Inter-Country Meeting on Cross-border Collaboration to Eliminate Malaria in South Asia, New Delhi, India, 12-13 February 2016

Inter-Country Meeting on Cross- border Collaboration to Eliminate Malaria in South Asia Report of the Meeting New Delhi,12–13 February 2016 W o r l d H e a l t h O r g a n i z a t i o n Regional Office for South-East Asia

SEA-MAL-283 Distribution: General Inter-Country Meeting on Cross-border Collaboration to Eliminate Malaria in South Asia New Delhi, India, 12–13 February 2016 !

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 CONTENT ABBREVIATIONS EXECUTIVE SUMMARY BACKGROUND OBJECTIVES SESSION 1: OPENING SESSION SESSION 2: ISSUES AND SOLUTIONS FOR CROSS-BORDER PROGRAMMES SESSION 3: EXPERIENCES FROM THE GREATER MEKONG SUBREGION (GMS) GROUP WORK CONCLUSION RECOMMENDATIONS ANNEXES Annex 1: Programme Annex 2: List of Participants Annex 3: Results of 6 Bilateral Working Groups on Cross-Border Collaboration for Malaria Annex 4: Summary of Group Work and Next Steps ABBREVIATIONS ABER Annual blood examination rate ADB Asian Development Bank APLMA Asia Pacific Leaders Malaria Alliance ASEAN Association of Southeast Asian Nations BCC Behaviour change communication EDPT EQAS ERAR Early diagnosis and prompt treatment External quality assurance scheme Emergency Response to Artemisinin Resistance Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria GMS Greater Mekong Subregion IHR International Health Regulations (2005) IOM International Organization for Migration IRS Indoor residual spraying ITN Insecticide treated nets IVM Integrated Vector Management LLIN Long-lasting insecticidal nets M&E Monitoring & Evaluation MBDS MMP Mekong Basin Disease Surveillance Project Mobile and migrant populations MoU Memorandum of Understanding PoE Point of Entry RAI Regional Artemisinin-resistance Initiative RDT Rapid Diagnostic Test SAARC South Asian Association for Regional Cooperation SEAR South-East Asia Region UNHCR United Nations High Commissioner for Refugees USAID United States Agency for International Development WHO World Health Organization EXECUTIVE SUMMARY Malaria remains endemic and a public health concern in nine out of 11 countries in the WHO South-East Asia Region. About 40% of the global population at risk of malaria live in the South-East Asia Region (SEAR), with India carrying the highest burden. Among South Asian countries, India, the largest country, borders on four endemic SEAR countries of varying degrees of transmission (high: Bangladesh and Myanmar; medium: Nepal; and low: Bhutan). Approximately, 8% of India’s malaria burden occurs in bordering districts, of which approximately 5% originates in 25 districts of five states (Assam, Meghalaya, Mizoram, West Bengal and Tripura), which share border with Bangladesh, and 1.5% from 15 districts of four states (Arunachal Pradesh, Manipur, Mizoram and Nagaland), which border Myanmar. One of the three strategic pillars of the new WHO Global Technical Strategy for Malaria 2016–2030 is accelerating efforts towards malaria elimination. All malaria endemic countries in the Region have committed to reaching the malaria elimination goal by 2030. Multicountry regional initiatives to tackle intercountry issues are required to achieve and sustain the elimination of malaria by creating functional mechanisms to strengthen surveillance, information exchange and access to interventions between borders, and address issues such as multidrug and insecticide resistance and population movement. Challenges in controlling and eliminating malaria along international borders include: poor accessibility leading to transportation and communication issues; poor health-care infrastructure; prevalence of efficient and diverse vectors; sociopolitical, cultural and language issues and barriers; population movement; major development projects; inadequate cross-border cooperation, collaboration, management and ownership of the programme; limited surveillance capability, epidemic preparedness and response capacity; multidrug resistance, including resistance to artemisinin-based combination therapies; and a growing trend of reported insecticide resistance. Member States are aware of these challenges. Many have made plans and set aside funding for cross-border collaboration but due to lack of an effective, functional cross-country mechanism, implementation remains limited. Several meetings on cross-border collaboration and initiatives for control of priority communicable diseases have been organized in SEAR in the past, including in 2001 in New Delhi, India and Kathmandu, Nepal (resulting in the publication of operational guidelines); 2004 and 2007 in Bangkok, Thailand; 2009 in Kolkata, India; and in 2012 in Paro, Bhutan. Despite high levels of commitment in the health sector, the operationalization of cross-border activities has faced limitations. Due to a new strong commitment by Member States to malaria elimination and the increasing threat of malaria multidrug and insecticide resistance, the issue of cross-border collaboration for elimination of malaria has gained new importance. Two South-East Asian Member States are already free of malaria (Maldives and Sri Lanka) and others are moving towards malaria elimination. India has recently made a strong commitment to malaria elimination. To eliminate malaria and prevent its return to areas previously free from malaria, cross-border collaboration at national and local levels is mandatory. Several Member States have set aside funds for this purpose but are not able to utilize them due to the lack of a functional mechanism. During a side meeting at the recent Executive Board briefing in the WHO Regional Office for South-East Asia, 7 January 2016, representatives clearly expressed their wish that WHO take a leading role in facilitating and supporting this, and to raise resources, for example, through the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Learning from past and present experiences (such as the joint Greater Mekong Subregion (GMS) malaria elimination initiative), this meeting on 12–13 February was planned. This meeting was organized back-to-back with the India malaria elimination strategy launch meeting on 10–11 February in New Delhi, taking advantage of having all regional Member States represented (national malaria programme managers) at this event. Against this background, the intercountry meeting on cross-border collaboration to 
 eliminate malaria in South Asia was held in New Delhi, India on 12–13 February 2016. The main objective was to reignite the cross-border collaboration effort for malaria in South Asia and identify and establish a suitable collaboration mechanism, and identify key areas of collaboration based on an assessment of the situation in different countries. Possible areas of collaboration include the following. • Exchange of information on various epidemiological data, including outbreaks, vectors, drug and insecticide resistance, data on malaria programme strategies and approaches; general health information systems data; population mobility across borders; malaria interventions, coverage and resources, including relevant supplies, such as bed nets, repellents and medicines in border areas; relevant private sector data, including availability of private facilities; and others, such as development projects. • Collaboration across neighbouring districts on malaria control, elimination and prevention along borders, based on collaborative/joint workplans. • Joint/coordinated activities of malaria programmes, including joint planning, implementation, monitoring and evaluation of interventions, outbreak investigation and control; sharing of expertise; joint capacity building and advocacy in areas related to malaria control and elimination. • Joint training and capacity development in areas related to malaria control and elimination, with a focus on boosting commitment of programme personnel in border areas. It was proposed that a second meeting would be organized in a few months, when key cross-border adjoining districts’ health managers would be invited in order to agree on joint/coordinated cross-border workplans at the local level. It was also envisaged that in parallel, a draft Global Fund regional proposal to address malaria issues in cross-border settings in South Asia would be developed with the hope of raising required resources, including a budget for coordination. In these meetings representatives from other health programmes with extensive cross-border collaboration experience as well as health systems colleagues would be invited. It was expected that this cross-border malaria initiative would intensify collaboration across countries in other disease control areas, and that this would be pursued in further bi- or multilateral meetings at different levels. General objectives To strengthen collaboration for elimination of malaria in South Asia, contributing to a malaria-free SEAR by 2030. Specific objectives 1. Review the present malaria situation (including drug and insecticide resistance) and malaria programme activities and their quality/coverage in South Asian countries along borders, including related challenges and existing cross-border collaboration mechanisms. 2. Identify areas of practical and effective mechanisms of collaboration across borders to accelerate malaria elimination and prevent re-establishment of local transmission in malaria free areas. 3. Outline a framework for cross-border collaboration in malaria elimination in South Asia. Participants were from National Malaria Programmes (Bangladesh, Bhutan, India, Indonesia – which shared Pacific cross-border collaboration plans – Myanmar, Nepal, Sri Lanka – which shared experience/ lessons on cross-border collaboration to prevent re-establishment of local transmission – and China (as China shares long borders with many SEAR countries); WHO Country Offices from these countries and Thailand, relating to GMS Mobile and Migrant Populations; WHO Regional Office for South-East Asia and WHO headquarters; civil society organizations, research and training institutes, representatives from Ministry of External Affairs and Ministry of Home Affairs of India; the Global Fund, SEA Constituency to the Board of The Global Fund, the Asian Development Bank (ADB), International Organization for Migration (IOM), Asia Pacific Leaders Malaria Alliance (APLMA), South Asian Association for Regional Cooperation (SAARC) Secretariat, Partners in Population Development, and the Mekong Basin Disease Surveillance Project. The meeting started with a welcome and opening address and self-introduction by the participants. This was followed by global and regional updates on malaria, with special reference to cross-border malaria as well as nomination of office bearers. Subsequently, the technical sessions focused on issues and solutions for cross-border programmes, experiences on cross-border collaboration from other communicable disease programmes and partners and group work on existing mechanisms for cross-border collaboration and definition of key areas for collaboration. It was concluded that border malaria is a major public health concern and a threat which could slow malaria elimination in SEAR. The following key recommendations were made. 1. Cross-border collaboration requires strengthening of service delivery, information sharing, action coordination, surveillance and M&E, implementation research, as well as addressing special technical problems, such as multidrug (especially related to artemisinin-based combination therapies) and insecticide resistance management. 2. Agreement to develop a protocol for assessment on malaria in cross-border settings of neighbouring countries of South Asia with special emphasis on current malaria situations, existing programme strategies, approaches, interventions, challenges and gaps, and conduct relevant cross-border assessments. The exercise would be led by WHO and identified focal points in each country in South Asia. Possible involvement of certain partners would also be explored. 3. Establishment of networks by designating/nominating focal persons (national, state, district levels), bilateral working groups, bilateral district level coordination committees. 4. Setting up a core group (WHO and national programme focal points) for immediate coordination action. 5. Launch of a regional coordination mechanism by reaching mutual agreements on the one year coordinated cross-border action plans at the country and intercountry levels. 6. Initiating high-level action, including and not restricted to MOUs, with the aim of creating an enabling environment for local action, starting with policy agreement by different ministries, such as the Ministry of Health, Ministry of Foreign Affairs and Ministry of Home Affairs, facilitated by WHO. 7. Planning and conducting cross-border district meetings at regular intervals and country and intercountry meetings preferably annually, facilitated by WHO. 8. Collaboration with existing cross-border mechanism, such as existing border security meetings. 9. WHO SEAR strategic guidance and technical assistance to facilitate cross-border collaboration on malaria elimination within South Asia. 10. Review of the operational case definition of malaria (indigenous/imported) cases by WHO to be stringently followed by all Member States. 11. Initiating a Memorandum of Understanding (MoU) between countries to provide an overall framework and platform for dialogue and developing activities that could be implemented at the local level drawing from lessons from other regions, such as GMS and other programmes, including the polio eradication programme and leveraging on the existing international regulations such as International Health Regulations 2005, or (IHR 2005), for malaria elimination towards addressing border malaria within SEAR in an effective and sustained manner. BACKGROUND Malaria remains endemic and a public health concern in nine out of 11 countries in South East Asia Region (SEAR). About 40% of the global population at risk of malaria lives in SEAR, with India carrying the highest burden. Among South Asian countries, India, the largest country, borders four endemic SEAR countries of varying degrees of transmission (high: Bangladesh and Myanmar; medium: Nepal and low: Bhutan). Approximately, 8% of India’s malaria burden is contributed by bordering districts, of which approximately 5% originates in 25 districts of five states (Assam, Meghalaya, Mizoram, West Bengal and Tripura), which share a border with Bangladesh, and 1.5% from 15 districts of four states (Arunachal Pradesh, Manipur, Mizoram and Nagaland), which share a border with Myanmar. The new WHO Global Technical Strategy for Malaria 2016–2030 has as one of its three strategic pillars the acceleration of efforts towards malaria elimination. All malaria endemic countries in the Region have committed to reach the malaria elimination goal by 2030, at the latest. Multicountry regional initiatives to tackle intercountry issues are required to achieve and sustain the elimination of malaria by creating functional mechanisms to strengthen surveillance, information exchange and access to interventions among borders, and address issues such as multidrug and insecticide resistance and population movement. Challenges in controlling and eliminating malaria along international borders include: poor accessibility leading to transportation and communication issues, poor health-care infrastructure, prevalence of efficient and diverse vectors, sociopolitical, cultural and lingual issues and barriers, population movement, major development projects, inadequate cross-border cooperation, collaboration, management and ownership of the programme, limited surveillance capability, epidemic preparedness and response capacity, multidrug resistance, including resistance to artemisinin-based combination therapies, and a growing trend of reported insecticide resistance. Member States are aware of these challenges. Many have made plans and set aside funding for cross-border collaboration but due to lack of an effective, functional cross-country mechanism, implementation remains limited. Several meetings on cross-border collaboration and initiatives for control of priority communicable diseases have been organized in SEAR in the past, including in 2001 in New Delhi, India and Kathmandu, Nepal (resulting in the publication of operational guidelines); 2004 and 2007 in Bangkok, Thailand; 2009 in Kolkata, India; and in 2012 in Paro, Bhutan. Despite high levels of commitment in the health sector, the operationalization of cross-border activities has faced limitations. Due to the new strong commitment of Member States to malaria elimination and the increasing threat of malaria multidrug and insecticide resistance, the issue of cross-border collaboration for elimination of malaria has gained new importance. Two SEAR Member States are already free of malaria (Maldives and Sri Lanka) and others are moving towards malaria elimination. India has recently made a strong commitment to malaria elimination. To eliminate malaria and prevent its return to areas already free from malaria, cross-border collaboration at national and local levels is mandatory. Several Member States have set aside funds for this purpose but are not able to utilize them due to the lack of a functional mechanism. During a side meeting at the recent EB briefing in the WHO Regional Office for South-East Asia, 7  January 2016, representatives clearly expressed their wish for WHO to take a leading role to facilitate and support this, and to raise resources, for example, through the Global Fund. Learning from past and present experiences (for example, from the joint GMS malaria elimination initiative), this meeting on 12–13 February was planned. This meeting was organized back-to-back with the India malaria elimination strategy launch meeting on 10–11 February in New Delhi, taking advantage of having all regional Member States represented (national malaria programme managers) at this event. Against this background, the intercountry meeting on cross-border collaboration to eliminate malaria in South Asia was held in New Delhi, India on 12–13 February 2016 (see Annexes 1 and 2 for programme and list of participants). The main objective was to re-ignite the cross-border collaboration effort in malaria in South Asia and identify and establish a suitable collaboration mechanism, and identify key areas of collaboration based on an assessment of the situation in different countries. Possible areas of collaboration include the following. • Exchange of information on various epidemiological data, including outbreaks, vectors, drug and insecticide resistance, data on malaria programme strategies and approaches; general health information systems data; population mobility across borders; malaria interventions, coverage and resources, including relevant supplies such as bed nets, repellents, medicines in border areas; relevant private sector data, including availability of private facilities; and others, such as development projects. • Collaboration across neighbouring districts on malaria control, elimination and prevention along borders, based on collaborative/joint workplans. • Joint/coordinated activities of malaria programmes, including joint planning, implementation, monitoring and evaluation of interventions, outbreak investigation and control, sharing of expertise, joint capacity-building and advocacy, for example, in areas related to malaria control and elimination. • Joint training and capacity development in areas related to malaria control and elimination, with a focus on boosting commitment of programme personnel in border areas. OBJECTIVES General objectives To strengthen collaboration for elimination of malaria in South Asia, contributing to SEAR by 2030. Specific objectives 1. Review the present malaria situation (including drug and insecticide resistance) and malaria programme activities and their quality/coverage in South Asian countries along borders, including related challenges and existing cross-border collaboration mechanisms. 