Questions/Answers

Teluk Bintuni is a Regency in West Papua Province with a population of 62,500 people in 2016 and an area of 18,637 km2. 50% of this Regency is covered with mangrove forests while another 50% is still difficult to reach. The distance of the furthest village from the center is about 100 km and can only be accessed by a pioneer plane with capacity of 7 people, while other villages could only be accessed by road with distances greater than 60 km from Bintuni town center. Other areas are located by the beach / mangrove forests, about 2-6 hours journey by sea using longboats belonging to the local community. 70% of malaria cases in Indonesia occurred in Papua and West Papua Provinces, including in Bintuni Regency. A baseline survey result in 2004/2005 showed that malaria mortality rate in Bintuni (prevalence) was 9% or 1 out of 11 people in this area is malaria positive whereby the groups most vulnerable to malaria are pregnant women, babies and children. Due to the high malaria cases in Bintuni Regency we developed an approach system for malaria programs known as Early Diagnosis and Treatment System (EDAT). This program is a collaboration of various parties through partnerships between Local Government, Non-Governmental Organizations and private sectors. As of 2017 the EDAT program has succeeded in reducing the malaria prevalence rate from 9.2% in 2006 to 0.02% in 12 pilot villages. This program also managed to reduce the malaria morbidity rate from 114.9 per 1000 people to 2.7 per 1000 people (2016) all over Bintuni Regency.

The objective of this program is to reduce malaria cases in Bintuni Regency, particularly among vulnerable groups living in remote areas through EDAT (Early Diagnosis and Treatment) system with the decline target on malaria cases from 114.9 per 1000 people (2009) to 5 per 1000 people (2016). Malaria prevalence rate of 9% in 2004/2005 is targeted to decrease to less than 1% while malaria morbidity rate declined from 114.9 per 1000 people in 2009 to less than 5 per 1000 people in 2016. This measure will be achieved through the development of Early Diagnosis and Treatment (EDAT) system implemented through the establishment of Juru Malaria Kampung or Malaria Specialits (JMK) in remote areas, repackaging of malaria drugs for convenience among undereducated people, utilization of malaria kits, malaria social marketing programs and integrated quality assurance.

The main idea of this program is to provide access affordable, quality, equal and equitable access services for people living in remote areas, of low income, illiterate and vulnerable to diseases in order to gain health access and services similar to those living in the Regency government center. All this while, malaria eradication programs were still concentrated in areas accessible by health personnel while people in remote areas faced difficulties to obtain health services with decent quality due to lack of health infrastructure and personnel. Through the EDAT system, communities in remote areas would receive convenient and affordable malaria checks and treatments, promoting appropriate health seeking behavior, providing accurate malaria drugs and control, so that malaria is no longer a health dilemma in Bintuni Regency.

To achieve the target of SDGs, Bintuni Regency Health Office has a malaria control roadmap for malaria morbidity reduction rate to less than 1 per 1000 by 2020. The Malaria-free National Target in West Papua Province including in Teluk Bintuni should be achieved after 2030 based on the National malaria control roadmap and SDGs. This program is primarily aimed at improving public services and combating malaria as listed in SDGs 3.3. This effort is done by providing access that facilitates the establishment of malaria diagnosis and treatment through JMK in remote areas, repackaging malaria drugs for appropriate use by illiterate people, conducting social marketing to increase community support and participation, prohibiting the distribution and sales of malaria drugs that are not recommended (fake medicine), arranging a tiered reference system, providing malaria logistics to remote areas through malaria kits, increasing participation from private sector through the establishment of Juru Malaria Perusahaan (JMP), enhancing diagnostic capabilities by crosschecker personnel and improving the management of malaria cases in hospitals.

This program has made significant impacts particularly to the groups most vulnerable to malaria attacks: pregnant mothers, infants and toddlers. Coverage of pregnant mothers in Bintuni Regency examined for malaria is 100%. The total number of pregnant mothers examined for malaria in 2016 was 1063 and in 2017 reached 962 people. Since 2009, these vulnerable groups have been reached by providing better access through JMK, actively searching for malaria cases through home-to-home visits, drug usage compliance monitoring and malaria screening for all family members when one of the member is found to be malaria positive. Pregnant mothers, infants and toddlers become a priority and specific monitoring is conducted especially when these groups are infected with malaria. Drugs compliance monitoring forms are given to health personnel and head of families in order to conduct daily medicine intake supervision. These vulnerable groups also receive long lasting insecticide-treated nets to prevent mosquito bites among other family members. Allocation of funds for patient referrals is also made so that patients receive free of charge treatments when referred to other health facilities.

This innovation presents a very positive impact because peoples who living in remote areas and in the remote area now have easier access to health services. The local peoples do not have to walk too far for malaria treatment. Pregnant women, infants and toddlers get better care and malaria morbidity rates in the vulnerable group become severely declining.

