labor, migration, education and other sectors has led to substantial decrease in the disease transmission of HIV in the region. Information, education and communication (IEC) can readily be incorporated into the design, operation and maintenance of infrastructure projects. However, infrastructure task managers need ready access to resources and tools which can help to respond to such opportunities. The issue of counterfeit and sub-standards medicines can be tackled more aggressively by appropriate medicines authorities in the countries involved. Border authorities can also play an important role in the surveillance and monitoring of the flow of these medicines along and across the border areas. The multi-sectoral approach in malaria emphasizes the need for strategic partnerships at national and sub-regional levels with different sectors/ministries, civil society 40

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion organizations, private sector operators, regional organizations and development partners. Sub-regional partnerships should complement and strengthen national partnerships through joint production and provision of public goods. Examples of such activities include: (i) costsharing for common activities such as generation of knowledge, training and capacity building; (ii) promoting regional standards to guide national programmes; (iii) joint actions to eliminate sub-standard and counterfeit medicines and elimination of oral artemisinin monotherapy; and (iv) disseminating and sharing of knowledge and lessons learned from implementation. In all these partnerships and multi-sectoral responses, the greater challenge is the leadership that the health sector needs to show to be able to advocate and engage the different sectors and groups to proactively and collectively address the problem of malaria at the national and sub-regional levels.

41

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion LIST OF REFERENCES 1. 2. Introduction: Mekong Malaria II. The Southeast Journal of Tropical Medicine and Public Health. Volume 34 (Supplement 4) 2003: p3 O’ Shannassy, T. Greater Mekong Sub-region (GMS): Context. The Southeast Journal of Tropical Medicine and Public Health. Volume 44 (Supplement 1) 2013: 1-45 ESCAP. 2012 ESCAP Population Datasheet. Social Development Division, UNESCAP. Thailand. 20 December 2012. Available at: www.unescap.org/sdd/publication/datasheet2012/2012%20ESCAP%20Population%20Datasheet.pdf Mekong Basin Disease Surveillance Website. Available at:       5. Cambodia: www.mbdsoffice.com/index_camb.php China: www.mbdsoffice.com/index_cn.php Lao PDR: www.mbdsoffice.com/index_lao.php Myanmar: www.mbdsoffice.com/index_myan.php Thailand: www.mbdsoffice.com/index_th.php Vietnam: www.mbdsoffice.com/index_vn.php;

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Asian Development Bank. Key Indicators for Asia and the Pacific 2012. Philippines: ADB, 2012. Available at: www.adb.or/sites/default/files/pub/2012/ki2012 (Cited on 25 July 2013) Pan, W., Bilsborrow, R., et al. Migration, health and environmental change along the Interoceanic Highway in Peru. Available at: www.para.princeton.edu/papers/121863 Asian Development Bank. Overview Greater Mekong Subregion Economic Cooperation Programme. Philippines: ADB, 2012. Available at: www.adb.org/sites/default/file/gms-overview.pdf Joint Assessment Team. Joint Assessment of the Response to Artemisinin Resistance in the Greater Mekong Subregion Conducted November 2011 to February 2012 (Full Report). Available at: www.malaria2012conference.com/cms/wp-content/uploads/2012/10/JointAssessment-of-the-Response-to-Artemisinin-Resistance.pdf Hewitt, S. And Delacollette, C. et al. Malaria Situation in the Greater Mekong Subregion. The Souhteast Asian Journal of Tropical Medicine and Public Health. Volume 44 (Supplement 1) 2013. 46-72 Peeters, G., Xuan, X.n. et al. Low perception of malaria risk among the Raglai ethnic minority in south-central Vietnam: Implications for forest malaria control. Malaria Journal. 2010;9:23 Available at: http://www.malariajournal.com/content/9/1/23 Kritsiriwuthinan, K. and Ngrenngarmlert. Molecular screening of Plasmodium infections among migrant workers in Thailand. J. Vector Borne Dis. 2011 Dec: 48(4); 214-8 Available at: www.ncbi.nlm.nih.gov.elis.tmu.edu.tw/pubmed/22297283 Incardona, S., Vong, S., et al. Large scale malaria survey in Cambodia: Novel insights on species distribution and risk factors. Malaria Journal. 2007, 6:37 Available from: http://www.malariajournal.com/contents/6/1/37 42

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 13. Singhasivanon, P Foreword, Mekong Malaria III Towards Malaria Elimination in the Greater Mekong Subregion. The Southeast Asian Journal of tropical Medicine and Public Health. Volume 44 (Supplement 1) 2013 World Health Organization Regional Office for Southeast Asia. WHO Calls for Greater Investment to Eliminate Malaria. SEAR/PR1557. Available at: www.searo.who.int/mediacentre/releases/2013/pr1557/en World Health Organization Western Pacific Regional Office. Artemisinin Resistance in the Greater Mekong Subregion Fact Sheet. Available at: www.wpro.who.int/mvp/documents/docs/artemisinin_resistnce_fact_sheet.pdf Bustos, MD, et al. Monitoring antimalarial drug efficacy in the Greater Mekong Subregion: an overview of in vivo results from 2008 to 2010. The Southeast Asian Journal of Tropical Mediocine and Public Health. Volume 44 (Supplement 1) 2013 Thimasarn, K. Quality assurance of antimalarial drugs in Mekong Region. Roll-Back Malaria-Mekong. April 2004. Unpublished document Raymond, C. Combating counterfeit medicines in the Mekong: Reports from the Frontline. October 2010. Available at: www.kiasia.org/web/upload/Articles/file/50.pdf Newton, P., Proux, S. Et al. Fake artesunate in southeast Asia. Lancet. 2001 June 16:357 (9277): 1948-50. Available at: www.ncbi.nlm.nih.gov/pubmed/11425421 Dondorp, A.M., Newton, P.N., et al. Fake antimalarials in Southeast Asia are a major impediment to malaria control: multinational cross-sectional survey on the prevalence of fake antimalarial. Tropical Medicine and Interrnational Health. Volume 9 No. 13 1241-1246 Dec. 2004. Available at: www.ncbi.nlm.nih.gov/pubmed/15598255 Newton, P.N., Fernandez, F.M., et al. A Collaborative Epidemioological Investigation Into the Criminal Fake Artesunate Trade in South East Asia. PLoS Med. 2008: 5(2):e52 Malaria Control. 58th World Health Assembly WHA58.2. 23 May 2005. Available at: https://apps.who.int/gb/ebwha/pdf-files/WHA58.2-en.pdf Malaria, including p0roposal for establishment of World malaria Day. 606h World Health Assembly. WHA60.18. 23 May 2007. Available at: www.who.int/gb/ebwha/pdf_Files/WHA60/A60_R18-en.pdf Malaria. 64th World Health Assembly. WHA64.17. 24 May 2011. Available at: www.who.int/Malaria/piub;lications/WHA-malaria-resolution-2011.pdf Mekong Malaria Programme Partnership Initiative. Strategic Plan to Strengthen Malaria Control and Elimination in the Greater Mekong Subregion: 2010-2014. December 2009. Available at: http://whothailand.healthrepository.orf/handle/123456789/696 Roll Back Malaria. ASEAN political commitment critical to sustain malaria gains. Press Release 04.07.2012 Available at: www.rbm.who.int/globaladvocacy/pr2012-07-04.html AusAID. Consensus on malaria Control and Elimination in the Asia pacific. Available at: www.malaria2012conference.com/cons/wpcontent/uploads/2012/11/ SydneyConsensusOnMalaria.pdf 43

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 28. AusAID. East Asia leaders agree to collective action on malaria. AusAID Website – Latest News. 21 Nov. 2012. Available at: www.ausaid.gov.au/HotTopics/pages/Display.aspx?QID=884) ADB Powerpoint Presentation for WHO WPRO on APLMA Hewitt S., and Delacollette. C. Malaria Control in the Greater Mekong Subregion: An Overview of the Current Response and Its Limitations. The Southeast Asian Journal of Tropical Medicine and Public Health. Volume 44 (Supplement 1) 2013: 249-305 World Health Organization. Global Plan for Artemisinin Resistance Containment (GPARC).Geneva.WHO: 2011. Available at: www.who.int/malaria/publications/atz/9789241500838/en World Health Organization. Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion Regional Framework for Action 2013-2015. Geneva: WHO 2013. Available at: www.apps.who.int/iris/betstream/10665/7940/1/9789241505321-eng.pdf Declaration of the 7th East Asian Summit on Regional Response to Malaria Control and Addressing Resistance to Anti-malarial Medicines. Phnom Penh Cambodia: 20 November 2012. Available at: www.dfat.gov.au/asean/eas/121120_declaration_7th_eas_regional_response .html Asian Development Bank. The Greater Mekong Subregion at 20 Progress and Prospects. Philippines: ADB December 2012. Available at: www.adb.org/pubications/greater-mekong-subregion-20-progress-andprospects Asian Development Bank. The Greater Mekong Subregion Economic Cooperation Programme Strategic Framework 2012-2022. Philippines: ADB March 2012. Available at: www.adb.org/documents/greater-mekongsubregion-economic-cooperation-progra-strategic-framework-2012-2022 Asian Development Bank. Mekong Countries to Enhance Trade and Business in GMS Corridors. ADB Website – News and Events. 28 June 2011. Available at: www.adb.org/news/cambodia/mekong-countries-enhance-trafe-andbusiness-gms-corridors Swiss Agency for Development and Cooperation. Mekong Institute. Local Economic Development Promotion Fostering an Enabling Environment for Inclusive and Equitable Growth. Vientiane Lao PDR: March 2013. Available at: www.swiss-cooperation.admin.ch/mekong//.../resource.en.2033q.pdf World Bank. Workshop Report: Identifying opportunities to address malaria through infrastructure projects. World Bank. 1999 Caoutte, Therese, Sciortino, Rosalia, guest, Philip, Feinstein, Alan. Labor Migration in the Greater Mekong Sub-region. Available at http://piasdgserver.usp.ac.fj Asian Development Bank. Migration Subregion.Philippines: ADB. 2009. in the Greater Mekong

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 43. 44. 45. 8th WHO Global Conference on Health Promotion Official webite. http//www.healthpromotion 2013.org/health promotion/health_inall_policies Asian Development Bank. Strategic Directions Paper on HIV/AIDS 20112015. Philippines: ADB August 2011 World Bank Policy Seminar. What Should Schools Do About Malaria?World Bank November 1999.

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SESSION

2 Session 2: Border Health: Concepts, Models, and Applications for the Greater Mekong Subregion Submitted by Courtland Robinson1 Johns Hopkins Bloomberg School of Public Health

1. Introduction “The border can be an area of division and demarcation or alternatively of contact, exchange and integration. Borders can separate or they can connect” (Comelli et al., 2006, p. 3) This concept paper on border health was commissioned for the Mekong Healthy Border Meeting, a three-day meeting to be held in Bangkok, Thailand on 5-7 August 2013. The general objective of the meeting is to contribute to the improvement of health of mobile and migrant populations and those people living in border areas in the Greater Mekong Subregion (GMS) through multi-sectorial collaboration. Specific objectives for the meeting include: 1) To advocate for development and implementation of “health in all policies” in the GMS To secure consensus and political commitments on addressing through multisectoral action public health challenges related to borders in the GMS; ensuring universal health coverage and developing innovative approaches to strengthen access to and delivery of quality basic health services for people living in border areas, mobile and migrant populations and other vulnerable groups along and across GMS borders; ensuring access to quality-assured medicines in the GMS, including strengthened regulatory systems and enforcement actions; ensuring adequate prevention and health interventions along GMS borders to address maternal and child health, communicable diseases, nutrition, noncommunicable diseases, and victims of armed conflicts; and ensuring adequate prevention and response to outbreak-prone and emerging diseases across GMS borders. To secure political and multi-sectoral commitments for the Emergency Response to artemisinin resistance and for ultimately eliminating artemisinin resistance in the GMS.

2)

3)

In order to guide the meeting discussions, this paper seeks, in the first section, to define border health as a distinct but overlapping concept in relation to migrant health. To define border health requires at least a brief introduction to concepts and definitions of borders, 1

With acknowledgement of research assistance from Casey Branchini.

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion boundaries and border regions. The second section explores a “healthy border” concept, within the frameworks of the “social determinants of health” and the “health in all policies” approach. Within each of these, we incorporate a particular focus on migrants, ethnic minorities, and other sub-populations living in border regions, as well as the particular factors and conditions that affect their health. The third section examines international models of border health as well as models and examples from GMS countries. In this section, the paper adopts the approach of the WHO’s 2010 report, Health of Migrants–The Way Forward, which identified priorities and actions in four thematic areas. This paper adapts the language from a focus on migrant health to a focus on border health, thus the paper suggests monitoring border health (instead of monitoring migrant health); policy & legal frameworks; border region sensitive health systems; and partners, networks, and multi-country frameworks. The paper concludes with some recommendations as to how discussions in the meeting might be focused in addressing key priorities and actions for border health in the Greater Mekong Subregion.

2. Health - Framing Concepts and Definitions “In this contradictory world, borders create problems and borders are required to contain them (Anderson, 2001, p. 230).” Like borders all over the world, borders in the Greater Mekong Subregion have been flashpoints for tension (territorial dispute, ethnic and political conflict, unregulated movement of people and products, and transmission of disease) as they have been meeting points for economic and cultural exchange, and communication of cooperative ideas and aspirations. This section introduces some key concepts and definitions of borders, boundaries and border regions and then proceeds to a definition of border health as a distinct but overlapping concept with migrant health. 2.1. Borders, Boundaries, and Border Regions Terms for borders, boundaries, and frontiers exist in virtually all languages, though their connotations differ widely across cultures and over time (Anderson & Dowd, 1999). In a European context, Comelli, Greco, and Tocci (2006) write: “When the border is intended as an area of demarcation, separation or division, it has commonly been referred to by political geographers as a frontier or boundary. The border marks the line separating spaces of territorially defined sovereignty; it may act as a barrier to human, economic, cultural and social exchange and movement, or in the most dramatic instances, it can mark the interface of political or military confrontation. Alternatively, the border, when translated into terms such as borderland or border-region, acquires a diametrically opposite meaning. Far from being a line of division between the ‘inside’ and the ‘outside’, between the self and the other, the border becomes an area of exchange, interaction, and integration” (p.3). Anderson and O’Dowd (1999) note how borders and regions vary widely in terms of their history and geography though often are characterized by contradictions and ambiguity. Borders and border regions may be secure or insecure, open or closed, highly porous for certain things (such as capital flows), but relatively impervious to others (such as labor immigration or refugee movements). A proper understanding of borders and border regions, they suggest, requires concentration not only on regions and institutions within one state but in the bordering states as

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion well, with four dimensions being particularly important: relative economic wealth, political power, national loyalties, and cultural identities. “A border area’s comparative standing with regions and institutions in the neighboring state has a particularly crucial bearing on the nature and extent of its cross-border relations. They may have very similar or very different economies and levels of development. Degrees of cross-border difference, complementarity, or asymmetry—in terms of economic in/equality, political in/compatibility, and cultural and national identities—determine the potential for different types of cross-border relations that are affected, in turn, by the degree of ‘openness’ of the border concerned” (p. 597). Zúñiga (2012) defines border health as “a broad term that is characterized by the health care markets, regulatory environments, health laws, environmental factors, and health care consumer and individual behaviors (risk and protective) that shape the health of immigrant and other populations living in the region intersected by the geopolitical boundaries of two or more nations” (p. 1). She argues against the use of a strictly geographic definition of boundaries, which determine a border region generally and border health more specifically, and for the use of a more global conceptualization of border health, which may refer to population or environmental health in border counties or municipalities, border provinces, and even border countries: “Simple metrics of distance from the political boundary may not explain the influence on the health of populations near borders that can be exerted at state [or province], municipal, or national and international levels. The extent to which the health of border inhabitants and immigrants who cross borders is influenced by their proximity to a border region will depend on: regional, occupational, or environmental health risks or protective factors; the availability of and access to desirable health resources on either side of the border; the connectivity between the nations (e.g., roads, bridges, pedestrian crossing points); the regulation of a political border; how porous the region is to unregulated crossing; the ability to cross and costs that may be associated with crossing (e.g., visas); the perceived benefit of crossing or desire to cross among border inhabitants; and the physical distance of residents from the geopolitical border that can moderate cross-border care-seeking activities (e.g., distance lived from the border may be prohibitive to crossing for routine health care)” (Zúñiga, 2012, p.1). It is challenging to try to define a common, specific geographic unit within the Greater Mekong Subregion (GMS) in order to understand border health in this context. The U.S.-Mexico Border Health Commission (BHC, 2011) defined a border region (or border area; these terms will be used interchangeably in this paper) as 100 km north/south of the international boundary, a definition which has come to be accepted by the border health community on both sides of the boundary (Collins-Dogrul, 2013). Borrowing on Zuniga’s definition of border health, and as a first attempt to establish a common geographical unit, we define a border region for purposes of this concept paper as a first-level administrative division (generally a province) that includes a geopolitical boundary of two or more nations.

2.2 Migrant Health and Border Health In Zuniga’s (2012) definition of border health (see above), she describes the various factors (including markets, laws and regulations, environmental factors, and individual behaviors) “that shape the health of immigrant and other populations living in the region Session: 2, Border Health 3

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion [emphasis added] intersected by the geopolitical boundaries of two or more nations” (p. 2). “Border health,” thus can be distinguished from “migrant health” in its focus on “other populations living in the [border] region” on both sides of the boundary line(s), who are neither internal or external migrants. Border health thus encompasses migrant health but is a broader concept, including all non-migrant populations living in border regions (though generally not including migrants who move beyond these border regions). If border health is broader than migrant health, it might also be said that an understanding of migrant health is also moving toward a broader population-based, border region orientation. As several authors have noted (Waterman et al., 2009; Gushulak & MacPherson, 2006), the discussion of health activities at borders has moved away from a focus on the traditional roles of containing and controlling communicable disease (that is, stopping disease at the borderline, or boundary) to a focus on more strategic roles that include collaborative, cross-border and regional partnerships to not only prevent the spread of infectious disease but address non-infectious disease and health disparities (promoting health in border regions). Building on this approach, Gushulak, Weekers, and MacPherson (2009) observe that “many of the important public health aspects of migration originate from or are based on the diversity and disparity of the populations themselves and extend beyond the legal and temporal processes involved in changing one's residence. Addressing migration-associated health threats and risks will be more effectively accomplished if approached from this population-based framework, rather than from traditional disease or immigration status-based views” (p. 2). Kamel (2009) outlined seven current and continuing concerns of health and development in border areas: 1) The universal neglect and marginalization of border areas, border communities, and border crossers impact communities beyond the borders. “Border communities, regardless of their size, are often regarded by policy makers as peripheral in terms of social programs but paradoxically have high priority in terms of national security, a perception that leads to the marginalization of border residents’ concerns…. It makes greater sense strategically to have sparselypopulated border regions with poor infrastructure functioning as a barrier against external threats from the states across the borders. As a result of this neglect, inequitable access to resources prevails at the borders….Worldwide, there is a deficiency of basic information and statistics about health, environmental safety, and development at border communities, and health policies and public concern are often lacking or non-existent” (Kamel, 2009, p. 327). Borders are crucial entry points for communicable diseases, which, if not properly managed, would affect the country’s population significantly. “Communicable diseases, such as TB, AIDS, poliomyelitis, and malaria are among the most prevalent diseases at the borders. In many countries, depending on their border entrances, there are few or no restrictions upon entry in relation to health and immunizations” (Kamel, 2009, p. 327). While this seems to take more of a contain-and-control approach to infectious disease at borders, there certainly need for better surveillance of infectious disease in border regions and for promoting programs to treat and prevent infectious disease among border populations, including in the GMS.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 3) Border communities frequently suffer from lack of health care, minimal or nonexistent access to preventive health services, emergency health services, and health promotion. While much of Kamel’s (2009) analysis focuses on the U.S. Mexico border, many of his points—about the generally poor access to health care in border regions, the need for understanding the organization of health care services, and for improving communication between the health care providers on both sides of borders, and for establishing health care protocols and suitable health care financing mechanisms in border regions—have application to the GMS. Substance abuse, preventable injury, violence and behavioural health problems are prevalent at the borders. “Substance abuse is often higher at the borders due to lack of border control and high instances of smuggling, leading to greater availability of illicit drugs as well as discrimination and ethnic conflicts in border areas.” He emphasized “the importance of accurate tracking of data for behavioural health indicators such as alcohol and substance use/abuse as well as violence, to clarify the trends of border communities” (Kamel, 2009, p.329). An abundance of refugees and migrant workers cross borders due to political and ethnic conflicts and economic and natural disasters. “Economic disparity and natural disasters lead to wide-scale migration. Equally, ethnic conflicts and armed fights lead to a rush of refugees to the borders and to disruption of the limited local infrastructure” (Kamel, 2009, p. 331). In the last 40 years, the GMS has seen more than its share of refugees, migrant workers, and populations displaced by natural and human-made disasters, creating not only political tensions but strains on border health infrastructure. While regional political conflicts have receded, the frequency of natural disasters in the region has increased, as has the movement of migrant workers seeking greater opportunities in asymmetric regional economies. Borders are frequently threatened by environmental problems and occupational hazards. “High exposure to environmental hazards at the borders, including carcinogens, occurs via land through hazardous waste dumping, via water through illegal industrial wastes and inadequate sewage systems, and via air through poor regulations regarding equipment and commercial vehicles” (Kamel, 2009, p. 334-335). While environmental problems and occupational hazards in GMS border regions is not well researched, it is known that low income countries in Southeast Asia have nearly four times the number of deaths among males attributed to occupational injury risk than in middle- and high- income countries in the Americas (Findley & Gorski, 2005). It is also known that occupational injury risk generally is higher among migrant workers than among the native-born working-age population, and higher in the informal sector than the formal sector. Women, children and the elderly are more at risk, with less food security and more malnutrition at the borders. In general, and more so in low- and middleincome countries, women, children and older adults will face greater health risks, and border areas are likely to exacerbate these, given the compounding vulnerabilities of marginalized status, low income, limited access to quality health care services, and exposure to environmental and occupational hazards. The 5

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion burden of food insecurity and malnutrition likely varies from one border region to the next, and among population sub-groups, but cannot be discounted (Kamel, 2009, p. 336-337). In his article “Health dilemmas at the borders –A global challenge”, Kamel (1997) concludes by stating that the “universal neglect of border communities and associated borderrelated issues and problems is reflected in the lack of basic information and statistics about populations living in borderlands...This is a world health problem, and it calls for global action starting at the national and regional levels and leading to a global initiative…for health and development at border areas” (p.15). 3. Healthy Borders” Framework: Social Determinants of Health and Health -in-All-

Policies “Territorial borders both shape and are shaped by what they contain, and what crosses or is prevented from crossing them (Anderson & O’Dowd, 1999, p. 594).” In “Border Health”, Zúñiga (2012) also discusses how the inequalities in the distribution of historical, regional and societal factors influence the health of populations residing in border areas, especially those populations that migrate to and from the countries sharing the border. She then proposes that a socio-ecological perspective be used to develop a framework for characterizing and studying health outcomes in border regions. Such a framework would capture environmental factors (e.g., defining a border region, laws, policies, health service infrastructure), interpersonal factors (e.g., population mobility and disease exposures), and individual factors (e.g., health knowledge, perceptions, and practices) that impact the health of border residents (Zúñiga, 2012, p. 1). Without referencing the term “border health”, Zúñiga (2012) frames the concept within the “social determinants of health” (SDH) framework. Building on this work, this paper combines combines the SDH framework with the World Health Organization’s (WHO’s) “Health-in-All-Policies “ (HiAP) approach to describe the concept of “border health” and lay the foundation for the future development of a “healthy borders” framework. We propose that such a framework for understanding “border health” must address the factors that operate both inside and outside of the health system (i.e. immigration, labor, housing, social networks, etc.) that influence the physical, mental and social well-being in border regions.

3.1 Social Determinants of Health In 2003, the WHO published a report entitled the “Social Determinants of Health: The Solid Facts”, which reviews the evidence in support of a causal links between social and environmental factors and health outcomes and the implications for policy (Wilkinson & Marmot, Eds. The report notes: “Poor social and economic circumstances affect health throughout life. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Nor are the effects confined to the poor: the social gradient in health runs right across society, so that even among middle-class office workers, lower ranking staff suffer much more disease and earlier death than higher ranking staff. Both material and psychosocial causes contribute to these differences and their effects extend to most diseases and causes of death. Disadvantage has many forms and may Session: 2, Border Health 6

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion be absolute or relative. It can include having few family assets, having a poorer education during adolescence, having insecure employment, becoming stuck in a hazardous or dead-end job, living in poor housing, trying to bring up a family in difficult circumstances and living on an inadequate retirement pension. These disadvantages tend to concentrate among the same people, and their effects on health accumulate during life” (Wilkinson & Marmot (Eds.), 2003, p. 10). Many models show how these determinants are interlinked and how many lie beyond the direct influence of health care. One of the best-known models (See Figure 1 below) is Dahlgren and Whitehead’s (1991) multi-level ‘rainbow model’ of social determinants (also known as the “Policy Rainbow” or the “Social Model of Health”) (Stahl, Wismar, Ollila, Lahtinen, & Leppo, 2006).

Figure 1: Dahlgren & Whitehead's “Policy Rainbow” or Social Model of Health

The model highlights a relationship between individual lifestyle factors, social and community networks, and general socioeconomic, cultural and environmental factors, including agricultural and food production, education, work environment, living and working conditions, unemployment, water and sanitation, health care services, and housing. While the configuration of these different layers and factors can have both positive and protective influences on people’s lives, they can also undermine health and wellbeing, both for individuals and communities. Without mentioning border region populations per se, Dahlgren and Whitehead (1992) note that “groups at particular risk include people with low incomes or limited education, single-parent families, elderly people living alone or disabled people, the long-term unemployed, migrant workers and people in stressful or physically hazardous occupations…In some countries, black and minority ethnic groups are also at particular risk of poor living and working conditions, in addition to the racial discrimination that they face” (p.2). As is the case for many marginalized populations, the health of migrants is to a large extent determined by factors outside the health sector, such as educational attainment, employment status, and socioeconomic status. The World Health Assembly’s (WHA’s) 2008 Resolution on the “health of migrants” (WHA, 2008) recognizes “that health outcomes can be influenced by the multiple dimensions of migration” (p.1) and the need for WHO to “consider the Session: 2, Border Health 7

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion health needs of migrants in the framework of the broader agenda on migration and development” (p.1). Among other things, the framework outlined in the resolution called upon United Nations (UN) Member States to: o o o o o o o o o Promote migrant-sensitive health policies; Promote equitable access to health promotion and care for migrants; Assess and analyse trends in migrants’ health, disaggregating health information by relevant categories; Better identify the gaps in service delivery in order to improve the health of all populations, including migrants [emphasis added]; Gather, document, and share information and best practices for meeting migrants’ health needs in countries of origin or return, transit, and destination; Raise health service providers’ and professionals’ cultural and gender sensitivity to migrants’ health issues; Train health professionals to deal with the health issues associated with population movements; Promote bilateral and multilateral cooperation on migrants’ health among countries involved; and Promote strengthening of health systems in developing countries (WHA, 2008).

If one were to replace the term “migrant” with the term “border region populations” in the framework elements discussed above, the outline for a “healthy border” policy framework would begin to take shape. To develop such a framework, however, other sectors need to be incorporated.

3.2 “Health-in-All-Policies” Approach The term “Health-in-All Policies” (HiAP) was first used by the WHO in the 1990s and is defined as "an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequence of public policies on health systems, determinants of health, and well-being” (WHO, May 2013, p. 2). This approach has been adopted early on in Finland, whose 2010 Health Act states that “the promotion of well-being and health as well as the reduction of inequality will be taken into account in all societal decision-making and incorporated into the activities of all administrative sectors and ministries” (Leppo, Ollila, Pena, Wismar & Cook, 2013, p. 37). In Thailand, the Thai Health Promotion Foundation provides a governance structure for HiAP, including promoting the right of citizens to demand a health impact assessment when they have concerns about the health impacts of a government decision (Leppo et al., 2013). In the World Migration Report 2010, the International Organization for Migration (IOM) (IOM, 2011) identified a series of systemic gaps in fostering health provisions for migrants, including the need to mainstream migration health within governmental structures. Specific examples of capacity needs included:

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion o o o Establishment of Coordinating Units on Migration Health to facilitate coordination within government and between governments. Strengthened collaboration between the various stakeholders, including the private sector, migrant networks and NGOs. Policies for developing effective and sustainable means of meeting the health needs of migrants involves reviewing policies related to health, immigration, security, finance and labor. Strengthening health-care systems in border areas, which often exhibit weak health infrastructures, where counterfeit drugs are common, and a largely unregulated private sector often fills the service provision gap. Governments on both sides of borders need to work together in dealing with border area populations as a single health community. This will entail increased collaboration on surveillance of health and disease issues [Emphasis added].

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As a result of the 2008 WHA Resolution on “the health of migrants”, in 2010, a Global Consultation on Migrant Health was convened by WHO and IOM, in conjunction with the Ministry of Health and Social Policy of Spain. The resulting report, “Health of migrants – The way forward” (WHO, 2010) offers an outline for an operational framework to further action on migrant health, identifying key priorities and corresponding actions in four thematic areas: o Monitoring migrant health: ensure the standardization and comparability of data on migrant health; support the appropriate aggregation and assembling of migrant health information; map good practices in monitoring migrant health, policy models, health system models. Policy and legal frameworks: adopt relevant international standards on the protection of migrants and respect for rights to health in national law and practice; implement national health policies that promote equal access to health services for migrants; extend social protections in health and improve social security for all migrants. Migrant sensitive health systems: ensure that health services are delivered to migrants in a culturally and linguistically appropriate way; enhance the capacity of the health and relevant non-health workforce to address the health issues associated with migration; deliver migrant inclusive services in a comprehensive, coordinated, and financially sustainable fashion. Partnerships, networks & multi country frameworks: establish and support migration health dialogues and cooperation across sectors and among large cities and countries of origin, transit and destination; address migrant health matters in global and regional consultative migration, economic and development processes (e.g. Global Forum on Migration and Development)

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Building on a 2008 report “Closing the Gap in a Generation” (WHO-CSDH, 2008), the WHO adapted Dahlgren and Whitehead’s (1991) “social model of health” (discussed above) to create a model of the social determinants of migrant health (Figure 2 below). This model further demonstrates the relevance of the HiAP approach in addressing migrant health (WHO Regional Office for Europe, 2010).

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Figure 1: Policy Measures for Tackling SDH for Migrants and Ethnic Minorities This model (which was inspired by a presentation by Dr. Nani Nair, TB Regional Advisor, at a 2005 presentation at the WHO Regional Office for Southeast Asia) makes clear that policies need to go beyond improving health services to encompass actions addressing the social exclusion of migrants. The following are among the relevant policy measures to foster social inclusion for migrants: 1) Measures to combat discrimination against migrants and ethnic minorities include education of the public and effectively enforced legislation. Institutional discrimination should be combated by imposing statutory requirements on organizations to deal with all groups equitably. 2) Educational policies can pay special attention to the needs of migrant and ethnic children by, for example, facilitating their integration into mainstream schools and ensuring that selection policies make allowances for the extra time required for acculturation and language learning. Segregation, tracking and ability grouping can have particularly negative impacts on migrant and ethnic minority children. 3) Employment policies can be directed at the removal of barriers and systematic disadvantages for migrants and ethnic minorities in the labor market. 4) Social protection policies can ensure migrants and ethnic minorities do not fall into poverty, destitution and homelessness. 5) Housing and environmental policies (such as reduction of environmental health hazards, improved transport and other amenities) designed to improve the living conditions of migrants and ethnic minorities. 6) Health policies can ensure equitable access to appropriate services (including prevention and health promotion) for all groups. 7) Policies on naturalization, political participation, family reunification, etc. can reduce the gap between the rights of aliens and those of citizens. 8) Integration programs for new migrants can offer help with language-learning, orientation to the host country and access to education, health and social care services. Particular attention should be paid to the situation of refugees, who may spend years waiting for Session: 2, Border Health 10

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion their asylum claim to be processed. Limitations during this period on their opportunities to work, receive education (if over 18) and make contacts in the host country can seriously hamper their integration in the case that they are granted permission to remain (WHO Regional Office for Europe, 2010, p.13).

4. Border Health Models with Applications to the Greater Mekong Subregion “Diseases do not respect boundaries” (Kamel, 1997, p. 9) As noted previously, in the “Health of Migrants–The Way Forward”, the WHO (2010) identified key priorities and corresponding actions in four thematic areas. Adapting the language from a focus on “migrant health” to a focus on “border health” provides an approach for identifying priorities and actions for building border health models, drawing on international models and examples from the GMS: o Monitoring Border Health: ensure the standardization and comparability of data on health of populations living in border regions; support the appropriate aggregation and assembling of border health information; map good practices in monitoring border health, policy models, and health system models. o Policy & Legal Frameworks: adopt relevant international standards on the protection of migrants, ethnic minorities and other vulnerable populations in border regions and respect for rights to health in national law and practice; implement national health policies that promote equal access to health services for all border region populations; extend social protections in health and improve social security for all populations in border regions. o Border Region Sensitive Health Systems: ensure that health services are delivered to border region populations in a culturally and linguistically appropriate way; enhance the capacity of the health and relevant non-health workforce to address the health issues associated with living in border regions; deliver border region inclusive services in a comprehensive, coordinated, and financially sustainable fashion. o Partners, Networks, & Multi-Country Frameworks: establish and support border health dialogues and cooperation across sectors and among regions and countries that include border regions; address border health matters in global and regional consultative migration, economic, and development processes (WHO, 2010, p.4).

4.1 International Border Health Models In a publication on malaria control and prevention, Smith-Gueye, Teng, Kinyua, Wafula, Gosling, and McCoy (2012) offer several examples of multi-country initiatives aimed at prevention and controlling infectious disease, specifically across porous borders. They note that “Due to the combined effort of the Lubumbo Spatial Development Initiative (LSDI) of Mozambique, South Africa, and Swaziland, funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) malaria prevalence in targeted areas has been reduced by more than 90% (Sharp, et.al, 2007; Hlongwana et. al., 2009)). The Amazonian Malaria Initiative (AMI), funded by USAID, consisting of national ministries of health and technical partners of seven countries, is similarly on the path towards successful malaria eradication (Terrell & Brenner, n.d.). In the Middle East, Saudi Arabia, Kuwait, Oman, United Arab Emirates, Bahrain, and Qatar have combined efforts to donate $17 million (USD) towards malaria

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion elimination interventions along the Yemen border to support regional efforts for malaria control and elimination (Smith-Gueye et al., 2012). Despite progress, however, Smith-Gueye et al. (2012) note that a number of challenges remain, including “the relative neglect of cross-border and regional initiatives in malaria control and elimination. Border regions are often overlooked and hinder the goal of malaria elimination. Frequent human and vector border movements, a blurring of responsibility of individual countries in these regions, and relatively poorer access to health care and preventative measures, in particular for mobile populations, leave space for reservoirs of infection that can lead to continued low level transmission of malaria and vulnerability to malaria outbreaks and epidemics…. [C]ross-border population movement in the GMS of South East Asia impedes efforts to prevent the spread of drug-resistant malaria. An example of this challenge is in Yunnan Province of China, where, in 2009, 98.8% of total malaria cases and 75.0% of P. falciparum malaria cases were found to be imported from neighboring countries (Xu & Liu, 2011). Across the border in Myanmar there is poor access to malaria control interventions which is contributing to the continuing transmission in this area” (Smith-Gueye et al., 2012, p. 2). Zúñiga (2012) suggests that “the future of border health includes two important elements that will favor the health of populations living in border regions: better systems for electronic transmission of health information and movement toward regional cooperative health agreements” (p. 303). o E-Health. “Technological innovations and improved capacity to transmit and share health information electronically is a rapidly growing field. Although public health tends to fall behind in the adoption of new technologies, the ‘e­health’ movement is already being explored among border nations in the USA, Mexico, Asia, and the Pacific. Use of e-health in cross-border health care services can include referrals for care, continuing education for clinicians and other health practitioners, cross-border communication between health care providers, surveillance, medical records, and international travel for the sole purpose of seeking health care (i.e., medical tourism)” ( Zúñiga, 2012, p. 303304). Regional Health Agreements. “Cooperative cross­border or pan­border surveillance and health coordination initiatives are emerging from many regions throughout the world and will also favor the health of border-dwelling populations. The role of binational health organizations or organizations that represent public health interests from two or more countries can serve as a platform to bring together clinicians, researchers, and other public health practitioners to move border health agendas forward. Border health dialogue should include the representation of non-government agencies as well as government-sponsored agencies. Examples of cross-border coordination agencies and initiatives include the US--Mexico Border Health Commission; the US Center for Disease Control and Prevention's Early Warning Infectious Disease Surveillance Program; the Euro-Mediterranean consortium, Impact of Migration on HIV and TB Epidemiology in the Mediterranean Area; the 2010 border health plan implemented jointly by Bolivia, Chile and Peru; and European Commission collaboration among member nations to improve cross-border care. These activities will ultimately lead to improved regional surveillance data and to better management of infectious and chronic diseases in border regions throughout the world” (Zúñiga, 2012, p. 303-304).

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion In “Disease knows no borders: The emergence and institutionalization of public health transnationalism on the US-Mexico border”, Collins-Dogrul (2007) uses the US-Mexico Border Public Health Association and the Pan American Sanitary Bureau (PASB) as examples of what she calls “public health transnationalism,” that is, “transboundary epidemiological understanding combined with sustained cross-border professional and organizational ties” (p.1). The US Mexico Border Health Association she describes as a “transnational governance system” with the presidency alternating between the two countries. PASB functioned to broker “task-oriented cooperative networks” (Collins-Dogrul, 2007, p. 6), initially focusing on a cross-border venereal disease campaign but now with 28 country offices in the Western Hemisphere.

4.2 Border Health Examples in the GMS Below are several examples of border health initiatives from the Greater Mekong Subregion that offer models and approaches for consideration: Monitoring Border Health. o The Mekong Basin Disease Surveillance (MBDS) network was launched in 1999 with support from the Rockefeller Foundation and WHO and was formally established in 2001 through a Memorandum of Understanding signed by six Ministers of Health in the GMS. Main areas of focus for the MBDS network are 1) to improve cross-border infectious disease outbreak investigation and response by sharing surveillance data and best practices in disease recognition and reporting, and by jointly responding to outbreaks; 2) to develop expertise in epidemiological surveillance across the countries; and 3) to enhance communication between the countries (Phommasack, Jiraphongsa, Oo, Bond, Phaholyothin, Supanchaimat, Ungchusack, & MacFarlane, 2013; Bond, Macfarlane, Burke, Ungchusak, & Wibulpolprasert, 2013). Described as a “trust-based network” (Phommasack et al., 2013, p.1), MBDS comprises senior health officials, epidemiologists, health practitioners and other professionals from the six GMS countries. Its Phase 3 (2008-2011) included seven key strategies (and the country responsible): 1) Enhance cross-border communication and information exchange (Lao PDR) 2) Improve the human-animal sector interface and strengthen community surveillance (Vietnam) 3) Develop human resources and strengthen epidemiological capacity (Thailand) 4) Strengthen capacities for information and communications technologies (Cambodia) 5) Strengthen laboratory capacity (China) 6) Strengthen risk communications (Myanmar) 7) Conduct and apply policy research (collective) (Phommasack et al., 2013, p.5) Thailand’s Bureau of Vector-borne Diseases, has implemented an electronic Malaria Information System (eMIS) as part of a strategy to contain artemisinin-resistant malaria. The attempt corresponds to a WHO initiative, funded by the Bill & Melinda Gates Foundation, to contain anti-malarial drug resistance in Southeast Asia. The eMIS has been functioning since 2009 in seven Thailand-Cambodia border provinces. The eMIS has covered 61 malaria posts/clinics, 27 Vector-borne Disease Units covering 12,508 hamlets at risk of malaria infections. The eMIS was designed as an evidence-based and near real-time system to capture data for early case detection, intensive case 13

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion investigation, monitoring drug compliance and on/off-site tracking of malarial patients, as well as collecting data indicating potential drug resistance among patients (Khamsiriwatchara et. al., 2012). Policy & Legal Frameworks o APSED (Asia Pacific Strategy for Emerging Diseases) was launched in 2005 as a common strategic framework for countries and areas of the region to strengthen their capacity to manage and respond to emerging diseases including epidemic-prone diseases (WHO, 2011). In June 2007, the revised International Health Regulations (2005), known as IHR (2005), entered into force and called upon countries and WHO to strengthen their capacities to detect, report and respond to acute public health events in order to build a global public health defence system. APSED serves as a road map to guide all countries in the region towards meeting the IHR (2005) core capacity requirements, thus ensuring regional and global health security. The goal of APSED is to build sustainable national and regional capacities and partnerships to ensure public health security through preparedness planning, prevention, early detection and rapid response to emerging diseases and other public health emergencies. To achieve the goal, five interrelated objectives have been identified: 1) Reduce the risk of emerging diseases, 2) Strengthen early detection of outbreaks of emerging diseases and public health emergencies, 3) Strengthen rapid response to emerging diseases and public health emergencies, 4) Strengthen effective preparedness for emerging diseases and public health emergencies, 5) Build sustainable technical collaboration and partnership in the Asia Pacific region. To provide a focus for operational program work and to achieve the goal and objectives of the strategy, eight focus areas have been identified: 1) 2) 3) 4) 5) 6) 7) 8) surveillance, risk assessment and response; laboratories; zoonoses; infection prevention and control; risk communications; public health emergency preparedness; regional preparedness, alert and response; and monitoring and evaluation.

