The Royal Government of Cambodia aims to eliminate malaria by 2025, with many remaining cases in forested areas - home to many plantations and other agricultural businesses. In 2013, Population Services International (PSI) launched a program to provide malaria services to workers employed on private plantations, which typically include mobile and migrant populations (MMPs) – a group that is considered both more at risk, and harder to reach. Plantation workers are not only more at-risk due to the location and timing of their work, but many cases remain undiagnosed due to their mobility, lack of access to appropriate services, and sometimes their own lack of knowledge. Thus, the program brings malaria testing and treatment services to the plantations by training selected plantation staff as Mobile Malaria Workers (MMWs). MMWs are trained on national treatment guidelines, including conducting RDTs in accordance with global standards, and are required to report testing and cases to PSI for sharing with the NMCP. By the end of 2017, PSI supported 248 MMWs on 161 plantations who conducted 18,500 malaria tests and confirmed 1,280 positive cases – representing approximately 4% of the 30, 145 cases reported by the private sector networks supported by PSI.
Despite the availability of services, uptake was initially slow. A mix of qualitative methods and analysis of quantitative program data was used to: i) identify barriers to using MMW services, ii) generate insights into beneficiaries’ preferences in relation to malaria case management, and iii) identify strategies to increase access to quality malaria case management amongst those most at risk of malaria. Human Centered Design methods, including beneficiary journey mapping, behavioral trials, ideation, and rapid prototyping of intervention options, were used to learn and to co-design potential interventions with plantation workers. This process revealed a preference for access to a wider range of services than malaria alone and also highlighted that the availability of MMWs was limited as they were also full time plantation workers. From the workers’ perspective, it would be more time efficient to go to a shopkeeper who would be consistently available and could cater to a wider range of medical and non-medical needs.
PSI has used these insights alongside routine program data, to design and adapt strategies to increase testing rates on worksites, including providing MMWs with additional health commodities, screening on entry, mass screening events, increased visibility to promote services, and performance-based incentive systems for MMWs. More recent efforts to target those most at risk, include testing the family and co-travelers of people testing positive for malaria – have been particularly effective in identifying additional cases. Shopkeepers are also now being recruited for training as MMWs around plantations.
Surprisingly, however, 2017 data show that private providers not only tested more people, but detected 16 times more malaria positive cases among people who identified themselves as forest goers than MMWs, and twice as many plantation workers. Geo-locating the point of diagnosis for malaria cases revealed a higher utilization of private providers, even in instances where plantations with MMW services were only 3 km away. The 600 private providers supported by PSI conducted 153,800 malaria tests and confirmed 28,850 positive cases in 2017 – representing higher absolute numbers, but also higher testing and positivity rates per outlet. This indicates that some plantation workers prefer to see offsite private providers, even though onsite services are available.
Emerging evidence suggests that not everyone on plantations is at-risk of malaria and targeting those most at risk is an iterative and complex process that requires significant input from the risk group themselves to understand the social norms, movement patterns and health seeking preferences of a heterogeneous group that is often targeted as a homogenous one. PSI is now developing participatory community engagement methods to co-create new interventions to reach those most in need.