In general, the approach to malaria prevention focuses more on vector control. Considering the conditions of Teluk Bintuni whereby 50% of its areas are mangrove forests which are typical for mosquito breeding, hence more innovative approach is needed - breaking the source chain of malaria parasites in mosquitoes. The EDAT approach has proven to decrease malaria morbidity rate from 114.9 per 1000 people to 2.7 per 1000 people (2016) in Bintuni Regency. This program relies on the community engagement through JMK and all specially-trained village health personnel to achieve accurate diagnosis capabilities and drugs prescription, administering easy-to-use malaria kits and frequently implementing social marketing on the importance of combating malaria. To overcome limited availability of health personnel that could reach remote areas, JMK are recruited and required to stay in the village, literate, recommended by the local community, willing to be trained and conduct the routine malaria surveillance system. To overcome the misuse of drugs due to the habit of taking existing medication and being illiterate, malaria drugs repackaging system is implemented utilizing color, code, body weight category and type of malaria cause. This is very helpful for illiterate patients.

This program was initiated in 12 villages with high malaria morbidity rate in Bintuni Regency. The attempt was successful and EDAT was adopted into the Regency’s malaria program. The malaria prevention method was initially carried out for areas with no health personnel or other health infrastructure. JMK was then created. Malaria boxes for logistics storage are placed at the residence of JMK personnel, educational posters for local people were placed in public places and quality assurance programs were conducted through regular supervision. This program took about 2 years to become stable and currently implemented throughout Regency. EDAT’s success and uniqueness lie in the establishment of JMK, repackaging of malaria drugs, Malaria Kit utilization, aggressively implementing Social Marketing and supported by Integrated Quality Assurance. It is conducted through integrated and consistent training, field monitoring program implementation, internal and external cross-checking, refresh training and scoring system implementation for health personnel performance evaluation at Puskesmas.

Human resources involved in this program are JMK, JMP, laboratory staffs at Puskesmas and Health Office, malaria surveillance personnel; doctors, nurses and midwives at Puskesmas, community figures, private practice doctors and pharmacies. JMK are required especially in areas far from health services / facilities. Certified laboratory personnel are a key, thus accurate malaria drug types can be determined from RDT or microscopic results. The city government also established a malaria control team under the Regency Health Office. The team designs the Integrated Quality Assurance mechanism system, creates malaria surveillance training for all health personnel, conducts trainings for new health personnel assigned at Puskesmas. The team also increased collaborative program opportunities with private CSR. An example was the collaboration with Tangguh LNG that allocated approximately USD 147,000 / year to support the malaria program staff and operational costs; with the Global Fund of USD 4,400 for baseline survey and USD 145,000 for the purchase and distribution of nets in 2014. Special allocation for malaria programs was given by the Regency Government budget amounting Rp.100,000,000 (USD 73,500) for logistics and quality assurance programs.

Yes

The idea in this program is conveniently transferrable by implementing a new approach that not only emphasizes on vector control, but through the EDAT strategy that will break the source of malaria transmission – the malaria parasite. This program applies simple technology in the form of drug repackaging, malaria kits utilization containing diagnostic tools (RDT, slide etc.), appropriate medicines understandable by illiterate people and microscopic equipment for blood diagnosis. The system is not new but only emphasizes on: (1) early detection of malaria cases and proper treatments, (2) repackaging of malaria drugs based on color and weight category, (3) distribution of malaria kits, (4) social marketing, (5) Establishment of JMK (6) Quality assurance through consistent and continuous supervision and monitoring. Nationally, this program has been adopted by the Indonesian Ministry of Health and is part of the National Malaria Control Program Strategic Plan 2015-2019 to be implemented throughout Indonesia. South Manokwari Regency, Teluk Wondama Regency, Timika Regency Health Office, Unicef Papua and Papua Province Health Office have conducted visits to Bintuni Regency to implement the EDAT system for malaria control in their areas.

This program has been sustainable for more than 10 years. Launched in the pilot project area, it was adopted as the Health Office formal program since 2010 and shall continue until malaria-free status is achieved, in line with SDG’s objectives. A short-term malaria roadmap for a period of 1-2 years and a long-term roadmap until 2030 are established to ensure a consistent and sustainable program. The Regent Regulation concerning Acceleration of Elimination of Malaria has been stipulated since 2010 to ensure the continuity of this program. Cooperative agreements between private parties, NGOs and Health Offices are always reviewed and updated every 3 years, enabling this partnership to provide maximum social and economic impacts for the Bintuni people. The decline in malaria morbidity rate, previously the main cause of morbidity rate and currently no longer a health burden proves that this program has given a real social impact and increased the productivity of local people. This economic social impact is felt since launching the program until present, while the people become very cooperative and familiar with malaria programs. The community's awareness of malaria programs created a sense of belonging on this program among them thus this program could be assured of long-term sustainability. This innovation has become the Regency’s official program and was published to a book entitled "Towards Malaria-Free Bintuni 2020". To maintain the program’s continuity, several regulations have been formulated: 1. In June 2012 the Head of the Health Office issued 10 Guidelines for malaria surveillance, EDAT and Stock Management to be implemented by each health service facility 2. Kadinkes Letter No. 440/298 / x / 2011 concerning the use of repackaged malaria drugs 3. Kadinkes Letter number 440/12 / II / 2014 concerning examination and treatment of Malaria patients for private practice doctors in Bintuni