2. Identify areas of practical and effective mechanism of collaboration across borders to accelerate malaria elimination and prevent re-establishment of local transmission in malaria-free areas. 3. Outline a framework for cross-border collaboration in malaria elimination in South Asia. SESSION 1: OPENING SESSION The meeting started with a welcome and opening address. This was followed by objectives and expected outcomes of the meeting, introduction of meeting participants, global and regional updates on malaria, with special reference to cross-border malaria, as well as nomination of office bearers. Subsequently, the technical sessions focused on: issues and solutions for cross-border programmes, experiences on cross- border collaboration from other communicable disease programmes and partners, and group work on existing mechanisms for cross-border collaboration and definition of key areas for collaboration. The participants were from National Malaria Programmes: Bangladesh, Bhutan, India, Indonesia (included to share their Pacific cross-border collaboration plans), Myanmar, Nepal, Sri Lanka (Sri Lanka included to share their experience/lessons on cross-border collaboration to prevent re-establishment of local transmission), and China (as China shares long borders with many SEAR countries), WHO Country Offices (from these countries and Thailand (relating to GMS Mobile and WHO Thailand (ERAR) Migrant Populations), WHO Regional Office for South-East Asia and WHO headquarters, civil society organizations, research and training institutes, representatives from the Ministry of External Affairs and Ministry of Home Affairs of India; the Global Fund, SEA Constituency to the Board of the Global Fund, ADB, IOM, APLMA, SAARC Secretariat, Partners in Population Development, and Mekong Basin Disease Surveillance Project. Dr Eva Christophel, Regional Advisor Malaria, WHO Regional Office for South-East Asia, began the meeting by extending a warm welcome to participants and highlighted that the current meeting was scheduled to coincide with the launch of the National Framework for Malaria Elimination in India 2016–2030. Dr Swarup Sarkar then formally welcomed the participants on behalf of the Regional Director. He highlighted that in view of the malaria elimination target in SEAR by 2030, for the first time, the cross- border aspect was being given more importance. This is not only a global or regional issue but also an urgent reality. Within SEAR, Maldives has achieved elimination and sustained it, Sri Lanka is waiting for elimination status, Bhutan is moving toward elimination soon and Nepal has no malaria deaths. Dr Sarkar said that addressing cross-border issues at regional meetings is extremely important. He stressed that committing resources to the problem and local level action is important. All countries have a malaria elimination policy, strategy, and framework which need to be translated into activities backed by supplies and logistics to tackle cases and deaths. He also noted that there was a particular need to focus on specific needs at border areas with different and innovative approaches to ensure that cross-border issues are addressed. Resources are available at the country level through the Global Fund and other sources. The Global Fund has also adopted a flexible mode and if required, countries can re-strategize/re-programme to address country needs and cross-border issues. The Region needs to account for lessons learnt and develop a framework to be adopted by other countries. He called attention to the fact that many countries of the Region would graduate from Global Fund resource allocation. However, to keep the Global Fund grant “global” and to allow countries to participate in the global diplomacy of Global Fund grant allocations, there is a need for a regional mechanisms to keep the Global Fund focus and related activities within the Region. The Global Fund and others would also get an opportunity to partner in the regional endeavour of eliminating malaria from the region by 2030, or even earlier. Global and regional updates on malaria, with special reference to cross-border malaria Dr Pedro Alonso, Director, WHO Global Malaria Programme, presented the global scenario in terms of a decreasing trend in estimated malaria case incidence and mortality in the world by 37% and 60%, respectively from 2000 to 2015. Also, country-level trends in malaria incidence in terms of fewer than 1000, 100 and 10 cases 2000–2015 were shared. He said that the world has never witnessed such an accelerated decrease in malaria cases and deaths, and everyone should receive recognition for this success, but at the same time also be responsible for the future path. Nevertheless, it was underlined that the task was far from over in view of continued high incidence and mortality: ~214 million cases occurring globally, of which ~88% is in the WHO Africa Region, as well as ~438 000 malaria deaths worldwide, of which 90% are also in the WHO Africa Region with ~70% occurring in children under age 5. Further, continuing disease burden at the global level was presented in terms of estimated proportion, cumulative proportion of the global burden of malaria cases and deaths in 2015 for countries accounting for the highest share of malaria disease burden: Nigeria, Democratic Republic of the Congo and India, followed by other countries. In order to achieve the global target for control and elimination annually, the funding needed is $ 5.1 billion, yet the amount available in 2014 through international and domestic funding has only been $ 2.5 billion. A mention was made concerning SEAR countries with the potential of eliminating local transmission of malaria by 2020: Bhutan, Democratic Republic of Korea, Nepal, Sri Lanka, Timor- Leste, and by 2025 Bangladesh, Myanmar, Thailand and India. The key elements of the Global Technical Strategy for Malaria 2016–2030 were also presented including the five principles, vision, goals, milestones and targets, as well as three pillars and supporting elements. Regarding cross-border collaboration and the way forward, Dr Alonso mentioned the implementation of the resolution WHA68.2 on Global Technical Strategy for Malaria 2016–2030 that urges Member States to: intensify national, cross-border, regional and subregional efforts to address the threat posed by rising insecticide and drug resistance, including artemisinin resistance; to develop a comprehensive cross- border malaria control and treatment model, where appropriate, strengthen cross-border collaboration, improve the effectiveness of malaria elimination using primary health-care as the main platform, and integrate the model into broader health delivery systems; consider lessons learnt from other regions; and capitalize on the current political momentum on malaria elimination in the Asia Pacific. Dr Eva Christophel, Regional Adviser Malaria, WHO Regional Office for South-East Asia, further presented the malaria scenario in SEAR. Reported cases in SEAR in 2000 were 2 million, which dropped to 1.6 million in 2014. The distribution of cases in 2o14 showed that the contribution of malaria by India was 71%, Indonesia 16%, and Myanmar 10%, meaning these three countries accounted for 96% of cases. At the same time, the success story of Maldives as the first malaria-free country in the Region was shared, for which the WHO Regional Director for South-East Asia awarded a citation and plaque to the Maldives Honourable Minister of Health. Progress towards elimination of each country in SEAR was presented. Sri Lanka is in the prevention of re-introduction phase and has since made a formal request for certification of malaria elimination in 2015 in view of their malaria-free status for three years. In Bhutan, interruption of transmission is expected soon and the country is targeting zero indigenous malaria by 2018. Due to a substantial reduction in malaria incidence, both Nepal and Timor-Leste are targeting malaria elimination by 2020. The Democratic People’s Republic of Korea is targeting malaria elimination by 2025, since a large-scale P. vivax epidemic has been contained with the number of cases around 10 000. In Bangladesh and Thailand, transmission is largely in border areas and within mobile/migrant population groups. In Bangladesh, outbreaks were also noted in 2014. These countries are aiming at malaria elimination by 2015. In February 2016, India also launched the National Framework for Malaria Elimination in India 2016–2030. Both Indonesia and Myanmar are also targeting malaria elimination by 2030. These countries have the highest burden, but there is an encouraging trend of significantly reducing malaria incidence and deaths in recent years. While presenting percentage decrease in incidence and death rates (2000–2015) in terms of estimated malaria case incidence and malaria death rate, it was noted that SEAR lags behind. An example of political commitment was presented in terms of the Strategy for Malaria Elimination in the Greater Mekong Subregion (2015– 2030) that was launched in May 2015 by the WHO Regional Directors for South-East Asia and the Western Pacific regions for acceleration of malaria elimination in the GMS in response to multidrug resistance. This is a subregional six country initiative supported by multiple partners with an estimated total malaria programme cost of US$  3.2 to 3.9 billion over 15 years. She also highlighted the endorsement of the World Health Assembly for the Global Technical Strategy for Malaria 2016–2030. Dr Christophel also highlighted hurdles involving technical challenges: insecticide resistance, drug resistance, a high burden of P. vivax (burden of P. vivax in SEAR is more than half of the global burden); and financial challenges in terms of investment in malaria control activities and funding sources in SEAR. It was mentioned that international financing would be a challenge in the future considering eligibility criteria adopted for countries. Operational challenges, especially in border areas, were underscored. The need for cross-border collaboration was emphasized in view of the factors enabling malaria in border areas, such as poor accessibility, malaria ecology, forest-related environment, efficient and diverse vectors, vulnerable populations, families living in/near forests, mobile and migrant populations, ethnic communities, displaced populations, access to and quality of health services, sociopolitical and cultural issues, and ecological changes. As next steps for malaria elimination in 
 SEAR, the regional goal of elimination of malaria in all countries by latest 2030 was mentioned. The proposed interim goals are: reduce mortality and morbidity due to malaria in the Region by 50% by 2020 and by 90% by 2025 (2015 baselines); accelerate malaria elimination; maintain malaria-free status and prevent reintroduction of malaria in areas and countries where malaria transmission has been interrupted. Dr Christophel also shared the plan for upcoming cross-border meetings, in addition to the key areas for cross-border collaboration in malaria – (1) exchange of information: epidemiological (health and malaria information systems, drug and insecticide resistance, outbreaks); population mobility across borders; programme interventions, coverage and resources in border areas; other examples of development projects; (2) collaboration across neighbouring districts in high burden areas along borders, based on a joint workplan; and (3) joint activities of malaria programmes: outbreak investigation and control; sharing of expertise; capacity building in areas related to malaria elimination; advocacy; and multisectoral action. DISCUSSION: In order to target malaria elimination in SEAR, malaria in border areas should be a priority. It was discussed that despite success, there are still gaps in resources, both in terms of financing and reaching out to people in need with services. It was highlighted that business as usual within the Region may not suffice in achieving elimination targets. Nomination of Office Bearers The forum nominated Dr N.S Dharmashaktu, Additional Director General, Health Services, Ministry of Health and Family Welfare, New Delhi, as the Chairperson of Day 1 and Dr Babu Ram Marasini, Director, Epidemiology and Disease Control Division, Department of Health Services, Ministry of Health and Population, Kathmandu, as the Vice Chair. Dr Tashi Tobgay, Director, Khesar Gyalpo University of Medical Sciences of Bhutan, was the rapporteur. On Day 2, Group Work was carried out. S E S S I O N 2 : I S S U E S A N D S O L U T I O N S F O R C R O S S - B O R D E R PROGRAMMES Partnership Panel on Cross-border Malaria Elimination • Cross-border issues thus far has been mostly focusing on conducting meetings and there was no institutional framework to address the issues. There is a need for institutional framework with nodal agencies and involvement of the Ministry of Foreign Affairs. Nodal officers should be identified and a system of notification and information exchange should be established. Discussions in many cross- border collaboration meetings were dominated by issues such as security, relative to public health issues. Therefore, there is a need to strengthen advocacy to include a public health agenda and malaria within cross-border meetings. A major focus should be on operational aspects. It is imperative to clarify roles and responsibilities at all levels. • Bilateral meetings should be conducted and mechanisms for information sharing should be developed. Cross-border networking should be prioritized at the local level, recognizing the fact that the last mile, especially in border areas, is always more challenging. • APLMA is an alliance of heads of government and can facilitate garnering political and resource support. The platform may be used to periodically remind all regarding achievement of goals as well as the need for commensurate financing. Other ministers are also equally important and should also be approached. The APLMA Secretariat engages with national malaria programmes as well as the Ministry of Health, Ministry of Finance and Ministry of Foreign Affairs, as and when necessary. APLMA is open to accelerating such advocacy efforts. A particular attempt would be made to discuss migrant workers and others with national malaria programmes. • The issue of cross-border collaboration is recognized by the Global Fund. Where needed, appropriate changes in programme implementation and re-programming may be discussed through dialogue. • Addressing cross-border issues is beyond the government of one country, therefore, the issue is political in nature and requires collaboration at the highest level. However, the local level should reap the maximum benefits. • Addressing cross-border issues should be centred on establishing joint malaria surveillance mechanisms, services and stock of diagnostics and antimalarials on the ground, improving