Collaborate Program with EDAT System
District Health Office, Bintuni Regency, West Papua Province, Indonesia

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Teluk Bintuni Regency is one of the regencies in West Papua Province where malaria is very common in all circles of society. For more than half a century, malaria has topped the list as the main cause of morbidity and mortality in the provinces of Papua and West Papua. In fact, in May 2015 there was a doctor serving in Papua who died of malaria. Hence, it is not surprising that Papua becomes very identical to malaria, giving rise to stigma and causing fear to residents of other areas to visit Papua. This fear is very reasonable since more than 70% of the total cases of malaria in Indonesia occur in the provinces of Papua and West Papua. Totally 4 million people have a risk for malaria attack in this provinces and it is recorded as the largest contributors of malaria cases in Indonesia. Before the program is run, Teluk Bintuni Regency was one of the regencies having a high malaria morbidity rate. The high morbidity rate of malaria in Teluk Bintuni Regency is evident from the results of the baseline survey in 2005-2006 in several coastal villages serving as the locations where this program was started. The prevalence survey results showed the malaria prevalence rate of 9%, or about 1 among 11 people suffers from malaria. The high morbidity rate in Teluk Bintuni Regency is also due to its geographical condition, which makes it a very potential breeding place of malaria mosquitoes. Geographically, Teluk Bintuni Regency is located in an area with a very diverse topographical structure. Part of its territory consists of forrest that can only be accessed by small plane with a total passengers ranging from 6 to 12 people, some areas are only accessible through overland routes with a distance of over 100 km from the city center of Bintuni, while the other areas are located on the seashores/close to mangrove forests within 2-6 hour journey using a longboat owned by local people. Sea travels from some regions which only have Puskesmas (community health centers) to regions having hospitals cannot be done when the ocean waves are high. At such times, access to hospitals can only be reached after the waves subside a few days later.

B. Strategic Approach

 2. What was the solution?
The solution is to find a new model/approach that can be used to replace the previous approach that has implemented for several decades in the provinces of Papua and West Papua since proven approach that has been applied failed to address the causes of malaria as a major health problem in both province. The model developed should be simple, can be implemented by health workers in the field with limited resources and can be implemented by the community itself in remote areas far from health-care facilities. This model is also expected to involve the private sector, local governments, non-government organizations and the community in which it is implemented