Border Region Sensitive Health Systems 1) Thailand’s Second Border Health Development Master Plan (BHDMP), 2012-2016, was developed by the Ministry of Public Health in collaboration with other line ministries, local administrative agencies, and international and non-governmental organizations. The objective of the plan is “to improve the health of people residing in border areas through the development of a quality health service system, improvement of access to primary care services, and encouraging the active and sustained participation of all relevant stakeholders” (Thai Ministry of Public Health, 2012, p.6). The plan covers “all subpopulation groups residing in the border areas…[including] Thais, ethnic minorities, registered and non-registered migrants, [and] displaced persons living in the temporary shelters” (Thai MoH, 2012, p. 6). The 2012-2016 BHDMP consists of four core strategies: Session: 2, Border Health 14

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

1) 2) 3) 4)

Developing a quality health system Promote access to primary health care services Strengthen collaboration and participation from all stakeholders and sectors Effective Management

Partners, Networks, & Multi-Country Frameworks o The Joint United Nations Initiative on Mobility and HIV/AIDS in South-East Asia (JUNIMA) is a partnership forum that works on universal access to HIV services to migrant and mobile populations. It was initially established as the UN Regional Task Force on Mobility and HIV Vulnerability Reduction in Southeast Asia and Southern of China in 1997. This task force has since expanded to cover all the remaining Southeast Asian countries. The partnership includes governments, UN and intergovernmental organizations, and NGOs and civil society. JUNIMA identifies priorities and gaps and facilitates programmatic, policy, and advocacy actions to reduce mobility-related HIV vulnerability and address issues of care and support throughout the migration cycle (Mosca, Rijks, & Schultz, 2013).

o The U.S. Government’s President’s Malaria Initiative (PMI) Operational Plan for the GMS was developed by representatives from U.S. Agency for International Development, the U.S. Centers for Disease Control and Prevention, and the national malaria control programs of Myanmar, Thailand, and Cambodia, with the participation of other major partners working on malaria in the area. The PMI GMS program includes support for regional/cross-cutting activities, such as surveillance for antimalarial drug resistance and antimalarial drug quality monitoring, but also focuses on activities to reduce malaria transmission in geographically-focused cross-border areas with emerging artemisinin resistance, as a means of reducing the burden of malaria and eliminating the resistant parasite from these high-risk areas. These cross-border focus areas will be centered in 2013 on the Tanintharyi-Ranong border areas of Myanmar and Thailand and the Trat-Pailin border areas of Thailand and Cambodia (USAID, 2013).

5. Conclusions and Recommendations “The challenges of promoting coordinated border health are many, and …political and social will to address these issues is critical” (Zúñiga, 2012, p. 4). Collins-Dogrul (2007) offered the examples of the US-Mexico Border Public Health Association and the Pan American Sanitary Bureau as, respectively, a “transnational governance system” and a “task-oriented cooperative network.” The Greater Mekong Subregion comprises six countries, not two, and is a more complex and diverse environment—politically, economically, and socially—than the US-Mexico border. That said, it still may be worthwhile considering how a transnational governance system and task-oriented networks might be brokered in the GMS in support of border health across the region.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion As has been noted in another background paper for the meeting (HEALTHY BORDERS: Improving coordination mechanisms for better collaboration across sectors and borders), the GMS region offers an array of coordination entities, though none with a health-specific mandate. The Association of Southeast Asian Nations (ASEAN) does have the ASEAN Highly Pathogenic Avian Influenza Task Force and participates in the Regional Forum on Environment and Health in Southeast and East Asian Countries. Within the context of this Regional Forum, ASEAN committed in April 2009—as part of the Chiang Mai Declaration on Health Impact Assessment for the Development of Healthy Societies in the Asia Pacific Region—to set up a working group on health impact assessment (HIA) with three main objectives: to establish a body of knowledge with ASEAN guidelines on mechanisms for HIA in the region; to share studies and technical documents on HIA; and to support capacity development on HIA. There is a recent and successful model of regional and bilateral cooperation to draw upon, namely the ASEAN response to Cyclone Nargis. On 2 May 2008, Cyclone Nargis made landfall in the Ayeyarwady Delta region of Myanmar; in the devastation that followed, an estimated 140,000 people died and 2.4 million people were severely affected (Belanger & Horsey, 2008). On 5 May, ASEAN Secretary-General Surin Pitsuwan called on all member states to offer immediate relief assistance through the framework of the ASEAN Agreement on Disaster Management and Emergency Response (AADMER). Following acceptance of this ASEAN-coordinated aid approach, the ASEAN Secretariat established a two-tiered structure: a diplomatic body, the ASEAN Humanitarian Task Force (AHTF), and a Yangon-based Tripartite Core Group (TCG), comprising ASEAN, the Myanmar government, and the United Nations. Following a visit to cyclone-affected areas, UN Emergency Relief Coordinator John Holmes offered that “Nargis showed us a new model of humanitarian partnership, adding the special position and capabilities of [ASEAN] to those of the United Nations in working effectively with the government.” He added that ASEAN leadership was “vital in building trust with the government and saving lives” (Creac’h & Fan, 2008:7; see also ASEAN, 2010). In terms of “task-oriented networks,” the Mekong Basin Disease Surveillance (MBDS) network offers a good example of not only a task-oriented but “trust-based network” (Phommasack et al., 2013, p.1) working to improve cross-border infectious disease outbreak investigation and response, to develop expertise in epidemiological surveillance across the countries, and to enhance communication among countries in the network. More broadly, a WHO model (presented above in Figure 2) on Policy Measures for Tackling Social Determinants of Health for Migrants and Ethnic Minorities makes clear that policies need to go beyond improving health services to encompass actions addressing the social exclusion of migrants. Their recommendations included: 1) Measures to combat discrimination against migrants and ethnic minorities including education of the public and effectively enforced legislation. 2) Educational policies that pay special attention to the needs of migrant and ethnic children by facilitating their integration into mainstream schools. 3) Employment policies directed at the removal of barriers and systematic disadvantages for migrants and ethnic minorities in the labor market. 4) Social protection policies that ensure migrants and ethnic minorities do not fall into poverty, destitution and homelessness.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 5) Housing and environmental policies (such as reduction of environmental health hazards, improved transport and other amenities) that are designed to improve the living conditions of migrants and ethnic minorities. 6) Health policies that ensure equitable access to appropriate services (including prevention and health promotion) for all groups. 7) Policies on naturalization, political participation, family reunification, etc. that reduce the gap between the rights of aliens and those of citizens. 8) Integration programs for new migrants (and refugees) that offer help with languagelearning, orientation to the host country and access to education, health and social care services. More broadly still, we suggest that a “healthy borders” framework should incorporate the full dimensions of a “social determinants of health” model. One such model that may be appropriate for the GMS, with modifications, is adapted from a “place-based” organizing framework developed by Healthy People 2020 (HHS, 2013), reflecting five key areas of SDH: (1) economic stability, (2) education, (3) social and community context, (4) health and health care, and (5) neighbourhood and built environment. To be more relevant to a “social determinants of border health” model, we have added Policy and Legal Frameworks on labor migration, refugees, and displacement as an additional “ring”; and have also added SDH specific to border regions within the five existing domains. The suggested additions to HHS’ place-based framework are in italics in Figure 3 below: 1) Economic Stability  Poverty  Employment status  Access to employment  Cross-border trade and development  Working conditions/workplace safety  Housing stability 2) Education  Access to education for migrants, refugees, displaced and/or stateless persons  School policies that support health promotion  School environments that are safe and conducive to learning  High school graduation rates  Enrolment in higher education 3) Social and Community Context  Family structure  Social cohesion  Perceptions of discrimination and equity  Civic participation 4) Health and Health Care  Access to health services, including clinical and preventive care  Access to primary care, including community-based health promotion and wellness programs  Appropriateness of health services for migrants, refugees, and displaced and/or stateless persons

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion   Availability of health information systems to assess and analyse trends in border health (including cross-border health) Health technology

5) Neighbourhood and Built Environment  Quality of housing  Crime and violence  Environmental conditions  Access to healthy foods/food security  Border security 6) Policy and Legal Frameworks  Pre-arrival screening, border screening, and communicable disease control policies  Immigration (including labor migration) and refugee laws and policies  Nationality laws and regulations, including vital registration systems  Border control, detention, and deportation laws and policies  Bilateral and multilateral cooperation mechanisms

Economic Stability/ Trade and Development

Policies & Legal Framework

Neighborhood & Built Environment

Social Determinants of Border Health Health & Health Care Education

Social & Community Context

Figure 3: Conceptual Framework for the SDBH [adapted from HHS’ Conceptual Framework for SDH] As noted at the outset, like borders all over the world, borders in the Greater Mekong Subregion have been flashpoints for tension (territorial dispute, ethnic and political conflict, unregulated movement of people and products, and transmission of disease) as they have been meeting points for economic and cultural exchange, and communication of cooperative ideas and aspirations. Border regions can be areas “of division and demarcation or alternatively of contact, exchange and integration” (Comelli et al., 2006, p. 3). Ultimately, whether borders Session: 2, Border Health 18

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion separate or connect has much to do with how border regions are governed and whether the affected states and populations perceive healthy borders as being of mutual interest for security, prosperity and public health.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

References:      Anderson, J. (2001). Towards a theory of borders: States, political economy, and democracy. Annales Ser. Hist. Sociol, (2)26, 219-232. Anderson, J, & O’Dowd, L. (1999). Borders, border regions and territoriality: Contradictory meanings, changing significance. Regional Studies, 33, 593-604. Association for Southeast Asian Nations (ASEAN) (2010). A Humanitarian Call: The ASEAN Response to Cyclone Nargis. Jakarta, Indonesia: The ASEAN Secretariat. Belanger J, Horsey R. (2008) Negotiating humanitarian access to cyclone-affected areas of Myanmar, Humanitarian Exchange 41:2-5. Bond KC, Macfarlane S, Burke C, Ungchusak K, & Wibulpolprasert S. (2013). The evolution and expansion of regional disease surveillance networks and their role in mitigating the threat of infectious disease outbreaks. Emerging Health Threats, 6. Carballo, M. (2006). The challenge of migration and health. World Hosp Health Serv, 42(4),18-9. Collins-Dogrul, J. (2013). Disease knows no borders: The emergence and institutionalization of public health transnationalism on the U.S–Mexico border. [published online ahead of print]. Journal of Borderlands Studies. Comelli M, Greco E, & Tocci N. (2006). From boundary to borderland: Transforming the meaning of borders in Europe through the ENP. (Working Paper). Retrieved from: http://www.eu-consent.net/library/brx061012/Comelli-Greco-Tocci_D40.pdf. Creac’h Y-K, Fan L. (2008) ASEAN’s role in the Cyclone Nargis response: implications, lessons and opportunities, Humanitarian Exchange 41:5-7. Dahlgren, G & Whitehead, M. (1991). Policies and strategies to promote social equity in health: background document to the WHO’s strategy paper for Europe. Dahlgren, G., & Whitehead, M. (1992). Policies and strategies to promote equity in health. World Health Organization (WHO) Regional Office for Europe. Enemark, C. (2013). Drug-resistant tuberculosis: Security, ethics and global health. Global Society, (ahead-of-print), 1-19. Greer, S. (2010). Global health policy: governing health systems across borders. In Healthcare Management, eds. Watshe, K & Smith, J. Gresham, L. S., Pray, L. A., Wibulpolprasert, S., & Trayner, B. (2011). Public--private partnerships in trust-based public health social networking: Connecting organizations for regional disease surveillance (CORDS). Journal of Commercial Biotechnology, 17(3), 241247. Gushulak B, & MacPherson D. (2004). Population mobility and health: an overview of the relationships between movement and population health. J Travel Med, 11:171-4. Gushulak, B., Weekers, J., & Macpherson, D. (2009). Migrants and emerging public health issues in a globalized world: Threats, risks and challenges, an evidence-based framework. Emerg Health Threats J, 2(10). Gushulak, D & MacPherson, D. (2006). The basic principles of migration health: population mobility and gaps in disease prevalence. Emerg Themes Epidemiol, 3:3.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Hlongwana KW, Mabaso MLH, Kunene S, Govender D, & Maharaj R. (2009). Community knowledge, attitudes and practices (KAP) on malariain Swaziland: A country earmarked for malaria elimination. Malar J, 8:29 The International Organization for Migration (IOM). (2010). World migration report. The future of migration: Building capacities for change. Retrieved from: http://publications.iom.int/bookstore/free/WMR_2010_ENGLISH.pdf. Kaewkungwal, J., Singhasivanon, P., Khamsiriwatchara, A., Sawang, S., Meankaew, P., & Wechsart, A. (2010). Application of smart phone in "better border healthcare program": A module for mother and child care. BMC Medical Informatics and Decision Making, 10, 69. Kamel, WW. (2009). Health in border areas. Global Perspectives in Health, 2. Khamsiriwatchara A, Sudathip P, Sawang S, Vijakadge S, Potithavoranan T, Sangvichean A, Satimai W, Delacollette C, Singhasivanon P, Lawpoolsri S, & Kaewkungwal J. (20120> Artemisinin resistance containment project in Thailand: Implementation of electronic-based malaria information system for early case detection and individual case management in provinces along the Thai-Cambodian border. Malaria Journal, 11:247. Kohlbry, P. (2011). Border health: Its hidden issues and implications for nursing care. Home Health Care Management & Practice, 23(3), 193-200. Leppo K, Ollila E, Pena S, Wismar M, & Cook S. (2013). Health in All Policies: Seizing opportunities, implementing policies. Ministry of Social Affairs and Health. May, M. (2007). Arabian Peninsula states launch plan to eradicate malaria. BMJ, 344:117. Mosca, D, Rijks, B, & Schultz, C. (May 2013). Health in the post-2015 development agenda: The importance of migrants’ health for sustainable and equitable development. Migration Policy Practice, 3(2). Phommasack B, Jiraphongsa C, Oo MK, Bond KC, Phaholyothin N, Supanchaimat R, Ungchusack, & McFarlane SB. (2013) Mekong Basin Disease Surveillance (MBDS): A TrustBased Network. Emerg Health Threats J., 6: 19944. Sharp BL, Kleinschmidt I, Streat E, Maharaj R, Barnes KI, Durrheim D, Ridl FC, Morris N, Seocharan I, Kunene S, La Grange JJP, Mthembu JD, Maartens F, Martin CL, Barreto. (2007). A: Seven years of regional malaria control collaboration - Mozambique, South Africa, and Swaziland. AmJTrop Med Hyg, 76:42. Smith-Gueye, C, Teng, A, Kinyua, K., Wafula, F., Gosling, R., & McCoy, D. (2012). Parasites and vectors carry no passport: How to fund cross-border and regional efforts to achieve malaria elimination. Malaria Journal, 11(1), 1-10. Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K, editors. (2006). Health in all policies: Prospects and potentials. Helsinki: Ministry of Health and Social Affairs. Terrell S & Brenner, P. (n.d). External evaluation of the Amazon malaria initiative and the South America infectious disease initiative. Thai Ministry of Public Health. (2012). Border health development master plan: 2012-2016. United States Agency for International Development (USAID). (2013). President’s malaria initiative: Greater mekong subregion: Malaria operational plan FY 2013 . United States-Mexico Border Heath Commission (BHC). (2011). 2011 annual report: Moving forward. Retrieved from: http://www.borderhealth.org/files/res_2376.pdf. Wilkinson, R & and Marmot, M. (2003). Social determinants of health: The solid facts. Second Edition. Geneva: World Health Organization (WHO).

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  The World Health Assembly (WHA). (2008). Sixty-first world health assembly resolution (WHA61.17 on the Health of Migrants). Retrieved from: http://www.who.int/gb/ebwha/pdf_files/A61_R17-en.pdf. The World Health Organization (WHO). (2013). Health in all policies. Retrieved from: http://www.healthpromotion2013.org/health-promotion/health-in-all-policies The World Health Organization (WHO) (2011). Asia Pacific Strategy for emerging diseases: 2010. The World Health Organization (WHO) Regional Office for Europe. (2010). How health systems can address health inequities linked to migration and ethnicity. Copenhagen: WHO Regional Office for Europe. The World Health Organization (WHO). (2010). Health of migrants–the way forward. Report of a global consultation. Geneva: WHO. The World Health Organization (WHO) Committee on the Social Determinants of Health (CSDH). (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the commission on social determinants of health . U.S. Department of Health and Human Services. (April 2013). Social determinants of health. Available at http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39. Zúñiga M. (2012). Border Health. In: Sajatovic M., Loue S. Encyclopaedia of Immigrant Health.

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SESSION

3 Session 3: Improving access to good quality medicines in Greater Mekong Sub region

I.

Background

During the last 20 years or so, there has been a tremendous progress in economic development in Greater Mekong Sub-region, which encompass Cambodia, Laos, Myanmar, Thailand, Viet Nam and Yunnan Province, People Republic of China. A report by the Asian Development Bank 1, indicates that the Greater Mekong countries have enjoyed a constant high economic growth with an average of 8 % per year. The gross domestic product (GDP) per capita in 1992, ranged from US $ 63 in Myanmar to US $ 1,894 in Thailand, but in 2011 the range was from US $ 832 in Myanmar to US $ 5,394 in Thailand. The high economic growth has also helped reduce poverty, where in 1992, all countries in the region except Thailand had poverty levels, close to or higher than 50 %, but by 2011, the poverty incidence had been dramatically reduced – from 45 % to 23 % in Cambodia, from 63 % to 13 % in China as a whole, from 56% to 34 % in Laos, from 9% to less than 1 % in Thailand, and from 64 % to 17 % in Viet Nam. These figures indicate that GMS countries are on the right track of the Millennium Development Goals (MDG) in reducing poverty. More economic integration, more transportation, more connectivity and more migration within and across the region, are anticipated in the future. The increasing economic integration with high economic growth, easier transportation across the borders, and greater connectivity among populations in the borders areas, may have direct or indirect impact on access to health services. Borders and remote areas have insufficient health facilities to meet the increasing demands from the migrating workers seeking for works across the borders. These populations become more vulnerable to different kinds of health problems, especially communicable diseases as they may not have sufficient access to health services. Medicines and vaccines are essential elements for health services. Problems of access to the needed medicines are recognized in remote and border areas. Lack of access to good quality medicines could lead population to purchase and to use sub-standard and often counterfeit medical products to treat their health. Weak regulatory enforcement in borders and remote areas, due to lack of human resource capacity and infrastructures, may jeopardize the assurance of medical products safety and quality, where unregistered and illegal products are often traded in the market. The distribution of sub-standard and often counterfeit medicines in remote and borders areas of Greater Mekong countries have been documented. If left alone,

Asian Development Bank. The Greater Mekong Sub Region at 20. Progress and Prospects. ADB, Manila, 2012.

1

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion this problem would have serious impact on the people health, jeopardizing the economic gain that countries have enjoyed over the years. There is an obvious need for Greater Mekong countries to address the challenges, ensuring access to good quality medicines and their rational use, and minimizing the production and distribution of sub-standard and counterfeit medicines. Addressing these challenges will certainly have positive impacts both for economy as well for people’s health.

II.

Access to health services and human rights.

Issues concerning the right to health of individuals have long been recognized by international communities and state parties, emphasizing the obligations of the national governments to provide the needed health services to their population. There are already important international agreements or treaty which most countries, including GMS countries, have endorsed. The Universal Declaration of Human Rights (1948)2 article 25 mentions that “ (1). Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right of security in the event of unemployment, sickness, disability, widowhood, old age or other lack livelihood in circumstances beyond his control, and (2). Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection”. The constitution of the World Health Organization (1946), says that “ The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic and social condition” ( 3). The right to health is also recognized in the important international treaty, the International Covenant on Economic, Social and Cultural Rights (1966), a binding treaty for States parties to provide legal obligations under the right to health (4). In this treaty, State parties “ recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The treaty also provides several steps to be taken by State parties to achieve the full realization of this right, including the right to maternal, child, and reproductive health; healthy natural and workplace environment; prevention, treatment and control of diseases; and the creation of conditions which would assure to all medical service and medical attention in the event of sickness. 2

Universal Declarations of Human (http://www.un.org/en/documents/udhr/) 3

Rights,

United

Nations,

1948 . 1946.

Constitution of the World Health (http://whqlibdoc.who.int/hist/official_records/constitution.pdf). 4

Organization,

International Covenant on Economic, Social and Cultural Rights. Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966 ( http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx )

Session: 2, Access to Medicines

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

In South East Asia, the Heads of State/Government of the Association of Southeast Asian Nations (ASEAN) declared the ASEAN Human Rights Declaration in November 2012 (5). Article 29.1. of this declaration mentions that “ Every person has the right to the enjoyment of the highest attainable standard of physical, mental and reproductive health, to basic and affordable health care services, and to have access to medical facilities “. The statement also implies migrant workers and other vulnerable groups as mentioned in the General Principle of the declaration. United Nations General Assembly, the Human Rights Council , recently (15 May 2013) issued a report concerning the right to health of migrant workers. The report mentions that “Ensuring the availability, accessibility, acceptability and quality of health facilities, goods, services on non-discriminatory basis, especially for vulnerable populations like migrant workers, is a core obligation under the right to health (6). Access to health services including access to essential medicines is part of human rights. It is timely that Governments, move away from discussing about principles, and start implementing their obligations, to provide access to good quality essential medicines. Providing access to good quality essential medicines in Greater Mekong Sub-region, is one essential element in meeting the right of people to health.

III.

Improving access to medicines for better health

Common causes of morbidity and mortality in low and middle income countries can actually be treated or prevented with simple essential medicines. If the needed essential medicines are made available in health facilities when they are needed, substantial reduction in mortality and morbidity could be achieved. WHO Commission on Macroeconomic and Health estimated, that globally 10.5 millions untimely deaths annually, could have been prevented, if effective scale up to make the needed essential medicines available and accessible (7). Although, there has been tremendous progress globally in improving access to medicines during the last few decades, a significant proportion of population in low and middle income countries still face problem of access to good quality essential medicines. Often the needed medicines are not available in health facilities when they are needed. If they are available, often the price is not affordable to most patients, or their quality cannot be assured. Essential medicines are those that satisfy the needs of the majority of people. They become a vital component of health intervention in many instances. They save life and improve health, but only when they are available, and of assured quality and properly used by the providers and consumers. However, the health system in many developing countries, for

5

ASEAN Human Rights Declaration (2012) ( http://www.asean.org/news/asean-statement-communiques/item/asean-human-rights-declaration ). 6

United Nations General Assembly, 2013. Human Rights Council. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Anand Grover. United Nations, A/HRC/23/41. 7

WHO Geneva, 2001. Macroeconomics and Health. Investing in Health for Economic Development. Session: 2, Access to Medicines 3

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion various reasons, often fail to deliver them to those in need, nor to ensure their quality and rational use. Based on the World Health Organization and Health Action International survey on availability of essential medicines, indicates that in the Western Pacific Region of WHO, the average availability of essential medicines in public facilities is 43.% and in private facilities is 50.1 % (8). If the needed medicines are not available in public facilities, patients have to buy them in private outlets where the price are not affordable to most of them and at much higher price than the international reference prices. In Viet Nam, for instance , public sector availability of selected 42 generic medicines was found only 33.6 % (9). Similarly in Laos, the average availability of 10 selected essential medicines was found to be 37 % ( 10). These figures suggest that the problems of access and availability of the needed essential medicines are also common in GMS countries, especially in remote and border areas where the health delivery system is limited. Even when essential medicines are available in health facilities, either public or private, their quality cannot always be assured. There are various studies reporting the high incidence of poor quality and counterfeit medicines for the treatment of diseases with high mortality like malaria and respiratory infections. ( see Production, Distribution of Counterfeit and Poor Quality Medicines). One cannot expect a positive outcome of treatment, for serious diseases like malaria, child respiratory infections and others, if the products are of poor quality, containing no or very less active ingredients. Improving access and availability of the needed medicines, ensuring their quality and promoting their proper usage by providers and consumers, will certainly contribute to improved health , reducing morbidity and mortality, in Greater Mekong countries.

IV.

Challenges on access to good quality medicines in GMS countries

IV.1. Production & distribution of counterfeit and poor quality medicines The presence of poor quality and counterfeit medicines in the market of Greater Mekong countries has long been detected. In 1999, the World Health Organization already published a report based on the survey in Myanmar and Vietnam, showing that eleven (11 %) out of collected samples failed laboratory quality testing, and sixteen (16) % were found to be counterfeit (11). The products surveyed were amoxicillin, ampicillin, chloramphenicol, 8

Cameron A, Ewen M, Ross-Degnan D, Ball D and Laing R. Medicines prices, availability, and affordability in 36 developing and middle income countries : a secondary analysis. Lancet, Vol. 373 : 240 – 249 (2009). 9

Anh NT, Knight R, Mant A, Quang MC and Auton M. Medicines prices, availability, and affordability in Viet Nam. Southern Med. Review, Vol 2 (2) : 2 – 9. 10

Syhakang L, Singaloundeth S, Paphassarang C, Freudenthal S and Wahlstrom. Availability of essential drugs and sustainability of village revolving funds in remote areas of Laos PDR. Studies in HSO & P, 23: 519 - 520, 2008. Accessed 2013). 11

Wondemagegnehu E. Counterfeit and Substandard in Myanmar and Viet Nam. A report of study carried out in cooperation with the Government of Myanmar and Viet Nam. Wolrd Health Organization, Depertment of Essential Drugs and Other Medicines. WHO/EDM/QSM/99.3.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion chloroquine, cotrimoxazole, diazepam, metronidazole, paracetamol, ranitidine, rifampicin, salbutamol and tetracyclin. More studies have then reported similar findings on anti-malarials medicines. In 2000 – 2001, 38 % of shop bought oral artesunate sampled in remote areas of Viet Nam, Cambodia, Laos, and Burma, did not contain the active ingredient ( 12 ). Similarly, in 2002-2003, 53 % of samples of artesunate containing anti-malarials drugs purchased from drug sellers, shops and pharmacies in western Thailand, Viet Nam, Cambodia, Laos, and Myanmar, did not contain any active ingredients (13). The issues of poor quality and counterfeit medicines in GMS countries have been well documented. The production, distribution and sales of poor quality medicines, like anti-malarials, especially in remote and borders areas of Mekong countries remains a serious threat in public health, posing big impediment to malaria control. Poor quality antimalarial drugs also lead to emergence of drug resistance and inadequate treatment, which pose serious threat to vulnerable populations and jeopardize progress and investments in combating malaria. The emergence of artemisin resistance or tolerance in Plasmodium falciparum in Cambodia, Myanmar, Thailand and Viet Nam, will have a global implication as artemisin based combination is currently the mainstay of anti malarial treatment (14). The loss of artemisin based medicines to full blown resistance could become a global disaster – undermining gains in malaria control, not only in the region but across all endemic countries. Thus, promoting access to good quality anti malarial medicines and other technologies in both public and private sector is essential in the fight against resistance (15). The problems of poor quality and counterfeit medicines are not confined only to antimalarials medicines, but also involve other medicines such as antibiotics, anti TB etc. Thus, progress of other vertical disease control program may also be in jeopardy. The impact on health system cannot be underestimated, eroding the confidence of the people on health system, and on the genuine products. Not least the economic impacts, where limited resources are wasted for purchasing poor quality and counterfeit medicines. Causes for poor quality or substandard and counterfeit medicines, can be different but both can bear similar health consequences, in which the expected outcome of the treatment cannot be expected. In some instances, the products may not be safe anymore for the general publics. Poor quality or sub-standard medicines are genuine drug products which do not meet

12

Newton PN, Dondorp A, Green M, Mayxay M and White NJ. Counterfeit artesunate antimalarials in Southeast Asia. The Lancet, vol 362 : 169, 2003. 13

Dondorp AM, Newton PN, Mayxay M, Van Damme W, Smithhuis FM, Yeung S, Petit A, Lynam AJ, Johnson A, Hien TT, McGready R, Farrar JJ, Looareesuwan S, Day NPJ, Green MD and White NJ. Fake antimalarials in Southeast Asia are major impediment to malaria control. Tropical Medicines and International Health, Vol 9 No 12 : 1241 – 1246 (2004). 14

World Health Organization. Containment of Malaria Multi Drug Resistance on the Cambodia Thailand Border. Report of an Informal Consultation, Phnom Penh, 29 – 30 January 2007. 15

Alphs S & Yadav P. Malaria in the Asia Pacific : Challenges and Opportunities for access to quality malaria medicines and other technologies. Malaria 2012. Saving Lives in the Asia Pasific.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion quality specification set for them , whereas counterfeit medicines are those fake products which are deliberately and fraudulently mislabeled with respect to identity and/or source (16). The underlying causes of poor quality and counterfeit medicines are complex , which may include several factors, such as poor compliance or capacity for good manufacturing practices (GMP), weak regulatory enforcement from production to distribution, weak quality surveillance, lack of awareness on the aspect of quality by consumers. Dealing with substandard medicines would require improved compliance and capacity to good manufacturing practices, whereas dealing with counterfeit medicines, it would require forensic investigation and legal action on the counterfeiter. Both would need strengthening of regulatory capacity and enforcement. Regulatory authorities of the GMS countries and partners organizations, have indeed undertaken several actions to cope with the issue of poor quality and counterfeit medicines in Mekong countries, such as survey/monitoring of sub- standard and counterfeit medicines, training on combating counterfeit medicines, sharing of information etc. In the GMS, the proliferation and distribution of counterfeit and poor quality medicines, is aggravated by limitation in the reach and scope of medicine regulatory authority, including pre- registration evaluation, inspection, quality surveillance, financial and human resources capacity and laboratory facilities. Despite various initiatives in recent years in combating poor quality and counterfeit medicines in GMS countries, there is still an obvious need to strengthen the medicines regulatory authorities capacities to implement medicines regulation in remote and border areas, and in sustaining cross border collaboration between regulatory authorities.

IV.2 Health system barrier for access to good quality essential medicines. Access to medicines is a complex matter, involving various factors and actors. The Western Pacific Region of the World Health Organization, in collaboration with Member States and partners has developed Regional Framework for Action On Access to Essential Medicines in the Western Pacific, 2011 – 2016, providing guides to Member States (17). It provides principles and recommended actions from national medicines policy, pricing, financing, procurement and supply system, intellectual property rights and international trade agreement, regulation and quality assurance, including sub-standard drugs and counterfeit medicines, and rational selection and rational use. From the health system perspective, barrier for access to good quality essential medicines, especially in remote and border areas of GMS countries, may be viewed from three different aspects, namely, the regulation and quality assurance system, supply and distribution systems, and the quality use system.

World Health Organization, Department of Essential Drugs and Other Medicines. Counterfeit Drugs. Guidelines for the development of measures to combat counterfeit drugs. WHO/EDM/QSM 99.1. World Health Organization. Western Pacific Region. Regional Framework for Action on Access to Essential Medicines in the Western Pacific. 2011. 17

16

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

IV.2.1. Medicines regulation and quality assurance In all GMS countries, there are already functioning medicines regulatory authorities mandated to ensure safety, quality and efficacy of medical products distributed in the market. However, the capacity to implement and to enforce regulation in the market, especially in remote and border areas, vary greatly from countries to countries. Except for Thailand and China, lack of human resource capacity is a serious problem for most regulatory authorities in GMS countries, leading to inefficient implementation of medicines regulation. All GMS countries have adopted GMP guidelines, either following ASEAN GMP or other guidelines. But compliance to GMP is variable depending on the existing capacities for GMP inspection and enforcement. For example, despite the fact that China and Viet Nam are the major source of raw artemisin in the world, only Guilin Pharmaceuticals in China which is WHO prequalified for artesunate. Thailand has implemented GMP for almost three decades, adopting WHO ‘ guidelines, and later the ASEAN's version of the guidelines. In 2003, GMP was enforced by law after 25 years of voluntary compliance in Thailand, and in 2007, 153 out of 163 of modern pharmaceutical manufacturers have complied with GMP (93.87%). Viet Nam has a clear plan to develop their medicines industry by 2020, and currently 101 of 180 of their manufacturers are GMP certified, and by 2014 all manufacturers should meet GMP requirements. Cambodia, Myanmar and Laos definitely need to strengthen their good manufacturing practices. The adoption of GMP does not automatically assure the quality of products in the market, if quality surveillance is not efficiently implemented. Quality surveillance system although in place in all countries, it may be implemented systematically only in one or two countries, like Thailand and China. Post marketing quality surveillance to monitor product quality in the market mostly is not done routinely. Furthermore, most of the samples are usually collected from the licensed outlets, and seldom collected from unlicensed outlets where unregistered products, and often counterfeit products are marketed. Lack of laboratory infrastructure is also a common problem for most GMS countries. In all countries, there is already a medicines registration system requiring that all medicinal products marketed in the countries are registered with the national medicines regulatory authorities. However, often un-registered products and counterfeit medicines are illegally distributed in the market through unlicensed pharmacy outlets. Unlicensed outlets in Cambodia used to be a major source of sub standard and counterfeit medicines. Although recently the governments in Cambodia and Laos, had closed down significant number of unlicensed outlets, more efforts are needed to control the distribution of unregistered products in the market. Often the list of registered products are not widely known by health workers and consumers. Consumers are usually not aware about the quality of the products. They need to be reminded about the issue of counterfeit and poor quality medicines. Public campaign on quality medicines are not done routinely. Mechanism for consumers to report about defects of their medicines is not in place.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Strengthening the medicines regulatory system, especially in improving human resource capacity in implementing the regulation from production to distribution, improving compliance to GMP, implementing medicines registration, quality surveillance, and controlling medicine market, especially in remote and border areas, is of utmost importance. The following actions and collaboration can be useful in dealing with poor quality and counterfeit medicines:     Exchange of information on the registration status of products marketed in the borders and remote areas; In country and inter-country training on GMP; In country and inter-country training on implementing and strengthening medicines regulatory system, and implementing regulation in remote and border areas. Quality monitoring of product need to cover products needed for the treatment of diseases with high fatality.

IV.2.2. Supply and distribution system In all GMS countries, there is already a national list of essential medicines. The list serves as basis for medicines selection and procurement, at least in public facilities. The use of the essential medicines list in private facilities may be less. The compliance on using the list for procurement may vary from country to country, often products that are not listed on the national list, are purchased by staff in health facilities and sold to patients. Public procurement system exist in different levels of health system in GMS countries. In Myanmar, for example, medicines are procured and distributed by the Central Medical Store of the Division of Medical Care MOH, and distributed to government facilities (referral hospital, district hospitals, township hospitals, station hospitals, rural health centers and sub centers). In Laos and Cambodia, procurement and distribution of medicines are taken care of at provincial and district level due to decentralization. In Viet Nam, public procurement can be done directly by hospitals and health facilities, but they must follow the guidelines from the Ministry of Health. Weak management system commonly occur in the public procurement and supply system. Quantification of needs is usually based on previous years consumption. Supply and distribution of medicines may be channeled from public system and private sector. Supply and distribution through public sector is often erratic due to low funding or inefficient management. Stock outs in public facilities are commonly encountered. Supply and distribution through private sector often end up in high prices which are not affordable to most patients. Difficult transportation to remote geographical location, is a real barrier for timely distribution of medicines, affecting the availability and accessibility of the needed medicines in GMS countries. Except in Cambodia, there is no monitoring & supervision support system on the availability and management of medicines in health facilities. Cambodia has implemented a comprehensive monitoring and supervision system for medicines management in health facilities for decades. The system provides signal to the higher level, if some medicines are out of stock in any facilities. Except in Thailand, most of the medicines have to be paid out of pocket by patients at the cost that are not affordable to most patients. Myanmar, Laos and Cambodia are countries with a massive out of pocket payment for health, where over 80 % of expenditures have to be Session: 2, Access to Medicines 8

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion borne by patients out of their pocket. A revolving drugs fund scheme is implemented in Laos covering rural health facilities. Out of pocket expenditure on health, which most of them is for medicines can be catastrophic for low income families, and can drive the families to poverty. Prices of medicines are usually not affordable to these poor families.

From the financing perspective, Thailand is the only GMS country which already achieved universal health coverage, with 97 % of their population covered by Universal Health Coverage Scheme in 2007 (18), so cost of basic health services including essential medicines and commodities is borne by the system. China is expanding its universal health coverage policy. Other GMS countries may share experiences from Thailand in expanding their financing coverage, especially to poor families, and those living in remote and border areas. Improving management of supply, distribution and use of medicines and other commodities, is timely for other GMS countries to pave the way to universal health financing coverage in the future. Common weakness in the supply of distribution of medicines include, therefore,    Inefficient medicines management at national or district levels, Lack of monitoring and supervision of medicines availability and management, in health facilities especially in remote places, High out of pocket payment by patients. Depending on the feasibility, it would be important to,  Strengthen the district level medicines management from quantification, procurement and distribution, which would provide back up support and supervision to public health facilities, especially in remote places, Monitor system for the availability of essential medicines in health facilities, especially medicines for important illnesses with high mortality like malaria, infections, maternal and child health etc. Exchange of information of product registration, quality and suppliers within and across countries.

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IV.2.3. Rational use of medicines Even if the needed medicines are available in health facilities, and of good quality, they will unlikely end up in good outcome if they are not used rationally. Rational use requires that patients receive medicines according to their clinical needs, in doses that meet their own individual requirements, for and adequate period of time, and at the lowest doses to them and their community (19). Irrational use of medicines are commonly encountered in health facilities jeopardizing the outcome of treatment and wasting the limited resources for health. WHO estimates that globally, half of all medicines are inappropriately prescribed, dispensed or sold, and that half of all patients fail to take their medicines correctly (20 ). Irrational use of antibiotics has become a 18

Bates C & Annear P. What other countries can learn from Thailand’s path to Universal health Coverage. Ausaid Knowledge Hub for Health, No 5, December 2012. 19 http://www.who.int/medicines/areas/rational_use/en/ 20 World Health Organization. World Medicines Situation. WHO/EDM/PAR/2004/5

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion common practice in many developing countries, where the prevalence of infectious diseases burden is aggravated by uncontrolled availability of antibiotics and in many communities, antibiotics are used without prescription. The overuse of antibiotics and high incidence of resistance has also been reported in remote areas of Viet Nam (21). In a recent WHO publication (22), based on country experiences, the use of essential medicines list as a basis for procurement and reimbursement, the compliant use of evidence based medicines guidelines by providers, improving patient adherence to treatment, and monitoring of medicines usage are important elements for promoting rational and responsible use of medicines As earlier mentioned, there is already a national essential medicines list in all GMS countries, serving as a basis for medicines selection that prescriber can use. There are also treatment guidelines, guiding the prescribers in using medicines in all GMS countries. Training, workshop on rational use of medicines for prescribers are often conducted in GMS countries. However, training or workshop rarely produce sustainable impact on medicines use. There is no system for monitoring and feedback of drug use in health facilities in GMS countries. However, as earlier mentioned, Cambodia has implemented an integrated monitoring and supervision of medicines management and usage in public health facilities. There are experiences from other countries, like Indonesia, Thailand, Srilangka, India that some forms of community education and empowerment on rational use of medicines, either using a small group interactive discussions or targeted intervention, can improve rational use of medicines and reducing over use of antibiotics in the community (23). An interesting initiative in Thailand, campaigning rational use of antibiotics for providers and consumers (see Good Practic ) has been implemented successfully.

V.

Case studies on good practice for access to good quality medicine.

The following case studies are only examples of initiative which have been undertaken in one or more GMS countries, alone or in collaboration. They are potentially replicated or expanded to address the challenges of access to good quality medicines in GMS countries, especially in borders and remote areas. The list does not exclude other good experiences somewhere.

21

Larsson M. Antibiotic Use and Resistance. Assessing and improving utilization of antibiotics and other drugs in Viet Nam. Karolinska Institutet, Stockholm 2003. http://openarchive.ki.se/xmlui/bitstream/handle/10616/38492/thesis.pdf?sequence=1 22

World Health Organization. The Pursuit of Responsible Use of Medicines : Sharing and Learning from Country Experiences. Technical report prepared for the Minister Summit on The Benefit of Responsible Use of Medicines : Setting policies for better and cost effective health care. WHO/EMP/MAR/2012.3. 23 World Health Organization, Southeast Asia Regional Office. Promoting rational use of Medicines. Report of an Inter-country Meeting, New Delhi, India 13 – 15 July 2010.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

1.

Monitoring and supervision of medicines management at health facilities ( 24)

Since 1995, Cambodia’s Essential Drugs Bureau has implemented an integrated and comprehensive drug management and drug use monitoring and supervision system nationwide to ensure the supply, availability and correct management of essential drugs in pharmacy stores of public health centers and hospitals. Indicators on drug supply management and use are collected regularly, results analyzed and feedback given to officials and implementers at national, provincial and district levels and to health facilities. The system track drug availability well and prove particularly successful in identifying problems in drug availability, drug prescribing and dispensing. Supervision and intervention strategies to improve drug use are incorporated into the monitoring activity. Any findings on unavailability of certain essential medicines can be properly responded with remedial action from the district and provincial levels. Evaluation shows that this system is useful in monitoring and improving supply and availability of medicines in health facilities.

2.

Medicines quality monitoring (25 )

Since 2003, Promoting the Quality of Medicines Program (PQM), United States Pharmacopeia, in collaboration with medicines regulatory authorities, vertical diseases program of GMS countries, has undertaken medicines quality monitoring in sentinel sites in GMS countries. The monitoring focuses on selected medicines such as anti malarials, anti TB, and antibiotics. The quality monitoring selects samples from sentinel sites, undertake quality testing using Minilab and confirmatory testing by reference laboratories. Through data sharing and support to regulatory authorities, national infectious diseases control programs, medicines quality control laboratories, and other official entities in GMS countries, the program has also strengthened capacity to address many of the issues and deficiencies in ensuring good quality medicines in the GMS countries. Data gathered since 2003 from over 40 sentinel sites has shown significant reduction in the circulation of poor quality medicines in the region, the failure rates decreased from an initial of 30 – 40 % to less than 10 %. This is potentially expanded to cover other medicines such medicines for non- communicable diseases. Strengthening the regulatory capacity and enforcement at local and national levels is essential in order to respond to the findings of poor quality or counterfeit medicines.