access to communities, promoting dialogue and creating conducive harmonization mechanisms led by donor agencies. There is a need to identify the key risk groups, conduct operational research to improve access and integrated community case management and strengthen behaviour change communication (BCC) components, TES, drug resistance and insecticide resistance monitoring and reaching hard-to-reach areas. Resource needs (funds, infrastructure, staff, etc.) should be identified too. Lessons learnt from the Maldives on surveillance should be shared with all concerned. • Incorporate “health diplomacy framework” and intergovernmental platforms to address malaria issues across borders. A mention was made of the bilateral Indo-Nepal agreement signed by the Health Secretaries of respective countries, although minimal progress materialized. • Regarding information on migrant and mobile populations, governments (especially Social Welfare, Labour Ministries), nongovernmental organizations and others involved in health and non-health sectors should be approached and networked. • As countries move into elimination stages, there is a need to involve other partners, such as the United Nations High Commissioner for Refugees (UNHCR), and IOM to address cross-border issues. • Once service delivery systems are optimal, then one can take care of importation cases with relatively less difficulty. Country presentations: progress with malaria control and challenges to eliminate malaria with particular focus on border areas, including existing cross-border collaboration mechanisms Bangladesh In Bangladesh, 13 districts are endemic for malaria. Of these, three districts are identified as high endemic, one district as moderately endemic and nine districts as low endemic. The malaria risk population is 13.25 million. The cases and deaths were 57 480 and 45, respectively, in 2014, and 39 720 and nine, respectively, in 2015. Of the total cases and deaths mentioned, 51 480 cases and 20 deaths were from Chittagong Hill Tracts (CHT) in 2014 and 35 969 and three deaths were from CHT in 2015. Yearly malaria cases and deaths from 2000 to 2015, wherein a decline was portrayed, in addition to the details of Plasmodium falciparum and Plasmodium vivax cases. Upsurges in 2008 and 2014 were also highlighted. The monthly trend of malaria cases 2010–2015 showed peaks in June–August. The malaria situation in CHT was specially highlighted. Further, the vision and goal as delineated in the malaria national strategic plan 2015–2020 was presented. The goal is to achieve “zero indigenous transmission” and “zero death” and aiming for malaria elimination in Bangladesh by 2020. The strategic objectives were also shared. The Early Diagnosis and Prompt Treatment strategy (EDPT) comprise Rapid Diagnostic Test (RDT) by community-based service providers, blood slide examination in laboratories and sub-centres (70 laboratories at UHC and 120 peripheral laboratories are located in strategic locations at community-level, involving around 12 000 personnel). Treatment at the field level is done by community-based service providers/field staff and performance of national guidelines and even a doorstep service is provided by community volunteers. Follow-up of each patient is being done also. Treatment at the facility level is done through community clinics, UHC, District Hospitals and Medical Colleges. Further, details of integrated vector management (IVM) were also presented that includes: distribution of long-lasting insecticidal nets (LLIN), treatment of ordinary bed nets with insecticide (KO tab/KO tab123), house-to-house education for promotion of use of LLIN/ITN by health workers and volunteers (31 23 905 LLINs distributed, among them 11 81 277 LLINs replaced from the beginning of programme in addition to 15 63 984 ordinary bed nets treated with KO tab 123 in 2011 and 2012. Several community awareness activities are carried out through household visits, community-level BCC and advocacy using mass, mid and interpersonal media. Details of nongovernmental organization partnerships were also presented. It was mentioned that the national malaria programme established a partnership with BRAC-led by a 21 member governmental/nongovernmental organization consortium in 2006, with clearly defined geographical areas and work areas. Bangladesh secured malaria grants from the Global Fund in Round 6 and Round 9 through joint efforts and the New Funding Model until December 2017. It was highlighted that malaria is an important disease along the international borders fraught with such perennial problems as uncontrolled migration, a poor health delivery system and lack of coordination along border districts. Therefore, malaria flourishes along the international borders and is often transported to relatively low transmission areas. Border areas also require extensive special efforts on a sustained basis to bring the disease under control. Studies have revealed that the incidence of malaria is relatively higher along border districts than in interior regions. Challenges arise due to deficient information from and across the border. Cross-border coordination is very important, as the health facilities of neighbouring countries are nearby and available to bordering populations. Besides, drug-resistant malaria is a serious concern as it can multiply rapidly in ecosystems lacking malaria information on drug resistance and correct interventions are often wanting. Use of insecticide on either side of the border is also an issue. It was highlighted that actions are required in terms of enhanced surveillance (ABER above 10), early diagnosis and complete treatment, regular data analysis for detecting early warning signs for any malaria flare up in cases, instituting a system of rapid response to impeding/ outbreak for containment, initiate intercountry border meetings to ensure uniform malaria control activities implementation, a screening policy for migrant floating population/labourers, regular meetings between bordering district officials to review malaria situation and co-ordination of activities. As way forward, strong political commitment, the presence of WHO as a technical partner, scope of submitting a regional proposal addressing border malaria to the Global Fund, and scope to formulate and implement a joint plan of action in order to control/eliminate border malaria and to share facilities/expertise of bordering countries, possibly by signing an MoU between the bordering countries. Bhutan The malaria situation from 2006 to 2015 was presented. During this period, cases declined from 1868 to 104. In 2015, more cases were noted, which could be due to improved surveillance. Of the total cases in 2015, 70 were imported and 34 were indigenous per classification of cases. Since 2013, the country has had zero deaths. The Bhutan National Strategic Plan 2015-2020 vision and mission were shared. The goal is to achieve zero indigenous malaria in Bhutan by 2018 and obtain WHO malaria-free certification by 2020. The key strategic shifts are in the realms of governance, wherein the Bhutan Malaria Elimination Commission (BMEC) and Bhutan Malaria Elimination Technical Advisory Group (BMETAG) has been constituted. Additional actions include enhanced case and vector surveillance that ensure follow-up and investigation of all cases, active and reactive case detections, web-based Bhutan Malaria and Febrile Information System (BMFIS), SMS case alert and notification, and intensified monitoring and supervision. Bhutan is also ensuring quality assured laboratory diagnosis and treatment by establishment of external quality assurance for malaria diagnosis, obtaining certification and accreditation, confirmation and genotyping of malaria cases using polymerase chain reaction, and instituting malaria diagnosis quality assurance in all health facilities. Besides this, there is focused prevention and control through geographical reconnaissance via mapping, geo-wise (subdistrict) stratification of malaria risk areas and populations and targeted interventions. Regarding cross-border collaboration, Government of India support to malaria control and elimination and WHO-led collaboration activities and Indo-Bhutan Friendship Collaboration was highlighted. It was underscored that malaria cases are confined to border areas. The issues that need to be tackled include: unrestricted population movement, settlements across international borders within mosquito flight range, lack of harmonized and synchronized cross-border activities, especially at the local levels, information-sharing on malaria cases and outbreaks across border areas and an absence of any particular unit responsible for cross-border collaboration. In terms of the way forward, the following requirements were put forth: a regional unit for coordination and collaboration of cross-border activities, harmonization and synchronization of malaria activities in border areas of each country, establishing a network for sharing of malaria information, frequent coordination meetings between malaria programmes at local levels, submission of a regional grant for cross-border malaria elimination and utilization of effective platforms, such as India Bhutan Foundation and other local level organizations. India India shares borders with Bhutan, Nepal, Bangladesh and Myanmar, totalling 70 districts in 12 states. The total population in the border districts is 120 million, although total population bordering primary health centres is 18 million. Malaria cases in India 2010–2014 relative to countries sharing borders were also presented that showed that most were reported from India. An overall decline in cases was reported over the years, yet an upsurge was noted in 2014 due to a focal outbreak in Tripura. Likewise, deaths also slightly increased in 2014. In SEAR, the highest number of cases is reported by India, Indonesia and Myanmar. Within South Asia, India has the highest number of cases and deaths followed by Myanmar and Bangladesh. In 2014, in terms of per cent contribution, 87% of cases were reported by India, and 12% by Myanmar, with 80% of deaths reported by India, 13% by Myanmar and 6% by Bangladesh. Thereafter, details of malaria disease burden in districts bordering Bhutan and other neighbouring countries were also presented. Along the India-Bhutan border, there are four states, namely, Assam, West Bengal, Arunachal Pradesh, Sikkim and nine districts. The malaria problem is mostly confined to the districts in Assam, followed by West Bengal. Analyses of per cent change in cases and deaths were presented that showed an annual parasite incidence >2 in district Udalguri of Assam. In other districts also, the absolute number of cases were mostly high. Along the Nepal border, there are five states, namely, Bihar, Sikkim, Uttar Pradesh, Uttarakhand, West Bengal and 21 districts. Most cases come from Uttar Pradesh (Pilibhit, Balrampur) followed by West Bengal, Bihar, Uttarakhand. It was mentioned that the ABER in these areas is very low at less than 3%, although in West Bengal, it is 9%. However, no deaths were reported. Along the Bangladesh border, there are five states, namely, Assam, Meghalaya, Mizoram, Tripura, West Bengal and 25 districts. Cases and deaths are high in Meghalaya, Mizoram and Tripura relative to those in Assam and West Bengal. Along the Myanmar border, there are four states, namely, Manipur, Mizoram, Arunachal Pradesh and Nagaland and 15 districts. Cases and deaths are high in Mizoram, followed by Arunachal Pradesh, relative to those reported by others. District-wise, the malaria situation bordering each of the above-mentioned countries was also presented, in addition to the status of TES in 2015–2016 in some border districts, Lawngtlai in Mizoram and West Garo Hills in Meghalaya. Furthermore, similar challenges and the way forward were similar to Bangladesh. Indonesia The overall country profile and malaria situation, especially in border areas, were described with special emphasis on specific strategies based on malaria endemicity. These strategies comprise the following. (1) Acceleration: in high endemic areas (Papua, West Papua, North Maluku, Maluku and East Nusa Tenggara) interventions include improved diagnosis and case management, LLIN mass campaign and IRS at high endemic villages. (2) Intensification: in the focus areas (mining, agriculture, forestry, transmigration, evacuation); areas outside the eastern part of Indonesia interventions, including improved diagnosis and case management, LLIN in routine and foci areas, MBS and IRS at outbreak villages. (3) Elimination: in low malaria endemic areas, interventions are active case detection, strengthening of migration surveillance, and monitoring of receptive areas. The legal frameworks for cross-border collaboration on malaria in Indonesia include: IHR (2005); Bilateral MoU with Timor-Leste, Papua New Guinea and Singapore (in process); ASEAN Cross-border Collaboration and Brunei Darussalam-Indonesia-Malaysia-Singapore-Thailand (BIMST). Later, experiences and progress on cross- border collaboration were shared. In the Indonesia–Malaysia border, regular border meetings between Sarawak and West Kalimantan Province in Pontianak, Indonesia and Kuching, Sarawak Malaysia, Indonesia–Timor-Leste border were held. Major focus is to synchronize interventions and exchange information on the malaria situation and train identified malaria staff. In Indonesia–Papua New Guinea border meetings, discussions included: port health, management of toxic waste (Limbah B3), detection of quarantine-related diseases and collaboration on case management of malaria, TB, HIV/AIDS, prevention of outbreak of vaccine-preventable diseases, yaws eradication, filariasis elimination campaign and referral of cases. MoU for collaboration was signed. In the Indonesia–Singapore border meeting, discussions included exchanging information, cross-notification of malaria cases detected in Singapore, and training. As mentioned by other countries, major challenges include: traditional population movement, including migrant workers, geographical remoteness, which complicates availability and accessibility of health services, surveillance, communication, tribal and socioeconomically disadvantaged groups in the border areas, limited capacity and competency of human resources, country regulation and policy, and more optimal intersectoral collaboration, and the presence of highly efficient vectors and inadequate entomological studies. Drawing from experience, certain cross-cutting issues were highlighted related to cross-border collaboration for consideration within a context of building health systems, empowering communities and improving multisectoral coordination, which included: strengthening service delivery on both sides for malaria case management and other diseases, exchanging information to detect malaria and other disease outbreaks and response, multisectoral collaboration on legal aspects along the border with immigration and police departments, case management and prevention without discrimination to patients, training health staff on issues related to malaria and other diseases and precluding stock out on medicine and laboratory supplies. It was shared that Indonesia is proposing regional/cross-border collaboration for sharing information and building commitment in August 2016. Discussions would centre on malaria along the border and control policy and expertise, goal, strategy and activities for cross- border malaria with Malaysia, Papua New Guinea, Timor-Leste, Singapore, the Philippines and Brunei Darussalam, training on malaria transmission mapping and malaria surveillance along the border, diagnosis and case management, vector control, surveillance and outbreak investigation, including mapping of malaria transmission, cross-notification, IEC campaigns in common languages in bordering country sites and operational research. Involvement and roles of WHO and partners were emphasized in order to make cross-border  collaboration successful. Intensive advocacy is required to garner political and financial support, strategic communication for sharing innovations and best practices together with coordination and technical support to develop guidelines, strategy, capacity building and programme monitoring and evaluation and resource mobilization. Myanmar The country profile in relation to cross-border areas was presented. The total population in border areas is ~52 million, of which ~46 million is considered as population at risk. Of a total of 15 states, the number of those bordering five countries is nine. Malaria cases in states along border areas in 2014 were 205 000 and deaths were 91. A relatively high number of cases and deaths were reported from areas bordering Bangladesh and India. Cases were also reported from areas bordering China, Thailand and the Lao People’s Democratic Republic. Further details were shared in terms of number of villages, total population, population at risk, number of village health volunteers and implementing partners in Chin state bordering Bangladesh and India, Tanintharyi Region bordering Thailand, Kayah and Kayin bordering Thailand, Sagaing bordering India and Shan bordering China, Thailand and the Lao People’s Democratic Republic. Existing national policy, strategy and legal framework for cross-border collaboration on malaria were then shared, that included collaboration with bordering countries through organizing high-level and local-level meetings, applying the twin city approach (cities bordering Thailand), implementing intercountry component of the Global Fund supported Regional Artemisinin Initiative Project (RAI) and establishing screening points at the borders to screen mobile people and migrants. Myanmar is also a signatory of the APLMA declaration to eliminate malaria by 2030 wherein cross-border collaboration is one of the priorities. Existing cross-border collaboration, including initiatives, MoUs, projects etc. exist in terms of MOUs between China–Myanmar and Thailand–Myanmar. In addition, the RAI focuses on malaria screening points on the Myanmar–Thailand border, mapping of malaria hotspots, targeting mobile and migrants, establishing malaria posts, operation research on TMT (MDA), intensive community-case finding, DOT, case investigation, 3 day parasitaemia, vector control and surveillance. While further sharing experiences, progress made  and specific challenges with malaria control and elimination in cross-border settings, it was mentioned that advocacy and coordination mechanisms have been initiated, although this exists with Thailand (twin city approach) and China and not with other countries and the only high-level meeting has been with China. Joint operations currently exist on the Thai–Myanmar border under the twin city approach for sharing information and other efforts. Other endeavours include: capacity building of malaria staff at all levels, community-based organizations and village health volunteers in vector control, entomology surveillance and monitoring, case management, malaria diagnosis (microscopy and RDT) and therapeutic efficacy studies; early warning and response system in RAI areas (52 townships), although case investigation is low; reporting and surveillance in terms of routine reporting of cases, entomological surveillance and TES; and operational research (vector behaviour surveys, durability of LLIN, effectiveness of insecticide-treated nets, MDA, detection of asymptomatic malaria cases). Recent intercountry/cross-border meetings were shared for China– Myanmar wherein the objective was to enhance efforts in controlling malaria in border areas. The outcomes were to finalize the scope of the Yunnan–Shan North and Shan East activities, including a gap analysis, budgeting, implementing and monitoring, coordination, and other institutional arrangements and to mobilize required resources. However, no further progress has been made, although a follow-up meeting is planned soon. The objective of the Thailand–Myanmar twin city approach is to foster collaboration between officials of malaria control programmes across borders. The activities included: biannual coordinated workplans and reports, quarterly meetings to discuss progress and plans and regular exchange of monthly malaria information, utilizing the Mekong Basin Diseases Surveillance (MBDS) form. Additional activities are: real-time sharing of unusual data, such as instances of Day 3 positive cases and unusual weekly caseloads to support planning for potential outbreaks; health facility mapping; introduction of multilingual patient referral forms, appointment cards, and patient materials for cross-border patients; and bilingual billboards and posters to promote malaria awareness for cross-border migrants. The key areas of regional/cross-border collaboration to be further addressed should include the following: SEAR regional framework for cross-border collaboration; mapping of health facilities in border areas; coordinated action plan between bordering townships/districts/states; harmonized malaria control/elimination intervention across border areas; cross-border surveillance with defined set of indicators; sharing information (data) across borders; and extending cross-border activities with India, Bangladesh and the Lao People’s Democratic Republic. Regarding cross-cutting issues related to cross-border collaboration to be considered within a context of building health systems, empowering communities and improving multisectoral coordination, the following was shared: filling vacant posts in border areas and/or task shifting to VHVs for case management, vector control-community larval source management and entomology surveillance; capacity building of public health staff along the border; collaboration with ministries beyond health; community engagement and empowerment across borders for sustainability; establishing additional border screening points/post to address importation; expansion of other collaborative activities, such as the twin city approach; strengthening pharmaceutical interventions, regulation, replacement of oAMT, drug quality monitoring, counterfeit drugs across borders; continuous therapeutic efficacy studies to monitor partner drug resistance; operational research for strengthening health systems; and real-time data sharing with eHealth. Involvement and roles of WHO and partners to make cross-border  collaboration successful are imperative. They are expected to facilitate high and local level cross-border collaboration; support ERAR hub to implement cross-border collaboration activities targeting mobile and migrants; support implementation of Global Fund supported (New Funding Model and RAI) malaria-control activities in the bordering areas; support mapping of the mobile and migrants on the Thai–Myanmar border; and surveillance, monitoring and evaluation in border areas. Nepal The malaria situation and cross-border activities during 2004–2014 were presented. During this period, a declining trend of malaria was noted from 4895 to 1469. Further, malaria risk areas were also presented (255 VDCs in high and moderate risk of malaria). The details of ward-wise malaria risk micro- stratification of five priority malaria endemic districts conducted in 2015 were shared, in addition to the indigenous and imported malaria cases. It was also mentioned that resistant cases have a history of travel (migrant labour) to Indian states not close to the Nepal border but inland, indicating a need for intercountry collaboration, not only for cross-border activities. The positive impact has been possible with the resources for interventions (early diagnosis by RDT and prompt treatment by effective antimalarials and LLIN distribution in high and moderate risk areas) applied from domestic and the Global Fund, which additionally catalysed the declining trend. No malaria deaths were reported in 2012. No malaria outbreaks occurred after 2006. Increased coverage by interventions ensured that no further transmission is enabled, although improving socioeconomic status may possibly have contributed to this scenario. The improvements have encouraged Nepal to envision zero indigenous malaria cases by 2020 and a malaria-free Nepal by 2025 through application of the Nepal Malaria Strategic Plan 2014-2025. The strategic objectives are to: (1) strengthen strategic information for decision-making towards malaria elimination wherein surveillance, including case-based surveillance, foci elimination, and operational research would be priority for shrinking the malaria map; (2) further reduce malaria transmission and eliminate the foci wherever feasible through IRS (responsive IRS, IVM), and LLIN distribution in high and moderate risk areas; (3) improve the quality of and access to early diagnosis and effective treatment of malaria EDPT, external quality assurance scheme (EQAS) – cross validation, panel slides and competency assessment; (4) sustain support from political leadership and communities towards malaria elimination by generating policy, guidelines and resources; (5) strengthen programmatic technical and managerial capacities towards malaria elimination with trained human resources (epidemiology, clinical, laboratory and entomology and VC). Further, details of the Malaria Disease Information System (MDIS) were shared. This is in the process of rolling out and an SMS-based recording, reporting and surveillance system is planned to be embedded. Information on G6PD deficiency prevalence study and other studies were mentioned too. A Nepal–India cross-border meeting on Prevention and Control of Communicable Diseases
 was held 21–22 December 2012. The MoU recommendations included disease specific working groups in major areas, such as vector-borne diseases and integrated disease surveillance as decided by the two countries. Development of a cross-border-referral and cross-border notification system for identified diseases would be beneficial. Synergizing of preventive activities should be explored in addition to the sharing of information on disease patterns, treatment protocols, guidelines, outbreaks and subsequent containment measures. For complete treatment, and to prevent drug resistance, to the greatest extent possible, migrant population should be able to access diagnosis and continued treatment for diseases such as malaria and other communicable diseases, irrespective of their residential status. Both countries can gain by collaborative research on diseases affecting both countries. The key roles of WHO should be: intercountry collaboration meetings and annual reviews; revival of Bangladesh, Bhutan, India, Nepal, Myanmar, Sri Lanka (BBINMS) mechanism (earlier Bangladesh, Bhutan, India, Nepal (BBIN) during 1998 and 2003 through the United States Agency for International Development/Environmental Health Project) to be based at the WHO Regional Office for South-East Asia for coordination, sharing information and harmonization interventions, drawing from learning from successful polio surveillance and response mechanism (cross-notification etc.). Regarding cross-cutting issues, Nepal mentioned assurance in making available the diagnosis and treatment for migrant workers, temporary residents;Government of Nepal/Epidemiology and Disease Control Division attempts to restore malaria check posts across the strategic border points, unlike during the eradication era, and continue diagnosis and treatment of patients irrespective of nationality; and orientation of United Nations peacekeeping force going abroad which could be provided with protection measures (LLIN, medicines). Sri Lanka In Sri Lanka, no indigenous cases have been reported since 2012. The number of imported cases is also on the decline with 36 cases in 2015, relative to 49 in 2014. The imported malaria cases are mostly from India and Pakistan, and other countries. Current policies, strategies and the legal framework were presented. Regarding cross-border collaboration, attempts are often informal. These include: creating a Technical Support Group; increasing surveillance at ports of entries by screening high-risk personnel entering Sri Lanka from malaria endemic countries; screening high-risk populations in the country, such as workers returning and refugees from malaria endemic countries; prophylaxis treatment for malaria for travellers and members of the United Nations peacekeeping force to malaria endemic countries; early detection and prompt treatment of malaria cases by providing the required diagnostic and treatment facilities per national guidelines by trained health staff, and public awareness; complete case investigation and entomological investigation; entomological surveillance and vector control, including “disinfection” of aircraft and vector surveillance and control in and around ports. In recent years, intercountry/cross- border meetings were not conducted. The country is closely coordinating with the WHO, UNHCR, IOM and the Global Fund. The key areas being addressed include: sources of imported malaria (employment seekers, business travellers, asylum seekers, returning refugees, pilgrims and tourists) and members of the United Nations peacekeeping force. The cross-cutting issues being emphasized are: strengthening surveillance at border points, screening of high-risk populations, education of migration-related authorities/agencies, clinicians, and rapid response. Major challenges comprise: a relatively high rate of malaria importation (there is no local transmission in Sri Lanka); nearly half of importations are from neighbouring countries – India and some from Pakistan; no cross-border collaborations and no mechanism to share data with source countries; illegal migration of labour from neighbouring countries presents huge problems with malaria patients remaining outside the surveillance net, despite a migration health policy. Several activities were proposed, including bilateral cross-border strategy and mechanisms with cross-border strategic plan shared bilaterally, focusing on notification of cases (sources – place and time to take action at the source country), sharing incidence data and funding for cross-border activities in both countries; improving migrant health policies in Sri Lanka with emphasis on free diagnosis and treatment to all migrants and the ability to screen high-risk migrant populations, such as construction workers; travel-related strategies by making all outbound travellers aware of risks of contracting malaria, requesting source countries to provide information to their travellers on where to seek diagnosis and treatment for malaria in Sri Lanka; and collaboration with airlines operating between source countries and Sri Lanka to provide information to passengers. DISCUSSION: Diverse border areas, poor accessibility of health and services to people living along borders, malaria ecology, sociopolitical and cultural issues, and poor access to quality prevention and treatment pose considerable operational challenges when addressing border issues. The cross-border situation has heterogeneous sets of conditions within which the forum needs to develop a framework, implementation and monitoring activities. Availability of information is not yet optimal. The forum discussed that every cross-border issue needs to be addressed differently and conducting detailed situational analysis for population dynamics, malaria situation, vector and parasite and overall ecology of cross-border issues, mapping of access to health (including malaria), lessons learnt, among others issues, is imperative at this juncture. Efforts are needed both at local and national level for timely sharing of information/data and joint meetings for action/response, outbreak investigation. However, to overcome sensitivity of data sharing a platform is needed. Focal persons/responsible unit at local levels should be identified immediately. Health-care services in border areas are often deficient and it is a mandate for each country to strengthen services in those areas. Each country should also define what cross-border collaboration can be added drawing from the situational analysis, since objectives and priorities may vary in different settings. Country-owned action plans should be developed too. Innovations such as health and patient cards and regional buffer stock should be considered. . The lessons learnt during outbreaks on international borders (Tripura 2014) should be utilized to prevent and address future bottlenecks. These could include but are not limited to: developing strategies on joint outbreak management and action plans; drug policy and stocking positions to address the outbreaks, as many countries would have only minimal stocks of antimalarial drugs as the countries move into elimination stages; mechanisms for sharing of information, including possible use of social media, health infrastructure and other mechanisms during outbreaks along the borders for quick and prompt action. There is a need for a regional nodal agency and institutional framework to take cross-border issues forward. This requirement is especially important, considering that cross-border issues thus far are merely conducting meetings with no accountability and follow-up actions for the recommendations and action plans developed. Therefore, if there is such a unit with responsibility to coordinate and advocate cross-border activities, issues could be addressed in a formal and sustained manner. Further, it was discussed that WHO should provide updated operational case definition of imported cases to be stringently followed by all Member States. Countries could also initiate MoU between them to provide an overall framework and platform for dialogue and developing activities that could be implemented at the ground and local level. Available resources should be utilized first and further financing gaps should be identified. An important element is to ensure similar cross-border action within countries. SESSION 3: EXPERIENCES FROM THE GREATER MEKONG SUBREGION (GMS) Emergency Response to Artemisinin Resistance (ERAR) in the GMS Programmes on both sides of borders and in townships in endemic areas are carried out. Movement is noted within borders and across borders by different subsets of mobile populations. Multiple factors are responsible and dynamics of movement of migrant and mobile populations (MMPs) are complex. In the GMS, population movement is largely occupation-related (trade, plantation, extractive industries, etc.) versus those related to conflict, natural disasters etc. as seen in other parts of the world. It is important for programmes to understand these dynamics before assuming any intervention within national borders or those targeting cross-border populations at risk. Migrant population in the GMS is estimated at approximately 300 million with migration routes along GMS economic corridors. The forested biodiversity conservation areas, where malaria burden is at its highest in border areas, was also shown. It was also mentioned that most sites