 3. How did the initiative solve the problem and improve people’s lives?
A private company, Local NGO, Department of Health and the community then has established a model of malaria intervention approach called the EDAT System. EDAT system is implemented through: Formation of Juru Malaria Kampung (JMK). Several regencies and villages in Teluk Bintuni Regency are very remote and have not had adequate health workers and health care facilities. Due to this limitation, and in order to improve access to malaria diagnoses and therapies, a healthcare system based upon community participation and gender equality is developed through the formation of Juru Malaria Kampung (Village Malaria Cadres) or JMK. It is recommended that JMK cadres be women and they must be settled in the village in order to serve the local community where they reside. JMK cadres are trained by the Government Health Agency, supervised regularly, have ability and given a certificate of training by the Government Health Agency to perform their duties. Repackaging of antimalarial drugs. This packaging of antimalarial drugs is specific to Teluk Bintuni Regency. There are no other regencies or provinces in Indonesia which have ever developed or implemented antimalarial drugs repackaging. Packaging of antimalarial drugs with the color system not only facilitates the use of antimalarial drugs by illiterate patients but it is also very beneficial for non literate people who lives in the middle of junggel because it was very easy to use by patients. An antimalarial drug package for each patient is packed by weight categories and each category is color-coded specifically. By simply letting a patient stand on the scales that have been color-labeled, the appropriate package and drug dose for a patient can be precisely determined. Use of Malaria Kits. Health care providers in the sub-district level (kecamatan) often do not have sufficient capacity to carry out the management of antimalaria drug stocks in a consistent and continuous manner. Logistic supplies and antimalarial drugs are often exhausted and uncontrolled because they are put together with other medicines. These conditions resulted in an excess of stocks in one area and shortage of supplies of logistics and antimalarial drugs in the others. With the presence of malaria kits that contain all surveillance logistics and antimalarial drugs, the stock management can be greatly improved. Social Marketing. Social marketing activities relating to the malaria control program. All community health centers (Puskesmas), community health sub-centers (Puskesmas Pembantu), and JMK are specially provided with posters which are mounted on each health care facility and public place in the village. This poster contains a picture of the head of the community health centers (Puskesmas), community health sub-centers (Puskesmas Pembantu), and local JMK accompanied with proper suggestions on how to use antimalarial drugs and the place where the examination and treatment of malaria can be done. Consistent and continuous social marketing can change the local people’s behaviour. Integrated Quality Assurance. We perform quality assurance of malaria surveillance in an integrated and consistent manner. This system is implemented by the following methods: 1) Giving malaria surveillance training to all new doctors, nurses, midwives, nutritionists and all laboratory personnel to be placed in all health facilities in Bintuni before carrying out their duties; 2) Conducting monthly regular visits to community health centers (Puskesmas), community health sub-centers (Puskesmas Pembantu) and JMK. 3) Routinely sending microscopists in charge as cross-checkers to health care facilities of the national level to maintain competence as trained microscopists; 4) Conducting consistent and continuous training for personnel carrying out malaria surveillance 5). Using a scoring system to quantitatively assess the performance of surveillance of malaria in community health centers, community health sub-centers, and JMK.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
This approach is creative because it has successfully mobilizing cross-sectoral cooperation through the involvement of the private sector, non governmental organizations, local governments and local communities to jointly tackle malaria. This initiative is greatly innovative because the community-based pioneering endeavors in examination and treatment of malaria are made through Juru Malaria Kampung (JMK). Through JMK, the diagnosis and treatment of malaria can be performed quickly and accurately by the people themselves even though they reside in remote areas and in areas where there are no health care workers and health care providers available. This innovation is also based on gender equality because one of the requirements to become a JMK (Village Malaria Cadre) is being a woman and settled in the village concerned. This initiative is also creative since antimalarial drugs packaging using the color system is only developed in this area, and it has not been developed before in Indonesia. With the color system, antimalarial drugs are packaged in a way that makes them easy to use by patients even though the patients are illiterate. The implementation of this system also initiates changes in people’s behavior where it has become the habit of the people since more than 50 years ago to buy and take antimalarial drugs from traditional kiosks and stalls.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
This program is run and funded jointly by BP-Tangguh LNG, an oil and gas company private operating in Bintuni Regency, its management carried out by local foundation, synchronize and coordinate the program led by the Department of Health and its implementation in the field carried out by health workers and the local community. The Global fund participate trough procurement and distribution of mosquito Nets. Cooperation and joint collaboration is carried out under one room at the office of the Government of the District Health Office Bintuni. With this partnership, the health service is run to reach approximately 60,000 residents in the district of Bintuni.
 6. How was the strategy implemented and what resources were mobilized?
To support the implementation of the malaria program, the company (LNG Tangguh) allocates funds amounting to around Rp. 2,000,000,000 (USD 147,000) annually for support staff and the operational costs of the malaria program. The funding allocation is supported by a grant from the Government (from the APBD, the regional budget) amounting to Rp 100,000,000 (USD 73,500) for logistics and quality assurance of the malaria program. Additional aid funds have also been received from Global Fund amounting to 60,000,000 (USD 4,400) for baseline survey and Rp. 2,000,000,000 (USD 145,000) for the purchase and distribution of mosquito nets in 2014. In addition, there is also the logistical support directly distributed by the Provincial Government Health Agency of West Papua and from the Ministry of Health of the Republic of Indonesia. All of these resources are allocated in a specific manner so that the funding sources do not overlap one with another. As for the human resources, the personnel who are directly involved in the program are the Village Malaria Cadres (JMK), Company Malaria Cadres (JMP), laboratory personnel in Community Health Centers (Puskesmas) and in the Provincial Government Health Agency, malaria surveillance personnel, doctors, nurses and midwives in Community Health Centers (Puskesmas), community leaders, private practice doctors and pharmacy personnel.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The Private company (BP-LNG Tangguh, an Oil and Gas Company) provides funding for the malaria program has appointed a Non-Government Organization or NGO as a representative of the company in implementing the malaria program in Bintuni Regency. The NGO prepares annual programs with the Government Health Agency, and the progress of the activities is monitored through weekly, monthly and annual reports. To improve coordination in the implementation of the program, the NGO is given a special room along with the Division for Eradication of Communicable Diseases in the Government Health Agency Office. By working together under one roof, the NGO’s program and the Government Health Agency’s program can be in synergy and mutually support each other so that all programs that run are collaborative programs. In each field visit, the team from the Government Health Agency and the team from the NGO work together with all community health centers, community health sub-centers and Village Malaria Cadres (Juru Malaria Kampung) and Company Malaria Cadres (Juru Malaria Perusahaan) to make the diagnosis and treatment of patients better. In addition to the NGO, the Government Health Agency and the partner company, the stakeholders involved in the implementation of this program are doctors, nurses and midwives in community health centers that serve to implement the EDAT system that has been developed, as well as community leaders who also play a role in social marketing activities relating to the malaria program so as to encourage the behavioral change in the community. The Global Fund is also involved in the program by providing support in the form of 60,000 mosquito nets distributed to the entire population in Teluk Bintuni Regency. The Ministry of Health provides logistic support in the form of antimalarial drugs.