3.

Collaborative actions to eliminate counterfeit medicines

Under the auspices of WHO and INTERPOL, a multidisciplinary collaborative epidemiological and forensic investigations into the criminal fake artesunate in Mekong countries was undertaken, involving relevant experts from different backgrounds, namely police, criminal analysts, chemists, palynologists, and health workers to determine the characteristics 24 25

(http://www.inrud.org/ICIUM/ConferenceMaterials/997-or-_a.pdf

http://www.usp.org/sites/default/files/usp_pdf/EN/aroundTheWorld/PQM/pubs-success-se_asiapqm_in_greater_mekong_subregion_flyer-may_2012.pdf

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion and origin of counterfeit medicines (26). The study examined genuine and counterfeit samples of artesunate collected from Cambodia, Laos, Myanmar, Thai/Myanmar border and Viet Nam. The study showed the importance of cross disciplinary collaborations and the need of strengthening inter-agencies and inter-countries collaborations and strengthening forensic and medicines regulatory authority capacity. Subsequently, from 2008 and 2010, police, regulatory authorities, customs organization of the Mekong countries and South East Asia in collaboration with World Health Organization, World Custom Organization, and INTERPOL undertook Operation STORM, aimed to disrupt transnational criminal activities on producing and trading counterfeit medicines (27). Operation Storm is a multi-country operation combating counterfeit pharmaceuticals. In the run up to the operation, INTERPOL, together with the World Health Organization (WHO) and the World Customs Organization (WCO), coordinated planning meetings and organized training session. The overt phase of the operation took place between 15 April and 15 September 2008 (STORM I) and January 2010 (STORM II). Participating countries are Cambodia, China, Indonesia, Laos, Myanmar, Singapore, Thailand and Vietnam. Singapore’s Health Sciences Authority provided support in the laboratory analysis of the samples. The operations managed to seize huge number of counterfeit products including anti malarials, antibiotics, contraceptives, anti tetanus serum etc. Lessons learnt from this joint actions are the values of collaboration and coordination between regulatory authorities, customs organization and law enforcement agencies, and the importance of international collaborations in combating counterfeit medicines.

4.

Antibiotic Smart Use initiative (28) in Thailand

In the past five years Thailand has been at the forefront among developing countries in its active engagement to control antimicrobial resistance through the “Antibiotics Smart Use” program. The Antibiotics Smart Use (ASU) is a voluntary program deployed in selected provinces in Thailand between 2007 and 2012 to foster a more responsible use of antibiotics by directly engaging prescribers, dispensers and patients. Phase 1 of the project was intended as a pilot for the broader initiative and it was deployed in 2007‐08 showing encouraging results. Phase 2 was designed to be a scalability test of the Antibiotic Smart Use initiative, and it was deployed over 13 months (2008‐09) in three provinces and two hospital networks, ultimately involving 44 hospitals and 627 primary health centres. Phase 3, currently ongoing, is intended to achieve sustainability for the Antibiotics Smart Use program by stimulating policy advocacy, resource mobilization and public education throughout. 26

Newton PN, Fernandez FM, Placone A, Mildenhall DC, Green MD, Ziyong L, Christophel EM, Phanouvong S, Howels S, McIntosh E, Laurin P. Blum N, Hampton CY, Faure K, Nyadong L, Ray Soong CW, Santoso B, Zhiguang W, Newton J and Palmer K. A Collaborative Epidemiological Investigation into the Criminal fake Artesunate Trade in South East Asia. PLoS Medicine, 5 (2) : 0209 – 0219 (2008). 27 http://www.interpol.int/Crime-areas/Pharmaceutical-crime/Operations/Operation-Storm 28

World Health Organization. The Pursuit of Responsible Use of Medicines : Sharing and Learning from Country Experiences. Technical report prepared for the Minister Summit on The Benefit of Responsible Use of Medicines : Setting policies for better and cost effective health care. WHO/EMP/MAR/2012.3.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The guiding principle of ASU is that antibiotics should not be used to treat non bacterial infections. This notion derives from a fundamental of rational use of medicines that these should be used appropriately in accordance with clinical needs. ASU started by attempting to reduce unnecessary use of antibiotics in patients with three conditions : upper respiratory tract infections, especially common cold with sore throat, acute diarrhea and simple wounds. In Phase 1, the overall amount of antibiotics prescribed in the community hospitals targeted by the initiative declined between 18% and 23%, while the decline in primary health centres declined even further between 39% and 46%. The outcome of phase 2 confirmed the outstanding results of the pilot phase of the program, and phase 3 is currently underway to ensure the benefits of the Antibiotic Smart Use program are maintained. The National Health Security Office (NHSO) has adopted ASU as a key indicator for quality service in reimbursing community hospitals.

VI.

Proposed actions

The following proposed actions are intended to address the challenges of access to good quality essential medicines, especially in border and remote areas of Greater Mekong Sub region. The actions may be divided into i country actions and inter-country collaborative actions. In country actions, include the followings,

1.

Creation of monitoring mechanism for the availability & use of medicines in health facilities.

The objectives of the proposed monitoring mechanism are to monitor (1) the availability of selected essential medicines for treating common illnesses in health facilities, (2) the regulatory status of the medicinal products in private facilities, and (3) the use of selected essential medicines/antibiotics for treating common illnesses. Monitoring can be done regularly, depending on its feasibility, every 2 – 6 months. Data can be collected at public health facilities and/or in private pharmacies, and being sent to district levels for analysis and feed back. For urgent situation concerning stocks out, suspicion of counterfeit products, report can be sent to district level for back up support and resupply. District levels can submit report to higher levels at provincial or national levels for cases which cannot be dealt with at district level. Collection of data and submission of report do not have to be done through on site visit. Other ways of communication utilizing information technologies can be explored.

2.

Strengthening district level management

Strengthening district level medicines management and regulation is extremely important in providing back up support for health facilities where there are problems concerning availability, quality and use of medicines. Session: 2, Access to Medicines 13

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The objectives of strengthening district level management are, (1) to improve capacity in managing medicines supply and distribution, (2) to improve capacity in implementing medicine regulation & inspection , and (3) to improve capacity in promoting rational use of medicines, (4) to improve capacity in providing back up support and supervision to health facilities when there are problems concerning availability (supply) , quality (registration and quality assurance) and use of medicines.

3.

Promoting rational use of medicines/antibiotics for providers and consumers.

Focused and targeted campaign on improving rational use of medicines by providers and consumers is essential for improving quality of care, for minimizing waste of cost and therefore, for enhancing access to good quality care. The campaign should be targeted to health care providers, medicines dispensers/sellers and consumers and focused on some priority conditions (eg. respiratory infections, diarrhoeas, malaria etc) as well as products (antibotics, anti malarials, etc). Inter country actions and collaborations, include the followings Information exchange mechanism between GMS countries is important as various medicinal products and commodities are traded across the borders. Assurance of products safety, quality and efficacy, should be in place. The information exchange mechanism should allow the exchange on products registration status and/or the supplier qualification status, in any circumstances when it becomes necessary to do so. Inter country collaborations in strengthening in strengthening medicines regulatory authorities, through networking, human resource training, or information system support.

Executive Summary  Problems of access to health services, including to good quality medicines in Greater Mekong Sub Region, if left alone, could have serious impact on the people health, jeopardizing the economic gain that GMS countries have enjoyed over the years. There is an obvious need for GMS Mekong countries to address the challenges, and to ensure access to good quality medicines and their rational use, and minimizing the production and distribution of poor quality and counterfeit medicines. Addressing these challenges will certainly have positive impacts both for economy as well for people’s health. Access to health services including access to essential medicines is part of human rights. It is timely that governments, move away from discussing about principles, and start implementing their obligations. Providing access to good quality essential medicines in Greater Mekong Sub-region, is an essential element in meeting the right of people to health.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Improving access and availability of the needed medicines, ensuring their quality and promoting their proper usage by providers and consumers, will contribute to improved health , reducing morbidity and mortality. Despite various initiatives in recent years in combating poor quality and counterfeit medicines in GMS countries, there is still an obvious need in strengthening medicines regulatory authorities capacities to implement medicines regulation in remote and border areas, and in sustaining cross border collaboration. Strengthening the medicines regulatory system, especially in improving human resource capacity in implementing the regulation from production to distribution, improving compliance to GMP, implementing medicines registration, quality surveillance, and controlling medicine market, especially in remote and border areas, is of utmost importance. Proposed in country actions, include creation of a monitoring mechanism on the availability and use of medicines in health facilities, strengthening district level management which can provide back up support and supervision to health facilities, and promoting rational use of medicines/antibiotics for providers and consumers. Proposed inter country actions, include information exchange mechanism on products registration status and/or the supplier qualification status, and inter country collaborations in strengthening medicines regulatory authorities, through networking, human resource training, or information system support.

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SESSION

4 Session 4: Health Impact Assessment and Socially Responsible Infrastructure Development

HIA and Socially Responsible Infrastructure Page I. A. II. A. B. C. III. A. B. C. INTRODUCTION ........................................................................................................ 3 Background 3

SOCIALLY RESPONSIBLE INVESTMENT ........................................................... 3 Infrastructure and Development in Asia Health Implications of Infrastructure Socially Responsible Investment and Rationale for HIA 3 4 5

HEALTH IMPACT ASSESSMENT METHODS ....................................................... 6 The Scope of Health Impact Assessment (HIA) HIA and Other Impact Assessments Basic Models of HIA 1. Safeguarding 2. Economic Analysis of Health Impacts 3. Other Approaches to HIA. 6 6 7 7 8 9

IV. A.

HEALTH IMPACT ASSESSMENT PRACTICES .................................................. 11 HIA in Development Institutions 1. International Finance Corporation 2. International Petroleum Industry Environmental Conservation Association 11 12 12

3. International Council of Mining and Minerals 4. World Bank 5. European Investment Bank 6. PREVENT Program

13 13 13 14

7. Asian Development Bank B. HIA in South East Asia 1. Cambodia 2. Laos 3. Thailand

14 17 17 17 17

4. Vietnam 5. Malaysia 6. Philippines V.

18 18 18

FINDINGS AND RECOMMENDATIONS .............................................................. 19 1. Limited Awareness of Health Implications from Infrastructure Development 2. Identify Priority Sectors 3. Better Health Indicators 4. Guidance on Using HIA 5. Capacity Development 6. Improved Monitoring and Evaluation. 7. Studies and Advocacy 19 19 19 20 20 21 21

VI.

REFERENCES ..................................................................................................... 22

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

I. A.

INTRODUCTION Background

Governments, private sector, and partners recognize the need for greater emphasis on health impact of development plans, programs and projects in other sectors including agriculture, education, power, transport, and water and sanitation. Health impact of plans, programs and projects can be assessed in terms of both positive and negative effects of investments, and changes can be made to enhance positive health impact and mitigate negative health impact. Health Impact Assessment (HIA) refers to a suite of methods ranging from participatory planning to economic analysis to evaluate the health impacts of policies, plans and projects. The approach aims to enhance the use of data and participatory approaches to improve quality and transparency of decision making for investment. HIA is not only to benefit health, but can help governments, private corporations and partners reaching other goals as well. Yet adoption of the approach is not widespread across the region. The report recommends adoption of HIA as part of the operating principles of socially responsible infrastructure. Many of the required actions to mitigate negative health impact or enhance positive impact require engagement of other sectors. The World Conference on Social Determinants of Health in 2011 recognized that addressing health in other public policies would be crucial to the achievement of successful health outcomes and supported the 2009 WHA resolution endorsing a "health in all policies" approach. To achieve concrete health outcomes, multiple stakeholders from non-health fields must be engaged in order to systematically incorporate health issues into the myriad of relevant national security, labour, migration, and economic development policies.

II. A.

SOCIALLY RESPONSIBLE INVESTMENT Infrastructure and Development in Asia

The Asia Pacific region has been growing rapidly, at an average of 6% in the last 20 years. Infrastructure development (roads, power, telecom) has been at the heart of this success, combined with trade liberalization and capacity building. Rural unemployment and opportunities in industry and services have led to a major rural urban migration. Per capita income has increased sharply, and poverty and infant mortality have reduced by about half. Despite this growth, some 0.8 billion Asians lack electricity, 0.6 billion cannot source safe water and 1.9 billion1 are thought to be without access to basic sanitation. Financing new infrastructure and replacing existing capacity is a substantial challenge, with ADB calculating that to simply maintain current growth rates between 2010–2020 requires an investment of $8.22 trillion2 in the region. Around half of this expenditure would be required for energy infrastructure,

1

ADB. 2008. Strategy 2020: The Long-Term Strategic Framework of the Asia Development Bank, 2008 –2020. ADB. Manila 2008 real terms

2

3 Session 4: Health Impact Assessment and Socially Responsible Infrastructure Development

a third for transport, and the balance in key sectors such as water and sanitation and communications.3 Infrastructure development on this scale has both positive and negative health implications. Much of the development in the region has benefitted health, and improved health has also benefitted productivity and poverty reduction. HIA is perceived as a process to prevent irreversible damage to population health. Given the potential for infrastructure to also generate health benefits, the use of HIA as a tool to maximise social wellbeing also needs to be explored.

B.

Health Implications of Infrastructure

Examples of negative and positive health impacts for different types of infrastructure are included in Table 1. For example, the connection of a house to electricity as a result of a power plant development project may reduce reliance on the indoor burning of biomass for cooking and heating. The consequent reduction in smoke could reduce the incidence of respiratory problems such as coughing and eye irritation – resulting in considerable positive health benefits. In the case of households surrounding the power plant, emissions may result in increased particulate matter, SO2, and nitrogen oxides inflicting negative health benefits. Table 1: Examples of Positive or Negative Health Impact by Infrastructure Type Infrastructure Potential Type Impact Agriculture Roads or Actual Positive Potential or Actual Negative Impact

Ports

Hydropower

Increased food production and improved nutrition Accident rates may decrease and improved access to health facilities may reduce case fatalities Reduced occupational accidents compared with using facilities with limited capacity and out-of-date equipment Stable power supply leads to improved temperature control of housing reducing incidence of respiratory diseases.

Creation of dams may increase refuges for disease vector breeding Vehicle emissions are carcinogenic. Increased traffic may increase dust and noise pollution Workers and followers during construction can introduce HIV, STIs, or TB

Coal fired plants

Water supply

Less physical exercise in fuel collection may elevate cardiovascular, diabetes and other NCD prevalence. Dam development may displace agricultural communities reducing food supply. Connection to electricity reduces Air pollution from power generation results reliance on indoor burning of in particulates, SO2, nitrogen oxides for biomass, leading to less communities near to power stations respiratory and eye irritation issues. Biomass may also produce carcinogens Improved sanitation – through Dams, irrigation channels, and water latrine construction and personal courses may provide increased breeding hygiene; changes reduce potential sites of disease vectors. Contamination of

3

ADBI. 2009. Infrastructure for a Seamless Asia. Tokyo. Asian Development Bank Institute

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion for water-borne diseases through water sources with lead, arsenic, and oral-faecal path fluoride Improved sanitation in schools Education may lead to changes in diet or reduces water borne disease cultural practices adversely impacting incidence. health.

Education

The World Health Organisation (2011) 4 reported that nearly 1.3 million people die each year as a result of road accidents and traffic accidents have become the leading cause of death for people aged 15–29 years5. Most pertinent for development - is that 90% of the burden of traffic accidents occurs in low-income and middle-income countries. WHO (2011) estimated that, without action, road accidents will cause the deaths of approximately 1.9 million people annually by 2020. The development of new roads, coupled with road safety, can lead to substantial positive health benefits through reduced accident rates. New roads could also improve access to basic health services, increasing utilisation and decreasing case fatalities for a range of diseases. On the other hand, increased traffic can lead to elevated dust pollution and noise disturbance, creating negative health impacts.

C.

Socially Responsible Investment and Rationale for HIA

A key objective underpinning the notion of socially responsible infrastructure is that of minimising the negative affects developments have on local communities and their work forces. This theme is found in the Equator Principles (EPs), which are derived from the environmental and social performance standards of the International Finance Corporation (IFC). These standards ensure major projects are socially responsible and encompass acceptable environmental management practices. EPs6 have been adopted by 79 financial institutions in 35 countries as a framework for assessing and managing environmental and social risks. Examples of socially responsible infrastructure in this context were identified in this review of infrastructure projects at ADB. They mostly relate to energy projects in the Mekong where dams have resulted in the resettlement of large populations. For example, the HIA of the Nam Theun 2 hydroelectric project in Laos involved an assessment of health risks for 11 health areas covering respiratory diseases, vectored diseases, STIs, soil and water borne disease, accidents, food and nutrition, exposure to hazardous materials, health services, social determinants and cultural practices 7, for 10 potential impact areas of concern over the various phases of infrastructure development. Public health plans were developed to mitigate risks for each of the impact areas. Interventions included provision of health infrastructure, human resource development, health education, service delivery and surveillance and monitoring. A review of implementation during construction in mid 2007 found achievements of the plans to have been

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WHO. 2011. Decade of Action for Road Safety 2011–2020 Saving millions of lives http://www.who.int/gho/road_safety/en/index.html www.equator-principles.com 2008. Kreiger et al ‘Nam Theun 2 hydroelectric project, Lao PDR ‘ in Health Impact Assessment for Sustainable Water Management. Fewtrell L and Kay D (Ed.). IWA Publishing, London, UK

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substantial. Achievements include improved nutritional status of children, reduced infant mortality, improved utilization of health services and reduced parasitic infestation. The Chiang Mai Declaration8 on HIA highlighted the role of the EPs in promoting HIA in Asia, but also noted that ‘all government agencies have a major responsibility in enhancing good health.. [and] ..any policy and program must take health issues into account by conducting HIA’. This declaration implies that HIA needs to go further than merely safeguarding. Developing methods for enhancing health benefits, rather than simply protecting against environmental and social risks are required. Prior to discussing the potential for expanding HIA to meet this objective, an overview of HIA practices and their use in major development institutions and GMS countries is provided.

III. A.

HEALTH IMPACT ASSESSMENT METHODS The Scope of Health Impact Assessment (HIA)

Health Impact Assessment (HIA) is broadly defined as ‘a combination of procedures or methods by which a policy, program or project may be judged as to the effects it may have on the health of a population’9. It involves a range of methodologies from safeguarding as part of environmental and social impact assessments, participatory approaches, or cost benefit analysis.

B.

HIA and Other Impact Assessments

HIA is one approach in the wide field of impact assessment (IA). IA seeks to identify the potential consequences of proposed activities, as opposed to the situation if they did not go ahead. The most developed impact assessment approach is that of environmental impact assessment (EIA) which emerged from the environmental movement in the 1960s. Some EIAs only investigate environmental considerations while others include the social10 and health impacts of development proposals. Within EIAs, health is often assessed in relation to changes in water, soil and air quality. There are advantages of integration due to less duplication of effort and less time needed to complete the overall assessment. Integrating approaches reduce the likelihood of “impact assessment fatigue”11. The downside of integration is that the various dimensions of health may not be provided adequate attention during consultation and risk assessment. WHO defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’12 The Gothenburg HIA framework established in 1999 highlighted that in addition to health considerations, four values would be emphasised in

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2008 Asia and Pacific Regional Health Impact Assessment Conference, 24 April 2009, Chiang Mai, Thailand European Centre for Health Policy. 1999. Health impact assessment: Main concepts and suggested approach. The Gothenburg Consensus Paper, December 1999. WHO Regional Office for Europe Social impact assessments (SIA) examine the social consequences of planned developments on issues such as demographics, gender, ethnicity, local employment and business opportunities, lifestyle, behaviors, social infrastructure and governance mechanisms Integrated Impact Assessment (IIA). Association of Public Health Observatories, 2007. International Health Conference, New York, 19-22 June, 1946

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion HIA, being democracy, equity, sustainable development, and ethical use of evidence13. Various HIA models have emerged to meet integrated assessment, advocacy and equity demands.

C.

Basic Models of HIA

Most HIA in developing countries is conducted as part of integrated assessments to meet regulatory or statutory requirements. This ‘safeguarding’ type of approach is most often observed as part of industry-funded major project assessments14 and the International Finance Corporations guidance on HIA15. Economic analysis of health impacts is also undertaken by development banks to justify and advocate for investment in infrastructure that improves health outcomes. Three other approaches to HIA are outlined in this section using the typology provided by Harris and colleagues. 16 They include decision support, advocacy and community-based approaches.

1.

Safeguarding a. Comprehensive

A comprehensive ‘safeguarding’ HIA includes collection of new data, literature searches and interviews with stakeholders using focus groups and surveys. Baseline social and health characteristics of affected populations are gathered to determine potential health impacts. Quantitative models could also be developed to estimate the health impacts of the project. A comprehensive approach is generally pursued for large projects, particularly if resettlement or an influx of people to the development is anticipated. Comprehensive studies may take up to 4 months and involve a number of specialists and survey enumerators. Comprehensive studies have been supported by ADB for a number of hydro-electricity projects in the GMS. The Nam Theun 2 Hydropower Project in Lao commenced operation in March 2010 and was subject to EIA, SIA and HIA.

b.

Rapid Assessment

Rapid ‘safeguarding’ assessments17 comprise literature review and a broad assessment of health impacts. They are less labour intensive, typically taking an analyst 2-3 weeks and do not entail in-country consultation. The outcome of the desktop HIA may be the definition of scope

13

WHO Regional Office for Europe, European Centre for Health Policy. Health impact assessment: main concepts and suggested approach. December, 1999. IPIECA. A guide to health impact assessments in the oil and gas industry. London: International Petroleum Industry Environmental Conservation Association; 2005 IFC. Introduction to health impact assessment. Washington DC: International Finance Corporation; 2009 Taken from Harris-Roxas B, Harris E, Differing forms, differing purposes: A typology of health impact assessment, Environ Impact Asses Rev (2010) Taken from IFC 2009

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for the HIA, or whether further assessment of health impacts is required. Rapid assessments are appropriate where considerable primary data is available and in situations where project impacts are thought to be limited.

c.

Depth of Analysis and Cost

IFC18 note there are no definitive guidelines to prescribe whether a project needs a comprehensive or rapid HIA. Most HIAs fall between rapid and comprehensive classifications, involving desk top analysis, literature review and limited community consultation.

2.

Economic Analysis of Health Impacts

Economic analysis of health impacts at a development institution – such as ADB- typically begins at the early stage of project development. In general, the purpose of economic analysis of health benefits is to justify investment and ensure the distribution of project benefits and costs are in line with project objectives. Most economic analyses of health impacts at ADB have utilised cost-effectiveness analysis.

a.

Cost-effectiveness analysis

The first step of economic analysis involves a comparison of costs in relation to health impacts from different project alternatives. Following the World Bank burden of diseases study in 1993, disability adjusted life years19 have been commonly used by health economists as the metric for measuring health outcomes. Using this approach the projected costs of a project a divided by the number of disability adjusted life years avoided to determine the cost effectiveness of a project. If the cost per DALY avoided is less than GDP per capita in the implementing country, the project is deemed to be cost-effective. Estimating lives saved and DALYs avoided requires extensive pre and post implementation burden of disease data.

b.

Cost-benefit Analysis

Cost-benefit analysis of health impacts generally requires health outcomes be valued in economic terms. There are various possible approaches including willingness to pay for different health states using contingent valuation approaches and the ‘human capital approach’ to valuing labor productivity. The main component of the human capital approach is the discounted present value of future income forgone due to premature death or morbidity. Avoided medical and administrative costs also need to be added.

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IFC. Introduction to health impact assessment. Washington DC: International Finance Corporation; 2009 The disability-adjusted life year (DALY) measures the number of years lost due to early mortality, or years lived with a disability. See World Bank. 1993. World Development Report: Investing in Health. Washington.

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3.

Other Approaches to HIA.

Harris-Roxas 20 and colleagues categorise HIA into mandated (safeguarding), decision support, advocacy and community led approaches. Decision support HIAs have been developed to assess policies and programs, rather than projects, with more consideration of the social dimensions of health. Organisational learning processes are given greater consideration in this type of HIA, when compared to mandated safeguarding assessments. They are usually conducted on a voluntarily basis and in a less formal manner. The approach is most often used in developed economies, as part of health equity filtering of policies21 and for scoping the benefits of conducting HIA. The authors also noted that HIA can also be used as an advocacy tool, with the objective of influencing decision-making. Used in this context, HIA aims to ensure health considerations are addressed in project and policy design. The Chiang Mai Declaration on HIA and Gothenburg consensus both highlight the rights of people within affected communities to have a say in the formulation, implementation and evaluation of [decisions] that affect their wellbeing. To meet this demand communities are leading HIA. Some 30 communities who may have been affected from mining, industrial, energy, water management and other developments have conducted community HIA in Thailand. The process was thought to empower communities and make social values more transparent. 22 D.

HIA Steps

All IA approaches follow the same general approach. A proposal is screened to determine whether IA is warranted, then scoped to determine which issues require coverage. Risk assessment is undertaken; then a plan developed and implemented to mitigate key risks. All forms of HIA follow this structure. They all involve establishing a project rational, screening, scoping, risk assessment, a health plan to mitigate identified risks and implementation and monitoring.

a.

Project Description

The first step of an HIA is to outline the rationale, objectives and activities of a proposed infrastructure development. The description should include project scope, phasing, construction processes, types of equipment, volumes of inputs, and the nature of by-products.

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Harris-Roxas B, Harris E, Differing forms, differing purposes: A typology of health impact assessment, Environ Impact Asses Rev (2010) Harris P, Harris-Roxas B, Harris E, Kemp L. Health impact assessment: a practical guide. Sydney: UNSW Research Centre for Primary Health Care and Equity and NSW Health; 2007b. Sukkumnoed D, Nuntavorakarn S, Phoolchaeron W, Sabrum N, Sukkumnoed R. Healthy public policy and health impact assessment in Thailand. Bangkok: Toward Healthy Society; 2005

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b.

Screening

During screening the decision as to whether the proposal warrants HIA is determined. Direct and indirect influences of the project on health determinants need consideration. If these influences are deemed to be significant, then a HIA should be undertaken. 23 The decision to perform a rapid or comprehensive HIA is also executed during screening. As already mentioned, such factors as the scale of the project, potential health, environmental and social hazards, and community concerns are taken into considerations, along with primary data availability. Box 1: HIA Steps

HIA Steps Project Description Screening Scoping Rationale, objectives and goals of the project Determining whether or not a proposed development warrants impact assessment Identifying the particular issues that should be addressed Determing the impacts that a proposed development is likely to have on health Selecting public health plan options in response to risk assessment

Risk Assessment Public Health Plan Implement

Evaluate

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Tools for HIA. http://www.apho.org.uk/resource

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

c.

Scoping

Scoping aims to identify the key issues that need to be considered in the HIA. The Australian HIA guidelines state that ‘scoping firstly involves determining the factors to be considered, alternatives to the project, and the potential effects of the project to be considered. Secondly, prioritizing the issues to be addressed and determining the appropriate level of effort.’24 The geographical, timescale and population dimensions of the HIA are established at this stage.

d.

Assessing Health Risks and Impacts

Potential health impacts of a proposal are identified during risk assessment. Both positive and negative impacts may be analysed. Assessment of risk may be done by assessment against checklists or using qualitative techniques. Some guidelines note that impacts could be quantified during risk assessment. A review of 98 published HIAs in 2005 identified that quantitative techniques were used in only 16 studies25.

e.

Public Health Plan.

Risk management involves the assessment of various options to mitigate identified health risks and development of an action plan. In considering an appropriate action plan it is noted that ‘decision making will incorporate scientific, technological, social, economic and political information [and] alternative actions may be identified through a community consultation processes’.26 Plans are typically prepared for different sub-populations affected by the project and for different phases of development.

f.

Monitoring and evaluation

Monitoring and evaluation is required to determine whether the public health plan is effectively implemented and if the health status of the community has been sustained or improved. Evaluation also provides feedback on the accuracy of risk assessments conducted during the HIA.

IV. A.

HEALTH IMPACT ASSESSMENT PRACTICES HIA in Development Institutions

Only a small proportion (6%) of published HIAs have been conducted in developing countries27. Most of these studies follow a safeguarding approach and tend to be project24

Australian Department of Health and Aged Care. 2001. Health Impact Assessment Guidelines. September Veerman JL, Barendregt JJ, Mackenbach JP. Quantitative health impact assessment: current practice and future directions. Journal of Epidemiology and Community Health 2005; 59: 361 –70 Australian Department of Health and Aged Care. 2001. Health Impact Assessment Guidelines. September. Winkler MS, Krieger GR, Divall MJ, Cisse G, Wielga M, Singer BH, Tanner M, Utzinger J. 2013. Bulletin of the World Health Organization, April 2013, vol./is. 91/4(298-305), 0042-9686;1564-0604

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orientated and triggered by large infrastructure projects.28 Development institutions require environmental and social mitigation strategies be integrated into the planning and implementation of investments with high environmental and social risks. Mitigation measures could relate to environment, safety of dams; pest management, indigenous peoples, involuntary resettlement, cultural property, and health and safety29 Most agencies integrate health mitigation within broader environmental and social considerations. Policies at major development institutions and selected governments in the GMS are summarised in this section.

1.

International Finance Corporation

HIA guidelines30 were developed in 2009. The objective of the HIA guidelines was to present methodological approaches to assess and mitigate potential community health impacts. The trigger for conducting HIAs as part of SIA/EIA is articulated in IFCs performance standards footnotes. PS131 footnote (26) refers to disclosure of project information and that the decision to conduct a HIA depends on the scale, risk and impacts of a project. Depending on the scale of the project mitigation could range from IAs to summaries of key issues and commitments.32

2.

International Petroleum Industry Environmental Conservation Association

The global oil and gas industry association for environmental and social issues (IPIECA) developed guidelines33 in 2005 using similar a similar framework and expertise as the IFC guidelines. The guide defines and outlines the purpose and value of HIAs within the oil and gas industry. It is noted that impact assessment in the industry has evolved from environmental performance, to include a greater social focus, where they are increasingly asked to address health problems outside of occupational health and safety within the geographical boundaries of a proposed project. The decision to undertake a comprehensive HIA is also governed by the size, complexity and profile of concerned projects.

28

Krieger GR, Utzinger J, Winkler MS, Divall MJ, Phillips SD, Balge MZ, Singer BH. Barbarians at the gate: storming the Gothenburg consensus. Lancet 2010; 375: 2129–31 World Bank Safeguard policies. Available at http://www.worldbank.org/safeguard. Section 1 addresses the types of HIAs, and how to determine which type of HIA is appropriate for the project. It also describes how an HIA fits into the social and environmental impact assessment process. Sections 2 and 3 explain when a comprehensive HIA may be required. Sections 4 and 5 focus on the required levels of analysis and the baseline data needs. Sections 6 and 7 address health-specific stakeholder engagement and risk assessment aspects. Sections 8 and 9 provide information on the development of the health action plan and monitoring and verification, IFC. 2012. Performance Standard 1 - Assessment and Management of Environmental and Social Risks and Impacts. January, 2012 Personal Communication. D. Baird, Senior Social Specialist, IFC, Environment and Social Development Department. st 1 July. 2013. IPIECA. A guide to health impact assessment in the oil and gas industry. London: International Petroleum Industry Environmental Conservation Association, 2005

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3.

International Council of Mining and Minerals

ICMM developed a set of tools34 in 2010 to help practitioners assess and address health risks posed by hazards in the mining and metals sector. The guidance is designed to complement IFC and IPIECA safeguarding and accompanies the 2009 Good Practice Guidance on Occupational Risk Assessment. The tool provides an overview of how mining can affect health, summarises the HIA approach proposes a rapid assessment methodology. The guide stresses the need to integrate health impact assessment with environmental and social impact assessments.

4.

World Bank

The World Bank has a range of environmental and social safeguard policies and a separate policy framework for using country systems. The World Bank provided input for the 2009 IFC HIA guidelines. Given the Bank's 2-3 year lead time in project preparation, safeguarding specialists at the bank anticipated the number of projects warranting HIA would be very low.35 Environmental, Health, and Safety (EHS) Guidelines have been developed for different industries and are used in conjunction with safeguard policies. Clients are expected to refer to the EHS Guidelines together with other internationally recognized sources when evaluating mitigation strategies for a project. The numerical guidelines and performance indicators are considered to be default values applicable to new projects. These guidelines are currently being revised by the IFC. The objectives of the intended revision are to develop revised benchmarks to reflect the current state of good international practice36.

5.

European Investment Bank

The EIB's environmental and social safeguard policies are derived from the 2006 Declaration on the European Principles for the Environment (EPE) supported by the EIB and a number of major European multilateral financing institutions37. The policies do not contain explicit HIA procedures in relation to when an assessment should be conducted or how an HIA needs to be advanced in the course of due diligence. HIA currently rests on the assessment of the nature, severity and probability of impacts on public (and/or occupational) health as well as the

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ICMM. Good practice guidance on health impact assessment. London: International Council on Minerals and Metals, 2010 Personal Communication. H. Van Veldhuizen, Lead Environmental Specialist, Operations Policy and Country nd Services, World Bank. 2 July, 2013. Technical Revision of World Bank Group Environmental, Health, and Safety Guidelines, Approach Paper, February 2013. The Council of Europe Bank (CEB), the European Bank for Reconstruction and Development (EBRD), the European Investment Bank (EIB), the Nordic Environment Finance Corporation (NEFCO) and the Nordic Investment Bank (NIB); www.eib.org/epe

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professional judgement exercised by the assigned social development specialist who determines whether an HIA is required38.

6.

PREVENT Program

The USAID-supported PREVENT program notes the International Finance Corporation (IFC) have procedures to conduct HIA. Although these guidelines include veterinary and zoonotic diseases, they emphasize vector-borne diseases and diseases of livestock and domestic animals39. USAID-PREVENT have developed a supplemental guide for incorporating risk assessments of emerging infectious diseases of zoonotic origin. Key risks include, amongst others, resettlement and influx increasing person-to-person contact and amplification of disease; water management providing insect-breeding habitat; and increases in the potential for shared use of water between humans and wildlife.

7.

Asian Development Bank

In 1992, ADB published its first guidelines40 on the conduct of health impact assessment of development projects. A second publication41 came a decade later in 2003. While bothguidelines were applied by WHO and other partners, ADB's own HIA practice focused on a safeguards approach to reduce negative health impacts, specifically through social assessment, and community and occupational health and safety. HIA has started to be operationalized at the project level under EIA, mostly for Category A and B for environment, following harmonized guidelines for multilateral development banks. Only for HIV/AIDS mitigation may it be possible to analyze if more proactive health approaches in infrastructure and other non-health activities can yield better health outcomes. The current Safeguard Policy Statement (SPS) which encompasses environmental and social safeguards for ADB's operations was adopted in 2009. The objectives of the SPS are ‘to avoid, or when avoidance is not possible, to minimize and mitigate adverse project impacts on the environment and affected people, and to help borrowers strengthen their safeguard systems and develop the capacity to manage environmental and social risks’. In the case of environment, this involves pollution considerations impacting human health, along with occupation and community health. As part of involuntary resettlement and indigenous safeguards, communities need to be provided resettlement plans that ensure that livelihoods and standards of living of displaced persons are improved, or at least restored to pre-project (physical and/or economic) levels. Access to health facilities is one such consideration. Health considerations follow standards in the World Bank Group’s Environment, Health and Safety Guidelines. These guidelines cover sectors such as forestry, agribusiness/food production, 38

Personal communication, E. Kyrou, Social Development Specialist, Environment, Climate and Social Office (ECSO) th Projects Directorate, European Investment Bank. 10 July 2013. Proposed Supplemental Guidance to the IFCs Introduction to Health Impact Assessments, June 2012 Birley, M. and Peralta, G. (1992) Guidelines for the Health Impact Assessment of Development Project, Asian Development Bank Environment Paper No. 11. Peralta, G.L. and Hunt, J.M. (2003) A Primer on Health Impacts of Development Programs, ADB Manila

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion chemicals, oil and gas, power (wind energy, geothermal, thermal, transmission), mining, manufacturing, and general infrastructure42. ADB’s long term strategy, known as Strategy 2020,43 states the bank ‘will contribute to improvements in health mainly through infrastructure projects such as water management and sanitation and through governance work that focuses on public expenditure management for cost-effective delivery of health programs and services to all population groups’. At a strategic level, it logically follows, that health considerations should be articulated in operational plans and policies for key sectors such as transport, energy and water. 44 The Sustainable Transport Initiative Operational plan 201045, Energy Policy 200946 and 2011 Water Operational Plan47 include health considerations to varying degrees. For example, an objective of sustainable transport system development is improving access with consideration of accident and pollution implications for human health.48 The 2009 Energy Policy49 states that MDG targets (including health) could not be met without access to modern energy as the burning of traditional biomass results in higher incidence of health problems, such as bronchial diseases, and lower productivity. Research by ADB’s evaluation department examining the impact of electrification on general human health in rural Bhutan supports this conclusion, with 2.8, 5.6 and 13.5% less incidence of cough, respiratory problems eye irritation in households connected to electrification as a result on an ADB project50.

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Water and Sanitation, Waste Management Facilities, Health Care Facilities, Retail Petroleum Networks, Crude Oil and Petroleum Product Terminals, Telecommunications, Toll Roads, Gas Distribution Systems, Shipping, Airlines, Airports, Ports, Harbors and Terminals, Railways, Tourism and Hospitality Development ADB. 2008. Strategy 2020: Working for an Asia and Pacific Free of Poverty, ADB. 2009. An operational plan for improving health access and outcomes under Strategy 2020, ADB. Manila ADB. 2010. Sustainable Transport Initiative Operational Plan, ADB. Manila ADB. 2009. Energy Policy, ADB. Manila. ADB. 2011. Water Operational Plan 2011-2020. ADB. Manila The contribution of vehicle emissions to high air pollution levels and implications for respiratory ailments and other disease are noted in the sector plan. Similarly, the contribution of road accidents to the estimated 1.18 million global deaths and millions of injuries is recognized. Based on study by Modi, V., S. McDade, D. Lallement, and J. Saghir. 2006. Energy Services for the Millennium Development Goals. New York: Emergency Sector Management Assistance Programme, United Nations Development Program, United Nations Millennium Project, and World Bank. ADB. 2010. Asian Development Bank's Assistance for Rural Electrification in Bhutan - Does Electrification Improve the Quality of Rural Life, IED. Manila.

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BOX 1. HIV Impact Assessment in Infrastructure Projects Following on from Strategy 2020, a target of 70% of all ADB infrastructure projects having HIV/AIDS mitigation components initiated as a result of social and poverty analysis was envisaged51. A number of pilot prevention programs have been undertaken in the GMS to develop guidance for mitigation activities. They include the Baolong Healthy and Safe Action (BHSA) Project52 as part of the $582 million Western Yunnan Roads Development Project in the People’s Republic of China (PRC). The $1 million HIV prevention program focussed on providing prevention services in a range of settings, and was followed by evaluation that found HIV knowledge and condom use with risky sex had improved in most groups except unskilled workers and drivers. 53 The 22-km Northern Economic Corridor Project in Lao People’s Democratic Republic also incorporated an awareness and prevention education program on HIV, illicit drug use and human trafficking valued at $340,459.54 Energy projects, such as the O Mon Thermal Power Project in southern Vietnam, included around $223 thousand to support activities encompassing HIV/AIDS/STI awareness and promote behaviour change among construction workers, health care providers, community population, and commercial sex workers.

Key issues which posed a challenge to the development of HIV risk mitigation programming included a lack of HIV and AIDS data associated with mobility and the infrastructure sector, a need for a harmonized approach when engaging government counterparts and the lack of specifications for a minimum package of HIV prevention activities. Given the large number of HIV prevention sub-projects required to meet a target of 70% of infrastructure projects having this component there is a need for non-health project officers being able to effectively assess the need for HIV-related mitigation and effectively design and implement HIV/AIDS programs. Within the bank’s Strategic Directions Paper on HIV/AIDS 2011–2015 it was also noted that tools would be developed for monitoring the implementation of contractual obligations on HIV prevention by construction contractors. It was not clear during consultations as part of this HIA assessment as to whether this had occurred. Concern was expressed among interviewed staff about the inability of local contractors to implement HIV prevention activities and that monitoring was inadequate.

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ADB. 2011. Strategic Directions Paper on HIV/AIDS 2011–2015, RSDD, Manila. ADB. 2010. Practice guidelines for harmonizing HIV prevention initiatives in the infrastructure sector. ADB. ADB. 2003. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the People’s Republic of China for the Western Yunnan Roads Development Project. Manila ADB. 2007. Northern Economic Corridor Project: Promoting HIV Prevention in the Lao PDR. A case study in HIV and Infrastructure: ADB Experience. Manila

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B.

HIA in South East Asia 1. Cambodia55

In 1993 the Royal Government of Cambodia enacted legislation to protect the environment and health of the people in Article 59 of the Environmental Protection Act. HIA legislation is also being developed. A National Committee for Environment and Health was established in 2006, although a HIA policy has not yet been approved. HIA is seen as having the potential to be combined with other impact assessments such as EIA, SIA, Cumulative Impact Assessment and Strategic Environmental Assessment. A major challenge is advocacy to engender political commitment.

2.