with artemisinin resistance were found in border areas. The risk of the dynamics (population movement, development, etc.) is beyond the GMS with the rapid expansion of land transportation systems to other regions and continents. Road construction in many areas is in progress and/or in the stages of completion. The P. falciparum and P. vivax flows originating from the GMS were also shown, besides mentioning that the risk through land transport is now increasingly by air, as air travel becomes increasingly affordable and airline networks are expanding. Details of Emergency Response to Artemisinin Resistance (ERAR) were shared which has cross-border coordination as one of the major strategie, facilitated by a Regional Hub based at WHO in Cambodia. During 2013 and 2015, more than 20 meetings/workshops on migrants/cross-border issues, especially focusing on mobile and migrant populations, were held and programme, partners and WHO discussed the best approaches relating to cross-border linkages and defined priority areas and activities. The strategies currently being applied include: screening points, malaria post, fixed schedule mobile clinics, twin city initiatives, buddy health clinics, positioning village health worker/volunteer, teachers etc. in border villages, malaria corners in border areas, military camps and outpost/patrols as well as cross-border meetings/dialogue at local and national level, among others. The interventions are: diagnosis and treatment, DOT, bilingual messaging, patient cards, LLIN/LLIHN, repellent distribution, BBC, private sector accreditation and surveillance. More dialogue is needed between the country programme and the ministry of health within countries and with neighbouring countries. Polices and legal frameworks were also shared in addition to donor perspectives. It was mentioned that donor coordination that is more programmatically supportive of national malaria programmes is imperative. More focus is needed on integration of flexible, multiple sources of funding, appropriate implementing arrangements, and flexibility in reaching migrant and mobile populations, increasing engagement with the private sector as a sustainable way forward, and evidence generation of impact of interventions through a robust M&E system to reach elimination goals. The initiative for migrant and mobile populations has to be an inherent component within national strategic plans towards elimination. Additional funding and innovative/new interventions are required in addition to involvement of respective country governments, as well as donors. Lessons learnt from the GMS include: national/subnational elimination of P. falciparum requiring multisector and policy guidance on MMPs with responsive strategies and more involvement of economic, agricultural, and environmental planning bodies; understanding the influence of land use change as part of routine malaria programme surveillance; current and anticipated dynamics of the local area, risk mitigation, local transmission, timing and duration of mobility and prioritizing population movements with the most significance to malaria; border/cross-border strategy involving synergistic/complementary activities on the opposite side; standardized key data variables to be collected and platform/s for data- sharing across countries; constraints in cross-border collaboration, particularly requiring timely and regular policy dialogue with national and regulatory authorities and APLMA, ASEAN, development partners and WHO; and further strengthening of test-treat-track and BCC, especially for migrant and mobile populations. Comprehensive assessment of the border situation (current and anticipated) is to be carried out in terms of dynamics of population movement, receptivity and vulnerability in relation to malaria elimination, local/regional stakeholder (multisector) mapping, and local health systems. Border specific approaches with options/strategies for malaria elimination adapting to context, empowerment of local capacities and policies and legal frameworks are also required to be studied. Mekong Basin Disease Surveillance Project (MBDS) The Mekong Basin Disease Surveillance Project (MBDS) comprises six participating countries: Cambodia, China (Yunnan and Guangxi Provinces), the Lao People’s Democratic Republic, Myanmar, Thailand and Viet Nam and a growing number of development partners, who together, seek to reduce morbidity and mortality caused by outbreak-prone diseases in the subregion. MBDS countries have been working together since 2001 to progressively build local capacity, share information, and cooperate in outbreak response and pandemic preparedness. In May 2007, six participating countries signed a new MoU to continue MBDS cooperation indefinitely. At approximately the same time, the WHO revised International Health Regulations (IHR 2005) came into effect. These regulations specify the obligations of countries to develop and maintain capabilities to detect, respond to and communicate about public health emergencies of international concern (PHEIC); thus, they provide additional context for MBDS cooperation. In 2007, a conference in Bellagio led to a call for action related to subregional surveillance networking, and a newer initiative that began in 2009, connecting health organizations for regional disease surveillance, seeking to further strengthen subregional surveillance cooperation. The strategy (community-based surveillance, risk communication, cross-border information, information and communications technology (ICT)  forums, laboratory assessment report, human resource development in epidemiology, Field Epidemiology Training Programme (FETP) setup), coordination mechanism were also shared. The Global Health Security Agenda (GHSA) focus to prevent avoidable epidemics, detect threats early and respond rapidly and effectively was mentioned. The MBDS cross-border information exchange schedule, system, and content was also shared with a special mention of the use of web reporting, mobile application. The details of average percentage exchange of report from MBDS by country and sites were also presented. The MBDS as a model is able to prove that a subregional disease surveillance and information exchange can be made functional in addition to moving forward the issue of cross-border cooperation in the subregion. Challenges for malaria control and elimination in remote and hard-to-reach border areas: experiences from India Key challenges highlighted are: geographical, related to poor access, especially in remote and border areas and during monsoon, post-monsoon months; socioeconomic, relating to social, cultural, economic, political institutions of tribes, marginalized groups and others; occupational/developmental, relating to agriculture/mining/project/construction areas (such as migrant workers, other mobile populations, miners, forest workers and those engaged in shifting cultivation); behavioural, relating to health-seeking behaviour, adoption of appropriate preventive measures, etc.; and operational, relating to adequate and quality manpower, materials for effective and efficient programme/project as well as adequate resources and its timely availability and absorption. Experiences of Caritas India were shared as a principal recipient of a Global Fund grant and complementary partner of the National Vector Borne Disease Control Programme of the Government of India in seven north eastern states (in 27 border districts and elsewhere). LLINs were distributed in coverage areas, however, challenges were faced regarding coverage of populations not always covered under village surveys in view of non-availability of identification cards, especially among many seasonal workers and others, forest workers and miners, particularly those in border areas. Regarding diverse health-seeking behaviour issues: lack of awareness among such groups; inadequate provision of stock of diagnostics and antimalarials with sufficient shelf life for free diagnosis and treatment, especially the critical need for deployment at peripheral level; varied capacities at the grassroots; and programme data integration with the national management information system at designated Reporting Units, etc. require continued attention. In addition, timely and quality data flow and feedback, mapping and non-involvement of private health-care service providers for rational treatment and case reporting, as well as the requirement of continued advocacy at political, administrative, media, corporate, non-corporate, local influencers (tribal councils/autonomous councils, other groups, village chairpersons/heads) levels in view of many local level changes, also remain challenges. The sociopolitical situation in many areas of north-eastern states add to the complexity. Efforts are ongoing to overcome challenges and mitigation at all levels, especially on the ground in consultation and coordination with the stakeholders, such as public health authorities, other civil society organizations and security forces. Both health and community systems strengthening also remain a priority, together with continuous capacity building and strengthened M&E with customized packages per local context. It is also recognized that thorough situation analyses are also critical at this juncture. Experiences with cross-border collaboration for eradication of poliomyelitis in India India, one of the four endemic countries until 2012 in SEAR, is now polio-free. In 2014, the entire SEAR was certified polio-free. Key factors behind this success include: strong government ownership and accountability, strong surveillance and ongoing research to guide policy decision-making, meticulous planning and implementation of vaccination campaigns, capacity-building of vaccinators on operation and communication, robust communication strategy for demand generation, real-time monitoring and use of generated data, focus on high-risk areas, and seamless partnership and collaboration. It was mentioned that cross-border collaboration was very important for the polio eradication programme. Wild polioviruses closely linked to viruses in India detected in neighbouring (and distant) countries, not once but multiple times, and genetic mapping, indicated cross-border circulation of the polio virus. At the national level, synchronized timing of polio vaccination campaigns, vaccination of road/train travellers and those coming by air/sea and frequent sharing of surveillance indicator information (information on confirmed polio cases, genetic information on viruses) were emphasized. District-level activities included coordination between district immunization officers (facilitated by WHO Medical Officers through direct communication between bordering districts of India, Nepal and Bangladesh), joint cross-border immunization response to outbreak, joint physical verification of border areas for micro- planning for vaccination campaigns, sharing information on high-risk areas and vaccinating children in high-risk areas across the border. An example was presented about synchronized cross-border mop-up immunization in response to wild polioviruses importation (2010) in Nepal wherein districts were selected on both sides of the border for mop-up immunization activity. Also, vaccination of road/train travellers at cross-border vaccination posts (24 X 7 X 365) at Indo-Bangladesh, Indo-Myanmar and Indo- Bhutan borders since 2013 was presented. Further, mandatory vaccination of travellers from and to all recently polio-infected countries, eight polio-affected countries, four weeks prior to travel irrespective of age and previous vaccination status since 2014 and mandatory vaccination of all travellers from Pakistan (more than seven countries) at the point of entry irrespective of vaccination certificate, and coordination for surveillance of poliovirus was also done. Cross-notification of acute flaccid paralysis (AFP) cases, health facilities that missed reporting AFP cases, and coordination for case investigation of AFP cases, including specimen collection, were also part of district-level activities. Modalities of coordination included: national level cross-border meetings involving the Ministry of Health and WHO staff (mostly coordinated by the WHO Regional Office for South-East Asia), regular cross-border meetings of field medical officers supported by WHO, intercountry missions supported by WHO, UNICEF; and SEAR technical meetings and biregional meetings. The WHO National Polio Surveillance Project included support for surveillance for poliovirus detection through establishing and operationalizing a sensitive AFP surveillance, environmental surveillance for poliovirus, quality assurance, data management and analysis, cross-border collaboration, as well as support for supplementary immunization activities through micro-planning, capacity-building of frontline workers, monitoring quality of campaigns, supporting accountability frameworks, data management and analysis and cross-border collaboration. The transition of the WHO National Polio Surveillance Project is in progress with medical officers becoming increasingly involved in areas beyond polio, including application of lessons learnt and best practices from polio eradication to other programmes. New areas of support include: strengthening routine immunization; surveillance and immunization activities for measles elimination and rubella control; surveillance of other vaccine-preventable diseases; introduction of new vaccines: Hib, IPV, rotavirus; surveillance for adverse events following immunization; maternal and neonatal tetanus elimination; and kala azar elimination. Cross-border collaboration in the context of the International Health Regulations (2005) IHR (2005) is an internationally agreed instrument for global public health security. It represents the joint commitment for shared responsibilities and collective defence against disease spread and legally binding for WHO Member States since June 2007. The IHR (2005) provides the Asia Pacific Region with a unique opportunity to strengthen the fundamental public health system at both national and regional levels. Its purpose is to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade. IHR (2005) calls for strengthened national capacity for surveillance and control, designated points of entry (PoE) in travel and transport, prevention, alert and response to international public health emergencies, global partnership and international collaboration and rights, obligations and procedures, and progress monitoring. Points of entry means a passage for international entry or exit of travellers, baggage, cargo, containers, conveyances, goods and postal parcels as well as agencies and areas providing services to them on entry or exit. The points of entry can serve as points to check that prevention of known risks are in place, to detect events that may constitute a public health emergency of international concern, to take measures to detect disease at the source and to adopt initial measures to events related to travel and transport. The IHR (2005) national core capacities (legislation and policy, coordination, surveillance, response, preparedness, risk communication, human resources, laboratory) should be strengthened across the five relevant hazards: infectious diseases, zoonosis, food safety, chemical and radio-nuclear at points of entry. The control of diseases at border crossings remains an essential element of the regulations. The IHR (2005) focusing on strengthened public health security in travel and transport has control of diseases at border crossings as an essential element. The IHR (2005) routine requirements at PoE and during response to a public health emergency were also described. The expected results with IHR (2005) implementation at PoE include: facilities maintenance in a sanitary condition, kept free of infection or contamination, including vectors and reservoirs; routine measures for travellers, conveyances, cargo, goods and postal parcels; contingency plan for public health emergencies that is effectively available and operational at all designated PoE and in all countries; capacity to rapidly implement international public health recommendations at designated points of entry; and coordination between WHO and other organizations. The challenges however, are: designating PoE and identifying competent authorities for implementing IHR (2005); listing authorized ports able to implement ship sanitation certificates; strengthening links of PoE with national health surveillance and response system; updating national legislation and harmonization of IHR (2005) requirements with enforcement of provisions from others international agreements, such as the International Civil Aviation Organization, IMO and International Labour Organization conventions; strengthening intersectoral collaboration and coordination for designation, assessment and development of routine and response core capacity at PoE, including transport, customs, immigration and environment, to have harmonized best practices at PoE in a globalized world and in an all hazards approach. The key elements of cross-border collaboration from the global and local perspective were also presented that highlighted IHR (2005) as well as a need for local collaboration and actions on local issues that should not be restricted to a checkpoint approach only. The details of the assessment tool for core capacity requirements at designated PoE were also shared. Further, WHO support for such issues