The Partnership for Vivax Elimination (PAVE), funded by Unitaid and led by Medicines for Malaria Venture (MMV), PATH, Menzies School of Health Research, and The Burnet Institute, conducted feasibility studies across five countries to evaluate the operational integration of G6PD testing for guiding radical cure of P. vivax malaria. These studies, implemented in collaboration with national Ministries of Health and research institutes, examined the introduction of single-dose tafenoquine or high-dose, 7-day primaquine across various health system levels. They assessed feasibility, cost-effectiveness, acceptability, and readiness of health systems to safely deliver radical cure as part of routine services.
The studies spanned diverse epidemiologic contexts, from high-burden settings in Ethiopia and Papua New Guinea to pre-elimination settings in Vietnam. Mixed-methods approaches were employed, including assessments of healthcare provider compliance to revised treatment algorithms, management of adverse events, implementation processes, and qualitative and economic analyses. This comprehensive evaluation generated evidence applicable both to local contexts and to broader global guidance on scaling radical cure and G6PD testing.
In Ethiopia, early misdiagnoses of G6PD deficiency highlighted the importance of proper device storage and ongoing staff training, particularly amid high turnover and limited laboratory skills. Recommendations emphasized supportive supervision, context-adapted training, and peer-based in-facility mentoring to ensure healthcare professionals remain competent and confident in treatment protocols.
In Peru, modular, practical, learner-centered training approaches were essential for laboratory staff and healthcare providers, reinforcing G6PD test implementation and radical cure management. Post-training follow-ups, on-site or virtual, and regular refresher sessions were critical to maintaining skills amid high staff turnover, particularly in remote regions.
In Papua New Guinea and Indonesia, high-dose primaquine and G6PD testing required standardized training with sufficient hands-on practice and periodic refreshers to maintain staff competency. Coordination across the entire health facility was key to ensuring adherence to protocols, emphasizing the need for all cadres to understand their roles in safe treatment delivery.
Vietnam’s pre-elimination context posed challenges due to low case numbers and skill attrition. Maintaining health worker capacity required frequent refresher training, practical hands-on practice, and structured exposure to active case detection campaigns. Training was tailored to healthcare roles, ensuring both diagnostic and treatment competencies were sustained in low-case environments.
Equitable training and supportive supervision were critical across all settings. Multilingual contexts, such as Ethiopia, required adaptation of training materials and assessments to local languages, while in Peru, consistent supervision reinforced adherence to updated malaria protocols. In PNG and Indonesia, community health workers needed structural and financial support to sustain patient follow-up in high-burden and geographically challenging areas.
Supply chain and infrastructure challenges were evident, particularly in Ethiopia and PNG/Indonesia. Frequent stockouts of medicines and diagnostics, temperature-sensitive storage requirements, and alignment of commodity timelines were key constraints. Recommendations emphasized trend-informed supply planning, coordination with procurement teams, and robust distribution pathways to ensure uninterrupted service delivery.
Governance and health system engagement were essential for successful implementation. Coordinated efforts across facility, district, and national levels facilitated streamlined patient flow, adherence to treatment, and integration of revised protocols. Patient counselling, alignment with private providers, and structured active case detection campaigns supported effective implementation and strengthened community trust.
Patient engagement strategies highlighted the importance of culturally appropriate education, visual aids, and community participation. In Peru, simple incentives improved adherence among vulnerable groups, while in PNG and Indonesia, clear counselling and visual tools enhanced understanding of G6PD testing and primaquine treatment. In Vietnam, engagement of village leaders and health volunteers supported follow-up, trust, and equitable access, particularly in hard-to-reach populations.
Cross-cutting enablers included empowering local leaders and implementation champions to maintain motivation and ownership. Non-monetary incentives, supportive supervision, and digital communication tools were effective in sustaining engagement. Strong national and subnational leadership in PNG and Indonesia facilitated operational backing, community mobilization, and multi-level coordination.
Overall, the PAVE feasibility studies demonstrated that introducing G6PD testing and radical cure regimens requires sustained workforce capacity, context-adapted training, resilient supply chains, robust governance, and active patient and community engagement. Successful adoption beyond pilot settings depends on tailoring interventions to local epidemiology, health system structures, and disease burden, ensuring safe, effective, and equitable malaria elimination strategies.