Laos

A HIA policy was developed and approved by Prime Minister in March 2006. Decree No: 54/MP, 23/03/2006 on the declaration of use and Implementation of National Policy on HIA was issued to implement the law. The policy aims to contribute to poverty alleviation and sustainability through the timely identification of adverse health effects of development and opportunities for health protection and promotion in the planning.56 The country has established a HIA team and focal point and prepared practical guidelines for HIA. Large projects such as Nam Theun II requested HIA, which was undertaken with the assistance of WHO, the Ministry of Health and experts. HIAs have also been considered for traditional artisanal mining activities, indoor air pollution and assessments of climate change impacts.

3.

Thailand

The introduction of the National Health Act in 200757 and amendments to the Thai Constitution in the same year58 clarified the nature and purpose of HIA. In 2010, 11 types of projects were specified in Section 67 of the Constitution as requiring an EHIA 59: Projects include offshore or coastal landfill, mine operations, industrial estate, petrochemical productions, steel or ore mills, production, modification or disposal of radioactive material in operations of hospital, veterinarian clinics, or research, disposal facilities, airports, piers and ports, dams or reservoirs and non-gas power plants Key challenges for further advancing HIA in Thailand include increasing the number of experts with experience of conducting HIA, developing a common understanding of definitions, process, and limitations of HIA and improvements in health data

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Workshop of ASEAN Focal Point on HIA (AFPHIA) October 4-6, 2012 Bangkok, Thailand

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Health Needs Assessment in Impacted Populations Surinder Kaul et al Proceedings of the International Association For Impact Assessment Conference, 5-9 May 2008. Perth. Australia http://whothailand.healthrepository.org/bitstream/123456789/590/1/National%20Health%20Act_2007.pdf The law recognizes the ‘right of a person to participate .. in the protection, promotion and conservation of the quality of the environment for usual and consistent survival in the environment which is not hazardous to his health and sanitary condition, welfare or quality of life, shall be protected appropriately ’. http://healthimpactassessment.blogspot.com.au/2010/08/thailands-health-impact-assessment.html

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sets, health indicators, and health criteria for HIA. HIA guidelines for local people need to be developed to improve the general understanding of EIA and HIA.

4.

Vietnam

The Law on Environmental Protection was issued in 1993 and the associated decree regulates HIA as a part of EIA. Currently HIA focuses on assessing occupational health. The Law on Prevention and Control of Infectious Diseases was issued in 2007 and states in Item 2, Article 17 ’that all projects on construction of industrial area, urban area, residential parks, healthcare facilities of infectious diseases can be built only after having the HIA evaluation’. Technical guidance on how to implement this law has not yet been issued. An HIA Guideline’s has recently been developed. It provides an overview of rapid and comprehensive assessment methods, states the intensity of conducting HIAs should be appropriate to the level of existing resources and capabilities, the scope of the project and the size of potential impacts. The Ministry of Health with support from WHO and the Asian Development Bank implemented a pilot HIA for the Song Bung 4 Hydroelectric plant in 200760. Viet Nam is working to streamline procedures for planning, design, implementing, and monitoring development projects, as outlined in the Hanoi Core Statement on Aid Effectiveness. This statement commits partners to use strengthened country safeguarding systems, with at least 30% of project assessments being carried out using government systems. Scope for strengthening HIA systems, capacity development and policy support needs to be assessed.

5.

Malaysia

On April 1, 1988, the Environmental Quality Act of 1974 was enforced, with the overall aim of ensuring the environmental impact of developmental projects by requiring an EIA. The EIA, was defined in the legislation as “the process of identifying, predicting, evaluating and mitigating the biophysical, social, and other relevant effects of development proposals prior to major decisions being taken and commitments made61.” Similarly, the Department of Environment notes that environment impact corresponds to the “net change in man’s health and well-being, including the ecosystems on which man’s well-being depends, that results from an environmental effects.” Thus, HIA to a limited extent has already been incorporated into the EIA.

6.

Philippines

Presidential Decree number 1586 Philippine Environmental Impact Statement in 1978 requires an Environment Compliance Certificate (ECC) for environmentally critical projects and projects within environmentally critical areas. The 1997 Philippine National Framework and Guidelines for Environmental Health Impact Assessment feeds into the ECC as a secondary requirement prior to obtaining approval for project construction.

60

Nguyen Huy Ng. 2012. 1st HIA for ASEAN Workshop held on 13-14 February 2012, Phuket, Thailand http://www.hia2008chiangmai.com/pdf/B2.1_fullpaper.pdf

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V.

FINDINGS AND RECOMMENDATIONS 1. Limited Awareness of Health Implications from Infrastructure Development

There appears to be a lack of awareness and appreciation of the health-related implications of infrastructure development. In the case of ADB, only a limited number of project monitoring frameworks in water, transport, education and agriculture were found to have healthrelated indicators. In a recent study of ADB’s support for the MDGs, it was calculated that some 63%62 of financing that was not classified as directly supporting MDGs was in major infrastructure sectors such as energy and transport63. Efforts have been made in the past to encourage staff to consider health affects in projects and publications such as ADB. 2003. A Primer on Health Impacts of Development Programs were developed to provide menus of indicators for agriculture and forestry, water and sanitation, energy, transport, urban development, education Sector, public-private partnerships and regional public goods. Clearly greater efforts are required to raise awareness of the health impacts from these types of investments. The development of user friendly ‘tip sheets’ such as those for gender, and thematic studies could help in this regard.

2.

Identify Priority Sectors

Not all infrastructure development will have significant health implications. Water and sanitation projects have been identified as having large health benefits. Potential benefits may also be evident in sectors where health indicators are not commonly used. Improved sanitation in the education sector, guarding against creating refuges for vector-borne disease as part of irrigation projects or improving solid waste management in urban development projects may equally have important health benefits. HIA commentators64 have noted that two major issues of critical importance to human health in the Asia are water and biodiversity. Case studies should be conducted to highlight the potential magnitude of these benefits, or costs, in high health impact sectors currently neglecting health considerations.

3.

Better Health Indicators

Some sectors are developing indicators to better track health outcomes. For example, the ADB transport sector is developing the Sustainable Transport Appraisal Rating (STAR) tool for assessing the sustainability of ADB’s transport projects. The tool measures improved access to health care, reduced transport-related pollutants and cutting accident rates. In the case of water and sanitation, mortality rate indicators are included in project monitoring. A major gap in water sector health impact analysis is establishing causality between mortality data, project coverage, facility utilization, and output data at the project level. Systematic reviews have, however, established the link between water quality and mortality. The need for confirming this

62

ADB. 2013. ADB’s Support for Achieving the Millennium Development Goals, IED, Manila. From the standpoint that MDGs were designed to mobilize effort beyond the usual attention of governments and aid agencies Harris-Roxas B. Health impact assessment in the Asia Pacific. Environ Impact Assess Rev 2011;31:393-5

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relationship in every project is costly. The use of proxy indicators such as water quality could be used as a surrogate measure for health impacts in such cases. A range of proxy indicators should be identified for health benefits (eg. water, soil and air quality) in other sectors where empirical evidence of causality is sound. Identifying proxy health indicators that professionals in each field commonly use may facilitate greater attention to project level health benefit determination. A literature review and consultation with experts to identify useful proxies, along with development of indicator tip sheets may help facilitate use of health-related indicators.

4.

Guidance on Using HIA

Most development institutions have adopted an integrated approach to HIA, as part of EIA or SIA processes. The templates and timeframes for rapid and comprehensive approaches are provided in the IFC guidelines. Given the time pressures associated with project processing it is likely most development financing agencies will continue to follow this type of approach. Although health considerations are thought to be given insufficient attention in some cases, HIA integrated within an EIA process reduces duplication, costs of consultation and leverages existing impact assessment approaches. Reviews65of the use of HIA have noted key challenges to greater adoption are a lack of clarity about the definition of HIA and its methodological criteria; limited capacity for HIA practice; lack of cooperation between sectors and difficulties of budgeting and project management when integrated HIAs are being conducted66. Guidance notes need to be developed on when to undertake an HIA. Most current triggers relate to the scale or sensitivity of project risks. Triggers should be more explicit and specify whether rapid or comprehensive assessment is required.

5.

Capacity Development

Countries need to develop their own systems for delivering safeguards. This objective is in line with the Paris Declaration on Aid Effectiveness. Many national safeguarding systems are not equivalent to development institutions and legislation may not support HIA. In the case of ADB, a large number of IAs are conducted by borrower countries. A review of country led and ADB supported assessments is required to identify whether health impacts are covered in sufficient detail and any gaps in current practice identified. Training activities and education should be pursued to improved HIA practice and augment the body of health professionals able to conduct HIA. WHO’s Western Pacific Regional Office has established a thematic working group for HIA, with more than 1000 HIA practitioners across Asia67. ASEAN has been active in developing HIA capacity and networking across the region. The Regional Forum on Environment and Health in Southeast and East Asian Countries established a thematic working group on HIA in July 2010 to share information and knowledge on HIA practices, to develop and promote HIA and to build capacity.

65

Lee JH, Röbbel N and Dora C. Cross-country analysis of the institutionalization of Health Impact Assessment. Social Determinants of Health Discussion Paper Series 8 (Policy & Practice). Geneva, World Health Organization, 2013. Birley M. Health impact assessment: Principles and practice. London: Earthscan, 2011 Winkler MS, Krieger GR, Divall MJ, Cisse G, Wielga M, Singer BH, Tanner M, Utzinger J (2013) Bulletin of the World Health Organization, April 2013, vol./is. 91/4(298-305), 0042-9686;1564-0604

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6.

Improved Monitoring and Evaluation.

An ADB evaluation of the bank’s current safeguard policies noted that considerable emphasis was placed on meeting procedural requirements and milestones during project processing, however limited supervision was provided in achieving results during project implementation. The study noted that ‘there is almost no monitoring of environmental matters after project completion’. This observation was also made during this review when discussing health mitigation strategies under current safeguarding - particularly in relation to HIV prevention. A review of the constraints on implementing HIV prevention and current performance of HIV prevention within infrastructure projects is required. Methods for improving monitoring and evaluation, such as strengthening project completion reporting were suggested as means for addressing this issue.

7.

Studies and Advocacy

An interest in enhancing the health impacts of projects, and minimising negative impacts needs to be fostered. WHO note that ‘the promotion of HIA in the developing world is constrained by the small number of available references of best practice that can be used as benchmarks for future HIA.. [and]..experience gained in HIA practice in the high-income countries is rarely directly applicable to a low- or middle-income country context68. Where appropriate; development agencies and governments should pilot HIAs in sectors currently lacking these assessments. Economic appraisal is commonly used to justify investment. Health benefits are infrequently considered due to methodological complexities associated with human health valuation. It is unlikely health considerations would be included in routine project processing assessments due to this constraint. Economic case studies should be undertaken where health benefits are not currently perceived to be significant to engage stakeholders from non-health fields.

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Erlanger TE, Krieger GR, Singer BH, Utzinger J. The 6/94 gap in health impact assessment. Environ Impact Assess Rev 2008;28:349-58

21 Session 4: Health Impact Assessment and Socially Responsible Infrastructure Development

VI. 

REFERENCES Asian Development Bank. 2003. Report and Recommendation of the President to the Board of Directors on a Proposed Loan to the People’s Republic of China for the Western Yunnan Roads Development Project. Manila Asian Development Bank. 2006. Guidelines for Preparing a Design and Monitoring Framework. Manila Asian Development Bank. 2007. HIV and the Greater Mekong Sub-region: Strategic Directions and Opportunities, ADB. Manila. Asian Development Bank. 2007. Northern Economic Corridor Project: Promoting HIV Prevention in the Lao PDR. A case study in HIV and Infrastructure: ADB Experience. Manila Asian Development Bank. 2008. Strategy 2020: The Long-Term Strategic Framework of the Asian Development Bank, 2008–2020. Manila. Asian Development Bank. 2009. Energy Policy, ADB. Manila. Asian Development Bank. 2009. An Operational Plan for Improving Health Access and Outcomes under Strategy 2020. Manila. Asian Development Bank. 2010. Sustainable Transport Initiative Operational Plan, ADB. Manila Asian Development Bank. 2010. Asian Development Bank's Assistance for Rural Electrification in Bhutan - Does Electrification Improve the Quality of Rural Life, IED. Manila Asian Development Bank. 2010. Practice guidelines for harmonizing HIV prevention initiatives in the infrastructure sector. ADB Asian Development Bank. 2011. Project Performance Management System. Operations Manual. OM J1/BP. Manila; Asian Development Bank. 2011. Water Operational Plan 2011-2020. ADB. Manila Asian Development Bank. 2011. Strategic Directions Paper on HIV/AIDS 2011–2015, RSDD, Manila. Asian Development Bank. 2013. ADB’s Support for Achieving the Millennium Development Goals, IED, Manila ADBI. 2009. Infrastructure for a Seamless Asia. Tokyo. Asian Development Bank Institute Australian Department of Health and Aged Care. 2001. Health Impact Assessment Guidelines. September. Birley M. 2011. Health Impact Assessment: Principles and Practice. London: Earthscan.

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         

Erlanger TE, Krieger GR, Singer BH, Utzinger J. 2008. The 6/94 gap in health impact assessment. Environ Impact Assess Rev; 28:349-58 European Centre for Health Policy. 1999. Health impact assessment: Main concepts and suggested approach. The Gothenburg Consensus Paper, December 1999. WHO Regional Office for Europe

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Garbarino, S. and Holland, J. 2009. Quantitative and Qualitative Methods in Impact Evaluation and Measuring Results,. Issues Papers, Governance and Social Development Resource Centre (GSDRC), Issues Paper Harris-Roxas B. 2011. Health impact assessment in the Asia Pacific. Environ Impact Assess Rev; 31:393-5 Harris-Roxas B, Harris E, 2010. Differing forms, differing purposes: A typology of health impact assessment, Environ Impact Asses Rev, doi:10.1016/j.eiar.2010.03.003 Harris P, Harris-Roxas B, Harris E, Kemp L. 2007. Health impact assessment: a practical guide. Sydney: UNSW Research Centre for Primary Health Care and Equity and NSW Health. ICMM. 2010. Good practice guidance on health impact assessment. London: International Council on Minerals and Metals. IFC. 2009. Introduction to health impact assessment. Washington DC: International Finance Corporation; 2009 IPIECA. 2005. A guide to health impact assessments in the oil and gas industry. London: International Petroleum Industry Environmental Conservation Association; 2005 Kemm J. 2006. Health impact assessment and health in all policies. In: Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K, (Ed). Health in all policies: prospects and potentials. Helsinki: Ministry of Social Affairs and Health; 2006. p. 189–208 Kreiger et al 2008. ‘Nam Theun 2 hydroelectric project, Lao PDR ‘ in Health Impact Assessment for Sustainable Water Management. Fewtrell L and Kay D (Ed.). IWA Publishing, London, UK Krieger GR, Utzinger J, Winkler MS, Divall MJ, Phillips SD, Balge MZ, Singer BH. 2010. Barbarians at the gate: storming the Gothenburg consensus. Lancet; 375: 2129–31 Lee JH, Röbbel N and Dora C. 2013. Cross-country analysis of the institutionalization of Health Impact Assessment. Social Determinants of Health Discussion Paper Series 8. Geneva, World Health Organization. Modi, V., S. McDade, D. Lallement, and J. Saghir. 2006. Energy Services for the Millennium Development Goals. New York: Emergency Sector Management Assistance Programme, United Nations Development Program, United Nations Millennium Project, and World Bank National Health Commission Office Thailand. 2010. Thailand’s Rules and Procedures for the Health Impact Assessment of Public Policies. April Sukkumnoed D, Nuntavorakarn S, Phoolchaeron W, Sabrum N, Sukkumnoed R. 2005. Healthy public policy and health impact assessment in Thailand. Bangkok: Toward Healthy Society; 2005 Veerman JL, Barendregt JJ, Mackenbach JP. 2005. Quantitative health impact assessment: current practice and future directions. Journal of Epidemiology and Community Health; 59: 361–70 Wood, C. and Leighton, D. 2010 Measuring Social Value – The Gap Between Policy and Practice. London: Demos World Bank 1998. Assessing Aid: What Works, What Doesn‟t and Why, World Bank Policy Research Report. Oxford: Oxford University Press WHO. 1978. Declaration of Alma-Ata. International conference on primary health care, Alma-Ata, USSR, 6–12 September. World Health Organization; 1978 23 Session 4: Health Impact Assessment and Socially Responsible Infrastructure Development

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WHO. 1986. Ottawa charter on health promotion. Geneva: World Health Organization; 1986 WHO. 2011. Decade of Action for Road Safety 2011–2020 Saving millions of lives Winkler MS, Krieger GR, Divall MJ, Cisse G, Wielga M, Singer BH, Tanner M, Utzinger J. 2013. Bulletin of the World Health Organization, April 2013, vol./is. 91/4(298-305), 00429686;1564-0604 World Bank. 1993. World Development Report: Investing in Health. Washington: World Bank

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Prepared by: Ross McLeod This consultant’s report does not necessarily reflect the views of ADB, and ADB cannot be held liable for its contents.

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

SESSION

5 Session 5: Health Situation and Health Systems Analysis: Cambodia, Lao PDR, Myanmar, Thailand, Viet Nam

Table of Contents

Introduction to five country studies ....................................................................................... 2 Cambodia country study .................................................................................................... 3 Lao People’s Democratic Republic country study .......................................................... 20 The Union of Myanmar country study ............................................................................ 35 Thailand country study .................................................................................................... 46 Policy recommendations ................................................................................................. 82 Summary and Conclusions ............................................................................................... 84

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Introduction to five country studies The 2010 Global Consultation on Migrant Health, building on the 2008 World Health Assembly’s resolution on the Health of Migrants, proposed a framework of action points to promote migrant health and provide migrant sensitive policies and practices. 1 The four components of this framework are:     Monitoring migrant health (for example, ensure the standardization and comparability of data on migrant health); Policy and legal frameworks (for example, implement national health policies that promote equal access to health services for migrants) Migrant sensitive health systems (for example, enhance the capacity of the health and relevant non-health workforce to address the health issues associated with migration Partnerships, networks and multi country frameworks (for example, address migrant health matters in global and regional consultative migration, economic and development processes

This framework emphasizes the need to simultaneously focus on the health of migrants (for example, extend social protections in health and improve social security for all migrants as a part of actions on policy and legal frameworks), as well as a focus on health systems that respond to and address migrant and border health issues (for example, ensure continuity and quality of care for migrants in all settings). The Concept Paper alongside these five country studies, Border Health: Concepts, Models, and Applications for the Greater Mekong Subregion, goes into these themes and areas in further depth. Some notes on the scope and structure of these papers are warranted. Firstly, the five papers are country papers for Cambodia, Thailand, Lao PDR, Myanmar and Vietnam. While Yunnan Province and Gungxi Zhuang Autonomous Region in China are considered part of the Greater Mekong Subregion, these areas are not addressed in these papers. Secondly, while there is considerable internal migration within countries in the region, primarily from rural areas to the large urban centers, the focus of this analysis is on influences on border health in each country, and cross-border migration. Thirdly, the health of migrants in receiving countries is primarily addressed in the country report on the receiving country – for example, the health of migrants from Vietnam living in Thailand is addressed in the paper on Thailand, rather than the paper on Vietnam. Each of the five country studies includes the following sections:   Demographic, economic and social background; Health status – a broad overview of health status from a national perspective;

1

WHO, Health of migrants: the way forward - report of a global consultation, Madrid, Spain, 3-5 March 2010.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Health systems – using the WHO’s six building blocks of health systems, providing an overview of health service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/ governance; Migration and border specific health issues; Migration and border specific health systems issues; Policies, legal frameworks and institutions; and Data gaps and challenges.

   

In an effort to provide comprehensive information to address these areas, these papers are based on a wide range of data sources, which include international organizations, national health systems and institutions, published academic literature, and grey literature from nongovernmental organizations and research institutions. Following the five country studies, recommendations and conclusions are provided that tie together common themes found in each of the individual studies.

Cambodia country study I. Background:

Cambodia has a population of 14.31 million, and shares a 541 km border with Lao PDR, a 803 km border with Thailand, and a 1,228 km border with Vietnam. The Mekong Border Disease Surveillance initiative collects cross-border information on the following provinces that border Vietnam, Thailand or Lao PDR: Stung Treng (bordering Lao PDR, population of 111,734) 2 , Banteay Meanchey (bordering Thailand, population of 678,000)3, Takaeo (bordering Vietnam, population 843,931)4, Kampot (bordering Vietnam, population 627,884)5, Battambang province (bordering Thailand, population 1,036,523) 6 , Svay Rieng (bordering Vietnam, population 482,785) 7 , Kampong Cham (bordering Vietnam, population 1.68 million) 8 , and Koh Kong

2

National Institute of Statistics, Ministry of Planning, Government of Cambodia, 2008 Ibid. Ibid. Ibid. Ibid. Ibid.

3

4

5

6

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion (bordering Thailand, population 139,722).9 Koh Kong has been identified as both a destination and transit point, where internal migrants within Cambodia come to work and then move on to Thailand.10 Other border provinces include Mondolkiri province, bordering Vietnam (population 60,811) and Kratie (bordering Vietnam, population 318,523). 11 Life expectancy in 2012 was 63.612 and 35% of the population is under the age of 15.13 Cambodia ranks 138th in the UNDP Human Development Index, and according to the most recent UNDP data, 22.8% of the population of Cambodia live on under $1.25 PPP per day, and 30.1% of the population live below the national poverty line. Cambodia’s primary exports are petroleum products, cigarettes, gold, construction materials and machinery, and 24.6% of its exports go to Thailand, while 20.6% go to Vietnam. There is already considerable cross-border movement and trade, particularly from Cambodia to Thailand, and current and future plans for increased economic integration may impact border health issues. For example, there are a number of activities underway to boost trade between Thailand and Cambodia, with a new Joint Commission on Border Area Development and Connectivity planning two special economic zones, between Sa Kaeo province in Thailand and Banteay Meanchey province in Cambodia, and Trat province in Thailand and Koh Kong province in Cambodia.14 Cambodia has also recently set up a Joint Trade Commission with Lao PDR in an effort to increase cross-border trade.15 Economic analysis indicates that while there has been considerable economic growth over the past decade, this has not benefitted the poorest segments of the population,16 and has not contributed sufficiently to increased employment.17

8

Ibid. Ibid.

9

10

Raks Thai Foundation, Source, Transit, Destination and Back Again: An assessment of possible cross-border linkages to improve Cambodian migrants’ health, 2007. 11

National Institute of Statistics, Ministry of Planning, Government of Cambodia, 2008 UNDP, Human Development Report: The Rise of the South, 2013.

12

13

National Institute of Statistics, Directorate General for Health, and ICF Macro, 2011. Cambodia Demographic and Health Survey 2010. Phnom Penh, Cambodia and Calverton, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF Macro. 14

http://www.bangkokpost.com/breakingnews/354563/more-checkpoints-to-be-launched-on-thai-cambodianborder 15

http://www.phnompenhpost.com/business/cambodia-eyes-laos-trade World Bank, Equity, Growth and Poverty Reduction in Cambodia, 2007. Kingdom of Cambodia, Policy on Labour Migration for Cambodia, 2010.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Widening disparities within rural areas may continue to contribute to internal migration and cross-border migration as a livelihood strategy.18

II.

Health status – national level

Health status in Cambodia, across a number of indicators, is amongst the lowest in the Western Pacific region, with indicators of neo-natal mortality, maternal mortality and rates of infectious diseases generally higher than neighboring countries and other countries in the region. The 2010 Global Burden of Disease Study found that the highest-ranking causes of years of lost life [YLLs] in Cambodia were lower respiratory infections, ischemic heart disease, cerebrovascular disease and pre-term birth complications.19 Diarrheal diseases, as a cause of disease burden, showed the largest decrease in contribution to disease burden from 1990 to 2010. In terms of morbidity, the top fives causes of years lived with disability are iron-deficiency anemia, major depressive disorder, low back pain, chronic obstructive pulmonary disease, and tuberculosis. Leading causes of DALYs in 2010 that were not leading causes in 1990 were ischemic health disease, cerebrovascular disease, road injury, and major depressive disorder. Differences in leading cause of DALYs between 1990 and 2010 show that, overall, the disease burden of non-communicable diseases and injuries is increasing, while communicable, maternal, neonatal and nutritional causes are decreasing. However, compared to the regional average, Cambodia has higher years of life lost due to communicable diseases and lower due to noncommunicable diseases.20 The top three risk factors accounting for disease burden overall in Cambodia are dietary risks, household air pollution from solid fuels and tobacco smoking, while for children under 5 it is childhood underweight. Prevalence of tuberculosis per 100,000 population is 817, compared to a regional average of 138; prevalence of HIV per 100,000 population is 447 compared to a regional average of 72, and prevalence of malaria per 100,000 population is 1353 compared to a regional average of 104. High levels of multi-drug resistant malaria have been found in some areas.21 The burden of TB in Cambodia is high, with prevalence of 817 per 100,000 population.22

18

World Bank, op. cit. Institute for Health Metrics and Evaluation, Global Burden of Disease Country Profile: Cambodia, 2010. WHO, Vietnam Country Profile, 2010. WHO, Roll Back Malaria Monitoring and Evaluation Profile, 2005. http://hiip.wpro.who.int/hiip/

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion UNICEF data indicates that across a number of indicators, reproductive health is a significant challenge in Cambodia. However, a number of indicators have improved significantly, as shown in the recent Cambodia Demographic and Health Survey. For example, in 2005, 44% of births were attended by a skilled health provider, whereas in 2010, this figure was 71%.23 The maternal mortality ratio – 250 per 100,000 births – is high for the region, which has an average of 49 [see Textbox 1, below].24 Services and treatment for key child health challenges are also limited, with only 50% of children under 5 with diarrhea receiving oral rehydration therapy or increased fluids, with continuous feeding. 25 Under-5 mortality dropped from 83 per 1,000 live births in 2005 to 54 per 1,000 live births in 2010. The percentage of children with suspected pneumonia taken to a health provider has risen from 37% in 2000 to 48% in 2005, and the percentage of infants who are exclusively breastfed under 6 months rose from 12% to 60% from 2000 to 2005.26 In 2010, 28% of children under 5 years of age were underweight, and 8.2% of newborns were considered low birth-weight.27 Mental disorders are a significant concern in Cambodia. A study of post-conflict mental health in four countries found a prevalence of 28.4% Post Traumatic Stress Disorder, with the following risk factors: conflict-related trauma after 12 years, psychiatric history and current illness, death or separation in the family and alcohol abuse in parents.28 Additional data on the prevalence of common mental disorders is limited, however, prevalence of depression and anxiety is suspected to be high. In order to respond to these challenges, a number of programs and activities have been developed, including efforts to train more psychiatrists 29 and implementation of community-based mental health activities in rural areas.30

23

Cambodia Demographic and Health Survey 2010 Factsheet. WHO, Vietnam Country Profile, 2010. UNICEF, Maternal, Newborn and Child Survival Country Profile, 2008. Ibid. http://hiip.wpro.who.int/hiip/ De Jong, et al. Lifetime events and posttraumatic stress disorder in 4 postconflict settings, JAMA, 2001.

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29

http://www.iom.int/cms/en/sites/iom/home/what-we-do/migration-health-2/health-of-migrants-incrisis/cambodian-national-program-for-mental-he.html 30

Somasundaram, D. and van de Put, W. Mental Health Care in Cambodia, Bulletin of the World Health Organization, 2011.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Textbox 1: Improving maternal health While the 2010 DHS indicators significant improvements in maternal and child health indicators in Cambodia, Cambodia still lags significantly behind its neighbors and remain significant public health problems throughout the country. To address these issues, the Government of Cambodia initiated the 2010-2015 Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality. The WHO states that with the initiative, “the Ministry of Health signals its intention to allocate national resources [to this issue], and its desire for development partners to similarly support with funds and technical assistance.”31 The strategy has identified a number of priority areas and interventions – including emergency obstetric and newborn care, skilled birth attendance, safe abortion and removing financial barriers to access to services – and has put in place activities to reach these objectives, as well as mobilizing donor support around these objectives.32 A case study has also identified improvements in the deployment and retention of midwives in rural areas as part of the strategy, as well as other activities to improve human resources for health, as a factor behind the reduction in maternal mortality in Cambodia.33 Activities included providing incentives to midwives for each delivery they perform at a health facility. However, gaps remain in provision of skilled midwives in health facilities, and the Initiative contains a number of activities to address this issue. One study has indicated that unsafe abortion is an issue that significantly affects unmarried migrant Cambodian women along the Thai-Cambodia border, and efforts to increase and improve access to reproductive health services may need to specifically account for the experiences of women who migrate temporarily to Thailand for work, which include risky sexual experiences, including multiple unsafe abortions.34

31

http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_khm_09_en.pdf

32

For example, http://www.ausaid.gov.au/HotTopics/Pages/Display.aspx?QID=838; Cambodia Global Health Initiative, 2011. 33

Fujita N, et al. Addressing the human resources crisis: a case study of Cambodia’s efforts to reduce mater nal mortality (1980–2012). BMJ Open 2013. 34

Hegde, S. et al., Unsafe Abortion as a Birth Control Method: Maternal Mortality Risks Among Unmarried Cambodian Migrant Women on the Thai-Cambodia Border, Asia Pacific Journal of Public Health, Vol. 24, 2012.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

III. i.

Health systems – national level Health service delivery: Cambodia’s health system is delivered through health centers and health posts. 1,049 of these facilities cover between 10,000 and 20,000 people each. In 2010, only 43% of health centers offered the full minimum package of services. 35 There are .84 inpatient beds per 1,000 population. 36 There is a total density of .43 per 100,000 population of district or rural hospitals, 7.02 per 100,000 population of health centers, .12 per 100,000 of provincial hospitals and .06 per 100,000 of specialized hospitals.37 There are national, district and referral hospitals that offer various levels of services – for example, in 2011 there were 33 CPA-1 hospitals, which provide basic obstetric care but no large-scale surgery, 31 CPA-2 hospitals, which additionally have emergency care services, ICU and large-scale surgery, and 26 CPA-3 hospitals, which also offer additional specialized services. Limited data on number of inpatient beds available for the population exists. One study showed that there are 14 in-patient psychiatric beds in the country, the lowest ratio of psychiatric beds per person in Southeast Asia.38 Aside from availability of services, some reports indicate concerns about quality of services at all levels. 39 Data on the number and distribution of inpatient beds per 10,000 population, and specificservices and general services readiness scores for health facilities could not be obtained. Low quality and lack of access to public health facilities has meant that a large proportion of the population utilizes private health facilities, which are often unregulated and have high user fees.40 Health workforce: There are 2.3 doctors per 10,000, compared to a regional average of 15.2, and 7.9 nurses and midwives per 10,000, compared to a regional average of 19.5.41 Human resources for mental health are also limited, with the WHO mental health atlas in 2005 finding that there are .16 psychiatrists for 100,000 population, .45 psychologists per 100,000 population and .05 social workers per 100,000

ii.

35

WHO and Ministry of Health, Cambodia, Health service delivery profile Cambodia, 2012. WHO and Ministry of Health, Cambodia, Health service delivery profile Cambodia, 2012. http://hiip.wpro.who.int/hiip/

36

37

38

Leitner Center for International Law and Justice, Mental Health and Human Rights in Cambodia, Fordham University, 2012. 39

WHO, Country Cooperation Strategy Cambodia, 2009-2015. Cambodia Department of Planning and Information, Strategic Framework for Health Financing. WHO, Vietnam Country Profile, 2010.

40

41

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion population. 42 The WHO recommendation is 2.5 skilled birth attendants per 1,000 population, however, Cambodia only has .77 per 1,000 population (10,333 nationally), including secondary nurses, secondary midwives, and medical assistants.43

iii.

Health information: The Health Information System in Cambodia has been implemented nationwide since 1995. A 2007 assessment of the HIS found that there are inadequate resources and policies to guide the HIS, limited use of HIS data in planning and monitoring health service delivery, and inadequate dissemination of data, while the strengths include that it has integrated nearly 20 reporting and monitoring systems into one system in order to reduce duplication and that definitions and reporting forms are standardized. 44 The 2008-2015 Health Information System Strategic Plan seeks to address a number of these challenges and improve the system overall.

iv.

Essential medicines: Data on median consumer price ratio of 14 essential medicines and average availability of the medicines is not available. Some data show that there are significant differences between brand and generic medicines, and that these price differences are higher in private facilities. Availability of medicines is a problem; NGO facilities were only able to dispense 50% of prescribed medicines, private facilities 59% and public facilities, 80%.45

v.

Health financing: Total expenditure on health as a percentage of GDP was 5.8% in 2010, and general government expenditure on health as a proportion of general government expenditure was 10.5%. Per capita expenditure on health, at purchasing power parity, was $17. 46 Out of pocket payments as a percentage of health expenditure is 64.3%, which is one of the highest in the Western Pacific region.47 Data from the recent DHS shows that these payments often come from savings, sale

42

WHO, Mental Health Atlas: Cambodia, 2005. WHO, World Health Report: Working Together for Health, 2006.

43

44

Health Metrics Network/ Department of Planning and Health Information, Ministry of Health, Cambodia Health Information System: Review and Assessment, 2007. 45

http://apps.who.int/medicinedocs/en/d/Js6160e/9.html http://hiip.wpro.who.int/hiip/ http://hiip.wpro.who.int/hiip/

46

47

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion of assets and borrowing with high interest rates,48 and literature has shown that out of pocket payments cause delays in seeking treatment and can have long-term impacts on household health and well-being.49 A number of forms of health insurance and health financing exist, including health equity funds, community-based health insurance and the SKY health insurance plan [see Textbox 2, below].50

vi.

Leadership and governance: The Health Strategic Plan (2008-2015) forms the basis of the Ministry of Health’s plan for improvement of health systems in Cambodia. The plan focuses on cross-cutting issues in order to identify and improve system-wide services and programs: health service delivery, health care financing, human resources for health, health information systems, and health system governance, with a mission statement to “provide stewardship for the entire health system and ensure a supportive environment for increased demand and equitable access to quality health services.”51 A number of other relevant policies and strategies exist, including the Framework for Health Financing (2008-2015), the Health Workforce Development Plan (2006-2015), and the Fast Track Initiative on Maternal and Child Health, which signals the Ministry of Health’s intention to allocate specific resources towards improving key maternal and child health indicators. Despite this, there are problems with fragmentation due to multiple donors and implementing partners.52

48

National Institute of Statistics, Directorate General for Health, and ICF Macro, 2011. Cambodia Demographic and Health Survey 2010. 49 50

World Bank. Sharing Growth: Equity and development in Cambodia . Washington, D.C., 2007. WHO Thailand, Health Systems in the ASEAN Region: Migrant Health Systems and Country Profiles, 2012 Ministry of Health, Cambodia Health Strategic Plan. WHO, Country Cooperation Strategy Cambodia, 2009-2015.

51

52

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Textbox 2: Building Block 5 – Health financing in Cambodia Out of pocket spending on health in Cambodia is amongst the highest in the world.53 User fees are charged in all health facilities in Cambodia, and expenditures on health care costs are a major cause of debt amongst poor Cambodians.54 Households use a combination of savings, selling assets and borrowing money to finance health care expenditure, which can be considerable; in the case of one study of health care costs for dengue fever, out of pocket costs totaled up to half a year’s salary, and debt incurred resulted in households having to sell land. 55 The current health system in Cambodia severely limits access and equity; the WHO ranked Cambodia 183rd out of 191 countries in terms of fairness of financial contribution to health systems, where fairness means that “the risks each household faces due to the costs of the health system are distributed according to ability to pay rather than to the risk of illness.”56 A number of approaches have been used to address this issue. Health equity funds [HEFs] provide for waiving of user fees, alongside other benefits, including payment for costs of transport and food costs at the hospital, depending on eligibility, for poor patients. The design of the HEF rests on the principles that the specific fund is established in order to compensate the health facility for providing services for patients who receive waived fees, and that the management of the fund is independent of the health facility, i.e. that the HEF itself determines targeting. 57 Voucher programs have also been used – for example, in one case in Kampong Cham, eligible pregnant women were given vouchers that entitled her to free antenatal services and transportation costs.58 HEFs operate in 49 of 77 operational districts across Cambodia. Methods of targeting and composition of benefits packages vary.59 Some of these approaches to addressing health financing in Cambodia have showed

53

Van Damme, W., Van Leemput, L., Por, I., Hardeman, W., & Meessen, B. Out-of-pocket health expenditure and debt in poor households: Evidence from Cambodia. Tropical Medicine and International Health, 2004, 9(2): 273-280. 54

Economic Institute of Cambodia, Health Care in Cambodia, 2004

55

van Damme, W. et al, Out-of-pocket health expenditure and debt in poor households: evidence from Cambodia, Tropical Medicine and International Health, 9(2), 2004. 56

World Health Organization, World Health Report: Health Systems, 2000.

57

Noirhomme, M. et al., Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia, Health Policy and Planning, Vol. 22, 2007. 58

Ir. P. et al., Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia, BMC Pregnancy and Childbirth, 10(1), 2010. 59

Cambodia – user fees

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion significant results. For example, a combination HEF and voucher scheme in Kampong Cham led to an increased in deliveries at facilities, while failing to address some barriers, such as cost of transportation to health facilities, and supply side barriers, such as availability of skilled human resources for deliveries in health facilities. 60 HEFs have resulted in increased utilization of health services by poor people. HEFs are perceived to be more effective than full waiver systems, as they allow health facilities to retain income, and in some cases, increase income due to an increase of new patients who access services due to the HEF.61 However, assessment of eligibility for user fees is often done after the patient arrives that the facility, meaning that the patient may still delay seeking care as they do not know in advance of their entitlements. Impacts have been most substantial in cases where performance of health facilities was improved through investments in staff motivation and higher quality of care. 62 Hardeman et al found that only 12% of beneficiaries of a HEF in Takeo province were aware of the HEF before seeking care.63 It is probable that large numbers of poor people are still delaying or avoiding treatment due to concerns and uncertainties about financial contributions to health services. In terms of addressing the key constraints to accessing health services, HEFs and voucher systems can be effective. However, addressing the core challenge of health system financing in Cambodia will also require increased government expenditure on health.

IV.

Migration and border specific health issues

Numerous sources identify the importance of cross-border migration as a livelihood strategy in Cambodia. Issues of land confiscation, debt and poor conditions for agricultural production have contributed to migration to Thailand being a key livelihood strategy in Cambodia, primarily amongst poor rural Cambodians. Border areas are affected by these migration patterns in a number of ways. Migration patterns differ. Some migrants cross the border with Thailand for short-range migration close to the border, while others travel further into Thailand for longer periods, to access other industries such as fishing and construction. Cambodia’s framework for

60

Ir. P. et al., op. cit. Noirhomme, M., op. cit.

61

62

Meesen, B et al., Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia, Lancet, Vol. 368, 2006. 63

Hardeman, W., et al., Access to health care for all? User fees plus a Health Equity Fund in Sotnikum, Cambodia. Health Policy and Planning: 19(1), 22-32, 2004.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion labor migration does include provisions for pre-departure health services and information,64 and the Cambodian Ministry of Labor and Vocational Training requested that the IOM produce manuals for pre-departure information, including on health needs, for migrant workers. 65 However, this is aimed towards documented migrants who move to Thailand, Malaysia, Korea and Singapore using recruitment agencies, and while statistics are unclear, it appears that a substantial amount of cross-border migration from Cambodia is irregular. 66 Following a regularization program introduced by the Thai Government in 2004, 110,025 Cambodians working in Thailand obtained work permits, however, in subsequent years official deployment of migrant workers from Cambodia to Thailand, through channels established in a Memorandum of Understanding, has declined. 67 A small study of four villages in a commune in Battambang identified the high prevalence of forms of labor migration within these villages, and anecdotal evidence suggests that migration is often of short duration, entailing trips to Thailand to work during non-harvest season or when livelihoods difficulties emerge.68 Recent data from the 2010 Demographic and Health Survey indicates disparities in health status between provinces. For example, the infant mortality rate in Phnom Penh is 13 per 1,000 live births, 50 in Siem Reap province, and 57 in Kampong Thom, compared to rates in border provinces that include 82 per 1,000 live births in Mondolkiri, 95 per 1,000 live births in Preah Vihear/ Stung Treng and 76 per 1,000 live births in Kratie.69 The national average is 45 per 1,000 live births. However, it is also the case that these provinces are all in the Northeast of the country, which is more remote and has less access to services in general, with much lower rates of skilled attendant at birth and birth in a health facility in Mondolkiri and Preah Vihear/ Stung Treng.70 Banteay Meanchey province, which sees considerable cross-border movement to Thailand, has above average infant mortality rate of 61 per 1,000 live births, but this does not differ from a number of non-border provinces, indicating that patterns in health status between border and non-border areas need to be further disaggregated and examined in order to establish the role of border health issues in influencing health status disparities, whereas other

64

USAID and the Asia Foundation, Cambodia’s Labor Migration: Analysis of the Legal Framework, 2011.

65

http://www.iom.int/jahia/webdav/shared/shared/mainsite/published_docs/brochures_and_info_sheets/Cambo dia-Health-Project-Info-Fact-Sheet-Feb-2011.pdf 66

Kingdom of Cambodia, Policy on Labour Migration for Cambodia, 2010. Ibid.

67

68

Cooperation Committee for Cambodia, Labor Migration to Thailand and the Thai-Cambodian border – recent trends in four villages in Battambang Province, 2003. 69

Cambodia Demographic and Health Survey 2010, Key Findings. Cambodia Demographic and Health Survey 2010.