as building capacities and PoE guidance were also conveyed. In SEAR, two Member States, Indonesia and Thailand, have achieved IHR (2005) core capacities. Member States requesting an extension require further core capacity development while others that have not requested an extension require continuous maintenance of IHR (2005) core capacities. Implementation of core capacities continues to vary between SEAR Member States and across different technical areas. Implementation rates are still seen to be low for chemical and radio-nuclear hazards. As illustrated by the joint assessment missions for Ebola undertaken in nine of the 11 countries in SEAR, there is evidence that activities that need to be functional is “significant” but not “substantial” in some Member States. The recent meeting of the IHR Review Committee has recommended going beyond mere compliance as a continuous process, as opposed to one that comes to an end at any particular date, including in 2016. Many issues and observations raised include poor awareness and/or incomplete understanding of IHR (2005) at many levels; importance of strengthening core capacities with a costed plan; inadequacy of self- assessment and the need for better monitoring of capacity-building and health systems concurrently with strengthening core capacities; need to ensure effective implementation of IHR (2005) at all points of entry; development of effective incentives and disincentives in compliance and notification; importance of regional collaboration and knowledge-sharing; critical need for community engagement; and the importance of refraining from taking unnecessary traffic and trade restrictions. Cross-border elements focus on capacities at PoE and other core capacities. Cross-border work for malaria control should be dealt with through a broader health system approach. GROUP WORK The group work was scheduled to discuss existing mechanisms for cross-border collaboration and definition of key areas for collaboration, with focus on: learning from existing cross-border initiatives applicable to malaria; key opportunities for cross-border collaboration focusing on strengthening national health systems towards malaria elimination and increasing coverage of antimalaria services for underserved populations; identification of possible practical and effective mechanism/s for cross-border collaboration in malaria, and defining key areas for collaboration; roles and responsibilities of parties concerned to make cross-border collaboration successful; and critical policies, challenges and constraints that need to be addressed  with regards to cross-border collaboration. The groups were requested to: specify key districts targeted in each country; describe on-going local transmission, problems faced, and actions being currently taken. In addition, identify the objectives of cross-border collaboration in these districts and describe the areas of action needed for effective cross-border collaboration for malaria elimination in each country and who should be responsible (roles and responsibilities) at district, national and regional levels, as well as any other relevant issue. A summary of the group work is presented below. Diverse challenges are presented in the fight against malaria in border areas that include, but are not limited to, poor access to interventions on account difficult geographical terrain - forested and forest fringe areas inhabited by many ethnic groups and often from relatively low socioeconomic status (low literacy, high level of poverty) having varied health-seeking behaviour; poor communication (roads, etc.); not yet optimal health-care services and human resources; deficient health information system; dispersed population; drug and insecticide resistance in many areas; uncertain quality of diagnostics and antimalarials; presence of non-formal private providers; sociopolitical conflict situation; and a large number of migrant and mobile populations (mix of legal and others without proper identification – illegal movement). Even though cases are diagnosed and treated, follow-up of cases as well as notification are not pursued. The groups also highlighted minimal or episodic information sharing, near absence of harmonization and synchronization of policy, strategy, interventions (prevention: LLIN coverage, information, education and communication and BCC activities; and diagnosis and treatment), surveillance and M&E, research/survey/study (TES, insecticide resistance, vector prevalence, etc.), local- level capacity building in the absence of consultation/collaboration/MoU/regional mechanism. Innovations, for example, patient cards, should also be encouraged. A major gap is the absence of comprehensive situation analyses. Information on the key players in the border areas also remains to be generated and should be an inherent component of situation analysis. Immediate national and local programme-to-programme cross-border notification on the upsurge in cases, specific events, resistance, and implementation research should be pursued. Emphasis should also be placed on joint planning and coordination (meetings, cross-border visits/missions); joint outbreak investigation; application of BCC materials in local languages; improved surveillance; case investigation in low endemic areas; increasing access to quality services through community health workers/volunteers; mobile and community clinics; and strengthened health systems and border posts/health centres, among others. In addition, dialogue with concerned departments should be initiated for improving communication, such as by road. Importantly, as these aspects are being discussed and pursued, a comprehensive situation analysis should be one of the first priorities, besides identification of resources. Thereafter, participants agreed upon key next steps (kindly refer to “Recommendations”). CONCLUSION The meeting provided a platform for productive exchange of information on the malaria situation in border areas and challenges, gaps and the way forward. It was concluded that border malaria is a major public health concern and a threat to impeding the pace of malaria elimination in SEAR and each Member State. RECOMMENDATIONS The following key recommendations were made. 1. Cross-border collaboration requires strengthening of service delivery, information sharing, action coordination, surveillance and M&E, implementation research, as well as addressing special technical problems, such as drug (especially related to artemisinin derivatives) and insecticide resistance. 2. An agreement to develop a protocol for assessment on malaria in cross-border settings of neighbouring countries of South Asia with special emphasis on current malaria situations, existing programme strategies, approaches, interventions, challenges and gaps, and to conduct relevant cross- border assessments. The exercise would be led by WHO and identified focal points in each country in South Asia. Possible involvement of certain partners would also be explored. 3. Establishment of networks by designating/nominating focal persons (national, state, district levels), bilateral working groups and bilateral district-level coordination committees. 4. Setting up a core group (WHO and national programme focal points) for immediate coordination action. 5. Launch of a regional coordination mechanism by reaching mutual agreements on the one year coordinated cross-border action plans at the country and intercountry levels. Initiating high-level action, including and not restricted to MOUs, with the aim to create an enabling environment for local action, starting with policy agreement by different ministries (Ministry of Health, Ministry of Foreign Affairs, Ministry of Home Affairs, etc.), facilitated by WHO. 6. Planning and conducting cross-border district meetings at regular intervals and country and intercountry meetings preferably annually, facilitated by WHO. 7. Multisectoral involvement and support by partner organizations is crucial. 8. Collaboration with existing cross-border mechanisms, such as existing border security meetings. 9. WHO SEAR strategic guidance and technical assistance to facilitate cross-border collaboration on malaria elimination within South Asia. 10. Review of operational case definition of malaria (indigenous/imported) cases by WHO to be stringently followed by all Member States. 11. Initiating MoUs between countries to provide overall framework and platform for dialogue and developing activities that could be implemented at the local level, drawing on the lessons from other regions, such as GMS and other programmes, including the polio eradication programme and leveraging existing international regulations, such as IHR (2005), for malaria elimination with the goal of addressing border malaria within SEAR in an effective and sustained manner. Annex 1: Programme 12 February 2016 Time Presenter/Facilitator 1. Opening session 0830-0900 0900-0930 Registration of participants Welcome and Opening Address Objectives and expected outcomes of the meeting Introduction of meeting participants Global and regional updates on malaria, with special reference to cross-border malaria Nomination of Office bearers D r S w a r u p S a r k a r , D i r e c t o r Communicable Diseases, WHO Regional Office for South-East Asia Dr Eva Christophel, Regional Adviser Malaria, WHO Regional Office for South-East Asia Dr Eva Christophel, Regional Adviser Malaria, WHO Regional Office for South-East Asia Dr Pedro Alonso, Director, WHO Global Malaria Programme and Dr Eva Christophel, Regional Adviser Malaria, WHO Regional Office for South-East Asia D r S w a r u p S a r k a r , D i r e c t o r Communicable Diseases, WHO Regional Office for South-East Asia 1000-1030 Group Photograph Tea/Coffee 2. Issues and solutions for cross-border programmes 1030–1045 Partnership panel on cross-border malaria elimination Panel discussion 1045–1200 Country presentations: Progress with malaria control and challenges to eliminate malaria with particular focus on border areas, including existing cross-border collaboration mechanisms (10 minutes each, followed by 5 minutes Q&A each) Bangladesh Bhutan India Indonesia Myanmar Country representatives 1200-1300 Lunch 1300-1330 1330-1400 Country presentations continued Nepal Sri Lanka Plenary discussion and summary on common issues requiring cross-border collaboration Country representatives 3. Experiences on cross-border collaboration from other communicable disease programmes and partners 1400-1430 1430-14.45 1445-1500 1500-1515 (10 minutes each, followed by 5 minutes Q&A each) Experiences from the Greater Mekong Subregion (GMS): - Emergency Response to Artemisinin Resistance in the GMS (ERAR) 
 - Mekong Basin Disease Surveillance Project (MBDS) Challenges for malaria control and elimination in remote and hard-to-reach border areas – experiences from India Experiences with cross-border collaboration for eradication of poliomyelitis in India Cross-border collaboration in the context of the International Health Regulations Dr Deyer Gopinath, WHO ERAR Dr Moe Ko Oo, MBDS Dr Shampa Nag, Caritas India Dr Sunil Bahl, WHO Regional Office for South-East Asia polio focal person, IVD Dr Roderico Ofrin, Director Health Security and Emergency Response, WHO Regional Office for South-East Asia 1515-1545 Tea/Coffee 4. Defining areas of collaboration and mechanisms of collaboration 1545-1700 Group work: Discussion on existing mechanisms for cross- border collaboration and definition of key areas for collaboration, with focus on: • What have we learnt from existing cross-border initiatives applicable to malaria?  • What are the key opportunities for cross-border collaboration focusing on strengthening national health systems towards malaria elimination and increasing coverage of antimalaria services for underserved populations?   • Identify possible practical and effective mechanism/s for cross- border collaboration in malaria, and define key areas for collaboration • What are the roles and responsibilities of parties concerned to make cross- border collaboration successful? • What are the critical policies, challenges and constraints that need to be addressed with regards to cross- border collaboration? Participating countries, WHO and partners 
 Facilitators: 
 WHO staff and partners Welcome reception 13 February 2016 Group work 0830-1000 Group work continued Discussion on existing mechanisms for cross- border collaboration and definition of key areas for collaboration (cont.) 1000 - 1030 Tea/Coffee Group work 1030-1130 1130-1200 1200-1230 1230-1300 1300-1315 Feedback from working groups/presentations Plenary discussion Comments and inputs from partners Conclusions and recommendations Closing remarks Global Fund and SEA Constituency Representative, ADB, IOM, APLMA, SAARC Secretariat, Partners in Population Development, Mekong Basin Disease Surveillance Project, Malaria Consortium Dr Eva Christophel, Regional Adviser Malaria, WHO Regional Office for South-East Asia D r S w a r u p S a r k a r , D i r e c t o r Communicable Diseases, WHO Regional Office for South-East Asia 1315 - 1400 Lunch Annex 2: List of participants Member States Bangladesh Dr Abu Nayeem Mohammed Sohel Deputy Program Manager (Malaria and VBDC) Ministry of Health and Family Welfare Dhaka Bhutan Mr Pandup Tshering Director Department of Public Health Ministry of Health Thimphu Dr Tashi Tobgay Director Khesargyalpo University of Medical Sciences of Bhutan Thimphu Mr Non Tobgyel Senior Program Officer Vector Born Disease Control Programme (VDCP) Ministry of Health Gelephu India Dr N. S. Dharmashaktu Additional Director General Health Services Ministry of Health and Family Welfare Delhi Dr Mukesh Saxena Additional Director General (Med.) CAPR and AR Dr Delhi Mr Amal Pusp Director (III) Ministry of Health and Family Welfare Delhi Dr A. C. Dhariwal Director National Vector Borne Disease Control Programme Ministry of Health and Family Welfare Delhi Dr Neena Valecha  Scientist G & Director National Institute of Malaria Research (NIMR) Delhi Dr Pradeep Joshi Commandant (SG) Deputy Director (Med) Shashatra Sema Bal Delhi, SSB (bordering Nepal, Bhutan) Delhi Dr G. S. Sonal Additional Director National Vector Borne Disease Control Programme Ministry of Health and Family Welfare Delhi Dr Avdesh Kumar Additional Director and Nodal Officer for GFATM National Vector Borne Disease Control Programme Delhi Dr S. N. Sharma Joint Director and Nodal Officer for Malaria Elimination National Vector Borne Disease Control Programme Delhi Dr Sher Singh Kashyotia Additional Director and Nodal Officer for Cross Border Malaria National Vector Borne Disease Control Programme Delhi Dr Alok Yirang Joint Director Health Services cum State Programme Officer (Vector Borne Diseases) Directorate of Health Services Naharlagun Arunachal Pradesh Dr T Zamkhokam Kuki Lamphelpat Imphal West Manipur Dr Bethabara Decruse Senior Medical Officer cum State Programme Officer I/C (Vector Borne Diseases) Office of Deputy Director of Health Services Directorate of Health Services Shillong Meghalaya Dr C Zarzolina Joint Director S & SPO Directorate of Health Services Dinthar, Aizwal Mizoram Dr Chandrasekhar Biradar Public Health Specialist CMO (SG) Composite Hospital Shokhuvi District Dimapur (Indo-Myanmar Border) Nagaland Dr K Medikhru Joint Director of Health Services (Malaria) Kohima Nagaland Dr Laxman Singh CMO (SG) Composite Hospital Agartal Tripura Dr Kajal Debgupta C/o the Directorate of F.W. & P.M Government of Tripura Agartala Tripura Dr R. K. Patel Joint Director Malaria/Vector Borne Diseases Lucknow Uttar Pradesh Dr Adhip Ghosh Swasthya Bhawan West Bengal Dr Neelima Mishra Scientist National Institute of Malaria Research (NIMR) Delhi Dr Hardeo Prasad Gupta Research Scientist National Institute of Malaria Research Indian Council of Medical Research Field Unit Guwahati, Assam Dr P.L. Joshi Public Health Consultant Delhi Indonesia Dr Elvieda Sariwati, M.Epid National Programme Manager Malaria & Head Sub-Directorate of Malaria Directorate of Vector Borne Diseases Control DG Diseases Control and Prevention Ministry of Health Jakarta Myanmar Dr Than Win Deputy Director General (Disease Control) Department of Public Health Ministry of Health Naypyitaw Dr Aung Thi Deputy Director (Malaria) Department of Public Health Ministry of Health Naypyitaw Dr Kay Thwe Han Deputy Director (Research) Department of Medical Research Ministry of Health Naypyitaw Nepal Dr Babu Ram Marasini Director Epidemiology & Disease Control Division Department of Health Services Ministry of Health & Population Kathmandu Dr Garib Das Thakur Chief, Public Health Administrator Monitoring and Evaluation Division Ministry of Health Ramshahpath, Kathmandu Dr Ram Raj Panthi Senior Integrated Medical Officer Focal Person for Malaria Control Epidemiology & Disease Control Division Ministry of Health Teku, Kathmandu Mr Mohammed Daud Public Health Administrator District Health Office Ministry of Health Kathmandu Sri Lanka Dr H. D. B. Herath Director, Anti Malaria Campaign Ministry of Health Colombo Temporary Advisers Dr Kamini N Mendis Consultant Colombo Sri Lanka Dr Suriya Wongkongkathep Director General Department of Development of Thai Traditional and Alternative Medicine (DTAM) Ministry of Public Health, Thailand Board Member, GFATM Thailand Observers Dr Ben Rolfe Executive Secretary wAsia Pacific Leaders Malaria Alliance (APLMA) Manila Philippines Mr Perry Mwangala Fund Portfolio Manager India The Global Fund Geneva Switzerland Mr John Mcharo