Last week, government leaders, senior officials, academics, and regulators from across the Asia Pacific region came together in Singapore for the Global Health Security Conference (GHS2022), a topic more critical now than ever for the world and region.

With the growing influence of globalisation on disease transmission, as evident from the COVID-19 pandemic, a coordinated global and regional response for disease control and elimination is fundamental not only for emerging diseases but also for age-old infectious diseases like malaria which continue to threaten countless lives in the region.

To strengthen global health security, cooperation and cross-border collaboration among neighbouring countries is key and a prerequisite for achieving our malaria elimination goal in the South Asia region. 

Meeting the challenge of cross-border cooperation in South Asia

The burden of malaria in South Asia is unequal, with high-burden countries like India and Pakistan, seeing over 90% of their citizens at risk, while other neighbouring countries including Bangladesh, Bhutan, and Nepal are paving the way for last-mile elimination.

This unequal burden poses a challenge for both high-burden and near elimination countries, at both international borders and district borders, as border areas are harder to reach and routine malaria interventions are not always optimal. In addition, South Asian countries receive an influx of imported malaria cases from other states via ground, water and air transport from locations far beyond their immediate borders. In 2020, 17% and 83% of total cases reported in Bhutan and Nepal, were imported cases, respectively. Cross-border engagement is necessary to meet these challenges, however the unequal burden of malaria, in addition to other political and geographical considerations, complicates the ability to engage and the effectiveness of engaging between countries.

Past efforts towards cross-border cooperation

Declaration and framework

In 2017, a Ministerial Declaration on Accelerating and Sustaining Malaria Elimination in South-East Asia was signed by the health ministers and representatives from  WHO Southeast Asia region to sustain the momentum towards a “Malaria-Free South-East Asia Region by 2030” and the Sustainable Development Goals (SDGs). The WHO also launched an operational framework which focused on providing leadership and technical guidance to member states to encourage strengthening of efforts to effectively tackle cross-border malaria and improve cross-country coordination.  

Consultation with regional stakeholders

With the groundwork laid out, India, Bangladesh, Bhutan, and Nepal made great steps towards joint cross-border efforts to tackle malaria. Several cross-border meetings and consultations were conducted by regional stakeholders, including the Southeast Asia Regional Coordination Mechanism Forum (SRCMF) and Asia Pacific Leaders Malaria Alliance (APLMA), under WHO’s guidance. These platforms have been instrumental to establish and ensure effective cross-border collaboration, to operationalize the 2017 Ministerial Declaration, and to develop a mutually agreeable strategic “roadmap” with special emphasis on a border-relevant package of interventions at the subnational (district) level.

However, the COVID-19 pandemic halted much of the progress of such previous cross-border initiatives, resulting in disrupted inter-country communications and limited implementation of harmonised activities in the bordering areas.

To revitalise this important issue and bring back the prior momentum, in September 2021, the WHO convened a virtual cross-border collaboration meeting for elimination of malaria and kala-azar (visceral leishmaniasis) along the international borders of India with Bangladesh, Bhutan and Nepal. It brought together participants from border states and districts as well as technical experts and partners. The participants discussed the challenges for cross-border collaboration and prioritized immediate and short-term activities, reinstating the commitment towards continued collaboration for cross-border efforts for malaria elimination.

Current status of cross-border collaboration in South Asia

To further accelerate the renewed momentum, in 2022 the Southeast Asia Regional Coordination Mechanism Forum (SRCMF) began facilitating several in-person cross-border collaboration meetings between India and Bhutan as well as India and Nepal. Stakeholders from national and state-level malaria programs, including the bordering districts, were part of these bilateral meetings. Topics discussed included status updates on malaria in district and international borders as well as the impact of COVID-19 on inter-country and inter-district cross-border coordination efforts.

From these discussions, delegates identified key actions to guide the ongoing cross-border efforts between India and the neighbouring countries of Bhutan and Nepal:

• Strengthen bilateral communications - establish and receive joint information through sharing mechanisms (i.e., WhatsApp groups, emails) and identify focal points to support regular inter-country and inter-district coordination of district-level joint activities.
• Initiate Joint cross-border surveillance plan - ensure effective implementation of on-ground activities including vector surveillance, insecticide resistance, and M&E.
• Identify simultaneous activities - organize activities to run in parallel including joint IRS, LLIN distribution, harmonised treatment policies and case referrals.
• Build capacity - organize joint capacity building initiatives for health personnel and communities in bordering districts.

A way forward for cross-border collaboration

Despite continued dialogue between India and its neighbours on political and programmatic commitment for cross-border collaboration for malaria elimination, success on the ground is still limited. Lack of harmonised programmatic guidelines and limited implementation of joint activities for surveillance, management, classification, and data sharing of malaria cases across the shared borders are still challenges to success. To move forward, there are three steps critical for sustained collaboration and effective implementation of cross-border efforts.

Sustained commitment

To establish effective bilateral district-to-district efforts, both national and sub-national governments must continue high-level political commitment and engagement. This engagement requires regular communication to address the challenges in implementation of joint activities in a timely manner.  It is critical that district-level officials are involved in planning joint efforts to ensure both accountability across borders and to sustain momentum of ongoing efforts. Collaborative efforts from national and regional partners in South Asia and the Asia Pacific region also play a critical role in ensuring sustained commitment.

Strong surveillance and data sharing systems at the border areas

The current practice of data sharing must be strengthened between the bordering malaria-endemic districts of India and neighbouring countries of Bangladesh, Bhutan, and Nepal. A robust surveillance platform and tools are required to improve data sharing, inform cross-border planning, and ensure timely management of outbreaks. For example, a cross-border dashboard with common indicators to track malaria activities would provide important information for communities on both sides of the border. In addition, current informal data sharing mechanism must be strengthened to ensure real-time information.

Joint elimination plan for border areas

As countries move towards elimination, they must develop plans and set goals that reflect an unequal malaria burden outside their borders. A joint action plan provides much-needed guidance to implement the harmonized activities critical to reaching sustainable elimination, holding leadership accountable, and measuring progress against set targets.

Many South Asian countries already have a history of strong commitment and cooperation in malaria elimination. While uneven malaria burden is an ongoing challenge, continued commitment, and engagement between stakeholders, as well as direct action to see improvements on the ground, will lead to overall benefits to the South Asia region as a whole. These cross-border collaborative efforts will not only contribute to the achievement of malaria elimination but will also improve collaboration efforts to strengthen health security for infectious diseases in the South Asia region.