70

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion patterns of disparities – for example, the association of infant mortality to rural residence and lower mother’s education, are clearer.71 The pattern of child immunization nationally (the % of children between 12 and 23 months who have received all basic vaccinations) also shows patterns whereby provinces in the Northeast have much lower rates of vaccination, but Northwestern border provinces and non-border provinces show less variation. In 2003, Battambang contributed 14% of malaria cases and had highest number of malaria cases72 and UNAIDS data shows that border provinces bordering Thailand have higher prevalence compared to other provinces.73 Some specific programs and activities have identified border areas in Cambodia as at risk for specific health challenges. For example, an IOM program focused on pandemic preparedness focused on the Cambodia/Vietnam border area generally and Svay Rieng province specifically, recognizing the potential vulnerability to specific groups such as crossborder labor migrants and returnees in rural and cross-border communities who have limited access to health services.74 Health systems preparedness for surveillance of and response to pandemics, such as influenza or avian flu, is considered limited.75 Other activities, including the Community Action for Preventing HIV/AIDS project, have been implemented in border areas (Battambang, Koh Kong, Prey Veng and Svay Rieng), recognizing that the prevalence of highly mobile populations in these areas put individuals and communities at risk for higher rates of HIV transmission.76 Activities implemented as part of this project included increased voluntary testing and counseling, provision of STI services, promotion of 100% condom use and behavior change communication activities. The programs described here – pandemic preparedness and HIV/AIDS prevention – are focused on border areas based on the understanding that these areas are more vulnerable to these risks. There are limited data that provide clear evidence as to the argument that Cambodian border provinces experience significantly higher health challenges. Evidence of vulnerability of border areas used to support specific programs for these areas is often tied to general

71

Cambodia Demographic and Health Survey 2010, Key Findings. WHO, Roll Back Malaria Monitoring and Evaluation Profile, 2005. WHO and UNAIDS, Epidemiological Country Profile on HIV and AIDS.

72

73

74

http://www.iom.int/cms/en/sites/iom/home/what-we-do/migration-health-2/health-promotion-formigrants/pandemic-preparedness-in-lao-pdr-and-cam.html 75

de Sa, J. et al., Responding to pandemic influenza in Cambodia and Lao PDR: Challenges in moving from strategy to operation, South East Asian Journal of Tropical Medicine and Public Health, 41(5), 2010. 76

Sopheab, H. et al., Community action for preventing HIV in Cambodia: evaluation of a 3-year project, Health Planning and Policy, Vol. 23, 2008.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion arguments around vulnerability and risk behaviors of mobile populations, and links to various forms of adverse health outcomes due to these behaviors and risks. Some data supports the argument that border areas are particularly susceptible to challenges in health status and health systems. A small study of Cambodian female returned migrants in a commune close to the border with Thailand illustrates some of the sexual risks experienced by female irregular migrants, including rape and unsafe abortion. 77 Programmatic research has also identified challenges in ARV adherence amongst mobile populations crossing through and returning to Koh Kong province.78 Evidence of high levels of abuse and violence experienced by Cambodian migrants who returned from Thailand indicate that returned migrants are likely to have specific physical and mental health needs that are often left unaddressed, with only 23% of respondents in a survey of returned migrants in Banteay Meanchey province reporting having had a health check in the past two years.79 Drug-resistant malaria has emerged in Thailand-Cambodia border regions, and is thought to be associated with migratory patterns, given that in Thailand, a significant percentage of malaria cases are found amongst short-term labor migrants. 80 One study of migratory patterns amongst Cambodian migrant workers on the Thailand border found that workers were often short-term migrants (had been in Thailand for less than six months), and had plans to return to Cambodia, indicating migratory patterns that constitute risks for spread of drug-resistant malaria.81 Data collected by an electronic malaria information system in districts in Thailand, along the border with Cambodia, identified higher malaria prevalence amongst migrant workers who had been in Thailand for less than 6-months and/ or crossed the border regularly for work, compared to local Thai populations [see Textbox 3 for more on approaches to malaria treatment].82

V.

Migration and border specific health systems issues

77

Hegde, S et al., op. cit. Raks Thai Foundation, op. cit.

78

79

ILO, The Mekong Challenge: Destination Thailand. A cross border labour migration survey in Banteay Meanchey Province, Cambodia, 2005. 80

Containment of artemisinin resistance and moving towards the elimination of Plasmodium falciparum in Thailand. 2010, CCM-Thailand Round 10 malaria proposal to the GFATM. 81

Kamsiriwatchara, A. et al., Artemisinin resistance containment project in Thailand. (I): Implementation of electronic-based malaria information system for early case detection and individual case management in provinces along the Thai-Cambodian border, Malaria Journal, Vol. 11, 2012; Kamsiriwatchara, A. et al., Respondent-driven sampling on the Thailand-Cambodia border. I. Can malaria cases be contained in mobile migrant workers?, Malaria Journal, Vol. 10, 2010. 82

Ibid.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Ratios of indicators for child and maternal health services between rural and urban areas indicate some patterns of disparities of access to maternal and child health services between rural and urban areas. 83 Given border areas are primarily rural, this may broadly indicate challenges to health service utilization in border areas. However, more specifically, data showing utilization of services for reproductive health by province indicates that the border provinces of Battambang, Banteay Meanchey, Koh Kong and Kampot have higher rates of utilization of reproductive health services compared to other provinces, although it is unclear what factors contribute to this.84 It is unclear the extent to which services in Cambodia are “migrant-sensitive,” though notably, the key health strategies and discussion of health services and health systems do not contain reference to migrant populations or migration dynamics from Cambodia. IOM has migrant health programs with a specific focus on border regions, including programs to strengthen migrant health structures, services and systems in selected border provinces, and cross-border pandemic preparedness activities, focusing on capacity building for migrants, host communities and border agencies.85

Textbox 3: Access to artemisinin combination therapy [ACT] for malaria in remote areas Cambodia is the first country to change its national malaria treatment policy to ACT as first-line treatment for P. falciparum malaria, in 2000. 86 Use of artemisinin as a monotherapy response to malaria in the area is not recommended, given concerns about the rise of resistance to artemisinins.87 Strategies to address implementation of this policy have included Malaria Outreach Teams, established and funded by Medicins Sans Frontieres, who go from health facilities in teams to diagnose and treat malaria cases, and Village Malaria Workers, who are based in villages and supervised by the National Malaria Control Programme, and perform rapid diagnostic tests on villagers suspected of having malaria. Since 2001, the Village Malaria Workers program has been scaled up to 1528 villages in 17 provinces.88 A study conducted in four provinces (Battambang, Siem Reap,

83

UNICEF, Maternal, Newborn and Child Survival Country Profile, 2008. Ibid. http://www.iom.int/cms/en/sites/iom/home/where-we-work/asia-and-the-pacific/cambodia.html#mh

84

85

86

Yueng, S. Cost of increasing access to artemisinin combination therapy: the Cambodian experience, Malaria Journal, 7(84), 2008. 87

Resistance to artemisinin derivatives along the Thai-Cambodian border. Wkly Epidemiol Rec, 82(41):360, 2007.

88

Lim, S. et al., Promoting community knowledge and action for malaria control in rural Cambodia: potential contributions of Village Malaria Workers, BMC Research Notes, Vol. 5, 2012.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Odar Meanchey and Koh Kong) sought to compare malaria diagnosis and treatment in three different types of areas: with Mobile Outreach Teams, with Village Malaria Workers, and with no intervention, finding low utilization of ACTs overall, given the majority of patients seek care in the private sector, which is largely unregulated and primarily provides artemisinin monotherapy for malaria treatment. The presence of Village Malaria Workers, in particular, significant increased the likelihood of receiving an accurate diagnosis and appropriate treatment.89 Various other studies have emphasized the role of Village Malaria Workers in providing information about malaria transmission and services for diagnosis and treatment comparable to that of health centers (although Village Malaria Workers were found to be less effective than health centers in informing villagers about malaria symptoms). 90 One study found that the low level of knowledge of malaria transmission routes amongst Village Malaria Workers, while still finding that they effectively conduct diagnosis with rapid diagnostic tests and provide appropriate treatment.91 Another study examined Village Malaria Workers’ knowledge and quality of service provision for malaria after scale-up of services to expand their scope to include treatment of fever, diarrhea and acute respiratory infection in children under 5, finding that service quality was retained. 92 Village Malaria Workers have also been found to be a strong source of surveillance, as well as providing high quality diagnosis and treatment.93 Approaches to address barriers in implementation of this strategy, including rapid diagnostic tests and interventions to improve identification and treatment of malaria, are relevant for border health, in that drug-resistant malaria has been identified as a significant concern in areas along the Thailand-Cambodia border, and malaria is thought to specifically affect mobile communities and vulnerable populations living in remote areas. Therefore, while these strategies are not specifically framed as border or migrant health strategies, they can be viewed as approaches to border health given they focus on these specific areas (in the case of the study discussed above, five of the six study sites were in border provinces) and on issues that affect mobile populations and border communities.

89

Malaria access study Lim, S. et al, op. cit.

90

91

Yasuoka, J. et al., Assessing the quality of service of village malaria workers to strengthen community-based malaria control in Cambodia, Malaria Journal, Vol. 9, 2010. 92

Yasuoka, J. et al., Scale-up of community-based malaria control can be achieved without degrading community health workers’ service quality: the Village Malaria Worker project in Cambodia, Malaria Journal, Vol. 11, 2012. 93

Hoyer, S. et al., Focused Screening and Treatment (FSAT): A PCR-Based Strategy to Detect Malaria Parasite Carriers and Contain Drug Resistant P. falciparum, Pailin, Cambodia, PlosOne, 7(10), 2012.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

VI.

Policies, legal frameworks and institutions

Cambodia’s 2010 Policy on Labor Migration for Cambodia recognizes challenges to migrants’ health in Thailand, including lack of access to health services, lack of insurance coverage, and exposure to risks in workplaces that can have long-term health consequences. The policy recommendations related to migration governance primarily refer to migration facilitated through formal channels, and include efforts to disseminate information pre-migration about the risks and benefits of migration, extending protection to migrant workers by posting a labor attaché in receiving countries, and establishing a social welfare or health insurance fund to help migrant workers cope with risks and contingencies while outside of Cambodia. The main legal framework for cross-border migration is the 2003 Memorandum of Understanding between the Governments of Cambodia and Thailand, which seeks to establish legal and organized deployment of migrant workers from Cambodia to Thailand and includes guidelines for safe and legal migration. In 2004, the Government of Cambodia signed the MoU for Joint Action to Reduce HIV Vulnerability Related to Population Movement, and also signed the ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers. Cambodia has signed, but not ratified, the Convention on the Protection of the Rights of All Migrant Workers.

Textbox 4: Migration management policies and practices in Cambodia Various laws and sub-decrees in Cambodia provide for the conditions for potential migrants in Cambodia to register with the Ministry of Labor and Vocational Training and be placed, through a recruitment agency, in a job overseas.94 These decrees include a number of provisions for pre-departure training, while there has been criticism of regulation of recruitment agencies and oversight of working conditions of Cambodian migrant workers in other countries. The primary migration management framework for Cambodians in Thailand is the Memorandum of Understanding between Cambodia and Thailand on Bilateral Cooperation in the Employment of Workers, 2003, and recruitment under the MoU started in 2006. The aim and scope of the MoU is contained in Article 1 and is:

1) Proper procedures for employment of workers; 2) Effective repatriation of workers, who have completed terms and conditions of employment or are deported by relevant authorities of the other Party, before completion of terms and conditions of employment to their permanent addresses; 3) Due protection of workers to ensure that there is no loss of the rights and protection of workers and that they receive the rights they are entitled to; 4) Prevention of, and effective action against, illegal border crossings, trafficking of

94

IOM, Review of Labour Migration Dynamics in Cambodia, 2006.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion illegal workers and illegal employment of workers The ILO noted that between 2006 and June 2007, 3,628 Cambodians had been recruited and sent to Thailand to work under the MoU, and the ILO reports that many Cambodians perceive the formal recruitment process as slow and expensive.95 The MoU is a limited tool to manage cross-border migration of Cambodians to Thailand. The MoU only covers formal, registered migration processes, and irregular migrants – who may already be more vulnerable to exploitation and exposure to health risks – are not provided with regular or specified services under this agreement. However, there are also indications that migrants recruited under the MoU also fail to receive protections, and are vulnerable to high recruitment fees, deduction of salaries and restrictive contracts.96 NGOs in Cambodia have noted that the registration process for Cambodian migrant workers in Thailand has at times been complicated and difficult, and an unknown number of Cambodian migrant workers in Thailand remain unregistered. The lack of capacity of the MoU, registration processes in Thailand, and current migration management policies and practices in Cambodia, to adequately provide for health and social services of migrants, prior to migration, during work in Thailand, and after returning to Cambodia, is thought to have a significant impact on migrants, their families and communities, and as such, on border health overall.

VII.

Data gaps and challenges

While the recent 2010 DHS provides some province-level data, there is a lack of sub-national data available on many indicators, as noted in a study of the availability of sub-national data for the purpose of monitoring the Millennium Development Goals.97 An analysis of the Cambodian Health Information System in 2007 identified significant gaps in data collection at a number of levels, including in population-based household surveys and health service records. 98 Data sources identified in the course of this review indicate that data that focuses specifically on migrants or monitoring the impacts of migratory patterns and migration on migrants themselves,

95

http://www.ilo.org/public/english/region/asro/bangkok/child/trafficking/downloads/trainingonmigrant/1labourmigration-from-cambodia-fact-sheet.pdf 96

Ibid.

97

National Institute of Statistics Cambodia, MDG Data at Sub-national Level: the experiences of Cambodia, MDG Monitoring Workshop, 2009. 98

Health Metrics Network/ Department of Planning and Health Information, Ministry of Health, Cambodia Health Information System: Review and Assessment, 2007.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion their households, and communities, are primarily ad hoc surveys and programmatic reports of varying quality.

Lao People’s Democratic Republic country study I. Background: 99

Lao People’s Democratic Republic (Lao PDR) has a total national population of over 6.2 million , and borders five countries: Myanmar, Thailand, Vietnam, Cambodia, and China. The borders shared between Lao PDR and these countries is a combined length of more than 4,000km with that total broken down to a border of 2,130km with Vietnam, 1,754km with Thailand, 541km with Cambodia, and 235km with Myanmar.100 Lao PDR has several official border crossings with Thailand, Vietnam, and Cambodia; however, there are no official border crossings with Myanmar. Lao PDR is landlocked and primarily covered with mountainous and thickly forested areas, making access to some areas difficult as illustrated by the fact that up to 21% of the population live in areas without roads. In 2010, an estimated 66.8% of the population was living in rural areas.101 The Mekong Basin Disease Surveillance (MBDS) initiative collects cross-border information on 10 provinces in Lao PDR that border Thailand, Vietnam, Cambodia, and/or China: Savannekhet province (Mukdaharn, Thailand; Quang Tri, Vietnam), Champasak province (Stung Treng, Cambodia; Ubon Ratchathani, Thailand), Luang Namtha province (Mengla, China), Bo Kaeo province (Chiang Rai, Thailand), Borikhamxay province (Ha Tinh, Vietnam), Vientiane province (Nongkhai, Thailand), Khammouane (Nakorn Phanom, Thailand; Quang Binh, Vietnam). Within this initiative, Lao PDR is tasked with taking the lead on the strategy to “enhance cross border communication and information exchange” with the goal of setting up cross-border sites for disease control cooperation and disease surveillance information exchange.102 Current demographic estimates report that 37.9% of the population is under the age of 15 years and 3.7% over the age of 65 years.103 The median age as of 2012 was estimated to be

99

http://www.who.int/countries/lao/en/ CIA world fact book Lao PDR health service delivery profile 2012 Emerg Health Threats J 2013, 6: 19944 – http://dx.doi.org/10.3402/ehtj.v6i0.19944 2013 estimate CIA World Fact Book

100

101

102

103

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 21.02 years.104 Although the nation is rural, there are signs of a rural-to-urban shift, which is illustrated by a decrease in the estimated percentage of the population living in rural areas from 72.9% to 66.8% between 2005 and 2010.105 Lao PDR ranked 122th in UNDP’s Human Development Index in 2010. 106 Based on international purchasing power parity (PPP) standards, 33.9% of the population was living on less than US $1.25 in 2008.107 Although the poverty rate has fallen in recent years, it is higher in remote and highland areas. Furthermore, increased poverty correlates with a decreased amount of road or river access. 108 Despite national-level increases in literacy (73% in the population above 15 years of age in 2005) and increases in school attendance, disparities in literacy and school attendance between men/boys and women/girls still exist. Following decades of war and political instability, Lao PDR has experienced GDP growth of 8% in the last ten years and is now classified as a low-middle income country.109 With a GDP of $8.2 billion, Lao PDR’s primary exports are wood products, coffee, electricity, tin, copper, gold, and cassava. Major imports include machinery and equipment, vehicles, fuel, and consumer goods. 110 Trade and economic development plans between countries are currently being implemented or planned. These include improved infrastructure to boost bilateral trade between Lao PDR and Thailand to over $8 billion by 2015 through closer cooperation within the ASEAN Economic Community. For example, Lao PDR and Thailand have agreed to build another Mekong Bridge, linking the Lao province of Borikhamxay with Bung Khan province in Thailand. The two countries have already opened three bridges linking central Lao PDR with Thailand.111 In addition, Lao and Cambodian officials recently agreed to start a Joint Trade Commission in order to promote expansion of trade and eliminate trade impediments between the two countries, with a particular focus on border trade. A main focus of this is aimed particularly at farm productions along the border, along with the establishment of border markets

104

WHO apps.who.int/gho/data/view.country.11900 Country Health Information Profile - WHO Country Health Information Profile-WHO WHO Country Health Information Profile WHO Country Health profile Lao PDR health service delivery profile 2012 in DB World fact book Lao trade portal article

105

106

107

108

109

110

111

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion in order to push development of border trade. 112 Developments such as these mean that increased interactions across border may have implications for health as well and a cross-border approach is warranted to increase cooperation in tackling health concerns. An example of Lao PDR cooperation with neighboring countries to address health concerns comes from a joint survey and programmatic review carried out in Savannakhet, Lao PDR and Quang Tri, Vietnam in 2010 to improve malaria control methods through better cooperation between the two countries.113 The study carried out data collection in randomly selected villages within 5km of the border. It found that malaria prevalence was significantly higher in Lao PDR (5.2%) compared to Vietnam (1.8%). In addition, variations in prevention measures and health seeking behaviors were found. Together, the two countries assessed differences in access to public health facilities and government-led initiatives to control malaria. The need for cooperation was highlighted by the fact that inhabitants of this area, from the same ethnic group, are allowed to freely cross the border by both governments. The result of this study was an improved crossborder collaborative effort between both countries and an agreement to have regular exchanges of malaria surveillance data as well as to jointly carry out standardized malaria control efforts such as indoor residual spraying.

II.

Health status – national level

Since the introduction of market-based economic reforms in 1986, Lao PDR has been undergoing social and economic transformations, which have significantly improved health status and development. However, while Lao PDR has made significant progress in socioeconomic development, the health status remains one of the lowest in the WHO Western Pacific Region due to poor health infrastructure, poverty and inaccessible terrain in the poorest parts of the country. Lao PDR is landlocked between China, Thailand, Vietnam, Cambodia and Myanmar and cross-border disease transmission remains a big issue. There are many health challenges in the country. The 2010 Global Burden of Disease Study found that the highest-ranking causes of years of lost life [YLLs] in Lao PDR were due to premature death, lower respiratory infections, ischemic heart disease, and diarrheal diseases.114 In the same study, it was found that the leading causes of disability-adjusted life years lost [DALYs] were lower respiratory infections, ischemic heart disease, and diarrheal diseases. In addition, among the 10 leading causes of DALYs in 2010 and not 1990 were cerebrovascular disease, major depressive disorder, road injury, and neonatal encephalopathy. Overall, the three risk factors that account for the most disease burden in Lao PDR are household air pollution from solid fuels, tobacco smoking, and dietary risks. The leading risk factors for

112

Lao PDR Trade Portal website Pongvongsa – in DB Global Burden of Disease Country Profile

113

114

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion children under 5 and adults aged 15-49 years were childhood underweight and alcohol use, respectively. A limitation of this national-level data is that these estimates do not break down into subcategories by province and, thus, it is difficulty to know the specifics of burden of disease, mortality, and morbidity for the border areas. This illustrates the increasing burden from non-communicable diseases along with continuing concerns over infectious diseases. It is likely that there is an increased burden of many of these health problems in the border areas, which are less likely to have health facilities and infrastructure for increasing access. Despite current low-level prevalence of HIV/AIDS (0.2% among adults) there is cause for concern due to increases in prevalence among female sex workers. 115 In addition, increases in free trade zones, the opening of more casinos throughout the country, and the easing of migration formalities may result in increasing challenges in the control of HIV/AIDS, along with other communicable diseases. Malaria has been successfully controlled in most areas but at-risk areas still include remote, forested areas. Although recent efforts conducted with Global Fund support have seen positive impacts with falling numbers in confirmed malaria cases, malaria is still a major contributor to morbidity and mortality and 70% of the population still live in areas that put them at risk for contracting malaria. 116 From the Western Pacific Region Health Databank, 2011 Revision statistics, malaria is reported to be the leading cause of morbidity and mortality (4083.17 and 40.09 per 100,000, respectively).117 Maternal and child health is still a pressing issue. There is a high maternal mortality rate and relatively high infant and child mortality rates, despite decreases in recent years. The maternal mortality ratio (MMR) dropped from 656 to 405 deaths per 100,000 live births between 1995 and 2005, infant mortality rate (IMR) from 104 to 70 deaths per 1000 live births, and the under-five mortality rate (U5MR) from 170 to 98 deaths per 1000 live births.118 Further progress has been shown for both IMR and U5MR with a reduction from 20005 estimates to 61 per 1000 live births and 74 per 1000 live births, respectively, in 2010.119 However, these rates still remain of concern in comparison to other countries in the region and globally. In addition, these estimates may be underestimates of the actual situation with high variation between provinces.

115

Country Health Information Profiles - WHO Country Health Information Profiles - WHO Country Health Information Profiles – WHO. Statistical Annex Country Health Information Profiles - WHO WHO Country Cooperation Strategy at a glance

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Of concern for border health, for example, 2005 IMR estimates showed Vientiane Capital with the lowest rate (18) compared with the highest in Sekong province (122), indicating a need to look at variation between border and non-border areas. A 2007 Lao Reproductive Health Survey120 reported that antenatal care and skilled birth attendance had not experienced significant progress in the general population, but did show some improvements among younger women. For the general population, 28.5% of women were seeking antenatal care and only 18.5% of deliveries were taking place with a trained birth attendant present. In addition, a high percentage of women were still delivering at home (84.8%) despite some decrease from the year 2000 (89%). More recent 2009/2010 estimates report that 71% of women receive at least 1 antenatal care visit, 37% delivered with a skilled health worker.121 Progress was shown with regard to use of modern contraceptive methods with an increase from 28.9% to 36.6% between 2000 and 2005 among married women and a decline in the total fertility rate (4.07 between 2002 and 2005 and 3.90 in a 2009 estimate).122 In 2011, there were only two psychiatrists for six million people in Lao PDR and still no plan for a mental health implementation strategy, despite the government having a mental health policy in place. According to the WHO, mental health issues are still “completely new.” Although mental health services are scarce, Valium is allegedly over-prescribed in rural areas. Drug abuse is also a growing concern, although currently poorly reported. Since 2009 there has been an expanded focus on mental health in the Ministry of Health drug treatment program, but no dedicated mental health division. There is limited access to appropriate medication, particularly in rural areas.123 Currently, the majority of provincial hospitals have set up mental health teams comprising of a doctor and two nurses who received a four-day mental health training. Other mental health and neurological diseases issues include management of seizure disorders and psychosis. Food security and malnutrition continues to be a significant problem in Lao PDR with 41% of children under five years old stunted 124 and 7.3% underweight. 125 While 87% of

120

Country Health Information Profiles - WHO WHO Country Cooperation Strategy at a glance Country Health Information Profiles - Annex http://www.irinnews.org/report/92362/laos-mental-health-still-neglected-underfunded Country Health Information Profile - WHO http://www.who.int/countries/lao/en/

121

122

123

124

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion households nationally are reported to be food secure, this is true for only one in three households in rural areas, and the situation is worse in the more vulnerable populations living in remote areas.126

Textbox 1: Joint outbreak investigation of human H5N1 influenza, 2007127

Following an announcement of an avian influenza H5N1 outbreak among poultry in Nong Khai province, Thailand, which borders Lao PDR, a similar outbreak was confirmed in Vientiane, Lao PDR. The Lao PDR Rapid Response Team (RRT) found three suspected human cases. Following this, Lao RRT and Thai Surveillance and Rapid Response Team (SRRT) worked together alongside the respective Ministries of Health to establish confirmation of the first human avian influenza case in Lao PDR. This person was first admitted to a hospital in Lao PDR and two days later was transferred to Nong Khai with notification from the Lao RRT to the Nong Khai Provincial Health Office following shortly thereafter. Together, a joint Lao-Thai investigation began by collecting specimens for testing and was able to illustrate collaboration that strengthened the surveillance system, cooperation between health workforces, and border responses and practices on both sides of the border.

III.

Health systems

Health systems can be assessed according to six building blocks, using standardized indicators proposed by the WHO.128 Available data at the national level, according to each building block, is presented here. i. Health service delivery: There are four levels of administration in the health system: central, provincial, district, and village. The public sector is the primary provider of health services in the country through government owned and operated health centres and district, provincial and central hospitals. Furthermore, the health system is divided into three branches: health care; prevention, promotion and disease control; and health management and administration. 129 Although emerging, the

126

Country Health Information Profile - WHO Emerg Health Threats J 2013, 6: 19944 – http://dx.doi.org/10.3402/ehtj.v6i0.19944 WHO building blocks paper Asante and Roberts, 2011

127

128

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion private sector still remains relatively small with the majority of private sector health service access points being pharmacies. In the public sector, as of 2010, there were 20 general hospitals (4426 beds total, giving a ratio of 0.7 beds per 1000 population), 3 specialized hospitals, 16 provincial hospitals, 130 district-level referral hospitals (separated into Category A with surgical capacity and Category B without surgical capacity), and 862 primary health care centers.130,131 This is in comparison to the 222 private outpatient clinics.132 Combining public and private facilities, 2010 World Bank data show 0.7 inpatient beds per 10,000 population countrywide.133 Due to the fact that the state system is underutilized, particularly in rural areas, efforts have been made to increase access through village volunteers and village revolving drug funds. Through this effort, 5226 villages have been reached.134 Outpatient department visits per 10,000 population, data on the distribution of health facilities per 1000 population, and service readiness scores for health facilities are not available. ii. Health workforce: Lao PDR faces challenges regarding human resources for health such as underfunding of salaries and wages, poor distribution of qualified staff, and limited numbers of qualified health workers. The country is estimated to have 1283 physicians (0.23 per 1000 population) and 5291 nurses (0.93 per 1000 population).135 The total health workforce in 2005 numbered 18017 (3.21 per 1000 population), with approximately 70% of all health workers employed by the Ministry of Health. 136 Furthermore, high- and mid-level medical staff (physicians, nurses and midwives with two or more years of formal training) make up only 23% of the staff under the Ministry of Health (0.74 per 1000 population). A 2012 Health Service Delivery Profile from the Lao PDR Ministry of Health reported 14189 public sector health workers (2.17 per 1000 population), reflecting a critical shortage of staff.137

130

Country Health Information Profile - Annex Country Health Information Profile - WHO Country Health Information Profile - Annex http://data.worldbank.org/indicator/SH.MED.BEDS.ZS Country Health Information Profile - WHO Country Health Information Profile - Annex Country Health Information Profile - WHO Health Service Delivery Profile, 2012

131

132

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The majority of staff working at the district level are mid- and low-level health workers (88%), and physicians represent only 6% of district-level staff. Health centers are primarily staffed by low-level (81%) and mid-level (18%) staff. A pressing problem for the country is the misdistribution of staff. Distribution is poor with regard to geography and facility level with only 2992 regular high- and mid-level medical staff at the health-facility level. This ratio of 0.53 per 1000 population is well below the 2.5 WHO recommendation. 138 Rural areas have fewer health staff and recruitment of staff for these areas is often difficult given the remote locations and difficult living conditions.139 Annual number of graduates of health professions by level and field of education is only available for the Pharmacists and Nurses with 53 and 30, respectively, reported in 2005.140 Distribution of Ministry of Health staff by health system level reported in 2005 and 2008 indicate that the majority of workers are at the district level, followed closely by numbers reported for the provincial level (above 4,000 and 3500, respectively for both years). Staff at the central level was 2000 in 2005 and approximately 2400 workers in 2008. The lowest number of Ministry staff are working in health centers (just over 1000 in 2005), but there was an increase in the number of workers at this level by 2008 (over 1500).141 In 2009, 58% of health workers employed by the Ministry of Health were female and 16% were from ethnic minority backgrounds.142

iii.

Health information: The Lao PDR Government collaborates with international organizations to focus on improving health information systems (HIS). According to a 2006 Lao Health Information System Review and Assessment report, health information is still lacking in terms of completeness, timeliness and reliability due mostly to different and uncoordinated data collection methods, often due to donor-

138

Country Health Information Profile - WHO Health Service Delivery Profile, 2012 Country Health Information Profile - Annex Asante, Hall and Roberts, 2011 Asante, Hall and Roberts, 2011

139

140

141

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion driven reporting.143 In addition, the Statistic Division in the Ministry of Health has very limited capacity because they lack supportive legislation, regulation, policies and detailed strategic plans. Furthermore, there is a lack of necessary human resources, financial support and infrastructure that are necessary for developing the health information system into a stronger system. According to this same report, three main sections of HIS resources were present, but not adequate: policy and planning, HIS institutions, human resources and financing, and HIS infrastructure. A 2009 National Health Information System Strategic Plan (2009-2015) indicated five areas they aim to improve in order to strengthen HIS in the country: policy and resources; indicators and information products; data management; data sources; and data dissemination and use. 144 However, the report also points out that successful implementation depends on support from the central government (policies, mandates, legislation), adequate funding, proper and increased coordination, improved communication between stakeholders, and continued monitoring of progress. A health information systems performance index score is not available.

iv.

Essential medicines: Data on the availability of 14 essential medicines in public and private health facilities and the median consumer price ratio of the 14 essential medicines are unavailable. A study published in 2008 used a cross-sectional design to assess availability of essential drugs in remote areas in two provinces (Khammouane and Champasak). The study found that average availability of 10 selected essential drugs through the village revolving drug fund (a primary mode of health services in remote areas) was 37%. In some villages, availability was higher due to the presence of a private pharmacy, compared to other villages where only a revolving drug fund program was present. The report further indicates that low availability of high quality essential drugs in the village revolving drug fund appears to be due to poor management, which includes: lack of guidelines and equipment for village health volunteers, no reporting and feedback systems, and no regular monitoring or supervision.

v.

Health financing: The health system relies heavily on donor funding, with external sources accounting for approximately 52% of public health expenditures in 2006.145 Total health expenditures in 2009 were US $226.75 million and total expenditures on

143

Health Metrics Network HMN_Lao_StrPlan_Final_2009_03_en.pdf in DB Asante, Hall and Roberts, 2011

144

145

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion health as a percentage of GDP in the same year was 4.10%. 146 In comparison, private expenditures on health make up 80.9% of total expenditures on health with out-of-pocket expenditures accounting for 61.7% of total expenditures in 2010. 147 Total government expenditures on health were US $43.38 million with expenditures on health accounting for 3.8% of total general government expenditures, much of this going to staff salaries.148

vi.

Leadership and governance: The Ministry of Health’s VIIth Five-Year Health Sector Development Plan (2011-2015) provides the framework for specific directions of the health system. 149 Key components of this framework include strengthening the health system, improving organization, improving quality and reach of health services, and developing a sustainable health financing package. While financial investments outlined in this report show good support for reducing child mortality, combating HIV, and fighting malaria, other areas such as efforts to eradicate poverty and hunger, improve maternal health, and ensure environmental sustainability show, at the time of report publishing, low levels of financial investment. The National Growth and Poverty Eradication Strategy (NGPES) focuses on poverty and the poorest districts for an initial 10 initiatives. Principle health priorities within the NGPES include: information for health, expansion of services to rural areas, improved capacity of health workers, promotion of maternal and child health, immunizations, water supply and environmental health, communicable disease control, control of sexually transmitted infections, development of revolving drug funds for villages, food and drug safety, promotion of traditional medicine, and strengthening sustainability.150 The Government has pledged to increase health spending through support of policy dialogues with key institutions such as the World Bank and International Monetary Fund.151

146

Country Health Information Profile - Annex http://www.who.int/countries/lao/en/ Country Health Information Profile - Annex VIIth Five-Year Health Sector Development Plan - MOH Country Health Information Profile - WHO Country Health Information Profile - WHO

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Specific articles in the constitution obligate the Government to provide particular health services. For example, a new constitutional article enacted in 2004 obligated the Government to improve and extend the health network, disease prevention, and work to create conditions for mothers, children, and the poor – as well as other citizens – can access health care, and legalized private investment in health services.152 Textbox 2: Human resources for health in Lao PDR Lao PDR is facing a severe shortage of health staff and the country is included on the list of crisis countries in terms of health workforce. A key factor contributing to this problem is the low number of recent graduates from universities and occupational training schools. The Ministry of Health has made it a top priority to strengthen this area of the health system. Approaching the problem through the Ministry will be quite useful given that about 70% of the health workforce is working for the Ministry, 63% working at health facilities. A key area to focus on will be attempting to increase coverage of programs in rural areas by finding ways to increase the number of health staff in these areas. 153 In recognition of the problems facing the system with regard to the health workforce, the first National Health Personnel Development Strategy 2009-2020, endorsed in late 2010, addresses key issues and includes needs-based human resource planning, recruitment and retention using new mechanisms of incentivizing. In addition, the strategy calls for review and development of curricula for training health personnel. With regard to the incentives, the strategy will allow the Ministry of Health to adapt incentives schemes according to the needs in each region and by specific category of health personnel. It is hoped that the specialization of incentives will improve recruitment and retention of health staff, particularly in remote and rural areas.

IV.

Migration and border specific health issues

All provinces in Lao PDR have at least one international border, and as such, when examining border health issues, it is important to look at other factors as well, such as the fact that only 32% of the population live in urban areas with the rest residing in mountainous, hardto-reach parts of the country. 154 In some cases, specific health issues are of concern for

152

Country Health Information Profile - WHO Country Cooperative Strategy Country Cooperative Strategy

153

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion particular international borders. For example, more people are found to inject drugs in the provinces bordering China, Myanmar and Vietnam than in provinces bordering other countries.155 Regarding migration flows, the International Office of Migration (IOM) states that limited opportunities for cross-border migration through regular channels creates an environment in which irregular migration is common.156 In turn, this can also lead to increases in smuggling and trafficking in persons – both of which can be risk factors for poor health outcomes and increased vulnerability to communicable diseases. Due to limited job opportunities, it has been reported that annually approximately 60,000 individuals who enter the labour market in Lao PDR are unsuccessful in finding work in the country and, thus, choose to migrate to neighbouring countries in search of economic opportunities.157 In addition, a 2006 study found that 7% of the population migrated for employment.158 Although out migration is considerable, there are also an estimated 200,000 migrant workers officially in Lao PDR from neighboring countries such as Vietnam, China, Thailand, and Myanmar.159 In 2005 it was found that over half of the officially registered Lao migrant workers in Thailand were women. 160 While data does not exist on undocumented migrants, it can be assumed that actual numbers of women migrants is higher. This has implications for health such as the need for health programs that provide continuum of care for women with regard to sexual and reproductive health, in addition to programs aimed at communicable diseases. In addition to women needing specific services, high rates of child migration should also be considered when looking at border-specific health issues. It is estimated that 21.4% of the total population migrating abroad are children under the age of 18 years.161

155

Country Cooperative Strategy

156

IOM country profile: http://www.iom.int/cms/en/sites/iom/home/where-we-work/asia-and-the-pacific/laopdr.html 157

IOM country profile: http://www.iom.int/cms/en/sites/iom/home/where-we-work/asia-and-the-pacific/laopdr.html 158

http://www.migration-unifem-apas.org/laos/

159

IOM country profile: http://www.iom.int/cms/en/sites/iom/home/where-we-work/asia-and-the-pacific/laopdr.html 160

http://www.migration-unifem-apas.org/laos/

161

http://www.migrationdrc.org/news/reports/icm/InthasoneMappingMigration_in_laoPDR.pdf

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Textbox 3: Coordinated response to HIV in border areas Through grants provided by the Asian Development Bank (ADB) since 2012 and Government funding, Lao PDR and Vietnam are currently working to prevent the spread of HIV infections in 23 border provinces. These provinces are locations where risks are growing due to increased population movement and commercial activities along specific economic corridors. Aims of this initiative are to strengthen the HIV response systems of both countries to protect vulnerable populations with information, skills, supplies and access to quality healthcare services. Due to the fact that border regions have some of the poorest and most isolated populations, initiatives such as this are necessary to increase access to health services in these areas, particularly given that these border region areas are also the location of new construction developments such as roads, hotels, casinos, and other businesses. Many efforts to combat the spread of HIV specifically focus on key populations at higher risk in major urban areas, but resources are typically scarce for interventions in more isolated areas. This ADB-funded initiative is a unique step toward increased cooperation and standardization for programs specifically for people living in and moving through the border areas. Of particular interest are the joint pilot activities for HIV services in border areas, involving various state agencies, private sector stakeholders, and nongovernmental organizations. Lao PDR is contributing more than $0.5 million to the overall project (estimated to costs $21.9 million for the overall initiative), which is a promising step toward increased investment from the Government for health initiatives. However, one of the challenges noted for Lao PDR is the level of international aid currently relied upon for programs.

V.

Migration and border specific health systems issues

Given the high mobility of population in and out of Lao PDR, the Government has made efforts to partner with various organizations to strengthen the health system – specifically looking to provide culturally and linguistically appropriate health information for migrants. One example of this partnership is the Migration Health project implemented in partnership between IOM and local government institutions. 162 Migration Health program aims to strengthen the capacity of the Lao Ministry of Public Works and Transportation to locally adapt and test health information materials suitable for HIV prevention work in its different sectors. The majority of this work has focused on creating HIV prevention materials along with information on safe migration. A unique approach of this program has been to create health education materials suitable for outreach activities with construction workers, managers, supervisors, truck drivers,

162

IOM country profile: http://www.iom.int/cms/en/sites/iom/home/where-we-work/asia-and-the-pacific/laopdr.html

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion sex workers, and other mobile populations – particularly those in communities along road project sites. The health of migrants returning to Lao PDR is of concern as well. A study found that prevalence of HIV among migrants returning to Lao PDR was 0.98%, far greater than the national prevalence.163 Because Lao PDR borders a variety of countries, the country is very important for crossborder issues such as the control of infectious diseases, food and drug safety, and environmental health.164 VI. Policies, legal frameworks and institutions

Lao PDR has been a member of the International Labour Organization (ILO) since 1964 and has ratified eight ILO Conventions, including core Conventions covering forced labour, equal rights, discrimination, and child labour. 165 The National Economic and Social Development Plan includes specific language around increasing safe labour migration.166 Lao PDR (and neighboring Thailand) regulations do not acknowledge and protect the rights of domestic workers. The Memorandum of understanding on Labour Cooperation signed by both countries does not acknowledge the domestic sector. Since a vast majority of the out migrating population are women, specifically going to Thailand for domestic work, this gap can contribute towards irregular migration and can increase irregular female migrants’ risk of being exploited or trafficked into Thailand. Of note, however, is that, as of 2004, the Thai Government started registering Lao domestic workers already in Thailand. The Government has institutionalized policies related to agriculture and resettlement to either keep people in place or to resettle them to particular places. The policy restricting land use for shifting agriculture caused an increase in outmigration because of food insecurity, thus impacting overall migration as well as international migration. 167 In addition, economic development led the Government to promote resettlement schemes within rural areas as a way to address inequalities, which led to increases in migration along border areas as well. Both of these movements are typically managed by village authorities, unlike cross-border migration,

163

http://www.gfmer.ch/Activites_internationales_Fr/Laos/PDF-Course-2011/Migrant-labor-context-Lao-PDRChanthavysouk-2011.pdf 164

Country Cooperative Strategy http://www.ilo.org/asia/countries/lao-peoples-democratic-republic/lang--en/index.htm http://www.ilo.org/asia/countries/lao-peoples-democratic-republic/lang--en/index.htm UNFPA report on Regional Migration

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion which is government controlled.168 For example, Lao PDR and Thailand developed a bilateral agreement to regulate labour migration to Thailand in 2002. 169 This bilateral agreement, however, focuses more on documentation of labour migrants and does not specify information about access to health care other than to mention the need for establishing health insurance mechanisms.170 More recent economic development has seen the establishment of economic corridors through the construction of roads linking Lao PDR with neighboring countries, large scale mining and dam construction projects, as well as growth of light industry, all of which have increased migration for economic opportunities. Lao PDR signed the ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers in 2007.171 This declaration recognizes the contributions of migrant workers to society and economic development of both receiving and sending states, while also calling for improved coordination between sending and receiving states to increase data-sharing on matters related to migrant workers. Of note, however, is that health and access to health care are not specifically mentioned in this declaration. Some specific health-related policies are in place. For example, the MOU for Joint Action to Reduce HIV Vulnerability Related to Population Movement, signed in 2001, calls for increased collaboration to strengthen policies and systems aimed at reducing HIV/AIDS vulnerabilities.172 It also calls for cross-sector collaboration that involves Ministries of agriculture, construction, finance, health, home affairs, labour, public works, public security, and transport sectors to reduce HIV/AIDS vulnerabilities caused by migration and mobility.

