Challenges

The Northern Huetar Region in Costa Rica is at risk of importation of the malaria parasite due to internal migrations which occur between regions within the country and from migrations from other endemic countries. In addition, the region is highly susceptible to vector development due to the favourable ecological conditions. In 2020, 84 percent of malaria cases were from this region, 78 percent of them in Los Chiles. This situation is associated with the dynamics that exist in the northern border where agricultural activities and constant trade favour high population movement that allows the transmission of malaria on both sides of the border.

A challenge that has been identified involves integrated and coordinated local planning for malaria detection, diagnosis, treatment, research and response in the shortest possible time between countries. Other challenges are the creation of administrative and technical mechanisms for implementation of any agreement and the additional considerations that the COVID-19 pandemic poses for the local teams.

Toward a Solution

An agreement was signed under the Central American Integration System (SICA) that calls for joint cross-border interventions between Costa Rica and Nicaragua for malaria elimination. This initiative directly addresses SDG 3 and aims to implement cross-border actions that allow coordination and collaboration between the two countries, taking into account information on the stratification, description and micro-planning of the border areas that they share, so that the actions taken can advance the elimination of malaria and help prevent its reestablishment in their territories.

A technical operations meeting was held in January 2021 to generate the technical contents of the binational agreement between the two countries’ ministries of health. Participants included representatives of the Subregional Program for Central America, the Regional Malaria Program, PAHO/WHO Costa Rica, PAHO/WHO Nicaragua. Support was provided by technical teams and the Regional Malaria Elimination Initiative (an alliance between the countries of the Mesoamerican region and the Dominican Republic, the Inter-American Development Bank, the Carlos Slim Foundation, the Bill & Melinda Gates Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria). The subsequent signing of the agreement in April 2021 was managed by the Costa Rican Foreign Ministry within the framework of the pro tempore presidency of SICA.

The commitment assumed by the two countries involves conducting actions in cross-border areas, focusing on four main themes that will be addressed together: (1) effective actions on both sides of the border; (2) complementarity in dealing with cases at border crossings; (3) ensuring stocks of antimalarials and rapid diagnostic tests; and (4) sharing information.

A first local meeting was held at the border in July to plan joint operations that could be conducted in the shortest possible time for detection, diagnosis, treatment, research and response to an outbreak of P. falciparum malaria in the area of Santafé, Los Chiles and Mojón 9 in Nicaragua. As a result of this planning, immediate actions were carried out on both sides of the border, such as activation of voluntary collaborators, reactive searches and vector control activities. These measures made it possible to control the outbreak and the number of cases in this border area has been reduced to zero. This practice was innovative

because it took place by virtue of the goodwill of local teams. By overcoming barriers to geographical access, infrastructure and border permits, it became a starting point for, and an example of, coordinated work. Based on the technical operations meeting’s detailed plan, work is being done to coordinate operations taking place in all the malaria foci identified in the two countries.

The experience of this rapidly formalized joint initiative between Costa Rica and Nicaragua served as a model for a binational agreement between Honduras and Nicaragua to eliminate malaria in July 2021. This latter agreement will directly affect the behaviour of malaria in the border area with Costa Rica, because it is linked to the movement of people from northern Nicaragua who leave in search of areas for gold mining further south or in Costa Rica.

The exchange has allowed for the below results.

• PAHO/WHO facilitated a results-oriented cooperation framework for the elimination of malaria in the border region of Costa Rica and Nicaragua.
• Technical teams from the ministries of health in both countries were able to integrate the analysis of epidemiological information on malaria foci on both sides of the border.
• The two countries have developed a single plan to address malaria at the border.