 8. What were the most successful outputs and why was the initiative effective?
• Malaria morbidity rate decreased significantly from more than 87.5 per thousand of the population to less than 3 per 1000 population in 2016 • 60,000 mosquito nets are distributed to all residents in Teluk Bintuni Regency; • 800-1,200 antimalarial drugs are packaged and distributed every three months throughout Teluk Bintuni Regency; • More than 1,000 stalls and kiosks in Teluk Bintuni Regency no longer sell antimalarial drugs; • More than 200 doctors, nurses, midwives and laboratory personnel have been trained on surveillance of malaria; • 24 Community Health Centers (Puskesmas), 28 Community Health Sub-Centers, 8 Pharmacies in Teluk Bintuni Regency now perform diagnostic procedures and treatment of malaria correctly; • 20 Village Malaria Cadres (JMK) are formed in remote areas; • Memorandum of Understanding is made between the private company (BP) and the Regional Health Agency of Teluk Bintuni Regency to implement the malaria program ; • Instruction of Head of the Government Health Agency is issued regarding the correct use of antimalarial drugs.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacle in the implementation of the EDAT system is the difficulty in maintaining the quality and consistency of the program. Teluk Bintuni Regency is composed of several sub-districts which are distant from one another; one is 100 km away from Bintuni City Center, another can only be reached by small plane with a capacity of 6-12 people, and some areas can only be reached by sea using the locals’ longboat in 2-6 hours. Because these sub-districts are quite far and scattered in remote places, provision of quality assurance and assistance for the implementation of malaria surveillance by the malaria team in Community Health Centers (Puskesmas) and by the Village Malaria Cadres (JMK) is relatively difficult, and it takes several days to make one visit. To overcome this, the malaria team make scheduled visits once every 3-4 months for a remote place and once a month for a close place. We developed a scoring system to measure staff performance and the progress of the malaria program. Every Community Health Center (Puskesmas) personnel and Village Malaria Cadre conducts an individual evaluation each month to review the progress of their own program. As a result, the Puskesmas personnel and Village Malaria Cadres (JMK) can find out their shortcomings, and make improvements gradually.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
This innovation has a major impact both for Teluk Bintuni Regency and other regencies in Indonesia in malaria eradication efforts. - With this system, access to services becomes increasingly easy. All Puskesmas personnel be they doctors, nurses or midwives can now administer antimalarial drugs more easily as antimalarial drugs are now put together in packages which can be administered conveniently. - Patients with positive malaria, despite not being able to read and having never gone to school, can take malaria medication correctly just by looking at the colors in the drug packaging. - The system of drug packaging allows the people or the Village Malaria Cadres to administer the malaria medicines in the correct dosage without having to be a nurse or a doctor, making the system very effective to be applied in very remote places. - The public can access diagnostics and treatment of malaria with great ease. Anyone who has a fever can easily go to Community Health Centers (Puskesmas), Community Health Sub-Centers, Clinics or to the Hospital, and he/she can be examined for malaria using Rapid Test (RDT) or microscopy examination with the same standards. - There was a significant decrease in the rate of Annual Parasite Incidence (API), from 87.5 per mil in 2006 to less than 3 per mil in the end of 2016. - There was a decrease in the prevalence rate from 10% in 2006 to less than 1% in 2016.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative has given a major impact and it is very beneficial for health programs in Bintuni Regency as well as in Indonesia for successfully uniting the private companies, non government organizations, governments and local health authorities to jointly address the health problems that have existed for more than half a century ago. This initiative also ensures that collaboration and coordination between the programs across various sectors could be the key to eliminate other tropical disease that exist in Bintuni and in Indonesia

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This initiative has given the assurance that vulnerable groups such as pregnant women, babies and toddlers as well as women and the poor who live in a very remote area can get access to diagnostic and treatment of malaria, so the equivalent of the population living in urban areas. This initiative also ensures that the population can not read or write still get the maximum health services by the community itself so that the malaria morbidity rate can be decreased at all levels of society

Contact Information

Institution Name:   District Health Office, Bintuni Regency, West Papua Province, Indonesia
Institution Type:   Local Government  
Contact Person:   Russel Supit
Title:   Doctors  
Telephone/ Fax:   +628124835614, +6281248088256
Institution's / Project's Website:  
E-mail:   russel.supit.rs@gmail.com  
Address:   P2PL Dinas Kesehatan Bintuni, Jalan Raya Bintuni KM 4
Postal Code:   98364
City:   Bintuni
State/Province:   West Papua
Country:  

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