VII.

Data gaps and challenges

Although province-level data is available from most surveys conducted in the country, such as the Lao Social Indicator Survey conducted in 2011-2012,173 it is difficult to use this information when looking specifically at border health due to the fact that all provinces in Lao PDR have at least some portion that is an international border. Research on specifically done in

168

Asian Development Bank (2009). Migration in the Greater Mekong

Subregion . Manila, Philippines: Asian Development Bank. 169

Asian Development Bank (2009). Migration in the Greater Mekong

Subregion . Manila, Philippines: Asian Development Bank. 170

Thai-Lao MOU_October 18, 2002 ASEAN Declaration_January 2007 MOU HIV_September 5, 2001 Lao Social Indicator Survey (LSIS)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion border areas tends to be topic-specific (i.e. malaria, HIV/AIDS, reproductive health) whereas national statistics such as those collected to monitor progress toward the Millenium Development Goals174 do not allow for analysis of border areas within the provinces.

The Union of Myanmar country study I. Background:

The Union of Myanmar (Myanmar) is estimated to have a total national population of over 48.3 million as of 2011175, and borders five countries: Bangladesh, Thailand, Lao PDR, China, and India. The borders shared between Myanmar and these countries is a combined length of more than 5,876km. For this review, the borders with Thailand and Lao PDR will be considered. Myanmar’s border with Thailand and Lao PDR are 1800km and 235km, respectively.176 The country is diverse in ethnicity and language with over 135 different ethnic groups.177 Eight main ethnic groups are recognized and the country is divided into seven states and seven divisions. 178 Within these 14 states and divisions there are 69 districts, 330 townships, 82 sub townships, 396 towns, 3045 wards, 13,276 village tracts, and 67,285 villages. 179 In recent years, the country’s political environment has been marked by the transition from military rule to a civilian Government in 2011. The country is reported to have 808,075 stateless and 430,400 internally displaced persons.180 The Mekong Basin Disease Surveillance (MBDS) initiative collects cross-border information on three provinces in Myanmar: Tachilek (Chiang Rai, Thailand); Myawaddy (Mae Sot, Thailand); and Kawthaung (Ranong, Thailand). Within this surveillance system, Myanmar takes responsibility for strengthening risk communications. In this capacity, Myanmar takes the lead on documenting experiences of national-level disaster management collaboration within ASEAN and UNICEF.181

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http://mdgs.un.org/unsd/mdg/Data.aspx WHO health profile CIA world fact book http://www.oxfordburmaalliance.org/ethnic-groups.html http://www.unesco.org/education/uie/pdf/country/Myanmar.pdf Country Cooperative Strategy UNHCR country report Emerg Health Threats J 2013, 6: 19944 – http://dx.doi.org/10.3402/ehtj.v6i0.19944

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Current demographic estimates report that 26.7% of the population is under the age of 15 years and 5.2% over the age of 65 years.182 The median age as of 2012 was estimated to be 28.62 years.183 The population reported to live in urban areas as of 2011 was 33%, which means a significant proportion of the population live in rural and potentially hard to reach areas throughout the country.184 Myanmar ranked 149th in UNDP’s Human Development Index in 2010. 185 Based on international purchasing power parity (PPP) standards, 31.9% of the population was living on less than US $1.25 in 2009 and 91.3% on less than US $2.50.186 Differences can be found between poverty levels in rural and urban areas, and the national poverty level, with 20.4% of the urban population living on less than US $1.25 a day and 79.8% on less than US $2.50 per day, compared to 35.9% and 95.3% for rural areas, respectively. In addition, differences can be found between the national-level statistics and individual states and are geographically linked.187 For example, on the measure of less than US $2.50 per day, 92.9% of the population in Kayin State and 91.6% of the population in Shan State live on less than US $2.50 per day, which, when compared to the national-level statistics, may indicate that poverty is more widespread in particular border provinces. The latest Integrated Household Living Conditions Assessment survey indicates that one in every four Myanmar citizens is considered poor.188 According to a World Bank report published in 2010, 92.03% of the adult population (ages 15 and above) is literate.189 However, it is likely that variation between states within the country is considerable.

Myanmar is a developing country with a significant annual economic growth rate of 12% of GDP in 2002-2003, however, variation exists given that some areas of the country benefit less

182

2013 estimate CIA World Fact Book WHO http://apps.who.int/gho/data/view.country.14300 2013 estimate CIA World Fact Book http://hdrstats.undp.org/en/countries/profiles/MMR.html Scoring Poverty_Myanmar Country Cooperative Strategy Country Cooperative Strategy

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http://www.tradingeconomics.com/myanmar/literacy-rate-adult-total-percent-of-people-ages-15-and-abovewb-data.html

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion from the economic advances (particularly rural areas as compared to urban areas).190 The GDP in 2011 was US $51.44 billion.191 Primary exports from the country are oil, natural gas, wood products, rice, and mined minerals. 192 Trade partners in 2011 were reported as Thailand (36.7%), China (18.8%), India (14.1%), and Japan (6.6%) with more recent developments in bilateral trade agreements with countries such as the United States.193,194 Within the region, Myanmar has an agreement with Thailand for construction of a large port and industrial estate in Dawei, estimated to be a 10-year project worth an estimated US $58 billion.195 As has been seen in other settings where development projects take place, this may increase cross-border migration, impact internal migration, and is highly likely to have effects on health status of persons living in the area.

II.

Health status – national level

Throughout the country there is wide variation in access to basic services, such as housing, water and sanitation. From 2005-2010, overall access to safe drinking water increased from 75 to 83%, however, while 81% of the urban population had access to safe drinking water in 2010 only 65% of the rural population had similar access.196 Myanmar has identified protein energy malnutrition and micronutrient deficiencies as the principle nutritional problems in the country. The country is potentially on track to reduce the prevalence of underweight children under age five years, but further intensive interventions are required.197 According to government statistics, the Infant Mortality Rate (IMR), Under Five Mortality Rate (U5MR), and Maternal Mortality Ratio (MMR) have declined between 1988 and 2007. In 2010, the IMR was reported to be 50 deaths per 1000 live births and U5MR 66 deaths per 1000 live births.198 In the same year, MMR was 200 deaths per 100,000 live births.199 However, a

190

Country Cooperative Strategy Myanmar http://www.tradingeconomics.com/myanmar/gdp World Fact Book CIA World Fact Book CIA http://elevenmyanmar.com/business/2619-u-s-and-myanmar-reach-bilateral-trade-agreement http://www.eastasiaforum.org/2012/02/24/thailand-set-to-profit-from-burma-s-new-dawei-port-project/ Country Cooperative Strategy Country Cooperative Strategy Countdown to 2015 report 2012

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion joint survey conducted by the Government and United Nations Agencies indicated significant differences between urban and rural areas among regions of the country, with rural U5MR (72.5 per 1000 live births in 2003) almost twice that of urban rates (37.3).200 In addition, UN estimates of MMR report 240 deaths per 100,000 live births in 2008.201 The leading causes of death and illness are tuberculosis, malaria and HIV/AIDS. The TB prevalence rate confirmed by the 2009-2010 nationwide TB surveillance survey is three times higher than the global average and one of the highest in Asia.202 The WHO estimated that there were 506 prevalent and 381 incident TB cases per 100,000 population, respectively, in 2011. Multidrug-resistant TB was found to be 4.2% of new cases and 10% of previously treated patients and only 7% of MDR-TB cases among notified pulmonary TB cases in 2011 received adequate diagnosis, treatment and care.203 Extensively drug resistant TB has been detected since 2007. Approximately 10% of TB cases are co-infected with HIV/AIDS. Over three quarters of the population (76%) live in malaria endemic areas. Morbidity trends of 1988-2011 show the number of malaria cases ranging from 4.2 to 8.6 million per year.204 The HIV/AIDS epidemic is considered to have stabilized nationally since 2000, with higher rates of transmission in particular areas. 205 The prevalence among the general population is 0.61%. The proportion of people aged 15-24 with correct knowledge of HIV has increased from 21% in 2003 to 75.2% in 2007. A major challenge is to scale up HIV treatment, which now covers only 1 in 3 of those in need.206 The country is facing a double burden of diseases – communicable diseases and noncommunicable diseases. Chronic non-communicable diseases with shared modifiable risk factors – tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol includes: cardio-vascular disease, diabetes mellitus, cancer and chronic respiratory disorders. The

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion national STEPS survey, conducted in 2009, reported that the prevalence of hypertension, for example, was 30.99% in males and 29.34% in females among the sample population.207 The WHO and Ministry of Health joint WHO-AIMS report on the mental health system in Myanmar, published in 2006, reported 25 outpatient mental health facilities, 2 day treatment facilities, 17 community-based psychiatric inpatient units and 2 mental hospitals.208 The total number of human resources working in mental health facilities or private practice reported from the same survey found 0.477 per 100000 population. The report does point out, however, that data from remote areas was difficult to collect due to poor transportation and communication. Mental illness is one of the major emerging health problems. Several community surveys conducted between 1976 and 2004 in urban and suburban areas found that mental disorders ranged from 56 to 86 per 1000 population. Psychosis ranged from five to six per 1000 population; mental retardation from one to four per 1000 population; and epilepsy from two to four per 1000 population. Mental health care has shifted from hospital care to community care. However, community-based mental health programmes are implemented in selected townships only.209

III.

Health systems

Health systems can be assessed according to six building blocks, using standardized indicators proposed by the WHO. 210 Available data at the national level, according to each building block, is presented here. i. Health service delivery: The Ministry of Health (MOH) is responsible for raising the health status of the people through provision of comprehensive health services through seven departments for health, planning, and medical sciences.211 The largest is the department of health, which employs 93% of over 58,000 personnel employed and accounts for approximately 75% of the ministry’s expenditure. Other Ministries also run health care facilities (Defense, Railways, Mines, Industry, Energy, Home and Transport). Most private sector services provide ambulatory care, but in-patient private facilities are developing in major urban centres. Community and faith based organizations are also providing ambulatory care and some institutional care and social protection.

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In 2011-2012 there were 987 public sector hospitals with a total number of 54,503 beds – an nearly two-fold increase from 25309 in 1988. 212,213 There are also 1565 rural health centers. However, rural health centers have not increased as hospital beds have, meaning that from 1988 to 2012, the increase in rural health centers was only 17% . The 2012 World Health Survey reports inpatient hospital beds as 6 per 10,000 population, but information is not available on distribution.214 ii. Health workforce: Health staff in Myanmar are comprised of the following general classifications: doctors, dental surgeons, nurses, dental nurses, health assistants, Lady Health Visitors, Midwives, Health Supervisors (1) and (2) and traditional medicine practitioners. 215 Human resources for health are of concern. It is estimated that there are 23,709 physicians (4.6 per 10000 population), 41424 nursing and midwifery workers (8.0 per 10000 population), and 3247 community health workers (0.6 per 10000 population).216 However, it is likely that density of these workers varies greatly by geography. This includes 26,435 medical practitioners, 25,544 nurses and 19,556 midwives. 75% of health workers are women.217 In 2010, there were 2,108 new medical graduates.218 Distribution of the health workforce is shown to be in favor of urban areas with the ratio of doctors per 1000 population in urban and rural areas 0.83 and 0.24, respectively. The same is true for nursing staff with 0.82 and 0.23 per 1000 population for the ratio of nurses in urban and rural areas, respectively.219 Under-staffing in rural areas was confirmed by the Health Systems Survey assessment in 20 Townships, which confirmed that in 50% of locations, 1 staff was covering from between 4000 and 10000 population and every rural health center in the sample had unfilled

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion positions.220 Furthermore, the ratio of midwives to public health supervisors was found to be 11:1 in 2011-2012, far from the idea ratio of 1:1.221 Having more midwives than public health staff means that midwives are taking on more communicable disease control activities, including immunizations, and may be creating a burden of workload for midwives or putting them in the position of dealing with health issues for which they do not yet have proper training and supervision. Community health workers (a broad term for a variety of workers including auxiliary midwives, maternal and child health promoters, malaria volunteers, general community health workers, etc) play an essential role in helping with data collection, facilitating access to treatment, providing surveillance of disease control programs, and conducting health promotion activities. They are seen as key change agents in community health development and work together with other local leaders and local administrative authorities.222

iii.

Health information: An analysis of the six areas of health information systems (HIS) was conducted in 2010 223 and results found that vital statistics and population surveys were adequate, but census functions were considered to be inadequate. Health and disease and health service record were present, but were not considered to be adequate. Data management (data collection methods, estimation methods, etc) was considered to be present but not adequate. In addition, disaggregation and completeness of data was reported to be present but not adequate. While a nationwide GIS mapping of health infrastructure is underway, the system is constrained by lack of village tract-level population data. Finally, there are gaps in the HIS infrastructure regarding data on availability of services, accessibility of services, and acceptability of services.

iv.

Essential medicines: Information on the median availability of selected generic medicines, median consumer price ratio of selected generic medicines, and complete report of access to essential medicines is not available in the 2012 World Health Statistics report.224 It is believed, however, that 80% of essential medicines are produced through domestic sources, however, changes in the

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion essential medicines policy may require more to be sourced externally.225 Stock outs of essential medicines are widely reported and out-of-pocket payment for essential medicines by the population is common.226

v.

Health financing: Total expenditure on health as a percentage of GDP in 2009 was 2.1%. General government expenditure on health as a percentage of total expenditure on health in the same year was 11.3%. Information on the ratio of household out-of-pocket payments for health to total expenditure on health shows 87% in 2011 and out-of-pocket expenditure as a percentage of private expenditure on health in 2009 was 92.4%.227,228 Current resource allocations are made for salaries and infrastructure and there is yet to be a nationwide model for allocation of operational funds to support a comprehensive needs-based plan for States/Regions or Townships.229

vi.

Leadership and governance: The country is networked by a system of health committees from National to Township level. The National Health Committee was founded in 1989. At the national level there is a country coordination mechanism for management and oversight of key diseases and health program interventions. The new constitution of 2008 states that “every citizen shall, in accord with the health policy laid down by the Union, have the right to health care.”230 The National Health Committee and the Township Health Committees across the country are the main drivers for inter-sectoral action on health, along with a system of School Health Committees. Current community participation mechanisms include community-based health workforce, community-based organizations and local NGOs, health committees, INGOs, private sector, and the community. Specifically related to governance of the health workforce, the national health workforce strategic plan sets forth four pillars of the policy which include: strengthening leadership and management, improving availability of human resources for health, improving quality of human resources for health, and

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion ensuring equity in human resources for health – with planned actions ranging from immediate to short-term, and long-term.231

IV.

Migration and border specific health issues

According to 2009 estimates, up to 10% of Myanmar’s population lives overseas, a population that includes migrant workers, asylum seekers, refugees and other temporary or long-term residents living outside of the country.232 The main international migration flows from Myanmar are to other countries in the region, including Thailand, Malaysia, Singapore, Bangladesh, Korea and Japan. Migration from Myanmar to countries in the Greater Mekong Subregion (GMS) accounts for the largest migration flows within the GMS. The number of migrant workers from Myanmar in Thailand is estimated to be between 2-4 million with approximately 1.45 million officially registered as of March 2012, making Thailand the receiving country of the most international migrants from Myanmar out of all receiving countries.233 The official estimates may be lower than actual numbers, however, given that most people from Myanmar have migrated irregularly (i.e. without documentation) and also given the issue of children and dependents of migrant workers for whom there are no reliable estimates. Internal migration and movement of persons is also of issue in Myanmar with estimates between 446000 and 451000 individuals displaced within the country, particularly to and within states bordering Thailand.234 Both international and internal migration has implications for health along the border areas since these areas have often fall outside the reach of Government-led health initiatives. While organizations do exist who provide health services in these areas, there has tended to be a lack of coordination between the Government and these groups.235,236

Disparities in health exist between central Myanmar and more peripheral areas, typically along such areas such as the border with Thailand. For example, a study published in 2006 found that IMR and U5MR were higher among populations living in eastern Burma compared to estimates at the national level.237 This study found IMR to range between 122-135 deaths per

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 1000 live births between 2002-2003 and U5MR during the same time period to be between 276291 deaths per 1000 live births. Furthermore, these estimates show higher rates when compared to national-level estimates for rural areas, as stated earlier in this report. However, townships in Kayin State have reported IMR and U5MR lower than national estimates, which indicates the need for village tract-level standardized data collection in order to identify key areas in need of specific health services.238 Regarding malaria, malaria has been reported to be of more concern in the border areas of Myanmar – with case levels higher than both Myanmar national estimates and the prevalence of malaria in neighboring Thailand. A study published in 2007 explains this difference by comparing cases reported in 2003 in Kayin State, bordering Thailand.239 The study reports that during the year of 2003, the WHO reported 2016 cases in the entire state when two local health organizations reported treating 27000 cases. The implications of malaria along the border are also apparent when looking at the number of malaria cases confirmed and treated in a clinic on the Thailand-side of the border just across from Kayin State, which reported more than 5000 cases in that year. Furthermore, Tak province in Thailand, which borders Kayin State had the highest number of malaria cases that year with migrants from Burma estimated to have 4.4% prevalence of malaria, compared to only 0.2% prevalence among Thai citizens in the province.

V.

Migration and border specific health systems issues

Considering the number of international migrants from Myanmar to Thailand, it is important to looks at ways in which the health systems in both countries can develop to expand coverage of essential services to be inclusive of this mobile population. Village Health Volunteers and Community Health Workers have been utilized by both the Myanmar government and community-based organizations working in the country – and to some extent in Thailand providing services to migrants from Myanmar. For example, the Country Cooperative Strategy for Myanmar points out the role of Village Health Volunteers within State/Division health departments and community-based organizations also utilize similar community-level workers to expand coverage of programs. As noted by the WHO in 2006, Myanmar faces a critical health workforce shortage and suggested that “simplification and delegation” of health tasks could facilitate improved access to care.240 Community-based organizations in eastern Burma have been able to document expanded coverage for malaria control program efforts (from 3000 population to 8000 population coverage between 2003 and 2008) with outcomes of reducing morbidity and mortality from malaria through these efforts.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Due to the fact that international migrants from Myanmar account for the largest flow in the GMS, it is important to address the issue of health system service provision within the country and also collaboration between the Government and neighboring countries for coordination. Considering diversity of language in Myanmar and among migrants – with estimates stating that approximately 30% of migrant workers in Thailand from Myanmar are Tavoy ethnic persons, 25% Karen, 25% Mon, 15% Shan, and 5% Burma (although, reliable statistics are not available and these numbers are only based on estimates) – it is also important to note that this has implications for the health system and its response in terms of how such a diverse group of individuals can access health services and health information during migration and return.241

VI.

Policies, legal frameworks and institutions

Myanmar is currently without a comprehensive and holistic migration policy or an effective migration management body within the Government. 242 The Overseas Employment Service facilitated regular deployment of Myanmar migrants overseas in the past, but this was limited to higher skilled workers to specific locations such as Korea, Malaysia and Singapore. 243 Furthermore, the country has no clear policy to ensure that migration of its workers overseas contributes to the development of the economy in Myanmar and social development in the future. Progress has been shown, however, as evidenced by the shift of responsibility for migration policy development from the Ministry of Foreign Affairs to the Ministry of Labour in 2010 and the first legal process of migration for manual or domestic workers from Myanmar to Thailand by the end of 2011.244 Although these efforts to facilitate formal migration from Myanmar to Thailand did produce a record number of 2 million documented migrants from Myanmar living in Thailand during the last round of registration in 2011, limitations to the process are reported. 245 For example, lack of understanding of the official process, language barriers, and concern about personal safety in registering are reported to contribute to a continuation of informal migration patterns – which can lead to increased vulnerability, including vulnerabilities for poor health outcomes. Despite the formal channels for migration, lack of awareness about the policy and high broker fees continued to lead to informal migration.246

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The Governments of Myanmar and Thailand are seeking to create a process by which formal migration patterns can be further strengthened, however, the Myanmar government’s 11 th National Economic and Social Development Plan 2012-2016 does not explicitly address longterm migration policies to cope with ongoing labour demands in Thailand.247

VII.

Data gaps and challenges

The WHO Country Cooperation Strategy points out that various sources within and outside the Ministry of Health are involved in data generation, which makes comparison difficult due to the fact that data are collected in different ways. 248 Furthermore, some areas are not easily accessible and cross-border and internal migration creates challenges for a comprehensive health information system. Both scope and quality of data are issues related to health information in Myanmar. As outlined in the National Health Plan 2011-2016, development of a stronger health information system is a priority of the Government. 249 In addition, government health officials have themselves pointed out gaps in the health information system with regard to the following areas: data quality (not highly valid), data flow (still a manual process), and timeliness of data (affecting completeness of data).250

Thailand country study I. Background:  Geography The Kingdom of Thailand has a long border with four neighboring countries totally around 5,820 kilometers long as shown in Figure 1. To the north, Thailand is bordered by the Republic of the Union of Myanmar and the Lao People’s Democratic Republic. To the south, Thailand is bordered by the Federation of Malaysia. To the east, Thailand is bordered by the Lao People’s Democratic Republic and the Kingdom of Cambodia. To the west, Thailand is bordered by the Republic of the Union of Myanmar.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion There are 31 provinces lie along the border categorized as follows: Thai-Myanmar border (10 provinces): 1) Chiang Rai 3) Mae Hong Son 5) Kanchanaburi 7) Phetchaburi 9) Chumporn and 2) Chiang Mai 4) Tak 6) Ratchaburi 8) Prachuap Khiri Khan 10)Ranong

Thai-Laos border (12 provinces): 1) Chiang Rai 3) Nan 5) Phitsanulok 7) Bueng Kan 9) Nakhon Phanom 11) Amnat Charoen and 2) Phayao 4) Uttaradit 6) Nong Khai 8) Loei 10)Mukdahan 12)Ubon Rachathani

Thai-Cambodia border (7 provinces): 1) Si Sa Ket 3) Surin 5) Sa Kaeo 7) Trat Thai-Malaysia border (4 provinces): 1) Songkha 3) Yala and Figure 1 Map of Thailand 2) Narathiwat 4) Satun 2) Ubon Rachathani 4) Buri Ram 6) Chanthaburi and

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Source: vidiani.com (Vidiani.com)

 Population Number of population in Thailand in 2010 including Thais and Non-Thais are 65.9 million (Table 1). These figures are based on The 2010 Population and Housing census (1 September 2010) and corrected those using methods in demography. Details for correcting those numbers are in elsewhere (Institute for Population and Social Research, 2013). The number for non-Thai population whose names are not in household registration from the 2010 census is 2.1 million (Table 1). However, based on the data from The Bureau of Registration Administration, Department of Provincial Administration, Ministry of Interior, the updated figure is approximately 4.3 million in 2013 (Table 2), Those non-Thais are categorized into 1) migrant workers and dependants, 2) ethnic minorities, 3) stateless persons, and 4) displaced persons. Table 1 Number of population in Thailand (1 July 2010)

Population Thais, and non-Thais*

Male 31,084,000

Female 32,705,000

Total 63,790,000

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Non-Thais** Total

1,221,000 32,305,000

911,000 33,616,000

2,131,000 65,921,000

* Thais, and non-Thais whose names are in household registration. ** Non-Thais whose names are not in household registration at the same number as enumerated in 2010. Source: Population Projections for Thailand 2010-2040 (Office of the National Economic and Social Development Board, 2013). Table 2 Number of non-Thai population

Non-Thais Migrant workers and dependants Ethnic minorities Stateless persons Displaced persons Total

Male 2,007,707 175,181 139,086 51,584 2,373,558

Female 1,559,976 157,241 142,852 51,080 1,911,149

Total 3,567,683 332,422 281,938 102,664 4,284,707

Source: ข้อเท็จจริ งและตัวเลขเกี่ยวกับแรงงานข้ามชาติและผูม ้ ีปัญหาสถานะบุคคล (Achavanitkul, In Press)

 Economy Border trade volume is as high as 899,783 million Baht in 2011 (of which 62 percent with Malaysia, 18 percent with Myanmar, 12 percent with Laos and 8 percent with Cambodia), increased at 13 percent annually in the past 5 years and is targeted to rise up to 15 percent in the next 5 years by the 11th National Economic and Social Development Plan 2012-2016 (ธานินทร์ ผะเอม, 2012).  Thailand-Myanmar o Three major check points with custom houses: Sanklaburi, Mae Sot, and RaNong o During 2001-2011, border trade volume grew at 16.3 percent annum Thailand-Laos o Two major check points with custom houses: Nongkhai and Mukdaharn o During 2001-2011, border trade volume grew at 18.87 percent annum Thailand-Cambodia o Two major check points with custom houses: Alanyapradesh Klongyai During 2001-2011, border trade volume grew at 17.10 percent annum





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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion As for the ASEAN cooperation and attempt towards a regional single market, the National Economic and Social Development Board (NESDB) has recognized a more significant role of border cities in the national development as international checkpoints boosting trade and tourism ("Spotlight on provinces: Study shows corruption derails development," 2013). The 11th National Economic and Social Development Plan emphasizes the importance of border area development under the 3 principles including to be gateways of regional economic and business activities, to facilitate the connectivity of production and supply chain with neighboring countries, and to create mutual benefit and trust with neighboring countries (ธานินทร์ ผะเอม, 2012). With supports from the current government, border areas being assessed for the potential to be developed as a special economic zone (Ministry of Public Health, 2013e) include; o o o With Myanmar: Mae Sai and Chiang Saen districts in Chiang Rai, Mae Sot district in Tak, Kanchanaburi With Laos: Mukdaharn, Nakhonpranom and Nongkhai With Cambodia: Srakaew

 Relevant human development indicators o Human Achievement Index (HAI) 2009 The 2009 HAI (United Nations Development Programme, 2010) indicated lower levels of human achievement in most of major border provinces as compared to the national average. Mae Hong Sorn, Sra Kaeo, Tak, Sri Saket, Burirum, and Nakhon pranom are listed as the bottom 10 provinces with the least HAI out of the 76 provinces. Other border provinces i.e. Nongkhai, Chiangrai, and Kanchanaburi are not much different, in the rank 61, 59, 55 and 52 respectively of the 76 provinces.

o Education and household income (2007) Population in major border provinces obtained less education than the national average indicated by average years of schooling. Percentage of uneducated population is generally larger, especially among those located along the Thai-Myanmar border, i.e. Kanchanaburi, Chiangrai, Tak and Ranong (Table 3). Household income is also generally lower (Table 3), though the poverty incidence is clearly much higher than the county average figure. This is especially for Tak, Chiangrai (border Session 5: Five Country Health Systems Profile

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion provinces with Myanmar), (i.e.), Srakeao, Ubon rajathani (with Cambodia) and Nakhornpranom and Mukdaharn (with Laos). Table 3 Average schooling year and household income by major border provinces

National Bangkok Sa Kaeo Kanchanaburi Trat Nong Khai Nokhon Phanom Mukdahan Ubon Ratchathni Chiang Rai Tak Ranong

Average schooling year (2007) 7.68 10.11 6.77 6.5 6.87 6.91 6.77 7.34 6.97 6.23 6.45 7.14

% of uneducated population 4.9 3.2 7.1 12.4 8.9 2.7 2.7 3.4 1.7 13.9 14.7 8.7

Household Income 14778 29696 10753 11944 13961 11218 8080 9176 11333 8870 9431 14229

Poverty rate 8.48 1.14 19.85 10.71 6.16 3.37 17.87 14.32 13.69 14.43 17.86 1.96

Source: Thailand Human Development Report 2009: Human Security Today and Tomorrow (United Nations Development Programme, 2010) The results from the tuberculosis knowledge, attitude, and practice(TB KAP) survey (Boonchalaksi, Chamchan, Holumyong, Apipornchaisakul, & Muensakda, 2012) in selected border provinces; Chiang Rai: There are significant socio-economic disparities between Thai and non-Thai populations, i.e. in terms of income and education. Household monthly income of the non-Thai is lower at about two-third of that of the Thai household; about 10,000 Baht and 15,000 Baht, respectively. Nearly all Thai population were educated with about 8.2 years of schooling in average, while three-fourth of the non-Thai was reported received no education and mean of schooling years was at only less than 2 years. Session 5: Five Country Health Systems Profile

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Ubon Rachathani: Similarly to situation in Chiang Rai, socio-economic disparities between Thai and non-Thai populations are also obvious – household income of the non-Thai is significantly lower while the percentage of the uneducated is higher (though not as much as found in Chiang Rai) with lightly lower mean of schooling years as compared to those of the Thai.

II. Health status  Mortality The death rates per 100,000 population by leading causes of death in major border provinces in 2010 are summarized in Table 4. The data is from the National Statistical Office (Statistical Forecasting Bureau). The first leading cause of death was malignant neoplasm which is about 91 per 100,000 population from the whole country. The death rate from suicide, homicide and other injury in Chiang Rai (19/100,000) was almost twice as high as the national level (11/100,000). The death rate from HIV in Ranong (13/100,000) was more than 2 times as high as the national average (6/100,000).

 Morbidity The rates of In-patients per 100,000 population for non-communicable diseases and infectious diseases in major border provinces in 2011 are depicted in Figure 2 and Figure 3, respectively. For non-communicable diseases (Figure 2), looking at the whole country, diabetes mellitus was the main cause of morbidity, the in-patients rate was 730/100,000. The two highest in-patients rates from diabetes were from Kanchanauburi (1,150/100,000) and Trat (1,070/100,000) respectively.

Figure 2 Rates of In-patients for non communicable diseases by major border provinces, 2011

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 -

Rates per 100,000 population

DM HT IHD Stroke

DM = Diabetes mellitus; HT = Hypertensive diseases; IHD = Ischaemic heart diseases; Stroke

Source: Bureau of Non-Communicable Disease (Ministry of Public Heatlh, 2013)

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Table 4 Death rates per 100,000 population by leading cause of death, and major border provinces 2010 Cause of death (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Thai-Myanmar border Whole Country 91.17 51.59 31.42 28.88 25.70 21.61 13.80 11.09 7.01 5.71 Chiang Rai 97.19 61.26 28.92 24.49 28.75 28.08 15.29 19.14 6.27 8.52 Tak Kanchanaburi Ranong Nong Khai 81.64 35.38 13.41 13.19 8.24 26.81 13.73 3.08 5.27 3.96 Thai-Laos border Nakhon Phanom 102.70 31.34 15.95 19.37 10.97 34.90 9.54 5.27 3.42 3.13 Mukdahan Ubon Rachathani 95.83 51.98 36.72 25.22 28.09 38.49 11.61 6.69 7.96 3.43 Thai-Cambodia border Sa Trat Kaeo 87.98 45.10 26.32 53.93 29.64 11.78 15.28 9.94 8.84 6.07 82.55 57.15 28.58 17.69 33.11 21.32 16.78 9.98 8.16 7.71

65.43 35.59 22.00 27.74 20.47 10.33 11.29 11.67 3.83 4.78

63.11 59.77 25.34 24.50 27.73 14.46 14.82 11.36 9.92 4.66

50.43 32.89 18.64 25.77 22.48 9.87 3.84 12.06 6.58 13.16

83.82 35.71 14.76 18.00 11.81 37.19 7.38 5.31 4.13 6.20

Cause of death (1) Malignant neoplasm, all forms; (2) Accidents and poisonings; (3) Hypertension and cerebrovascular diseases; (4) Diseases of heart; (5) Pneumonia and other diseases of lung; (6) Nephritis, nephritic syndrome and nephrosis; (7) Diseases of liver and pancrease; (8) Suicide, homicide and other injury; (9) Tuberculosis, all forms; (10) Human immunodeficiency virus (HIV) disease. Source: National Statistical Office (Statistical Forecasting Bureau)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion On the other hand, for the infectious diseases (Figure 3), tuberculosis was the highest leading cause of in-patient morbidity at the rate of 135/100,000 on the national average. At the province level, the in-patient morbidity rate from malaria was highest in Sa Kaeo (460/100,000) while the national level was 29/100,000.

Figure 3 Rates of In-patients for infectious diseases by major border provinces, 2011

500 450 400 350 300 250 200 150 100 50 0

Rates per 100,000 population

TB HIV DHF Malaria

TB = Tuberculosis; DHF = Dengue Hemorrhagic Fever

Source: Bureau of Policy and Strategy, Office of the Permanent Secretary (Ministry of Public Health, 2013b) The results from TB KAP survey (Boonchalaksi, et al., 2012) in selected border provinces;

Chiang Rai: It is indicated by incidence of minor illness in the past month, inpatient illness and home-care illness in the past 12 months – illness rate reported by the non-Thai were lower than that of the Thai in all categories. The implications might be that the non-Thai are generally healthier than the Thai or, on the other hand, that they might be not healthier but less accessible to health care and services which resulted in the lower reported rate of illness. This is especially for in-patients illness which was obvious that none of the non-Thai reported ever got sick that needed to be admitted for inpatient care in a hospital.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion In terms of health care seeking behavior, Thai population appeared to have more choices of method or place that they would seek for care than the non-Thai did. For example, in case of minor illness, the majority of the Thai reported to seek for care at a public health unit and public hospital and some would go to private clinic or do selfmedication. On the other hand, all of the non-Thai reported to seek for care only at a public hospital. Less choices of treatment method, to some extent, implies less accessibility to care which support our hypothesis about the reason explaining the lower rates of illness of the non-Thai as compared to the Thai. Ubon Rachathani: The incidence of minor illness in the past month of the nonThai was quite indifferent from that of the Thai. Interestingly, though inpatient illness reported by the non-Thai was much lower than the number reported by the Thai (4.8% and 12.6%, respectively), home care illness was reported significantly higher (27.7% and 5.9%, respectively. This evidence, to some extents, reflects limited accessibility to inpatient care of the non-Thai in Ubon Rachathani. Incidence of sickness that results in inability to work or to perform daily activities was found higher among the non-Thai when compared to the Thai (by the definition used in the survey, it is referred to sickness that needs inpatient care or care at home), but most were treated at home rather than to be admitted for inpatient care at a health facility. This is opposite to the Thai’s that most were admitted to a hospital and only some were treated at home. In terms of health care seeking behavior, similar to situation in Chiang Rai, the survey result in Ubon Rachathani also indicated more choices of treatment method of the Thai than those of the non-Thai. For example, when having minor illness, threefourth of the non-Thai did self-mediation and rest went for care as a public health facility. For the Thai, only one-fifth was reported to do self-medication, more than 60 percent went for care at a public facility and the rest around 17 percent went for care at a private facility.

 Reproductive health The maternal health service in Thailand has improved significantly. Figure 4 shows that maternal mortality ratio (MMR), infant mortality rate (IMR), as well as child mortality rate (CMR) have declined steadily. For example, the MMR has decreased from 0.122/1,000 live births in 2007 to 0.089/1,000 live births in 2011. Similarly for crude birth rate (CBR), it has declined from 12.7/1,000 population in 2007 to 12.4/1,000 population in 2011 as shown in Figure 4. When comparing CBR of the major border provinces to the whole country, in 2009, it revealed that CBR in Tak (16.4/1,000) was the highest while the national average is 12.1/1,000 (Table 5). Table 6 summarizes the IMR and MMR in 2011 at the national level and by major border provinces. The MMR in Sa Kaeo (16.2/100,000 live births) was almost twice as high as that of the national level (8.9/100,000 live births). The IMR in Ubon Rachathani

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion was 9.3/1,000 live births which was highest while the national average is at 6.6/1,000 live births. Figure 4 Crude birth rate, Infant mortality rate, Child mortality rate, and Maternal mortality ratio, 2007-2011

16.0 14.0 Per 1,000 live births 12.0 10.0 8.0 6.0 4.0 2.0 0.0 2006 0.122 0.113 0.108 0.102 0.089 7.2 7.3 12.7 12.4 9.9 12.1 9.8 12.0 9.8 7.0 6.6 CBR IMR CMR MMR 12.4

10.0

7.1

2007

2008

2009

2010

2011

CBR = Crude birth rate (per 1,000 population); IMR = Infant mortality rate ( per 1,000 live births); CMR = Chile mortality rate (per 1,000 live births); MMR = Maternal mortality ratio (per 1,000 live births)

Source: Public Health Statistics 2011 (Ministry of Public Health, 2013c) and Statistical Thailand 2011 (Ministry of Public Health, 2013a)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Table 5 Crude birth rate by major border provinces, 2009

Whole Country Thai-Myanmar border Chiang Rai Tak Kanchanaburi Ranong Thai-Laos border Nong Khai Nakhon Phanom Mukdahan Ubon Rachathani Thai-Cambodia border Sa Kaeo Trat CBR = Crude birth rate (per 1,000 population)

CBR 12.1

9.2 16.4 11.6 11.8

10.3 9.9 10.8 11.5

11.0 11.2

Source: Statistical Yearbook Thailand 2011 (National Statistical Office, 2013)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 6 Infant mortality rate and maternal mortality ratio by major border provinces, 2011

Whole Country Thai-Myanmar border Chiang Rai Tak Kanchanaburi Ranong Thai-Laos border Nong Khai Nakhon Phanom Mukdahan Ubon Rachathani Thai-Cambodia border Sa Kaeo Trat

IMR 6.6

MMR 8.9

4.7 1.8 5.3 6.8

0.0 0.0 0.0 0.0

5.6 7.3 7.0 9.3

0.0 14.4 0.0 9.2

6.0 2.7

16.2 0.0

IMR = Infant mortality rate (per 1,000 live births); MMR = Maternal mortality ratio (per 100,000 live births). Source: Public Health Statistics 2011 (Ministry of Public Health, 2013d)

III. Health systems There are several major health insurance schemes for health security for all Thai namely 1) Universal coverage health care 2) Medical welfare for the poor 3) Medical benefits for civil servants and state enterprise employees 4) Social Security and workers’ compensation fund 5) Voluntary health insurance and 6) Others. In 2001, all the schemes covered 71.0% of the population. After the launching of the universal healthcare policy in 2002, the coverage of health security increased to 97.4% in 2009, meaning only 2.6% is without any health insurance ("Thailand Health Profile 2008-2010," 2011).

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

The health systems in Thailand according to the WHO’s Health System Building Blocks are summarized as follows:

1) Service delivery Universal Coverage Scheme (UCS) service delivery network consists of both public and private health facilities. Public health facilities are automatically registered in the delivery network while private health facilities are investigated prior to signing contracts with the UCS. In theory, people are free to choose any facility as their primary care units (PCU). However, in practice, the choices are restricted by small number of facilities that are close to their homes or workplaces. This is particularly true in the rural areas where the people are mainly assigned to public facilities that are close to them (Joint Learning Network, 2013). UCS provides beneficiaries with comprehensive care which focused on health promotion and disease prevention. The coverage includes immunizations, annual physical checkups, premarital counseling, antenatal care and family planning service etc. ARV treatment for HIV/AIDs and renal replacement therapy have also been added into the coverage recently (Joint Learning Network, 2013).

2) Human resources for health Allocation of human resources for health (i.e. doctor, dentists, nurses) as well as facilities (i.e. number of hospital and beds) to major border provinces are found underprivileged (when comparing the provincial figures to the national average) (Table 7). Ratios of population per one doctor, for example, in Sa Keao, Tak, and Nongkhai are as high as 5077, 4467 and 6692 respectively, while the national average is 2893.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Table 7 Ratios of population per health-care provider and population per bed Population Ratio of Population per health-care provider Doctor Dentist Professi Pharmac onal ist Nurse Health facility No. of hospitals No. of beds Popula tion per bed ratio

Whole Country

63,701,703

2,893

13,252

531

7,087

1,513

132,671

480

Bangkok

5,701,995

1,052

7,865

282

3,871

128

21,147

270

Sa Kaeo Kanchan aburi

543,276

5,077

23,621

864

20,895

7

764

711

836,600

5,295

16,404

668

11,305

21

1,571

533

Trat Nong Khai Nakhon Phanom Mukdaha n Ubon Rachatha ni Chiang Rai

220,465

2,826

16,959

338

7,349

8

586

376

910,094

6,692

21,165

840

13,190

19

1,186

767

702,041

8,069

26,002

745

10,801

14

960

731

338,812

6,050

16,134

648

10,267

11

541

626

1,808,422

5,037

19,239

717

8,908

30

3,260

555

1,196,576

3,751

14,773

595

8,486

47

1,977

605

Tak

522,673

4,467

15,373

543

10,453

13

1,244

420

Ranong

182,417

5,365

15,201

407

10,134

5

404

452

Source: Public Health Statistic 2010 (Ministry of Public Health, 2010)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

3) Health information Health information system in Thailand has improved continuously. During the 9th and 10th National Development Plan period (2002-2011), the modern management information system based on the electronic individual cards has been introduced. The new system can link all concerned agencies together and in the future, the smart card will be used to add more functionality to the system. In addition, the National Health Information System Development Program has officially been endorsed by the National Health Commission in 2010 ("Thailand Health Profile 2008-2010," 2011).

