Abstract
<title>Abstract</title> <p>Background Countries in the Greater Mekong Subregion (GMS) have pledged to eliminate malaria by 2030. Achieving malaria elimination is a complex undertaking that requires a strong and well-functioning health system. Assessing health system readiness comprehensively at both national and sub-national levels is critical, as commitment at the national level does not necessarily translate into adequate readiness at lower administrative levels. To better understand the requirements for implementing malaria elimination strategies at the sub-national level and to identify challenges that could hinder progress toward elimination, a qualitative study was conducted across the GMS. Methods Semi-structured interviews were conducted with 39 key stakeholders, including policymakers (n = 5), health personnel from Ministries of Health (n = 12), managers and field supervisors from malaria implementing partners (n = 16), and representatives from technical agencies and research institutions (n = 6). The data were analysed using reflexive thematic analysis, and the findings were organised according to themes derived from the World Health Organization’s six health system building blocks framework (service delivery, surveillance, elimination workforce, products and commodities, programme financing and leadership and governance). Results Stakeholders observed that sub-national level health systems for malaria elimination required inputs from all six WHO health system building blocks. They noted health system related issues in the current sub-national level malaria elimination programmes of the GMS included service disruptions, delayed implementation of reactive surveillance and response activities, human resource shortages, stock-outs of malaria commodities, and unorganised coordination with relevant sectors at the sub-national level – all of which could hinder the progress of GMS countries towards malaria elimination. Conclusions This study comprehensively evaluated sub-national health system needs and issues regarding implementation of malaria elimination activities in the GMS countries. It highlighted the importance of health system readiness at sub-national levels in translating political commitment into effective action. Furthermore, this study emphasised the need to evaluate the health system readiness comprehensively at sub-national level in order to accelerate the progress towards malaria elimination by 2030.</p>