All systems "go" for ERAR hub in Phnom Penh, Cambodia

30 January 2014

The WHO Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion (ERAR-GMS) hub is now fully staffed.

The ERAR regional hub, established following the launch of the WHO Emergency Response to Artemisinin Resistance Regional Framework for Action 2013–2015 on World Malaria Day 2013 in Phnom Penh, became fully operational at the start of the year. The regional hub aims to strengthen the response to artemisinin resistant malaria by coordinating action, strengthening technical leadership and catalysing resource mobilization.

“Successful containment of artemisinin resistant parasites will require urgent and coordinated action by a consortium of partners, including affected countries, donors, implementing agencies and global malaria partners,” underlined Dr Mark Jacobs, WHO Regional Director for Combating Communicable Diseases in the Western Pacific, during a meeting with development partners of the new hub on 29 January in Phnom Penh, which was held to present work plans and to update donors and partners on the ERAR implementation progress.

“Though the ERAR regional hub focuses on the Greater Mekong Subregion, it recognizes that artemisinin resistance poses a public health risk of global concern that requires a coordinated response at global, regional and national levels,” Dr Jacobs stressed.

Representatives from the Bill & Melinda Gates Foundation (BMGF), the Australian Government’s Department of Foreign Affairs and Trade (DFAT), the United States Agency for International Development (USAID), the Asian Development Bank (ADB) and the Malaria Consortium attended the meeting.

Dr Michael O’Dwyer of the Australian Government’s Department of Foreign Affairs and Trade said he was encouraged by the ERAR hub’s work plans and pledged DFAT’s continued support for ERAR.

Participants of the first meeting of the Emergency response to artemisinin resistance in the Greater Mekong subregion
Participants of the first meeting of the Emergency response to artemisinin resistance in the Greater Mekong subregion

The priorities and work plans for the ERAR hub for the current year were developed during a two-day ERAR hub staff meeting from 27 to 28 January and included the coordination of the hub, advocacy and communication, therapeutic efficacy, monitoring and operational research, access to services for migrants and mobile populations, support to the implementation of the Myanmar Artemisinin Resistance Containment (MARC) framework, strengthening the response to artemisinin resistance containment in Viet Nam, limiting the availability of oral artemisinin-based monotherapies, substandard and counterfeit antimalarial medicines, as well as improving the quality of ACTs.

In detail, the development partners recommended the following action items:

ERAR hub coordination

  • Work with GMS countries to develop a budgeted national artemisinin resistance work plan;
  • ERAR Hub to facilitate country ownership of plans, budgeting and implementation efforts;
  • Efforts on establishing/updating country databases to be in line with national health information system (HIS) plans;
  • With other development partners, work towards establishing a contingency stockpile of essential commodities;
  • ERAR Hub to document and share lessons learnt in the GMS in the form of stakeholder analysis/mapping, to showcase local solutions to local problems (governments, nongovernmental organizations, partners and other stakeholders). This can also be used as an advocacy tool with the Asia-Pacific Leaders Malaria Alliance (APLMA);
  • WHO to work with the Australian Government’s (DFAT) consultants at the country level to assess challenges and needs. In-country gaps will be identified and prioritized and appropriate budgets for technical advice will be costed in the work plan.

Monitoring and evaluation (M&E)

  • Work to translate the M&E indicators into existing national systems. The M&E framework in ERAR gives ownership to countries, which in turn translates into sustainability. ERAR indicators will be incorporated into M&E Plans as National Strategic Plans are updated with findings from programme reviews and studies.
  • ERAR will work closely with other initiatives on artemisinin resistance, e.g. APLMA and the Regional Artemisinin Initiative (RAI), to harmonize relevant indicators in the scorecards.
  • M&E technical working groups, to be established, will provide support to strengthen M&E systems at country level. Membership will comprise of representatives of key development partners with an M&E mandate such as The Global Fund, Malaria Consortium, ADB, University Research Co., etc.
  • Incorporate vector surveillance and insecticide resistance monitoring in the ERAR work plan as a way forward for malaria elimination.

Advocacy and communication

  • A calendar of events that will include both malaria-related events and other events that could provide opportunities for advocacy and monitoring;
  • Collaborate with APLMA’s proposed “Champions Group” to facilitate high-level advocacy with policymakers/leaders.

Migrants and mobile populations (MMPs)

  • Take needed practical steps to increase access of MMPs to timely diagnosis and treatment. There is a need to acknowledge that migration patterns in the GMS are complex and migrants fall into a range of different categories from irregular, short-term migrants to long-term migrants with many sub-groups in between.
  • Need innovative ways to carry out surveillance among mobile migrants using peer groups.
  • ERAR could look into national issues/policies and help overcome barriers in identifying mobile communities and providing targeted information and health care to these communities. This will include conducting political as well as anthropological research to identify push and pull factors for cross-border migration.
  • Country initiatives, including NGO activities, that increase mobile and migrant populations’ access to health services should be reviewed, documented and shared appropriately.

Therapeutic efficacy studies (TES)

  • The time to translate TES findings to drug policies could be quick (e.g. in the case of Cambodia) or delayed for up to 2–3 years depending on the readiness of the country, among other factors such as selection time from several appropriate alternatives and delayed procurement of new selected first line drugs. WHO recommends a 10% treatment failure rate as a threshold (i.e. 10% of Day 3 positives after appropriate treatment of recommended ACT is commenced).
  • ERAR’s role is to facilitate shortening the lead time between the identification of antimalarial drug resistance and change in drug policy.

Operational research (OR)

  • Countries are encouraged and supported to develop proposals and share plans with donors. ERAR can facilitate the linkage between donors and national programmes to translate priority operational research findings into policy and programme action. The Bill & Melinda Gates Foundation is interested in OR and will help in organizing donor support.
  • The results and recommendations from operational research should be used to expand the knowledge base of national strategic plans of GMS countries. ERAR should work more closely with policy-making and regulatory bodies in countries and at regional levels to quicken decision-making.

Myanmar Artemisinin Resistance Containment (MARC) implementation

  • Coordination of several efforts by different players in Myanmar is a challenge. WHO is strengthening effective coordination with the RAI budget for programme management and M&E support for activities under RAI.

Artemisinin resistance containment in Viet Nam

  • Multi-sector involvement in resource mobilization in Viet Nam is currently limited. ERAR should engage ministries other than health, including planning and finance.


  • There is need for a contingency plan for up-to-date stock management bearing in mind that medicines may expire if not utilized on time as a result of reduction in P. falciparum cases as transmission becomes lower.
  • ERAR needs to take inventory of all the first line drugs used in the GMS and then maintain a rotating stock.
  • One way of dealing with stockout is through an electronic management system of stockpile control.
  • Strengthen capacity for drug regulation systems across the GMS.
  • As a mechanism to coordinate the quality assurance of drugs, ERAR needs to assess quality at the point of use, especially when it comes to cross-border migrants.