4) Medical procurement There is an inequality distribution in high-technology medical devices such as CT scanners, magnetic resonance imaging devices (MRI), extracorporeal shortwave lithotripters (ESWL), and mammography devices. For example, mammography devices are used in large cities, such as Bangkok, about 54.4% (Table 8). High-tech medical devices, for instance, CT scanners, MRI, and mammography devices are in the private sector more than in the public sector (Table 8). Table 8 Number and percent of medical devices Devices Number of devices In Bangkok: In provinces: No. (%) 1. CT scanners 399 128 (32.1) 2. Magnetic resonance imaging devices (MRI) 3. Lithotripters 51 34 (66.7) 74 9 (12.2) 4. Mammography devices 5. Ultrasound devices 215 117 (54.4) 2158 323 (15.0) No. (%) 271 (67.9) 34 (66.7) 65 (87.8) 98 (45.6) 1835 (85) Number by sector Public Private (%) 145 (36.3) 23 (45.1) 48 (64.9) 85 (39.5) 1624 (75.3) (%) 254 (63.7) 2009 Remarks

Total

28 (54.9)

2008

26 (35.1)

2008

130 (60.5)

2009

534 (24.7)

2009

Source: Thailand Health Profile 2008-2010 ("Thailand Health Profile 2008-2010," 2011)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

5) Health financing There are three sources of health expenditure ("Thailand Health Profile 20082010," 2011) which are public sector (42.23%), private sector (57.60%), and international financial aid (0.17%). In 2008, the major source of public sector is government budget, especially through Ministry of Public Health which contributes 24.34%. The largest source of funds of private sector is households which contributes 55.31% in 2008. It slightly dropped from 62.58% in 2002 due to the launch of the universal health-care policy which decreased family burden expenditure. Nevertheless, the large portion of expenditure from households still shows that people pay high cost for services that are not covered by universal health-care scheme, for instance, drug cost for self-care, or visiting a private clinic.

6) Leadership and governance According to United Nations Economic and Social Commission for Asia and the Public (UNESCAP), the eight attribute for the good governance are accountability, participation, transparency, responsiveness, consensus orientation, following the rule of law, effectiveness and efficiency, and equity and inclusiveness. Overall assessment of UCS was concluded as “good enough”. The results of National Health Security Board (NHSB) survey is shown below

Source: Thailand's Universal Coverage Scheme: Achievements and Challenges (Health Insurance System Research Office, 2012)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

IV. Migration and border specific health issues Specific border health issues (in concerns) and challenges are summarized from the Border Health Development Master Plan (Bureau of Policy and Strategy, 2011) and a situation analysis on Health System Strengthening for Migrants in Thailand (Chamchan & Apipornchaisakul, 2012) include the following:  Communicable diseases: Emergence and also re-emergence of major diseases in border areas – i.e. Malaria, TB, STI including HIV and AIDS. Tak, Mae Hong Sorn, and Ranong reported the first three provinces with the highest Malaria incidence in Thailand in 2009. Reproductive health and maternal and child health (especially among the nonThai populations): o o Significantly higher rates of maternal mortality rate (MMR), infant mortality rate (IMR) and crude birth rate (CBR) than the national target. Improper practice of family planning method among the non-Thai population (including migrant workers, ethnic minorities), which result in high fertility rate and number of children born to these groups of population. Health problems of the newborn from infectious diseases and the quality of child-raising are consequent concerns. Risky sexual behaviors and other behaviors due to lacks of health literacy and proper attitudes (i.e. condom use, drug use , tobacco and alcohol use)



o



  

Negative impacts of border situations and its contexts on the performances of local health system i.e. from unrest situations, natural disasters (both natural and man-made ones), irregular migration along the border, large number of vulnerable population, challenges in addressing health needs, as well as in collecting surveillance data, due to political, language and cultural barriers, high mobility of the border population from cross-border movement and relocation. Limitations of referral system from and to the source countries especially for those patients with major infectious diseases Harms from Illegal health products Lacks of sufficient collaboration on border health works among relevant organizations in all sectors (i.e. public and private sectors) and levels (i.e. the central and the local levels)

V. Migration and border specific health systems issues Border specific health system issues (in concerns) are summarized from a situation analysis on Health System Strengthening for Migrants in Thailand (Chamchan & Apipornchaisakul, 2012) include the following;

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion    Availability and responsiveness of health facilities (and equipments), and human resources especially health personnel in the border areas Quality of health services provided by available facilities and personnel Coverage of health insurance or protection to each population group in border areas – i.e. the coverage of the Universal Coverage (UC) and Social Security Scheme (SSS) for the Thai, Compulsory Migrant health Insurance (CMHI) and the SSS for migrant workers, NGOs-run health programs for displaced persons in temporary shelters, and available health schemes for ethnic minorities. Accessibility to health services of the border population, both the Thai and the non-Thai. This issue also relates to the previous issue on coverage of health protection, geographical barriers in the border areas, and migrant insensitive or unfriendly health services which mainly results from language and cultural differences between the health personnel and the non-Thai population.



Barriers and challenges to be addressed in achieving border sensitive health system (with a focus on the non-Thai populations) are as follows On service delivery  accessibility and quality  Inefficient, unsafe and unqualified service delivery due to adverse attitudes of service providers, communication barriers, limited capacity of available facilities, limitation of referral system, discontinuity of service provision and treatment Non-financial barriers of access to health care and services of border population. These are for example, long distance and lacks of public transportation, insufficient outreach activities to the remote population especially for health promotion and infectious disease prevention Financial barriers of care accessibility to some population groups due to incomplete/limited health protection coverage in border areas (i.e. legal and illegal migrant workers and dependants, ethnic minorities, stateless person, and displaced persons)





On human resource  Availability (and responsiveness)   Inadequacy of health personnel, professionals, and other human resources for health Unresponsiveness of existing care providers (in servicing care for the non-Thai groups) due to negative attitudes, lacks of proper awareness and understandings about “health rights” of the non-Thai, and also communication barriers Lacks of supporting health workforce for interpretation, outreach activities on health promotion and disease prevention for border population in remote areas



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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion On health financing  Coverage  Limited and fluctuating coverage of health insurance among the non-Thai, resulting in limited financing resources and risk pooling of the existing health financing schemes (especially the CMHI) Uneven health benefit coverage provided under existing health insurance schemes for the border population (the UC the SSS and CSMBS for the Thai; and the CMHI, SSS and others for the non-Thai) Hugh reliance on the out of pocket payments and hospital exemptions (especially for the non-Thai patients) which result in financial risks to the patient and financial burdens to health facilities in the border areas





VI. Policies, legal frameworks and institutions Targeted on the 31 border provinces of the country, the Ministry of Public Health (MOPH) by Bureau of Policy and Strategy of the Permanent Secretary Office has developed and officially launched the first Border Health Development Master Plan 2007-2011 in 2007 (Bureau of Policy and Strategy, 2007), followed by the second plan 2012-2016 in 2012 (Bureau of Policy and Strategy, 2011). The plans were drafted and implemented with aims to improve the quality of life and health of border populations, including both the Thai and the non-Thai. In order to monitor the implementation according to the master plan, 4 border health indicators (Bureau of Policy and Strategy, 2011) have been adopted by the MOPH encouraging partners in the 31 border provinces to apply. These indicators include, (1) percentage of hospitals in border areas that provide migrant-friendly health services, (2) percentage of migrant populations with health insurance, (3) percentage of health products in border areas that pass the standard criteria of inspection and (4) percentage of health facilities in border areas that has complied with the standard migrant health information system.

VII. Data gaps and challenges Gaps and challenges to be addressed on “monitoring border health” are mainly about weakness in the border health information system (Chamchan & Apipornchaisakul, 2012) which might be summarized as follows.    Lacks of sufficient information of non-Thai population in border areas, especially irregular migrant workers and dependants (demographic and health profiles; i.e. health status and determinants, morbidity, care seeking behaviors) Fragmented, inaccurate, doubtful in term of reliability of the existing data about the non-Thai population from routine health information system Existing data (especially about the non-Thai) is incomparable from different sources

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

 

Though the border health indicators have been adopted by the MOPH, monitoring and evaluation mechanism on the performance of border health work and border sensitive health system are still in concern insufficient IT and technical supports at the local operating level in border provinces

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

References

 

Achavanitkul, K. (In Press). ข้ อเท็จจริงและตัวเลขเกี่ยวกับแรงงานข้ ามชาติและผู้มีปัญหาสถานะบุคคล: Institute for Population and Social Research, Mahidol University. Boonchalaksi, W., Chamchan, C., Holumyong, C., Apipornchaisakul, K., & Muensakda, P. (2012). Baseline Survey on Knowledge, Attitudes, and Practice for Tuberculosis (TB) among Thai Population, Migrant Population and Ethnic Groups, 2011. Nakhonprathom: Institute for Population and Social Research. Bureau of Policy and Strategy. (2007). Border Health Development Master Plan 2007-2011. Nonthaburi: Minsitry of Public Health. Bureau of Policy and Strategy. (2011). Border Health Development Master Plan 2012-2016. Nonthaburi: Ministry of Public Health. Chamchan, C., & Apipornchaisakul, K. (2012). A Situation Analysis on Health System Strengthening for Migrants in Thailand. Nakhon Pathom: Institute for Population and Social Research, Mahidol University. Health Insurance System Research Office. (2012). Thailand's Universal Coverage Scheme: Achievements and Challenges An independent assessment of the first 10 yearrs (2001-2010). Nonthaburi: Health Insurance System Research Office. Institute for Population and Social Research. (2013). การศึกษาเพื่อเตรี ยมการคาดประมาณประชากรของประเทศไทย พ.ศ. 2553-2583: ประชากรฐานและข้ อสมมุติ (1st ed., pp. 127). Bangkok: Office of The National Economic and Social Development Board.

  







Joint Learning Network. (2013). Thailand: Universal Coverage Scheme Retrieved 20 July 2013, from http://www.jointlearningnetwork.org/content/universal-coverage-scheme Ministry of Public Health. (2010). Number and ratio of population per healthcare provider Retrieved 20 July 2013, from http://hrm.moph.go.th/res53/resrep2553.html Ministry of Public Health. (2013a). Maternal mortality Ratio, Infant mortality Rate, and Child mortality Rate, 2006-2010. Statistical Thailand 2011 Retrieved 18 July 2013, from http://bps.ops.moph.go.th/Statistic/Statistical%20Thailand%202011/2.4.pdf

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

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Ministry of Public Health. (2013b). Number and rate of in-patients by province, 2011 Retrieved 20 July 2013, from http://bps.ops.moph.go.th/Healthinformation/index.htm Ministry of Public Health. (2013c). Number and Rates of Live births, Deaths, Infant Deaths, Maternal Deaths and Vital Index, 1997-2011. Public Health Statistics 2011 Retrieved 18 July 2013, http://bps.ops.moph.go.th/Healthinformation/statistic54/2.1_54.pdf from



 

Ministry of Public Health. (2013d). Number of Deaths and Maternal Mortality Rates, and Number of Infant Deaths and Infant Mortality Rate by Region and province, 2007-2011. Public Health Statistics 2011 Retrieved 18 July 2013, from http://bps.ops.moph.go.th/Healthinformation/statistic54/2.2.15_54.pdf Ministry of Public Health. (2013e). แนวทางการพัฒนาเขตเศรษฐกิจพิเศษ Retrieved 20

 

July 2013, from http://dmsic.moph.go.th/news/CabinetSynopsis/g310356.pdf Ministry of Public Heatlh. (2013). Data for Non Communicable Disease Retrieved 20 July 2013, from http://thaincd.com/information-statistic/noncommunicable-disease-data.php?pn=1 National Statistical Office. (2013). Number and crude birth rate per 1,000 population by region and province: 2008-2009. Statistical Yearbook Thailand 2011 Retrieved 18 July 2013, from http://service.nso.go.th/nso/nsopublish/pubs/syb_54/SYB_54_T.pdf Office of the National Economic and Social Development Board. (2013). Population Projections for Thailand 2010-2040 (in Thai) (1st ed., pp. 247). Bangkok: Office of the National Economic and Social Development Board Spotlight on provinces: Study shows corruption derails development. (2013). Bangkokpost. Retrieved from http://www.bangkokpost.com/business/news/356612/spotlight-on-provinces Statistical Forecasting Bureau. Death rates per 100,000 population by leading cause of death, sex, and provinces, 2003-2010 Retrieved 20 July 2013, from http://service.nso.go.th/nso/nsopublish/BaseStat/basestat.html . Thailand Health Profile 2008-2010. (2011). In S. Wibulpolprasert (Ed.). Nonthaburi: Ministry of Public Health. United Nations Development Programme. (2010). Thailand Human Development Report 2009: Human Security Today and Tomorrow. Bangkok: United Nations Development Programme.

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





 

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Vidiani.com (Cartographer). Map of Thailand. Retrieved from http://www.vidiani.com/maps/maps_of_asia/maps_of_thailand/large_detailed _administrative_map_of_thailand.jpg ธานินทร์ ผะเอม. (2012). แผนพัฒนาและนโยบายการจัดการเมืองชายแดน. Paper presented at the ่ ปลี่่ยนแปลง. สัมมนาวิชาการประจาปี 2555 สกว. เรื่ องการจัดการชายแดนในบริบททีเ



Vietnam country study

I.

Background:

Vietnam has a total national population of 87.84 million, and shares extensive borders with China, Lao PDR and Cambodia. As such, using the definition of “border provinces” in Vietnam as a province that borders another country is a limited approach. As highlighted in the accompanying concept paper, “a strictly geographic definition of the boundaries that determine a border region generally, and border health more specifically, is elusive. Simple metrics of distance from the political boundary may not explain the influence on the health of populations near borders that can be exerted at state, municipal, or national and international levels.”251 Vietnam shares a 2,130km border with Lao PDR and a 1,128km border with Cambodia, and a large number of official border crossing points exist in each border. The Mekong Basin Disease Surveillance initiative collects cross-border information on the following areas that border Lao PDR or Cambodia: Quang Tri province (population of 600,500 252 , bordering Savannakhet, Lao PDR), An Giang province (population 2.15 million,253 bordering Takaeo, Cambodia), Kieng Giang province (population 1.704 million, bordering Kampot, Cambodia), Ha Tinh (population 1.228, bordering Borikhamxay, Lao PDR), Tay Ninh (population 1.075 million, bordering Svay Rieng and Kampong Cham, Cambodia), and Quang Binh (population 849,300, bordering Khammouane, Cambodia). The median age of the population in 2010 was 28, and 24% of the population was under the age of 15. 254 Vietnam ranks 127th in UNDP’s Human Development Index. 255 According to the most recent UNDP Human Development Report, 40.1% of the 251

Zúñiga, M. Border Health. In: Sajatovic M., Loue S. Encyclopaedia of Immigrant Health, 2012. Vietnam General Statistics Office, 2010. Vietnam General Statistics Office, 2010 http://apps.who.int/gho/data/view.country.21300 http://hdrstats.undp.org/en/indicators/103106.html

252

253

254

255

70

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion population of Vietnam live on under $1.25 PPP per day, and 28.9% of the population live below the national poverty line. With a GDP of $123.6 billion, Vietnam’s primary exports are clothes, shoes, electronics, seafood, oil, rice and coffee, with major imports including machinery and equipment, steel products, electronics and plastics.256 Internal economic reforms have been significant, and have impacted health systems, health service delivery and health financing. 257 A number of issues relating to trade and economic development may currently and in the future impact border health. There are ongoing efforts to increase economic ties between Vietnam and Lao PDR, 258 with some border provinces also conducting talks to improve economic investment and trade between Vietnam and Lao PDR.259 Vietnam established a special economic zone in Lao PDR in 2011.260 Vietnam has established a number of bilateral economic and trade relationships with Cambodia, including over 60 legal documents for bilateral economic cooperation. In January 2013, the construction of a pilot Vietnam-Cambodia border market began along the border between Tay Ninh province of Vietnam and Kampong Cham province in Cambodia.261 These activities may lead to increased cross-border movement and mobility. Some policies and programs are responding to these challenges – for example, in 2012, the Asian Development Bank announced $20 million in grants and loans to address HIV infection risks in 23 border provinces in Lao PDR and Vietnam, given “risks are growing due to increased population movement and commercial activities along economic corridors.”262

II.

Health status – national level

The 2010 Global Burden of Disease Study found that the highest-ranking causes of years of lost life [YLLs] in Vietnam were cerebrovascular disease, road injury, HIV/AIDS, liver cancer and lower respiratory infections. A 2008 burden of disease study

256

https://www.cia.gov/library/publications/the-world-factbook/geos/vm.html WHO Vietnam Country Office, World Health Organization Country Co-operation Strategy, 2003-2006. http://www.saigon-gpdaily.com.vn/National/2011/6/93744/

257

258

259

http://en.nhandan.org.vn/en/politics/external-relations/item/1772202-vietnam-lao-provincesestablish-trade-alliance.html 260

http://www.sncsez.gov.la/ http://tuoitrenews.vn/business/6233/vietnam-cambodia-strengthen-cross-border-trade http://www.adb.org/news/adb-supports-lao-pdr-viet-nam-addressing-hiv-threat-border-areas

261

262

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion found that amongst men, alcohol use disorders, depression, and road traffic accidents were the three leading causes for disability burden in men, while amongst women the three leading causes were depression, vision loss and osteoarthritis. 263 The leading causes of disability-adjusted life years lost [DALYs] are stroke, road injury, low back pain, major depressive disorder and chronic obstructive pulmonary disease.264 In 2008, the top five causes of burden of disease measured in DALYs for males were: stroke, road traffic accidents, alcohol use disorders, liver cancer and HIV/AIDS. For females: depression, stroke, vision loss, diabetes and road traffic accidents. For children under age 15, the top 5 causes of burden of disease were: pneumonia, drowning, falls, road traffic accidents and epilepsy. The main causes of death are increasingly related to noncommunicable disease and injuries. Low back pain, major depressive disorder, HIV/AIDS, liver cancer and ischemic heart disease are all in the ten leading causes of DALYs in 2010 and new leading causes since 1990. The Global Burden of Disease study also found that the three risk factors that contribute to the most disease burden in Vietnam are dietary risks, tobacco smoking and high blood pressure, while for children the leading risk factor was childhood underweight. This data is limited to nation-wide estimates, and therefore the implications for border health of the global burden of disease and leading causes of mortality and morbidity in Vietnam is unclear. However, these estimates indicate that i) non-communicable and chronic diseases are increasing in importance, and it is likely that migrants from Vietnam to neighboring countries are impacted by these risk factors and health conditions, and ii) border provides are likely to have less access to treatments for chronic diseases, and iii) while non-communicable and chronic diseases are increasing, communicable diseases are still a significant challenge in Vietnam, with 29% of years of life lost due to communicable diseases compared to 19% on average in the region, with implications for border health due to permeability of borders to communicable diseases.265 Prevalence of HIV per 100,000 people is 283, compared to the regional average of 72. However, important differences in prevalence of HIV in vulnerable and at-risk populations compared to the national average exist – for example, prevalence of 32% amongst injecting drug users in 2002 and of 6.6% in female sex workers.267 Incidence of 266

263

VINE Project, Vietnam Burden of Disease and Injury Study, 2008 Institute for Health Metrics and Evaluation, Global Burden of Disease Profile: Vietnam, 2010. World Health Organization, Vietnam: Health Profile, 2010. Ibid.

264

265

266

267

Hien NT, Long NT, Huan TQ. HIV/AIDS epidemics in Vietnam: evolution and responses. AIDS Education and Prevention 2004;16: 137–54.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion malaria (29 per 100,000 population) is significantly lower than the regional average (104 per 100,000 population).268 Prevalence of TB is 323 per 100,000 (compared to 138 per 100,000 average in the region).269 A number of risk factors for chronic and non-communicable diseases have high prevalence in Vietnam – in 2008, 29.1% of males and 23.3% of females had high blood pressure, while 48% of men aged 15 and above smoke (compared to only 2% of women). 270 There are 339 deaths per 1,000 people due to cardiovascular and diabetes.271 Mental health disorders are prevalent, with a nationally representative epidemiological study showing that the ten most common mental disorders have a combined prevalence of 14.9%, representing around 12 million people in need of mental health services. 272 A range of studies emphasize the prevalence and impact of depression; data shows that 33% of women who attend general health clinics in Ho Chi Minh City are depressed, and that depressive symptoms impact daily functioning and suicidal ideation.273 Data on alcohol abuse is limited; one study showed that 66.7% of men between the age of 25 and 44 years consumed more than 3 standard drinks per day in the previous month.274 Services for mental health services are lacking, with 6.08 beds per 100,000 population for mental health patients, compared to 151.3 per 100,000 for general hospital beds. While community-based mental health programs cover 67% of the population, these activities are limited to epilepsy and schizophrenia.275 In 2010, 79.2% of women received at least four visits of antenatal care, and skilled health personnel attended 97% of births.276 The maternal mortality rate is 59 per

268

World Health Organization, Vietnam: Health Profile, 2010. Ibid. Ibid. http://hdr.undp.org/en/media/HDR2013_EN_Statistics.pdf

269

270

271

272

Vuong, D.A., et al., Mental health in Vietnam: Burden of disease and availability of services. Asian J. Psychiatry, 4(1), pp.65-70, 2011. 273

Cited in Ibid. Ibid.

274

275

Giang, K.B. et al, Prevalence of mental distress and use of health services in a rural district in Vietnam, Global Health Action, Vol 3, 2010. 276

http://hiip.wpro.who.int/hiip/

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 100,000 live births.277 The infant mortality rate in 2010 was 19 per 1,000 live births, and under give mortality rate 23 per 1,000 live births. 278 Food security and malnutrition continues to be a significant problem in Vietnam; in 2010, 29.3% of children aged under 5 were stunted and 17.5% were underweight. Many of the challenges identified by the WHO in 2003, in its 2003-2006 Country Strategy for Vietnam, remain, including i) high prevalence of chronic malnutrition amongst under 5s and low birth-weight, ii) continued high burden of infectious, communicable and vector-borne diseases, iii) increase in non-communicable and chronic diseases, including cardiovascular diseases and cancers, and iv) increasing importance of lifestyle in influencing risk factors, including tobacco, alcohol and drug use, injuries and mental health.

Textbox 1: Hypertension management in Vietnam Hypertension is a significant problem in Vietnam, with a national survey finding overall prevalence of 25.1% - 28.3% in men and 23.1% in women. 279 As noted above, high blood pressure is one of the three leading risk factors leading to burden of disease in Vietnam. In another study in Thai Nguyen province, amongst those with hypertension, only 34% knew they had hypertension, and of those, 43% received treatment.280 Noncommunicable diseases are increasingly a significant component of hospital admissions, increasing from 39% of patients in 1986 to 50% in 1996 and 66.3% of all hospital admissions in 2009. 281 A pilot community-based hypertension management program was found to be successful in reducing blood pressure and CVD 10 year risk, and increase the proportion of hypertensives who were treated and controlled,282 showing the feasibility, acceptability and applicability of such an approach in Vietnam. In 2008, the Vietnam National Health Institute developed a national program to target

277

http://hiip.wpro.who.int/hiip/ http://hiip.wpro.who.int/hiip/

278

279

Son, P.T. Hypertension in Vietnam: From community-based studies to a national targeted program, Umea University, Sweden, 2012. 280

Ha, D.A, et al. Prevalence, Awareness, Treatment, and Control of High Blood Pressure: A PopulationBased Survey in Thai Nguyen, Vietnam, PlosOne, 8(6), 2013. 281

Ministry of Health of Vietnam: Vietnam health statistics yearbook 2009. Son, op. cit.

282

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion hypertension, which was approved by the Vietnamese Prime Minister and incorporated into the 2002-2010 Program of Prevention and Control of Non-Communicable Diseases. 283 The program was modeled on the pilot program, including both hypertension management approaches, which included incorporating screening activities into current health programs, building human resource capacity and equipping healthcare staff with guidelines and essential drugs, as well as utilizing information, education and communication activities to improve local awareness, and encourage lifestyle and behavior change. A review of implementation of the overall 2002-2010 Noncommunicable Disease Prevention and Control Program identified limitations in coverage of hypertension programs, but successful implementation of the program for the populations it reached, and the achievement of national guidelines on diagnosis and treatment of hypertension.284 Health service provision in border areas for hypertension would need to include approaches to improve adherence to pharmacological treatment, address lifestylerelated risk factors and improve awareness of hypertension, while simultaneously collecting specific data to illustrate if rates of hypertension in border areas in Vietnam, and amongst mobile populations, are similar or different to the results of national surveys.

III.

Health systems

Health systems can be assessed according to six building blocks, using standardized indicators proposed by the WHO.285 Available data at the national level, according to each building block, is presented here. i. Health service delivery: Health services in Vietnam are organized and delivered at a number of levels. The Ministry of Health represents the central level, providing legislative and policy framework for health services; at the provincial level and district levels, there are technical agencies that assist in health care, including preventative medicine, consultation and treatment and health facilities; at the commune level, which is the primary care units accessible to people and provide primary health care services, early detection of epidemic outbreaks, and

283

Ibid.

284

WHO, Vietnam Noncommunicable Disease Prevention and Control Programme 2002-2010, Implementation Review, 2011. 285

WHO, Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and their Measurement Strategies, 2010.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion treatment of common diseases. 286 There are 10,926 commune health stations and high national coverage – 99% of communes have a health station, while 70% have a doctor and 79% have active village health workers. 287 2010 World Bank data shows that there are 2.17 inpatient beds per 10,000 population and 3.2 outpatient department visits per 10,000 population. There are 20 central hospitals, 63 provincial health offices, 197 provincial hospitals, 63 provincial preventive health centers, 697 district health center offices, 1507 district hospitals/ policlinics, and 3014 district preventive health teams.288 Other data on the proportion of health facilities offering specific services, services readiness scores for health facilities and distribution of health facilities per 10,000 population are not available. ii. Health workforce: There are 12.2 physicians per 100,000 in Vietnam (compared to a regional average of 15.2). 289 Further details on health workforce capacity for mental health care is available in the 2006 WHOAIMS assessment of Vietnam’s mental health system, which found that based on 2004 data, there are 286 psychiatrists in the country (.35 per 100,000), who all work in mental hospitals. 290 According to the same study, there were 2.1 per 100,000 nurses working in the mental health field, compared to 81.9 per 100,000 nurses in all fields. In 2009, there were 1644 midwifery graduates, contributing to a midwifery workforce of over 35,000, as well as over 100,000 community health workers with some midwifery training, leading UNFPA to characterize Vietnam’s midwifery workforce as strong.291 Ministry of Health Statistics indicate that Vietnam’s supply of doctors compares favorably with neighboring countries, while it has less nurses than the regional average.292 Further in-depth data on the occupation and specialization of the health workforce, region and place of work is unavailable; however, the Ministry of Health’s

286

WHO and Ministry of Health, Vietnam, Health Service Delivery Profile 2012. Ibid. Son, op. cit. WHO Vietnam Country Profile WHO-AIMS, Report on Mental Health System in Vietnam 2006.

287

288

289

290

291

UNFPA, State of the World’s Midwives, 2011.

292

Ngoc, N,B, et al, Human Resource for Health in Vietnam and mobilization of medical doctors to commune health centers

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 5 year strategy acknowledges that there is a imbalance in the structure and distribution of the health workforce, especially in rural areas. For further explanation of health workforce issues, see Textbox 2, below. Health information: A 2006 review of Vietnam’s health information system found that systems for collection of health indicators exist at central, provincial and district levels, however, standard indicators such as infant mortality and cause of death is often not collected regularly. 293 More recently, the Ministry of Health stated that health information systems in Vietnam have limited data on causes of death, risk factors noncommunicable diseases and health workforce, amongst other areas, and that collaboration between sectors on collection, dissemination and utilization of health information is weak.294 Essential medicines: Data on the availability of 14 essential medicines in public and private health facilities and the median consumer price ratio of the 14 essential medicines is unavailable. However, it is evident that availability of essential medicines is a public health concern as prices are high – lowest priced generics are 1.09 to 3.4 times the International Reference Price in the public sector and 1.7 to 5.14 times in the private sector. Medicines are highly overpriced compared to average wages – a one-month supply of medicine to treat a peptic ulcer would cost 27 days of average wages. 295 However, a 2009 review noted improvements in domestic supply and production of essential medicines, and improvements in drug distribution, storage and supply. 296 Health financing: In 2010, general government expenditure as a percentage of total expenditure on health was 37.8%, while general government expenditure on health as a percentage of total government expenditure was 7.8%.297 Total per capita expenditure on health (PPP) was $31. Out of pocket expenditure as a percentage of private

iii.

iv.

v.

293

Health Metrics Network, Viet Nam Health Information System Review and Assessment, 2006. Ministry of Health, Five year Health Sector Development Plan 2011-2015. http://www.wpro.who.int/vietnam/topics/essential_medicines/factsheet/en/index.html

294

295

296

Ministry of Health Vietnam and Health Partnership Group, Joint Annual Health Review: Human Resources for Health in Vietnam, 2009. 297

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion expenditure on health was 92,7%, and a 2011 WHO review of health financing in Vietnam identified serious issues in health financing that create significant hardship for the poorest, despite social health insurance schemes.298

vi.

Leadership and governance: The Ministry of Health provides leadership in the area of planning and strategy for health. The Ministry of Health’s 5 year health sector plan emphasizes the following areas: preventative medicine, communicable disease prevention, health education and school health, maternal and child health, and HIV/AIDS control amongst other areas. Other key policies, including the Socio-economic Development Strategy (2011-2020) frames overall development policies in Vietnam, and therefore influences the design, financing and delivery of health services, especially for the most vulnerable groups. There are also thirteen national health target programs for prevention and control of specific diseases, including malaria, TB, HIV/AIDS, child malnutrition, diabetes, dengue fever and hypertension.299

Textbox 2: Human resources for health in Vietnam Vietnam faces a severe shortage of human resources for health, specifically in distribution of health workers across the country. The Ministry of Health 5 year health sector plan states, “[m]igration of health workforce from lower to higher level, rural to urban and from public to private sector and high level facilities has reached an alarming rate, which affects secure availability of health workers in rural, mountainous and the grassroots level.”300 The 2009 Joint Annual Health Review also identified distribution of human resources for health across the country as a central problem in health workforce issues.301 Ministry of Health statistics from 2003 show that in some regions, only 22.6% of commune health centers had doctors, compared to 82.6% in more urban areas. Other data shows that while 84% of the health workforce is in rural areas, there are often open posts at the commune level, and some staff who are employed have inadequate skills for their expected role and tasks.302

298

WHO, Health Financing Review of Vietnam, with a focus on Social Health Insurance, 2011. Ministry of Health Vietnam and Health Partnership Group, op. cit. Ministry of Health, Five year Health Sector Development Plan 2011-2015. Ministry of Health Vietnam and Health Partnership Group, op. cit.

299

300

301

302

Dieleman, et al. Identifying factors for job motivation of rural health workers in North Viet Nam, Human Resources for Health, 1:10, 2003.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion The Government has implemented policies to address the lack of health workforce in rural and remote areas, including financial incentives designed to attract and retain the health workforce in these areas, of up to 70% additional salary for attraction to ‘hardship areas,’ and 70% extra salary for retention.303 Moreover, a study has shown that nonfinancial incentives for health worker quality improvement in rural areas is important, including appreciation, support and feedback from managers, which was found to often not be forthcoming, or limited, for example, using appraisal sessions for administrative purposes, rather than to adequately provide feedback.304

Policy analysis has concluded that efforts to attract and retain health workers to rural and remote areas have thus far been inadequate, for example, that the policy is “lacking in terms of concrete guidance and mechanisms for monitoring policy implementation, conditions such as budget resources, [and] accountability and responsibility to implement policies.” 305 Recommendations include to improve non-financial incentives, increase performance management incentives to improve quality,

IV.

Migration and border specific health issues

The comparative study of migration from Lao PDR, Myanmar, Cambodia and Vietnam discussed in the introduction to these five country papers found that in the case of Vietnam, as distinct from other countries, migrants primarily travelled with relatives and friends to Thailand to work. However, similar to migration experiences from other countries, once in Thailand, they often experienced difficult and harsh working conditions.306 Data on health issues in border regions and specific to migrants to neighboring countries is sparse. One project – Community Action for Preventing HIV/AIDS, funded by the Japanese Fund for Poverty Reduction – focused on border provinces in Vietnam, Cambodia and Lao PDR, through an intervention that included HIV prevention activities, such as communication, condom promotion and improved STI control. Findings from a

303

Tuan, K.A. Policy Analysis and Mapping on Rural Retention in Vietnam, Asia Pacific Action Alliance on th Human Resources for Health, 7 Conference. 304

Dieleman, et al. op. cit. Tuan, K.A. , op. cit. SERC, A Comparative Picture of Migration in Laos, Myanmar, Cambodia, Vietnam and Thailand.

305

306

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion survey of female sex workers conducted as part of the project in five border provinces in Vietnam - Lai Chau, Quang Tri, An Giang, Dong Thap, and Kien Giang – showed variation of HIV prevalence across the provinces, ranging from 1% in Quang Tri to 7% in An Giang, with factors including age of first sex being under 15, low income and having more than 9 clients per month associated with higher HIV prevalence. 307 These provinces were selected for intervention and research given specific risks and vulnerable groups present in the provinces, including, for example, that HIV infection is high amongst commercial sex workers in An Giang and Kien Giang, which may be associated with mobility of women, fishermen and border traders in these provinces, which border Cambodia.308 UNAIDS data provides further insight into distinctions between HIV prevalence in border and non-border areas in Vietnam. For example, there is data on prevalence amongst injection drug users and female sex workers from 2005 that provides some insight into differences between provinces, as well as statistics on cumulative number of people living with HIV, cumulative AIDS deaths and report new HIV cases by province. However, given many of the non-border provinces are also impacted by significant internal migration, it is difficult to disentangle patterns or causes behind disparities between provinces, and how these disparities might relate to border health issues. Research has also been used to improve understanding of border health issues and promote more effective co-ordination and co-operation. For example, a study of malaria in Savannakhet province of Lao PDR and Quang Tri province of Vietnam demonstrated different prevention, treatment and management approaches between the two bordering provinces. Findings from the survey showed that malaria prevalence was significantly higher in Lao PDR (5.2%) than in Vietnam (1.8%), and that while bed net coverage was high in both provinces overall, in Lao PDR, more than 60% of the nets were long-lasting insecticide treated, while Vietnam used indoor residual spraying. 309 This study showed significant differences in socio-economic status, health-seeking behaviors, and access to health services in districts that share a border, leading to collaboration on revised policy measures to address specific issues relevant to each province, and the border area overall.

307

Thuong, N.V. HIV in female sex workers in five border provinces of Vietnam, Sexually Transmitted Infections, 2005. 308

Baseline Survey Report in 5 provinces – Community Action for preventing HIV/AIDS project, 2005.

309

Pongvongsa, T. et al., Joint malaria surveys lead towards improved cross-border cooperation between Savannakhet province, Laos and Quang Tri province, Vietnam, Malaria Journal, 2012.

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V.

Migration and border specific health systems issues

A health systems analysis of six provinces in Vietnam included analysis of two relevant border provinces – Nghe An, bordering Lao PDR, and An Giang, bordering Cambodia.310 Across a number of indicators of governance, service delivery and human resources, the border provinces did not differ in health systems performance compared to non-border provinces, while in terms of total health spending per capita, the border provinces had lower health spending than the other provinces examined, and lower human resources supply.311 It is unclear from this analysis and other available policy and program documents and data whether border areas in Vietnam experience significant or specific burdens on the health system, and if so, what these issues are. One of the pillars of the Operational Framework for Migrant Health is that migrant-sensitive health systems should exist, including capacity of the health workforce to address migrant health issues. Given the extent of internal migration within Vietnam, the existing data and literature on this theme primarily focuses on access to health services for internal migrants. 312 However, health systems issues, including possible health financing issues in border provinces, or health insurances issues specific to cross-border migrants, are underexplored in the literature.

VI.

Policies, legal frameworks and institutions

One of the pillars of the Operational Framework for Migrant Health is policies and legal frameworks affecting migrant health, and more broadly, border health. This includes the status of key international conventions and protocols in Vietnam. In terms of engagement with migrant health, and border health more broadly, while there are some activities and initiatives that have been described above, the key health strategy does not include specific mention of border health or migrant health issues or challenges, nor specific policy, programmatic or legislative approaches to address these challenges. In the health strategy, rural-urban migration is recognized as a specific risk factor and internal migrants are identified as a potentially underserved and vulnerable group, however, beyond this, migration from Vietnam to neighboring GMS countries is not recognized or addressed. The Government of Vietnam has not signed or ratified the

310

USAID, Assessment of the Health System Performance in Six Provinces in Vietnam 2010. Ibid.

311

312

Webber, G. et al. Facilitators and barriers to accessing reproductive health care for migrant beer promoters in Cambodia, Laos, Thailand and Vietnam: A mixed methods study, Globalization and Health, 2012.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Convention on the Protection of the Rights of All Migrant Workers. However, in 2004, along with the other countries in ASEAN, it signed the MoU for Joint Action to Reduce HIV Vulnerability Related to Population Movement, and also signed the ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers. The Government of Vietnam, with the support of the International Organization for Migration, established a Migrant Resource Center in Hanoi, and conducts outreach activities at the provincial level with the Vietnamese Women’s Union. Another example of these activities is the ILO’s TRIANGLE project [Tripartite Action to Protect Migrants within the Greater Mekong Subregion from Labour Exploitation]. 313 Beyond specific health strategies, it is evident that the policies and legislation of a range of sectors can significantly impact border health, including migration, trade and labor policies. It is unclear the extent to which policies in these areas recognize or contribute towards addressing border health issues in Vietnam.

VII.

Data gaps and challenges

Another pillar of the Operational Framework for Migrant Health is that there should be specific monitoring of migrant health. From a border health perspective, this monitoring can be used to inform cross-border policies and programs. However, beyond regular data collection conducted as part Demographic and Health Surveys and population-based surveys, and some ad hoc studies discussed in this paper, there is a lack of specific monitoring of migrant health, and relevant border health data is lacking .

Policy recommendations  Governments and key stakeholders should establish and support cross-sector (labour, migration, and health) programs that support a continuum-of-care model for individuals throughout the migration process. o Expand the scope from the health sector alone to include other sectors such as social service organizations to increase reach into communities for health programs Continue and expand coordination between countries in the region to promote health, disease prevention, care and treatment along border areas. o Multi-country partnerships to make new and existing services more sensitive to the diversity of individuals seeking to access these services (e.g. culturally appropriate, translation to various languages, removal of barriers within the system when possible)



313

http://www.iom.int.vn/joomla/index.php?option=com_content&task=view&id=309&Itemid=294

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Identify and implement feasible, accessible and appropriate health services for irregular migrants to access upon return, as well as approaches to providing a continuum of care of health services during migration processes Develop systematic data collection mechanism at a country-level and, when possible, coordinated efforts specifically along border areas. o Include township, district, and village tract information o Expand monitoring beyond disease outcomes by also focusing on health behavior, utilization of and access to services, barriers to access, occupational safety, housing, and sanitation throughout the migration process o Further refine ‘border health’ to refer to specific districts or provinces in each country, based on more disaggregated data and health needs of specific populations Include community-based organizations specifically working along border areas in program development and data collection. o Compare data collection processes and health programs to create a standardized system o Increase collaboration at the community-level for development of appropriate and effective programs Adapt approaches to increase human resources for health. o Investigate the role of community members, particularly in rural and hardto-reach border areas, in data collection and service provision for health programs o Utilize existing programs – for example, Village Malaria Workers program in Cambodia – to improve access to health services in border areas o Expand focus of capacity building and health service expansion in border areas to beyond infectious diseases (malaria, pandemic flu) Improve understanding of the impact of expanded economic ties and trade on border health. o Conduct collaborative scoping studies, with economic and financial actors, to determine the impact of planned economic co-operation and expansion of trade on border health and migration dynamics o Establish communication and co-operation mechanisms to identify and address possible negative impacts Improve understanding of how trends in national health status impact border health. o Collate and analyze province and district-specific data, from Health Information System and Demographic and Health Surveys o Establish procedures to adequately monitor and collect data specifically on migrant health Build on existing border health programs and expand beyond infectious disease focus to address social determinants of health. o



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

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion o Expand focus of capacity building and health service expansion in border areas to beyond infectious diseases

Summary and Conclusions These five country reviews illustrate that border health is closely linked with socio-economic determinants, such as development, individual income, nutrition, and employment, along with factors including geographic distribution of populations, risk areas for communicable diseases, and location and density of health services. As a result, action steps and policies should be conducted in a multi-disciplinary way in order to account for the various sectors that have a role in influencing border health. Current data are difficult to disaggregate along border areas in many cases and, thus, a standardized and systematic system for collecting, analyzing and sharing information would aid the process of determining potential strategies for developing healthy borders. In the region, several examples of cross-sector coordination and collaboration between countries can be found. These examples should be used to create more platforms from which coordinated efforts to improve health status along border areas can be implemented. In addition, there are several initiatives from these countries that show the benefits of involving community members in programs in order to increase access to, acceptability of, and effectiveness of services. For example, involving community health workers in malaria control efforts and involving various sectors, not only health-specific stakeholders, in efforts to combat the spread of HIV. Particularly for border areas, including a diverse group of stakeholders can increase the likelihood that programs are holistic and take in to account the variety of factors influencing health status along border areas. While countries reported on in this study face challenges in attaining healthy borders, coordinated efforts between countries have shown to be effective in moving toward this goal and, thus, expansion of these types of programs and an increase in standardized and regular information sharing are recommended.