Programme Officer The Global Fund Geneva Switzerland Dr Richard Cunliffe Fund Portfolio Manager High Impact Asia Department The Global Fund Geneva Switzerland Ms Lalla Haidara Programme Officer The Global Fund Geneva Switzerland Dr Warin Choomsai Na Ayudhaya Project Manager Malaria (Migration Health Program) International Organization for Migration Bangkok Thailand Dr Joe Thomas Executive Director Partners in Population and Development Dhaka, Bangladesh Nongovernmental Organizations Dr Md Akramul Islam Director Malaria & Tuberculosis Control BRAC Dhaka Bangladesh Dr Mohammad Moktadir Kabir Programme Head WASH and Malaria BRAC Dhaka Bangladesh Dr Shampa Nag Malaria Project Director Caritas India New Delhi, India Ms Rody Gangte Project Manager Caritas India New Delhi, India Ms Mamta Aswal Grant & Finance Manager Caritas India New Delhi, India Dr Vikas Aggarwal Regional Director for Asia KalaCORE Consortium for the Control and Elimination of Visceral Leishmaniasis Noida, India Dr Sakib Burza Regional Operational Research Referent Médecins Sans Frontières New Delhi, India Dr Vivek Ahuja Director, Research and Development  PATH India New Delhi, India Dr Siddhi Aryal Malaria Consortium Asia Technical Director Bangkok, Thailand Dr Moe Ko Oo Secretary Mekong Basin Disease Surveillance Foundation Secretariat Nonthaburi, Thailand Secretariat Regional Offices for South-East Asia (SEARO) and the Western Pacific (WPRO) Dr Swarup Sarkar Director Communicable Diseases SEARO Dr Roderico Ofrin Director Health Security & Emergency Response SEARO Dr Lin Aung Coordinator Emerging Diseases Department of Communicable Diseases SEARO Dr Jigmi Singay Regional Adviser (Communicable Diseases and Focal Point for The Global Fund) SEARO Dr Eva Christophel Regional Adviser (Malaria) SEARO Dr Sunil Bahl Regional Adviser (Accelerated Disease Control) Immunization and Vaccine Development SEARO Dr Walter Kazadi Coordinator Technical Officer (Coordinator, Emergency response to Artemisinin Resistance in the Greater Mekong Sub Region) SEARO/WPRO Dr Mikhail Ejov Consultant SEARO Ms Rekha Bettina Gautam Consultant (Malaria) SEARO Mr Paramjeet Singh National Professional Officer Department of Communicable Diseases /SEARO Mr Ranjit Kathuria Executive Associate / SEARO Ms Susha Sreedharan Executive Assistant / SEARO Ms Anshu Butani Executive Assistant / SEARO Ms Naina Sethi Team Assistant / SEARO Mr Harpreet Singh Messenger / SEARO Country Offices Dr Saurabh Jain National Professional Officer WHO India Dr Anand Joshi Technical Officer WHO Indonesia Dr Badri Thapa Scientist (Malaria) WHO Myanmar Dr Md Mushfiqur Rahman Technical Officer (Malaria) WHO Myanmar Dr Prakash Ghimire National Professional Officer (Malaria) WHO Nepal Dr Gopinath Deyer Medical Officer (Malaria and Border Health) WHO Thailand WHO Headquarters Dr Pedro Alonso Director Global Malaria Programme Geneva Dr Sivakumaran Murugasampillay Medical Officer Global Malaria Programme Geneva Dr Leonard Ortega Team Leader, Technical Support and Capacity Building Global Malaria Programme Geneva Annex 3: Results of 6 Bilateral Working Groups on Cross-Border Collaboration for Malaria Group work Terms of Reference 1. Specify key districts targeted in each country 2. Describe these districts: a. To your best knowledge is there on-going local transmission in your respective districts? b. Describe the problems faced, and what is currently being done 3. Identify the objectives of cross border collaboration in these districts
 4. Describe: 
 
 a) the areas of action needed for effective cross border collaboration for malaria elimination in each country (please give details, eg information sharing: what is key information to be shared) and 
 
 b) who should be responsible (roles and responsibilities) 
 
 by level: i) District level ii) National level iii) Regional level 
 5. Any other relevant issue. Group 1: 
 Cross-Border Collaboration 
 India – Bangladesh 
 1. Key districts targeted in each country – specify Country A [India] Country B [Bangladesh] Name of district Name of province/ state Name of district Name of province/ state Lunglei, Mizoram Bandarban CHT Lawngtlai Mizoram Rangamati CHT Mamit Mizoram Khagrachari CHT West Tripura Tripura Brahmanbari Sipahijala Tripura Coomilla Gomti Tripura Mymensingh South Tripura Tripura Khagrachari CHT Khowai Tripura Sylhet? 1. Key districts targeted in each country – specify Country A [India] Country B [Bangladesh] Name of district Name of province/ state Name of district Name of province/ state Dhalai Tripura Bandarban, Rangamati CHT Unakoti Tripura Sylhet North Tripura Tripura Sylhet Jaintia Hills Meghalaya Sylhet E. Khasi Hills Meghalaya Sylhet W. Khasi Hills Meghalaya Sylhet S. Garo Hills Meghalaya Sylhet W. Garo Hills Meghalaya Sylhet 1. Key districts targeted in each country – specify Country A [India] Country B [Bangladesh] Name of district Name of province/ state Name of district Name of province/ state Karimganj Assam Sylhet Dhubri Assam ? Cachar Assam ? Coochbehar West Bengal Rangpur? Darjeeling West Bengal ? Uttar Dinajpur West Bengal Dinajpur? Dakshin Dinajpur West Bengal Dinajpur Malda West Bengal ? Murshidabad West Bengal ? Nadia West Bengal ? 1. Key districts targeted in each country – specify Country A [India] Country B [Bangladesh] Name of district Name of province/ state Name of district Name of province/ state N. 24 Paraganas West Bengal Jessore S. 24 Paraganas West Bengal Satkhira 2 (a) To your best knowledge is there on-going local transmission in your respective targets districts? 2 (b) Describe the problems faced and what is currently being done Country A Key challenges What is being done currently India Population movement – Legal, Illegal; ‘Chitmahal’ (no man’s land) – West Bengal; Conflict – socio- political Discussion at higher levels Access poor - forested & forest fringe areas, poor communication (road, etc.), deficient health services; dispersed population Health camps; community based service delivery – ASHA, CHV; LLIN distribution Dialogue with concerned Dept. for improving road, etc. Many ethnic groups, Low literacy, high level of poverty Awareness through IEC/BCC, Meetings by VHSNC Non-formal private providers Trainings/orientation being planned for rational treatment and case reporting Country B Key challenges What is being done currently Bangladesh Population movement – Legal, Illegal; Conflict – socio-political Discussion at higher levels Access poor - forested & forest fringe areas, poor communication (road, etc.), deficient health services Mobile clinics/health camps; Community clinics; Service delivery through volunteers; LLIN distribution Dialogue with concerned Dept. for improving road, etc. Many ethnic groups, Low literacy, high level of poverty Awareness through IEC/BCC 3. What is the objective of this cross border effort in the key districts? Goal: To eliminate malaria on both sides of border by rapidly increasing access to preventive, promotive and curative services. 4. Effective cross border collaboration: Country A (list districts) Area/s of action in context of elimination (existing mechanism and action to improve collaboration) Roles (mention who) and responsibilities District State National Regional 27 Border districts – India 13 border districts - Bangladesh Prioritization of districts for action District malaria programme CHT; Mizoram, Tripura National malaria programme Situation analysis WHO Harmonized action plan District malaria programme State Malaria programme National malaria programme Exchange specific information at local level District malaria programme State Malaria programme National malaria programme Mechanism for coordination District Malaria Officer State Malaria Officer National Malaria programme WHO 5. Next Steps • Network on e-mail created for Working Group for Bangladesh and India 
 • Issuance of memo to states/districts on cross border collaboration – assigning nodal officers for action
 • Policy agreement by MOH and MOFA, MOHA in Bangladesh and India facilitated by the WHO
 • Information sharing between national, state and district level 
 • Joint planning for synchronized activities 
 • District-to-district meetings. Group 2: 
 Cross Border Collaboration 
 Bhutan – India • Dr Pandup Tshering (Chair) • Dr Ortega (Facilitator ) • Mr Tobgye • Dr S N Sharma • Dr Neena Valecha • Dr Tashi Tobgay • Dr Allok Yirang 1. Key districts targeted in each country – specify Country A [India ] Country B [Bhutan] Name of district Name of province/ state Name of district Name of province/ state Tawang (Dudunghar, Bongleng Mukto) (Arunachal Pradesh) Trashi Yangtsi, Trashi gand Tashigand West Kemang (Balimu) Arunachal Pradesh Samdrupjongkhar, Baksa Assam Samdrupjongkhar, Pemagatshel Chirang Assam Samdrupjongkhar Kokrajhar Assam Sarpang Udalguri Assam Sarpang and Zhemgang Darjeeling West Bengal Chukha Jalpaiguri West Bengal Chukha East Sikkim Sikkim Samtsi 2 (a) To your best knowledge is there on-going local transmission in your respective targets districts? Country A [India ] Local transmission (Yes/No) (list districts) Tawang (Dudunghar, Bongleng Mukto) Yes? West Kemang (Balimu) Yes Baksa Yes Chirang Yes Kokrajhar Yes Udalguri Yes Darjeeling Yes Jalpaiguri Yes East Sikkim ?Yes Country B [name] Local transmission (Yes/ No) Trashi Yangtsi, Trashi gand Tashigand No Samdrupjongkhar, ?Yes Samdrupjongkhar, Pemagatshel Yes Sarpang Yes Sarpang Yes? Sarpang and Zhemgang Yes Chukha Yes Chukha No Samtsi No Samtsi No 2 (b) Describe the problems faced and what is currently being done Country A (India) Key challenges What is being done currently Tawang (Dudunghar, Bongleng Mukto) Transmission is doubtful, Connectivity difficulty Included in the malaria map of India West Kemang (Balimu) Connectivity difficulty Regular surveillance IRS twice a year Baksa -Inadequate surveillance - Forest reserves - No situational analysis - Do not know the area -IRS , -LLIN distributed -Jhoom Cultivators focused for LLIN -ASHA services -Diagnostics and treatment services Chirang Kokrajhar Udalguri Darjeeling -Forest areas -Connectivity difficult -Weak surveillances -EDPT -Vector control activities Jalpaiguri Forest areas -Connectivity difficult -Weak surveillances EDPT -Vector control activities East Sikkim Forest areas -Connectivity difficult -Weak surveillances EDPT -Vector control activities 2 (b) Describe the problems faced and what is currently being done Country B (Bhutan) Key challenges What is being done currently Trashi Yangtsi, Trashi gang Imported cases, Population movement Lack of human resources and Capacity to conduct research, high level laboratory, entomological analysis, Development projects with expatriates laborer, Surveillance Samdrupjongkhar IRS, LLIN, EDPT, case follow- up, surveillance Samdrupjongkhar IRS, LLIN, EDPT, case follow- up, surveillance Samdrupjongkhar IRS, LLIN, EDPT, case follow- up, surveillance Sarpang IRS, LLIN, EDPT, case follow- up, surveillance Dagana IRS, LLIN, EDPT, case follow- up, surveillance Chukha IRS, LLIN, EDPT, case follow- up, surveillance Chukha IRS, LLIN, EDPT, case follow- up, surveillance Samtsi IRS, LLIN, EDPT, case follow- up, surveillance Zhemgang IRS, LLIN, EDPT, case follow- up, surveillance 3. What is the objective of this cross border effort in the key districts? • Reduce the malaria cases in India side and malaria elimination in Bhutan. 4. Effective cross border collaboration (Short term): • Conduct joint Situational Analysis on both side (Director, NBVDCP, India & Director, DoPH, Bhutan) –by May 2016 • Joint planning and implementation of activities (National Program Directors and District Program Managers of both countries ) March 2016 • Empower the local authorities (District level coordination Committees) (National, State & District Program Managers) • Sharing of Information (Nomination of dedicated program officer ) (National, State & District Program Managers from India and VDCP from Bhutan) • Cases and deaths • Epidemiological information • Prevention • Malaria Prevalence survey in Border areas of India by June 2016 • District level consultation/planning meeting, First meeting by March 2016 and then on regular basis • Informal consultation among the program managers for adjoining districts by March 2016 ( may be supported by WHO). 5. Any other relevant issue (Long term). • MOU signing to be proposed • Sharing of Information through web based mechanisms • Regular reviews at the National and sub –national levels • Continuous joint vector surveillance and monitoring and other operational research • Formal Visits of district program managers on regular basis. Group 3: 
 India-Myanmar Cross-border Collaborative Framework ! India Myanmar Others Dr Sher Singh Dr Aung Thi (Chair) Dr Suriya (GF) Dr NS Dharmashaktu Dr Moe Ko Oo Dr Badri (WHO) Dr Neelima Mishra Ms Lalla (GF) Dr T Zamkhokam Dr Chandrashekhar Biradar Ms Rody Ms Mamta Key districts targeted in each country – specify Country A [India] Country B [Myanmar] Name of district/ blocks Name of province/ state Name of district Name of province/ state Anjaw Arunachal Pradesh Nan Yun Sagaing Changlang Lahe Tirap Mon Nagaland Layshi, Sagaing Kiphire Lahe Phek Tuensang 1. Key districts targeted in each country – specify Country A [India] Country B [Myanmar] Name of district Name of province/ state Name of district Name of province/ state Chandel Manipur Tonzang Chin Churachandpur Tidim Ukhrul Falam, homalin , tamu Champhai Mizoram Htantlang Chin Lawngtlai Madupi Lunglei Palawle Saiha Serchhip 2 (a) To your best knowledge is there on-going local transmission in your respective targets districts? (1) Country A [India] Districts Local transmission (Yes/ No) Anjaw Y Changlang Y Tirap Y Mon Y Kiphire Y Phek Y Tuensang Y Country B [Myanmar] Districts Local transmission (Yes/No) Nan Yun Y Lahe Y Layshi, Y Lahe Y 2 (a) To your best knowledge is there on-going local transmission in your respective targets districts? (2) Country A [India] Districts Local transmission (Yes/No) Chandel Y Churachandpur Y Ukhrul Y Champhai Y Lawngtlai Y Lunglei Y Saiha Y Serchhip Y Country B [Myanmar] Local transmission (Yes/No) Tonzang Y Tidim Y Falam, homalin , tamu Y Htantlang Y Madupi Y Palawle Y 2 (b) Describe the problems faced and what is currently being done Country Key challenges What is being done currently India /Myanmar 1. Inaccessibility to services -Geographical constraint -Transportation -Conflict 2. Porous border 3. Accessibility of markets across border 4. Hesitant to reveal the nationality (identity) Providing serves through civil society on either side -Community case management (RDT, Drugs) National challenges are partially addressed. None for cross border. Country Key challenges What is being done currently India/Myanmar No situation analysis National challenges are partially addressed. None for cross border. No MoU at the country level Illegal movement No sharing of information (data on cases, resistance-drug and insecticides) No permission to reach to indigenous village through Myanmar Exclusion of preventive services (LLIN) to non residents (sharing borders) No follow up of treated cases across border No channel of communication 3. What is the objective of this cross border effort in the key districts? Country India Objective (list districts) (Eg. Improve access, coverage, prevention of importation etc) Data sharing for improving services at all level (local to national) Strengthening cross border surveillance Improving access to services Cross border collaborative research/surveys/studies (TES, Entomology-insecticide resistance, vector prevalence) 4. Effective cross border collaboration (1) India/ Myanmar (list districts) Area/s of action in context of elimination Roles (mention who) and responsibilities District National Regiona l Thorough situation analysis of malaria across borders (mapping of HFs, epidemiology etc) CMO/DMO/CPO NVBDCP/ VBDC MoU MoH Access to diagnosis, treatment and preventive services irrespective of nationality and location CMO/DMO/SPO/CSOs/ private sector (India) TMO/STL /CSOs(Myanmar) NVBDCP (India) VBDC (Myanmar) Creating direct communicatio n channels across borders-local cross border meetings CMO/DMO/SPO/CSOs/ private sector (India) TMO/STL /CSOs(Myanmar) NVBDCP (India) VBDC (Myanmar) 4. Effective cross border collaboration (2) India/Myanmar (list districts) Area/s of action in context of elimination Roles (mention who) and responsibilities District National Regional Bilingual communication materials –IEC/BCC CMO/DMO/SPO (India) TMO/STL (Myanmar NVBDCP/VBDC Harmonized and coordinated action plan for malaria services across border CMO/DMO/SPO (India) TMO/STL (Myanmar NVBDCP/VBDC Access to travel through other country for providing / accessing services (specific pocket) NVBDCP/MHA Immigration Improving transportation services across border Ministry of transport 4. Effective cross border collaboration (3) 5. Any other relevant issue. • Innovations: Health card/patient card; drug issues - quality, access, regional stocks? • Multisectoral effort is essential • Regional coordination and collaboration agency • Monthly/quarterly flag meeting involving local health centers of front border areas Collaboration starts here…………………….. ! India/Myanmar (list districts) Area/s of action in context of elimination Roles (mention who) and responsibilities District National Regional Harmonized policy, strategy, guidelines for malaria interventions CMO/DMO/SPO (India) TMO/STL (Myanmar) MoH NVBDCP (India) VBDC (Myanmar) Resource mobilization MoH SEARO/GF/others Group 4: 
 Cross Border collaboration: India-Nepal ! 
 Nepal-India Bordering districts 1. Key districts targeted in each country – specify (1) India Nepal Name of district Name of province/ state Local transmission , Yes/No? Name of district Name of province/ state Local transmission , Yes/No? Champaw at Uttarakhand Yes, seasonal, sporadic cases Dadendhura Mahakali Yes, seasonal, Yes, seasonal Pithoraga rh Uttarakhand No Darchula, Baitadi Mahakali NO Udham Singh Nagar Uttarakhand Yes, seasonal Kanchanpur Mahakali Yes, seasonal Bahraich Uttar Pradesh Yes, seasonal Kailali Seti Yes, seasonal Balrampu r Uttar Pradesh Yes, seasonal Dang Rapti Yes, seasonal Kushinag ar Uttar Pradesh Yes, seasonal Nawalparasi Narayani Yes, seasonal Lakhimpu r Kheri Uttar Pradesh Yes, seasonal Kailali Seti Yes, seasonal Maharajg anj Uttar Pradesh Yes, seasonal Nawalparasi, Rupandehi Lumbini Yes, seasonal 1. Key districts targeted in each country – specify (2) India Nepal Name of district Name of province/state Name of district Name of province/state Pilibhit Uttar Pradesh Yes, seasonal, sporadic Kailali Seti Yes, seasonal Shravasti Uttar Pradesh Yes, seasonal Banke Rapti Yes, seasonal, sporadic Siddharth Nagar Uttar Pradesh Yes, seasonal Kapilbastu Lumbini Yes, seasonal Araria Bihar Yes, seasonal Morang, Sunsari Koshi Yes, seasonal, sporadic E.Champar an Bihar No cases, surveillance? Parsa, Bara, Rautahat, Sarlahi Narayani Yes, sporadic Kishanganj Bihar No cases, surveillance? Jhapa Mechi Yes, seasonal, sporadic Madhubani Bihar Yes, seasonal Dhanusa, Mahottari, Siraha, Saptari Bagmati Yes, seasonal, sporadic Sitamarhi Bihar No cases, surveillance? Mahottari, Sarlahi Bagmati Yes, seasonal, sporadic 1. Key districts targeted in each country – specify (3) India Nepal Name of district Name of province/state Name of district Name of province/state Supaul Bihar No cases, surveillance? Saptari, Sunsari Koshi Seasonal, sporadic W.Champar an Bihar No cases, surveillance? Nawalparasi, Chitwan, Parsa Narayani Seasonal, sporadic Darjeeling West Bengal Seasonal Ilam, Jhapa Mechi Seasonal North District Sikkim Seasonal, sporadic Taplejung No West District Sikkim Seasonal, sporadic Panchthar No 2 (b) Describe the problems faced and what is currently being done India Key challenges What is being done currently Udham Singh Nagar, Uttarakhand Even though accessibility is not an issue, transit route to Nepal, no screening. Sharada dam Routine surveillance is poor, no LLIN Lakhimpur Kheri, Siddharthnagar, Kushinagar, UP Surveillance is poor, no vector control as API low, large population Responsive spray Madhubani, Araria, Bihar Surveillance is poor Passive surveillance Sikkim, Darjeeling Few cases, issue with high numbers of tourists, need to micro-stratify and risk mapping Vector control for Kalazar Nepal Key challenges What is being done currently Kanchanpur Mostly imported cases, major transit route for returning migrants. Major re-settlement area. Routine surveillance, IRS, LLIN Kailali, Rupandehi, Nawalparasi Poor surveillance LLIN, IRS Dhanusa, Mahottari, Siraha, Saptari, Morang, Sunsari Poor Surveillance LLIN, IRS Jhapa, Ilam Intensive case based surveillance Routine surveillance, LLIN, IRS 3. What is the objective of this cross border effort in the key districts? • Harmonized policy- drugs, diagnostics, insecticides and vector control • Synchronized activities through joint action plan • Cross notification: alert system for any upsurge • Joint action plan for appropriate response & early control of transmission 4. Effective cross border collaboration Area/s of action in context of elimination Roles (mention who) and responsibilities District National Regional MOU at the high level, with legal provision of exchange of expertise facilitated √ √ Cross District collaboration mechanism √ Identification of resources, nationally and regionally √ √ Key technical capacity building, such as improved surveillance & response, cross notification, screening, etc. √ √ √ Effective case management √ Cross border BCC √ Regular data sharing at district level √ Immediate cross notification and response √ √ 5. Any other relevant issues: • Epidemiological situation analysis across the border for determining disease burden, vectors
 • Implementation research on characterization of migration patterns and disease association
 • Use of innovative mechanisms, eg, SMS messaging, use of technology 
 • Capacity building for strengthening surveillance
 • Alert system : Upsurge alert system at the district level
 • Facilitation to engage cross border security forces to provide assistance, eg, including health in regular agenda. Group 5 Cross border collaboration India – Sri Lanka Background • All malaria cases reported in Sri Lanka are imported • About half of imported malaria are contracted in India – mainly south India and most are P.vivax • Case investigations have revealed that a majority of malaria infections are in • Sri Lankan traders going to south India for short stays • Migrant Indian Labour (both organised and unorganised) • In construction industry and other development projects including industrial factories • Seasonal migration of labour for agriculture • Sri Lanka has variable vulnerability (migrants are found in many formally endemic areas) and receptivity (main & secondary vectors are found all over the country except in the hill country) • All cases in Sri Lanka are investigated and reviewed monthly by an independent committee – Importation confirmed by • Patients history of travel in the recent past • Complete parasitological and ento investigations of each case to show absence of local transmission in focus • Evidence verified by an independent committee Out migration from Sri Lanka to India • Sri Lanka serves as a sentinel surveillance site for some parts of India. • Because of detailed case investigation in Sri Lanka, the origin of the infection is nearly always traced to a location and recorded (eg., a hotel address- many business travellers who got infected have stayed in few hotels in Chennai, the addresses of which are known) • More rarely, people visiting relatives in S. India • No formal collaboration at present between the two countries. Traveller Category Malaria Risk Business travellers to Tamil Nadu (Chennai) High malaria incidence Pilgrims to Varanasi, Bodh Gaya (Bihar), Kerala NO reported Malaria Recommended Actions • Share information in real time between Sri Lanka and India – Through WHO Country Office – National Programme – And local district Office
 • Information shared should be – Case information from Sri Lanka – Response Information from India
 • Designate focal persons in each country for information sharing at national and local level in India and Sri Lanka 
 • Rapid case diagnosis, treatment and follow-up in Sri Lanka. Group 6:
 Cross-Border Collaboration 
 Myanmar – Bangladesh Group Members Dr. Than Win (Chair) Dr. Kay Thwe Han Dr. Moktadir Kabir (Rapporteur) Dr. Walter Kazadi Dr. Warin Choomasai Na Ayudhaya Dr. Elvieda Sariwati Dr. Md. Mushfiqur Rahman (Facilitator) Key districts targeted in each country – specify ! Country A [Myanmar] Country B [Bangladesh] Name of district Name of province/ state Name of district Name of province/ state 1. Maungdaw Rakhine State 1. Bandarban Chittagong Division 2. Cox’s Bazar Bandarban Cox’s Bazar 2 (a) To your best knowledge is there on-going local transmission in your respective targets districts? 2 (b) Describe the problems faced and what is currently being done Country A: [Myanmar] Local transmission (Yes/No) Maungdaw Yes Country B [Bangladesh] Local transmission (Yes/No) Bandarban Yes Cox’s Bazar Yes Country A [Myanmar] Key challenges What is being done currently Maungdaw Limited accessibility to universal malaria intervention 1. Community based intervention involving VHVs 2. Partnership with local and international NGOs 3. Mobile malaria team Insufficient health facilities as well as human resources Same as above Social conflicts Peace keeping by law enforcement agencies Weak health information system Drug and insecticide resistance Quality of antimalarials and diagnostics 2 (b) Describe the problems faced and what is currently being done Country B [Bangladesh] Key challenges What is being done currently Bandarban Limited accessibility to universal malaria intervention 1. Community based intervention involving field workers and volunteers 2. GO-NGO collaboration 3. Mobile malaria team Insufficient health facilities as well as human resources Same as above Social conflicts 1. Peace keeping accord done 2. Taking assistance from law enforcement agencies to implement some activities Cox’s Bazar Access to services for mobile and migrant population Collaborative activities with UNHCR and IOM For both districts Drug and insecticide resistance Quality of antimalarials and diagnostics 3. What is the objective of this cross border effort in the key districts? 4. Effective cross border collaboration: Country A [Myanmar] Objective Maungdaw Strengthen collaboration at all level Country B [Bangladesh] Objective Bandarban Strengthen collaboration at all level Cox’s Bazar Country A Area/s of action in context of elimination Roles (mention who) and responsibilities District National Regional Myanmar, Maungdaw Communicatio n and information sharing on drug and insecticide resistance and epidemics District Medical Officer and Regional Malaria Officer. DoPH, MoH WHO, AEGCD (ASEAN Expert Group on Communicabl e Diseases) Information on quality of antimalaria drugs and diagnostics, oAMT 1. Implementatio n of cross border collaboration based on MoU 1. Preparing MoU and endorsement 2. Collaboration with other relevant Ministries Advocacy and Facilitating information sharing and support Mapping of the health facilities along the common borders Information sharing on population movement 4. Effective cross border collaboration: 5. Any other relevant issue: • Conducting TES
 • Other priority operational researches such disease burden estimation, mapping of vectors etc. Country B Area/s of action in context of elimination Roles (mention who) and responsibilities District National Regional Bangladesh: Bandarban and Cox’s district Communication and information sharing on drug and insecticide resistance and epidemics Civil Surgeon NMCP, MoH&FW WHO Information on quality of antimalaria drugs and diagnostics, oAMT 1. Implementation of cross border collaboration based on MoU 1. Preparing MoU and endorsement 2. Collaboration with other relevant Ministries Advocacy and Facilitating information sharing and support Mapping of the health facilities along the common borders Information sharing on population movement Annex 4: Summary of Group Work and Next Steps Mapping of targeted Border Districts # d i s t r i c t s targeted # of states # districts with l o c a l transmission B o r d e r (km) India Bangladesh 25 5 25 4098 Bhutan 9 4 7 Myanmar 15 4 15 Nepal 21 5 16 1850 Bhutan India 7 1 Nepal India 30 13 1850 Bangladesh India 13 13 4098 Myanmar 2 2 271 Myanmar Bangladesh 1 1 271 India 12 12 TOTAL 135 105 Key Areas of Collaboration - 1 Key areas of collaboration Objective/s Responsibility District National Regional Information sharing Regular district-to-district, m o n t h l y ( e p i d e m i o l o g i c a l , outbreaks, treatment incl drug quality, drug and insecticide resistance, health facilities mapping, programme coverage etc.) x Regular national programme-to- programme (content to be specified) x Immediate national and local p r o g r a m m e - t o - p r o g r a m m e cross-border notification on
 surge in cases, specific events, resistance, etc x x x Identification of resources (x) x x MOU (medium term) x x Key Areas of Collaboration - 2 Key areas of collaboration Objective/s Responsibility District National Regional D i s t r i c t - t o - d i s t r i c t collaboration/action Joint planning and coordination (quarterly meetings, cross border visits/missions) x x Harmonization for effective malaria case management and prevention (incl cross border bilingual BCC, and increase access Improved access to services and quality and use across borders x Immediate cross notification and 
 joint response (eg outbreak investigation) x x Capacity building X x x Key Areas of Collaboration - 3 Key areas of collaboration Objective/s Responsibility District National Regional Situation analysis x x Collaborative implementation research C o m p l e m e n t s u r v e i l l a n c e i n f o r m a t i o n ; adapt strategies f o r i m p r o v e d coverage x x x Innovations 
 (eg patient cards) x x (Strengthen malaria programme and UHC in border areas) ( i m p r o v e access) x x Proposed Mechanism/s of Collaboration Next Steps • Create networks: • nominate focal persons (national, state, district levels – memo to states/ districts) • bilateral email groups • bilateral working groups • bilateral district level coordination committees
 • Coordination, facilitated by WHO: • Establish core group • District to district meetings, quarterly • Regional meetings, annually 
 • Policy agreement by different ministries (MOH, MOFA, MOHA etc) , facilitated by WHO – medium term
 • Collaborate with existing cross border mechanism/s, such as existing border security meetings. • Create core group (WHO and focal persons) for immediate coordination action 
 • Get national agreements on the minimum mutually agreeable cross-border action (coordinated by the core group) within the next 3 months
 • Develop prioritized coordinated 6months/1-year action plans • Conduct detailed national situation analyses, including identifying resources and gaps • Prioritize • Reconvene in approximately 4 months to finalize the joint action plans 
 • Initiate a regional coordination mechanism • Initiate high level action -including and not restricted to MOUs- with the aim to create an enabling environment for local action.