Submitted by Pojjana Hunchangsith, Institute for Population and Social Research, Mahidol University Chalermpol Chamchan, Institute for Population and Social Research, Mahidol University Catherine Lee, Johns Hopkins Bloomberg School of Public Health Sarah Meyer, Johns Hopkins Bloomberg School of Public Health

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SESSION

6 Session: 6 Improving mechanisms for coordination across sectors and borders to better meet health needs

BACKGROUND The economy dynamism of the Greater Mekong Sub-region (GMS) brings both benefits and challenges to the people and governments of these countries. Economic development can bring health gain, as well as new health hazards. Healthy population is a critical contributor to economic productivity. In order to ensure health needs of border populations are met or addressed, it would require not only addressing healthcare access, but also anticipating and managing the potential problems arising from rapid economic development as well as harnessing their benefits. Such an effort requires a multiplicity of institutions, at regional, national, and local levels, and across and beyond governments. Some of the complexities that make finding solutions to the challenges not easy include: 1) The diversity of populations and the health issues associated with population mobility, 2) The health systems are different and the health care entitlements not aligned across borders, with health financing and service delivery reforms being considered more from only a national perspective, and 3) The health issues experienced by the population reflect broader determinants that also go beyond borders, and are influenced by sectors other than health. The notion of ‘healthy borders’ involves consideration of a multiplicity of issues: impacts rising from development projects, drivers of migration, needs of ethnic minority groups, control of various health threats, and health service access and quality in border areas. No single organisation can have responsibility for addressing these underlying determinants of health or the drivers of migration, so stewardship for health of border populations necessarily involves coordination across multiple sectors, and across countries. There are two key constructs that are relevant in thinking about the integrated management of these issues: 1) healthy settings, 2) risk governance. These two frames bring together both the importance of controlling for risks as well as the empowerment of stakeholders to work together, to chart and manage the direction of development for these localities. Core to these constructs are principles of crosscutting assessment processes, participatory decision-making, partnerships, and policy coherence. The aim of this paper is to review current communication, coordination, and collaboration mechanisms for the relevant issues in the GMS. In light of the challenges relate, and to suggest some options to support greater institutional and policy alignment, in light of the challenges for different sectors and the highly complex nature of migration population and border health. The

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion paper will briefly recap the nature of issues that require attention, current institutional arrangements, some possible models for coordination, principles for institutional design, and suggest some options for discussion. Recognising the complex array of actors already working on various issues, the notion of network governance is proposed as central to the way forward.

NATURE OF ISSUES: A BRIEF RE-CAP Population and health Borders are always porous in relation to populations and goods, as well as health issues that arise from intermixing of migrants and local residents. Population migration in GMS is not new, as countries have been tied historically through families and ethnicities, as well as flight from civil conflict and economic opportunities. Rapid economic development has been a more recent driver for population movement. Planned and anticipated investments by private firms, governments, and international organisations support in transportation infrastructure, natural resource extraction, tourism, communications infrastructure, and energy production all contribute to growth in manufacturing, commerce and trade, with requirement for appropriate labour force. Rapid economic development (including development assistance projects, such as industrial, transport and other infrastructure projects), when not well managed, may bring a range of environmental health hazards, such as illegal dumping and use of chemicals and pesticides. Beyond these direct threats, there are also indirect threats, such as land clearance leading to increase in dengue fever, or deforestation for palm oil production for malaria. Mobile populations are particularly at risk for communicable diseases such as sexually transmitted infections, HIV/AIDS, tuberculosis, and malaria. Migrant workers also experience an array of other risks: unsafe working conditions, fear of arrest given lack of legal rights, inadequate health care, lack of access to education, language barriers, low income, social exclusion, prostitution and human trafficking. The lack of rights and entitlements means that migrants with TB and AIDS may not have access to treatment, thus increasing risk of transmission as well as prolonging ill-health. The rise in multi-drug resistant TB and artemisinin-resistant malaria has been related to population movement and inappropriate use and poor quality of medicines. Migrants and residents of border communities share some similar threats while experiencing some different risks. Health needs for both migrants and residents of border communities are met through access to formal and informal healthcare providers, traditional and western medicines procured through a variety of means. Their health also depends on their adoption of appropriate health practices and healthcare seeking behaviours, and action on conditions which give rise to poor health. While their health needs may not be the same, they share similar problems in terms of limited access to good quality health care, especially in the more rural and remote border areas. While migrants experience a range of vulnerabilities, there are also positive outcomes associated with migration, ranging from improved economic situation for individuals and families to narrowing the development gap between regions. Improved socioeconomic circumstances can have positive consequences for both individual and family health. Session: 6, Coordination Mechanism 2

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

Highly complex scenario There are many contrasting issues that make the creation of healthy borders a challenge. Mobility is not just a bilateral phenomenon but may involve multiple countries. Border communities may share common identities with each other, more than they identify with distant national capital cities. Health systems are designed as national entities. However, infectious diseases (eg malaria, TB, other emerging diseases) have no borders, while management of NCDs may be limited by borders even when people traverse borders. Health needs of migrants (and other ethnic minority groups in the border) may be given less priority by the health sector despite their high vulnerability, yet the risk of increase in artemisinin-resistant malaria for all may require high priority to be accorded to mobile populations and border populations Multisectoral responses (eg involving agriculture, education, forestry, transportation, social protection, etc) is required at national and at regional levels to address health hazards and risks, many of which arise from environmental, social, economic, and occupational conditions. Multisectoral responses across nations - such as harmonisation of laws and policies and financing of services - are also needed to align systems to support and improve access to health services for migrants in particular. One of the tensions is that health interests may not align with economic interests, yet healthy populations and communities is a key ingredient in being able to harness the economic benefits of development. Legal position and regulatory harmonisation may be a more significant issue than funding availability for some disease-specific programs. But even when national policies are harmonised, they may or may not be effectively implemented. This is in part a question about local capacities, resources, as well as local interests which may be different from national interests. There may be other political sensitivities about migration as well as about economic and trade interests in the border region, as some illegal activities may be quite lucrative. For border communities, health system financing and regulation issues become bilateral if not multilateral issues, because people may travel to different places to obtain care, have different entitlements to services, experience different quality of care as result of regulatory gaps. Current efforts on universal health coverage are focused on national health systems and may or may not include coverage for migrants. There is need for specific coverage for medicines for TB and HIV infected migrants, drugs for NCDs (such as hypertension, diabetes, cancer) as well as funding for vaccination programs and for institutional delivery. How cross-border health services are paid for require analytical work as well as negotiations within and between countries – and private sector driving economic development may need to be part of the solution for financing prevention. However, private sector interests are diverse and they are less well organised and more difficult to tap. Regional and crossborder strategies and programs also do not fit neatly into donor funding guidelines that are oriented towards national systems. Health service access, be in public or private sector, depends on willingness to access services as well as financing and payment arrangements. Low health literacy may be a barrier to care seeking. Whether the quality of care access is adequate depends in part on regulation of health providers and their training, including their cross-cultural skills. Language differences in the border areas may mean that health education and promotion activities need cross-border Session: 6, Coordination Mechanism 3

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion coordination. Some models for service delivery exist, such as the Migrant Health Program in Thailand (and the Migration Health Policy in Sri Lanka), however, scaling up requires crossnational efforts There have been international, national, and local non-government organisations (NGOs) working in various border communities. These grassroots organisations may be better placed to reach at-risk communities as well as work on integration between resident and migrant communities. However, NGOs tend to work at local, small scale and rely on fundraising which is unpredictable. Although there are some organised networks in place to link NGOs, coordination is voluntary. While there is a need for targeted services for migrants, having health services and health workers, particularly in primary health care, that are culturally sensitive and responsive will benefit all border residents. Overall system development is needed as well as targeted services.

INSTITUTIONAL ISSUES IN COORDINATION AND COMMUNICATION Current issues and networks At present, no single arrangements exist for ensuring that health needs of border populations are met. However, there is a complex array of regional and international bodies - nongovernment organisations as well as intergovernmental and international organisations - playing a relevant role. An inventory is in the Appendix. ASEAN is the main intergovernmental organisation. It has a brief for health sector coordination, like other regional bodies focused on political and economic affairs, such as the European Union, SADC, SPC and CARICOM. ASEAN has a number of technical working groups or task forces and work programmes of relevance to border health issues: pharmaceutical development, emerging diseases, multi-sectoral pandemic preparedness and response, HIV/AIDS, maternal and child health, food safety. ASEAN has a longstanding track record in coordination in the environment sector, such as around the haze problem. Within the framework of APEC, there is also a health working group, but the geographical scope is not focused on the GMS. A range of international organisations have been involved with issues related to migration, migrant workers, and migrant health in the GMS, and each has different mandates and responsibilities. Following the UN General Assembly High-Level Dialogue on International Migration and Development in 2006, The Global Forum on Migration and Development has been initiated as a global process to address interconnections between migration and development in a practical but non-binding way. Following the 2008 World Health Assembly Resolution on Health of Migrants, the WHO and the International Organization for Migration (IOM) has established a cooperation agreement. The shared framework calls for improving the monitoring of migrant health, harmonising policy and legal frameworks affecting migrants’ health, developing migrant sensitive health systems, and adopting partnerships, networks and multi-country frameworks . National migration health policy, such as Sri Lanka, further enunciates such principles as” adopting an inclusive and participatory approach, adopting a whole of government approach, adopting a strong evidence-based approach, establishing a

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion dedicated hub for coordination and knowledge transfer, adopting a pragmatic approach, and actively contribute to regional partnerships Additionally, a range of regional networks also exist in the non-government sector that has been working on issues related to migration in GMS, including health. Many international NGOs have presence in multiple countries in the GMS. There exist regional coordination mechanisms for emerging diseases and pandemics as well as for environmental health. The Regional Forum for Environmental Health works closely with ASEAN as well as the environment sector in each country to address issues ranging from water to waste to chemical hazards. The Asia Pacific Strategy for Emerging Diseases (APSED) provides the framework for implementation of the International Health Regulations (IHR). Strategic plans exist for coordination of emerging diseases, influenza, pandemics. While the WHO leads on technical coordination, there is need for continual multisectoral coordination for disease control efforts, and for securing and maintaining high-level political support. The ASEAN Working Group on Pandemic Preparedness and Response is an example of a regional multi-sectoral approach to strengthen mechanisms and capabilities across sectors and countries. Networks involving international, national and civil society organisations in addressing HIV and mobility have been active for some time in the region. JUNIMA (Joint United Nations Initiative on Mobility and HIV/AIDS in Southeast Asia) brings together international organisations, governments, and civil society organisations to coordinate concerns and actions around population mobility and HIV/AIDS, within a larger framework of health. There is also active network of NGOs – 7 Sisters – that bring civil society voice together on HIV/AIDS issues in the region. There is not a framework for coordination on health system issues. The universal health coverage agenda, coupled with the migration and health dialogue process, may provide the impetus for greater coordination around health systems issues. However, there have been discussions about the need for better communication and coordinated action in relation to regulation of medicines, in order to address such issues as counterfeit, adverse events, substandard quality of medicines, etc. Some of these concerns may involve additional international agencies at national and regional levels, such as INTERPOL. In summary, there are a myriad of issues with or without coordination points/networks in the region. The current coordination nodes – ie organisational entities and issues relevant to healthy borders can be mapped as:

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion communicabl e disease, emerging diseases, pandemic preparedness

migrant workers, migrant women, migrant children

environment al health, environment al impact, one health

HIV/AIDS, sexual and reproductive health

healthy borders

Infrastructur e and other economic development projects

health care, pharmaceutic als, m-health

education, social protection, legal rights

For each of these policy areas, there are complicated processes of policy coordination at national level – eg communication and consultation with other ministries and non-government stakeholders, negotiations for policy alignment, resolution of policy differences, establishing priorities and implementing strategies. This policy coordination process needs to be repeated at regional level (which may be inefficient but protects national interests) or there can be concurrent and iterative processes at national and regional levels (which may be more complex but allow for more policy learning and adaptation).

Models? While there is a wide array of regional political and economic development coordination entities, (such as SADC, SPC, CARICOM, and ASEAN) but there are no examples of border health programs as such. Health-specific cooperation or specific health programs are usually in response to leadership displayed by specific national governments or are issues beyond the control of any single government. The EU has adopted policies on cross-border health care, following research undertaken by the European Observatory for Health Systems and Policy. However, their considerations occur within a framework of European integration, including legal frameworks. Regional coordination in Africa and in Central and South America has focused strongly on HIV and mobility, alongside disasters and emerging and re-emerging diseases. In the Asian context, the Colombo Process brings together 11 countries (including China, Vietnam, Thailand) on an informal and non-binding basis, since 2003, to address migration issues including information provision for migrants, employment markets and data collection. Health has not been a featured issue, although this informal dialogue process is one model. Structures can be found for health-focused coordination. The US-Mexico Border Health Commission offers one example of coordination across a wide range of public health issues, but it is less complex than GMS insofar as it involves two countries only, albeit multiple and large states are involved. The focus is primarily on specific health issues and programs (and not systems or legal frameworks). On the northern side of the US, the Pacific Northwest Border Health Alliance (involving 5 US states and 3 Canadian provinces) was established to formalise communication for public health emergencies. Over time, its role has evolved and now fosters Session: 6, Coordination Mechanism 6

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion collaboration in indigenous health, public health laboratories, public health law, emergency medical services, as well as surveillance and emergency preparedness. This coordination effort, however, involves only public health officials. In a more informal vein, the Bi-national Health Week brings together government agencies in seven Latin American countries, public health agencies in the US, academic institutions in US and Mexico, and several major NGOs and healthcare providers as an annual promotional event. The Week fosters solidarity and promotes awareness of various health issues for the Latino population in US and Canada. Although an ongoing network, its main role is advocacy and education. Regional coordination arrangements through networks and working groups are in place in the Asia-Pacific region for a number of health issues: 1) HIV/AIDS – JUNIMA brings together national governments, international organisations, and civil society networks. The non-government networks have been separately such as the 7 Sisters (originally 7 NGOs that link key affected communities) for civil society and the Asia Business Coalition on AIDS as one of few examples of the business community rallying around a health issue in the region (with the intent of establishing national chapters), 2) pandemic preparedness - ASEAN Highly Pathogenic Avian Influenza Task Force set the minimum areas to be addressed for multisectoral preparedness and response (which includes national planning, subnational involvement, whole of society planning, and business continuing for essential services) and involved multisectoral simulation exercise; ASEAN medium term plan on emerging infectious disease involves multiple sectors in strengthening regional capabilities for risk communication, animal-human health collaboration, joint multisectoral outbreak investigation and response standards; ASEAN work plan on multi-sectoral pandemic preparedness and response promotes multisectoral coordination and planning and involves communities in whole-of-society preparedness, 3) APSED (Asia Pacific Strategy for Emerging Diseases) underpins the implementation of the International Health Regulations in WPRO (which includes a range of mechanisms to facilitate regional-level communication, coordination, management and monitoring of the strategy), 4) Mekong Basin Disease Surveillance is a self-organized, sub-regional cooperation spearheaded by health ministries from member countries to collaborate on infectious disease surveillance and control, 5) Regional Forum on Environment and Health brings together ministries of health and environment from ASEAN +3 and Mongolia and has thematic working groups on issues of concern (such as health impact assessment, environmental health emergencies, climate change), and works closely with ASEAN working , 6) APEC has working groups on Emergency Preparedness and on Health (both arise from concerns about health and the economy, with interest in public private partnerships) An Asia-Pacific network of regulatory authorities is under discussion to look at improved communication and regulatory convergence in relation to medicines. There are links to the APEC Life Sciences Forum which brings together stakeholders in health science innovation. Session: 6, Coordination Mechanism 7

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion High-level political coordination has also been seen: 1) An Asia-Pacific Leaders Malaria Alliance was agreed in late 2012 modelled in part on the African Leadership Alliance for Malaria which comprises heads of state and government who aim to use their individual and collective power across country and regional border, 2) The Asia Pacific Leadership Forum on HIV/AIDS and Development served to strengthen political and civil society leadership at country, sub-regional and regional levels, 3) The Alliance for Healthy Cities bring mayors in the Western Pacific Region and other interested organisations together to leverage international cooperation in assisting them to achieve their goal of protecting and enhancing the health of city dwellers. More informal and ad hoc processes can also be seen. Coordination for TB treatment protocols for migrants have been pursued through WPRO workshops, while an MOU is in place for the Greater Mekong Region to harmonise antiretroviral therapies for people with HIV/AIDS, in the context of project coordinated by the ADB. A more intervention-based approach to intersectoral coordination can be seen in relation to work on neglected disease. Specific and differently organised multisectoral interventions may occur as required, such as: agroforestry for food security and nutrition, education and school health, community action on environmental concerns. Intersectoral collaboration is also promoted and practiced in sectors other than health. Examples of interest include: fisheries co-management in Southeast Asia and Southern Africa (although this participatory approach is more at the local level), intersectoral coordination in forest policy in Europe (but this is applied at the national level), and coordinated border management as enunciated by the World Customs Organization as well as those being implemented in the Latin America and Caribbean Region. Another model that may hold promise is the Integrated Population Health and Environment approach.

DESIGNING COORDINATION MECHANISMS Criteria for consideration Coordination is not an end objective in itself, but a means for problem-solving. It can have high transaction cost, but it can also bring longer term system improvements and efficiencies. From that perspective, it is important to establish some criteria as the basis for assessing various approaches to coordination. Some potential criteria for assessing merits of coordination mechanisms in addressing health issues in the border areas of the GMS could be:    It should help resolve current bottlenecks (eg information, financing, regulation, etc) for action It operates efficiently, to achieve policy alignment, resource mobilisation and decisionmaking It provides benefit from economy of scale without excessive transaction cost 8

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion    It integrates with and strengthens existing systems wherever practical or feasible It is inclusive, to ensure key issues, perspectives, and relevant activities have been considered It facilitates transparent communications and fosters institutional trust for meeting mutual interests

If a coordination mechanism is working well, it should, in the longer run, be   Sustainable, and embedding improved policies and practices in existing systems An adaptive system, able to take on related issues, rather than having new entities created each time an issue arises

Underlying principles for institutional design The earlier recap of key issues in the border areas of RMS has pointed to the myriad of health issues and the need for multisectoral response. Managing cross-border issues – across 5 countries, with multiple sectors - is complex. In each country, stakeholders exist within and outside governments, health systems, across other sectors, in local resident and migrant communities. Improving coordination is not a simple task, and there is no simple model to duplicate, although there are relevant experiences. The fundamental question is how ‘governance for health’ is best designed within a complex system – indeed to create a system to connect multiple systems. When problems are simple, they can be solved through bureaucratic, command and control systems. Problems that are complicated but easily defined will be effectively solved through ongoing coordination. In dynamic systems, where problems change and their management involve networks of actors who are linked in multiple ways, then how best to link the network of actors is the challenge for governance design. In networked systems, there will be need to build trust and partnership relations, as well as ensuring there are incentives and resource exchange. In other words, given the effort required to interact with multiple stakeholders, the system needs to be designed such that there will be productive outcomes for all concerned. Not all stakeholders need to be involved in everything or in the same manner. Specific forms of engagement will depend on objectives, and require different levels of effort. The more actors involved, the higher the transaction cost, as more time and efforts are required to manage the interface between actors.

Thus, a ladder of participation might be: Information (provision) Community at large Beneficiaries/ communities x x x Consultation (feedback) Cooperation (resource sharing) Coordination (align work) Collaboration (Joint activities)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion at-risk Service providers Government agencies

x x

x x x x

Coordination mechanisms can evolve over time. Sharing information in order to management matters of mutual interest helps to achieve a common understanding, which can lead to sharing of resources if not greater alignment of work. For some issues, an enhanced and formalised information and communication system (such as disease reporting, or reporting of counterfeit medicines) would help resolve bottlenecks in implementation action. Even where officials in programmatic areas are already networked, ross-border coordination may require more formalised information and communication arrangements. Over time, trust and shared understanding – between institutions, via actors who represent them – will lead to more collaborative activities, and the effective functioning of any network. The creation of a safe policy space, sometimes through more informal mechanisms of consultation can help with evolution of coordination mechanisms, and MBDS and APEIR are two examples of trust-based, bottom-up approaches that have become more formalised over time. A more formalised approach may be the preferred starting point for national governments. As a country example, Switzerland’s cross-border cooperation began with classical inter-state agreements on specific priority issues and evolved to mutual exchange of information and closer coordination between agencies. Coordination and collaboration obviously take more time to negotiate and may last only so long as people see real benefit (eg reduced transaction cost, real gains in achieving core objectives, fewer boundary disputes, etc). In any case, a focus on the benefits for participating organisations – the return on their investment of human and other resources – is needed, as is attention to good processes (eg transparency, accountability, agreed priorities) that can build trust. Building on enlightened selfinterest may be the best way to achieve sustainable changes in institutional arrangements and practices.

Characteristics of Collaborative Governance for Systems and Networks In summary, effective governance in a networked system will need to incorporate the following elements:        Independent facilitation across networks – ie a clear convening role Clearly identified scope of shared goals, with some agreed shared values Incentives for cooperation A problem-solving orientation Participation by interested and affected parties in all stages of the decision-making process Accountability arrangements – with self-disclosure and shared monitoring System of preventing escalation of problems – ie decision ladder to expediently resolve issues

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  Review, reflection, and adaptation – processes to reassess policies and actions against changing contexts and assumptions, and allowing policy parameters to evolve as well as the coordination mechanism itself

Given the complexity of interests and players in the GMS, the principles of institutional design for governance suggest there is a need to retain a focus on the overriding and shared concern, which is to enable people residing in border regions to be healthier, and to recognise that the role of state actors is to create an enabling framework for protecting and promoting health while involving non-government interests (ie NGOs and businesses) to exercise informed choices and sustainable actions within the broad policy framework.

CHOICES FOR A GENERAL APPROACH Functional coordination A continuum of approaches, for policy, information and financing, might be appropriate to suit the needs of different issues. Arrangements may also progress from a ‘soft’ position and move to a ‘hard’ position over time, as illustrated below: Policy: Policy coordination policy alignment policy coherence Regulatory harmonisation

Information and programming: Information sharing Mandated data sharing Joint activity planning Health-in-All-Policies

Financing: Funding as available Coordinated funding Agreed funding formula Pooled financing

Networking the networks – linking leading nodes in the networks Given the existence of a range of issue-specific networks, it may be more sensible to connect the networks, rather than develop new groupings based on functional split. There are good regional coordination experiences to build on – influenza, disease surveillance, pandemic preparedness, environmental health – and there have been ongoing dialogue on malaria and other communicable diseases, as well as on migration and migrant health. What makes border health distinctive, however, is the very notion of border health, in addressing health conditions, health systems, and diverse populations, brings a new locality- (or Session: 6, Coordination Mechanism 11

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion setting-) based focus to current discussions. In a sense, healthy borders is a model of how ‘health in all policies’ could be applied in the GMS to address shared interests in health and development, taking into account development as a social determinants of health and ensuring governance for health is intersectoral Given the complexity of interrelated issues, and the existence of various networks, one way to conceptualise coordination is to recognise there are leading nodes for different issues, so the coordination task is to create a network of networks. For example: APSED currently leads for emerging diseases, IOM leads on migration policy and social issues, JUNIMA coordinates mobility and HIV issues with focus on migrant workers, Regional Forum on Environment and Health coordinates integrated environmental health plans. In addition, ASEAN provides the framework for economic and social integration and has a track record in environmental policy and management coordination. Furthermore, civil society networks such as Mekong Migration Network and Seven Sisters are able to reach to vulnerable communities, the WHO leads on a range of health issues, and ADB and World Bank are lead organisations on development projects including infrastructure development. APSED communicabl e disease, emerging diseases, pandemic preparedness

NGOs and ACADEMICS migrant workers, migrant women, migrant children

RF on Environment and Health environmental health, environmental impact, one health

JUNIMA HIV/AIDS, sexual and reproductive health

healthy borders

ADB infrastructure and other economic development projects IOM education, social protection, legal rights

WHO - health care, pharmaceutic als, m-health

Where an existing network is working well, there should be no duplication. While the networks may have different functions and objectives, existing networks could be asked to expand their brief where the new issue requiring attention has natural links with the existing network. New networks should be developed to reflect priority areas of work and can be terminated when it is no longer needed. A coordinating framework/system for the leading nodes in the region will need to be developed and its role should be to facilitate interactions in timely manner on strategic and critical issues. A governance framework also needs to ensure the alignment of policy development and implementation. From this perspective, the network coordination group will also need to take account of networks and institutions working at local and national levels.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

OPTIONS FOR DISCUSSION Key elements of coordination system – to support information flow, decisionmaking, aligned action, and rapid response Regardless of the final form of any coordination mechanism, there are some specific elements which will be important to have:        Focal points at national level Agreed information sharing arrangements Regional intersectoral technical committees and network of stakeholders (as per models seen in influenza and disaster management) Specific links between sectors and communities based on priority issues and localities for priority interventions/actions Shared alert system where harmonised cross-border action needs to be taken Shared analytical tools – such as a health lens, health impact assessment, or a border health impact lens – that can be applied to policy and project development Accountability to a high level

In the longer run, additional capabilities in a good coordination mechanism might include:     Capacity to consider mechanisms for financing of regional public goods Coordinated advocacy and communication with at-risk communities, particularly in relation to development projects and health threats Processes for national policy/system harmonisation – health care access, social protection, information systems, product regulation, legal rights, etc Processes for donor harmonisation

Some options can be explored within the context of other priority topics and planned action identified at the meeting on healthy borders in the GMS. Below are some different possibilities that could be discussed further: 1) Comprehensive development: create a new entity with terms of reference and secretariat to oversee border health issues in the GMS 2) Existing regional intergovernmental coordination processes: entrust ASEAN to take responsibility for progressing all issues through its various working groups and other new mechanisms that might be established 3) Parallel developments: entrust existing bilateral processes between countries to work out how communication, coordination and policy alignments can occur on specific issues as they emerge 4) Networking the networks: ask existing networks to expand their scope if necessary and align their work program; develop new networks where none exist to take on issues that require attention; form a coordinating group across the networks

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion 5) Pragmatic incrementalism, through regional consultation process or annual dialogues: hold regular meeting of key stakeholders to discuss and determine priority issues for resolution, then assign tasks to existing networks or establish new taskforces/working groups as appropriate, with a time frame to have issues resolved/acted upon and reported back to the regular dialogue forum 6) Brokerage team: establish a small project team who is empowered to negotiate with relevant bodies/ decision-makers to implement coordinated actions on key issues 7) MOUs: develop other MOUs (eg based on the HIV anti-retroviral therapy model in place through the ADB) for specific diseases, treatment protocols, health care and pharmaceuticals access and payments, and any other issues 8) Bilateral framework agreements, including reciprocal health care agreement: develop model agreements for prioritised issues which can be negotiated bilaterally over time, with agreement covering issues of financing, regulation, impact assessment, entitlements, service delivery, data sharing, etc) 9) Bilateral harmonisation plus regional funding mechanisms: develop a framework for harmonisation of laws and regulations with a separate system for pooling funds (from governments and/or levy on development projects) on the basis of agreed formula for service delivery Each of these options has merits as well as disadvantages. A quick appraisal of them point to some options being possibly more workable than others. Unlikely options:    1 would be costly and have long start-up time 3 is unlikely to allow for resolution of major issues, since they have not done so to date 7 may be inflexible and slow as it would require new discussions for each issue, although current model may be readily applied Soft options:  2 would minimise call on resources and rely on established intergovernmental processes, but may take time and leadership/drive will depend on interest of individual countries 4 would represent incremental shift to current agendas and be minimally disruptive, but overall coordination would require good leadership 5 would provide for incremental process of getting issues resolved, and in that process build trust, but it is likely to take time to achieve alignment across multiple issues Stronger options:   6 could move agendas more quickly, given a good team, but require resources and authority 8 would take time for agreements to be developed, but would allow for comparable approaches to be secured with timing that suits individual governments 14

 

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion  9 would take time to reach agreement and requires leadership to drive it, but could provide for longer term solution

Some combination of options may be appropriate in the first instance to progress more urgent concerns, while exploration is undertaken about more comprehensive strategies in the medium term.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

APPENDIX:

INVENTORY OF REGIONAL AND INTERNATIONAL INSTITUTIONAL INTERESTS IN MIGRATION AND HEALTH IN THE GMS Non-government, including academic, organisations ORGANSATION ARROW Asia Business Coalition on AIDS Asia Partnership on Emerging Infectious Diseases Research ROLES AND ACTIVITIES Advocate for women’s rights and needs, particularly in health and sexuality Brings together businesses across the region to support efforts to prevent and control AIDS Network of researchers, officials, and practitioners from 30 institutions in Cambodia, China, Lao PDR, Indonesia, Thailand and Vietnam. Priority areas of work are: drivers of EIDs, impact of EIDs on vulnerable groups, and prevention of EIDs Promote rights, dignity and empowerment of migrant workers and their families in Asia through information, monitoring, and research Open network with Special Consultative Status with the Economic and Social Council of the UN Undertake advocacy, capacity building, and action research for migrant workers, with particular focus on workers rights, health and HIV, and globalisation and development Communication and information exchange network for nongovernment organisations; originally comprising agencies serving refugees from Laos, Vietnam and Cambodia, now working mostly with displaced persons from Myanmar Research on migration

Asian Migration Center

CARAM-Asia

CCSDPT (Committee for Coordination of Services to Displaced Persons in Thailand) ISEAS (Institute for Southeast Asian Studies) Malaria Consortium

Mekong Migration Network Raks Thai/CARE International SEAMEO-TROPMED

Provides technical assistance to governments, NGOs, academic institutions, health providers, and communities to improve service delivery Particular focus on supporting strategic planning and monitoring and evaluation 72 representatives of government, academic and nongovernment institutions from GMS to promote integration and social cohesion Projects include enhancing labor migration and social protection Education, training and research in tropical medicine and public health; projects include disaster response, HIV/AIDS prevention, health equity, emerging diseases, health promotion An alliance of regional Asia Pacific HIV/AIDS networks since 2001 providing a collective voice for the marginalised, vulnerable, and affected communities, including migrant workers and other mobile populations Research and curriculum development - current projects include focus on regional coordination mechanisms to address common issues such as climate change, haze, and global warming

7 Sisters

UNIID-SEA (Universities and Councils Network on Innovation for Inclusive Development in Southeast Asia)

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion WHO Network for HIV and Health in the WPR World Wildlife Fund (WWF) International NGOs with presence in multiple countries Network of collaborating centres that provide technical support to countries for the health sector response to HIV/AIDS Campaigns for protection of species, sustainable forestry, sustainable use of freshwater resources, and supporting climate change adaptation MSF (Medecins sans Frontieres), URC (University Research Council), PATH, Oxfam, Save the Children, Family Health International, International Federation of Red Cross and Red Crescent Societies, etc

Intergovernmental and international organisations and networks ORGANISATION ADB ROLES AND ACTIVITIES Undertakes analytical studies Support infrastructure projects, economic integration, and human resources development (including HIV prevention and the infrastructure sector) There are working groups on Health and on Emergency Preparedness The Emergency Preparedness WG is now focused on business and community resilience, and build members’ capacity through sharing expertise and collaboration on specific issues; they also foster public-private partnerships The Health WG is concerned with health and the economy and has had interest in NCDs, HIV/AIDS, and maternal and child welfare. They have coordinated with both the Emergency Preparedness WG and the ASEAN Secretariat ASEAN Socio-cultural Community Blueprint guides work in human development, social welfare and protection, social justice and rights, ensuring environmental sustainability, and narrowing the development gap 2012 Health Ministers Meeting agreed to work plans for 55 health action lines related to implementing ASEAN Strategic Framework on Health Development (2010-15) and committed to priorities in NCDs, tobacco control, achieving universal health coverage, zero new infections of HIV/AIDS, and effective response systems for public health emergencies, emerging infectious diseases, artemisinin-resistant malaria, and dengue Asia-Pacific regional priorities in food and nutritional security, agricultural production, sustainable natural resources management, capacity building for responding to climate change and to food and agricultural threats and emergencies Promote cooperation for improved management of labour migration via the Asian Programme on the Governance of Labour Migration, with particular interest on gender and rights Support 2008 WHA Resolution on Health of Migrants through monitoring migrant health, advocating for policy and legal framework, strengthening migrant friendly health systems, and developing inter-country coordination and partnerships Co-chairs the Asia-Pacific Regional Thematic Working Group on International Migration, including Human Trafficking Network of UN family, ASEAN secretariat, governments, and leading NGO networks Promote universal access to HIV prevention, treatment, care and support for mobile and migrant populations through strategic 17

APEC

ASEAN

FAO

ILO

IOM

JUNIMA (Joint Initiative on Mobility and HIV/AIDS)

Session: 6, Coordination Mechanism

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion information, policy and advocacy, and multi-stakeholder mechanisms Intergovernmental organisation providing capacity building activities for government officials, private enterprises and civil society involved in the development of GMS Its Human Migration and Care program promotes migrant protection and safe labour migration by facilitation harmonised policies and systems, strengthening vocational-technical skills recognition systems, and provides policy briefs, learning programs, policy dialogues, and technical support on migration issues to partners Jointly serviced by WHO and UNEP, the Forum brings together ministries of health with ministries of environment from ASEAN countries and four others (China, Korea, Mongolia, and Japan) to strengthen cooperation in policy and regulation and support development of integrated national environmental health action plans. Thematic working groups cover air, water, waste, chemicals, climate change, environmental health emergencies, and health impact assessment. Has been supporting leadership development through AsiaPacific Leadership Forum Co-chairs and supports JUNIMA to coordinate around mobility and HIV Achievement of MDGs through focus on poverty reduction, crisis prevention and recovery, environment and sustainable development, and democratic governance, with cross-cutting themes being capacity development, south-south cooperation, and gender equality Regional Centre in Asia Pacific exists in Bangkok Strengthen regional cooperation and enhance capacity of governments to design and implement policies that manage migration and protect migrants (improve safety, facilitate access to social protection and combat trafficking Advocate for ratification of International Convention on the Protection of the Rights of Migrant Workers and Members of their Families Co-chairs the Asia-Pacific Regional Thematic Working Group on International Migration, including Human Trafficking Priorities are to reduce maternal deaths and to achieve universal access to reproductive health Provide leadership at national and global levels in developing policy to secure the basic rights of children, adolescents and women affected by migration Resolution on Health of Migrants endorsed by WHA in 2008 provides framework for various global and regional initiatives Country Office in Thailand supports Border Health Program in Thailand and facilitates the coordination of the WHO Mekong Malaria Program, the Vaccine Supply and Quality Unit in the Southeast Asia Region, and regional stockpile of medicines, commodities and emergency kits Undertakes analytical reports about economic and social development Supports regional programming in water, transportation, power, and labor migration Works at global level to disseminate information to countries 18

Mekong Institute

Regional Forum on Environment and Health

UNAIDS

UNDP

UNESCAP

UNFPA UNICEF

WHO

World Bank

World Organisation for

Session: 6, Coordination Mechanism

Biregional Meeting on Healthy Borders in the Greater Mekong Subregion Animal Health (OIE) about animal diseases, including those transmissable to humans

Donors and international philanthropies ORGANISATION Atlantic Philanthropies AusAID China Medical Board INTERESTS Contributes to HealthSpace.Asia Australia-Mekong NGO Partnership HIV Asia Regional Program Strengthen education in public, nursing and primary care in GMS; provide collaborative research and policy development platform (HealthSpace.Asia) Support establishment of Regional Centre for Social Science and Sustainable Development (based at Chiangmai University), with interest in resource management, environmental impact assessment, gender and ethnic relations, and social science and health Malaria is a top priority globally; supports the Global Plan for Artemisinin Resistance Containment Supports programs related to AIDS, TB, and malaria in all GMS countries New funding model focuses interventions and financing for specific populations and catchment areas, in order to reach highly vulnerable, marginalised, and stigmatized groups; to align investments in disease programs with national health strategies while strengthening health systems Global Migration and Human Mobility supports improved governance of international migration and research on the relationship between migration and economic development Largest nongovernment donor to the Global Forum on Migration and Development Contributes to HealthSpace.Asia Supported work on migration and health in GMS in 1990s and initiated Mekong Dialogue for senior policy makers, civil society groups, and development agencies on trans-border issues Now supporting Mekong Basin Disease Surveillance Network as well as global dialogue on universal health coverage Contributes to HealthSpace.Asia Focused on monitoring disease outbreaks and preventable maternal and child death Supports ASEAN’s work in combatting human and wildlife trafficking, food security, disaster risk reduction Concerned with strengthening public health infrastructure and capacity, with focus on HIV/AIDS, influenza, tuberculosis, immunization, and field epidemiology training; has program on immigrant, refugee, and migrant health in Thailand GIZ, Luxemburg, France, CIDA, SIDA, NORAD

Ford Foundation

Gates Foundation Global Fund for AIDS, Tuberculosis, and Malaria

MacArthur Foundation

Rockefeller Foundation

USAID

US CDC

Other bilateral donors

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion

KEY REFERENCES

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ASEAN Health Profile: Regional Priorities and Programmes. ASEAN Secretariat, Jakarta. 2012. Ault S. Intersectoral Approaches to Neglected Diseases. Annals of New York Academy of Science. 1136:64-69. 2008. Briggs DJ. A framework for integrated environmental health impact assessment of systemic risks. Environmental Health. 2009 (7): 61. Burns M. Improving access to healthcare for migrants and refugees. 2010. Caouette T, Sciortino R, Guest P, and Feinstein A. Labor Migration in the Greater Mekong Subregion. Cheema GS, McNally CA, and Popovski V. (Eds). Cross-border Governance in Asia: Regional Issues and Mechanisms. UN University Press. 2011. Coker R, Hunter B, Rudge J et al. Emerging infectious diseases in southeast Asia: regional challenges to control. Lancet. 377: 599-609. 2011. Collins-Dogrul J. Managing US-Mexico ‘border health’: An organizational field approach. Social Science and Medicine. 63: 3199-3211. 2006. Dombkins D. Realising Complex Policy: Using Systems-of-Systems. Manuscript. 2013. Emerson E. The Thai/Myanmar border health program: lessons in working migrant population. 17(1): 43-49. 2008. Health of Migrants – the way forward. Report of a global consultation. 2010. Huguet, JW. Linking International Migration and Development in Asia. Paper for Workshop on Strengthening National Capacities to Deal with International Migration. 2010. Huguet, JW (Ed). Thailand Migration Report 2011. IOM, Bangkok. 2011. Ibitz A. Environmental Policy Coordination in ASEA: The case of waster from electrical and electronic equipment. Current Research on South-East Asia. 5(1): 30-51. 2012. Institute for Population and Social Research. Situation Analysis on Health System Strengthening for Migrants in Thailand. Report submitted to WHO (Thailand Office). Mahidol University. 2011. Joint Assessment of the Response to Artemisinin Resistance in the Greater Mekong Sub-Region. Summary Report. 2012. Kidambi S. Health Systems in the ASEAN Region: Migrant Health Services and Country Profiles. Prepared for WHO/Thailand. 2012. Middleton C. AASEAN, Economic Integration and Regional Environmental Governance: Emerging Norms and Transboundary Environmental Justice. ICIRD. 2012. Nielsen JR, Degnbol P, Viswanathan KK, et al. Fisheries co-management – an institutional innovation? Lessons from South East Asia and Southern Africa. Marine Policy. 28:151-160. 2004. Fisher J. Disease responsts no borders: Governance, the state, and regional health security. In Pandya A and Laipson E. (Eds). Transnational Trends: Middle Eastern and Asian Views. Henry Stimson Center, Washington DC. 2008.

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Biregional Meeting on Healthy Borders in the Greater Mekong Subregion         Polner M. Coordinated border management: from theory to practice. World Customs Journal. 5(2):49-64. 2012? Scheftel H. Multi-stakeholder Partnerships for Human Security. Revue de la Securite Humane. 8:43-56. 2009. Schimmelfennig F, Leuffren D, and Rittberger B. Ever looser union? Towards a theory of differentiated integration in the EU. Paper presented at EUSA Conference, Boston. 2011. Shannon MA and Schmidt CH. Theoretical Approaches to Understanding Intersectoral Policy Integration. In Cross Sectoral Policy Impacts on Forests. 2002. Silkavute P, Gung DX, and Jongudomsuk P. Sustaining a Regional Emerging Infectious Disease Research Network: A trust-based approach. Emerging Health Threats Journal. 6 (10). 2013. Smith Gueye C,Teng A, Kinyua K, et al. Parasites and vectors carry no passport: how to fund cross-border and regional efforts to achieve malaria elimination. Malaria. 11:344. 2012. Souvannaphoum K. Migration and Health Impacts among Low-skilled Labors in the Greater Mekong Subregion: A case study. Mekong Institute, Kohn Kaen University. 2008. Stern A. International Population Movements and Public Health in the Mekong Region: An overview of some issues concerning mapping. Southeast Asian Journal of Tropical Medicine and Public Health. 29 (2): 201-212. 1998. Stuckler D, Hawkes C, and Yach D. Governance of Chronic Diseases. Manuscript. 2006. Thailand Ministry of Health. Border Health Development Master Plan 2012-2016. Ministry of Public Health., Bangkok. 2011. UNDP. Delivering Human Security through Multi-Level Governance. UNDP. Regional Dialogue on the Health Challenges for Asian Labour Migrants. 2012? UNESCAP. Repor t of the Asia-Pacific Regional Preparatory Meeting for the Global forum on Migration and Development 2010. Bangkok, 2010. Varkkey HM. The Asean Way and Haze Mitigation Efforts. 2012? Verbij E and Schanz H. Intersectoral Coordination: State of the Art and Beyond. In Cross sectoral Policy Impact on Forests. 2002. WHO (Euro). How health systesms can address health inequities linked to migration and ethnicity. WHO (Euro), Copenhagen. 2010. WHO (WPRO). Consultation on the Strengthening of the World Health Organization Network for HIV and Health in the Western Pacific Region. WHO (WPRO), Manila. 2009. WHO (WPRO). Regional Framework for Action on Access to Essential Medicines in the Western Pacific, 2011-2016. WHO (WPRO), Manila. 2012. WHO (WPRO). Tuberculosis Control in Migrant Populations: Guiding principles and proposed actions. (draft). 2013. Wismar M, Pal W, Figueras J, et al. Cross-border Health Care in the European Union: Mapping and analysing practices and policies. European Observatory for Health Systems and Policies. 2011. Zadek S. Collaborative Governance: The New Multilateralism for the 21 st Accountability Compacts: Collaborative Governance for the 21 Century. st

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Century.

In

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www.wpro.who.int