This program has been progressing for more than 10 years since being introduced in 12 pilot villages in 2004/2005. As of 2017 the EDAT system has been adopted by the Health Office, resulting in more than 200 villages in Bintuni receiving convenient access to malaria diagnosis and treatments. This initiative will continue to proceed over the long term through ongoing cooperation between private parties and local foundations as well as the Health Office. In 2007, a cooperation agreement on the implementation of malaria program in Bintuni was established between Tangguh LNG and Yayasan Anak Sehat Papua (2007-2010), Yayasan Sosial Agustinus (2010-2013 and 2013-2016) and Yayasan Tifa Mandiri (2016-2019). Apart from this, several regulations have been issued from the Head of the Health Office, among are: Regent Regulation No.4 2010 concerning Acceleration on Malaria Elimination, Head of Health Office Letter No. 440/298 / X / 2011 concerning the use of repackaged malaria drugs and Kadinkes Regulation concerning malaria surveillance, EDAT and stock management. Collaboration programs between private sector, local foundations, Health Offices, JMK and local as well as involvement by local communities in malaria programs will be implemented in accordance with the workplan to achieve the objectives of SDGs.

Yes

To further maintain and improve, a program monitoring and evaluation are conducted using 2 tools: A scoring system to assess the availability of health personnel and readiness in combating malaria; and an annual target achievement evaluation of Puskesmas. Results in 2016 concluded that there were 5 Puskesmas scored Good performance, 13 obtained Medium while 6 needed more improvement. Malaria programs’ system and performances are consistently evaluated with mitigation plan every 1, 3 and 6 months. Annual meetings are conducted to evaluate implemented activities in a year. In 2016 the program’s formal evaluation was conducted through external review visits by the Ministry of Health, Unicef and WHO. The results of these reviews became part of National Malaria Program today.

EDAT program successfully improved Bintuni people’s quality of life prior to malaria morbidity rate decline from 114.9 per 1000 people (2009) to 2.7 per 1000 people (2016), while the 14 pilot villages program succeeded reduce from 87.5 / 1000 (2009) to only 1.03 / 1000 (2017). The decrease from 114.9 to 2.7 per 1000 people is equivalent to the morbidity rate from 5,700 to only 162 malaria cases per year. This showed that EDAT has successfully prevented 40,000 malaria cases in Bintuni for the past 7 years. In 2016 and 2017 more than 30,000 malaria checks were conducted, reaching even people in very remote villages. EDAT has clearly become a paradigm changer in malaria intervention methods.

We use indicators set by WHO as a leading indicator to measure the success of malaria programs in our region. The indicator is Annual Parasite Incidence / API per 1000 population per year. This is in accordance with indicators of SDGs to eliminate malaria in the world by 2030. Currently the case of malaria in Teluk Bintuni regency has decreased from 114.5 per 1000 population at risk to 2.7 per 1000 population (2016). Our target is to reduce malaria morbidity to less than 1 per 1000 population by 2020.

Malaria programs in Bintuni Regency are implemented through the cooperation of private companies, Non-Governmental Organizations, Health Offices, Puskesmas and participation from the local community. Each year, the private sector (LNG Tangguh) supports capacity building of malaria programs in the Health Office, trains newly-recruited doctors and health personnel, strengthens database systems, supports microscopic expert certification and conducts field collaboration visits with local NGOs. These partnership and engagement systems have been progressing since 2010 and have empowered 3 local NGOs in order to implement programs on a platform that suits the needs of the local community. To enhance the integration of program, coordination meetings are held each week with the disease prevention staffs while the managerial-level program evaluation is conducted every 3 months involving Head of Health Office, Head of Disease Prevention Division, Private Company (BP-LNG Tangguh) Manager Team and Head of Non-Governmental Organizations. This coordination system has been implemented for more than 6 years and still continues until today. To encourage more participation from communities, local people are involved in the decision-making process including the recruitment of JMK. The locals recommend candidates that will be trained as JMK through a training of 1-2 weeks by local NGOs. JMK is trained on how to perform simple checks for malaria, administer medicines, perform data reporting, provide education and promote health to the surrounding community. For each team visit, refresh training and guidance to JMK are conducted as part of the mentoring and knowledge transfer processes which are implemented in stages.

This program has proven that vulnerable people living in remote areas could receive health services equivalent to those living in the government center. This program clearly provides solutions for the handling of malaria and other health problems in remote areas without doctors or other health personnel. We have also developed a number of methods and procedures known as the low cost Early Diagnosis and Treatment (EDAT) system using existing local resources. This system can be copied and implemented by JMK as well as other health personnel in order to provide access and more equitable services to the marginalized population groups. This program also demonstrates how private companies, NGOs, Health Offices and local communities could address the problems of malaria in remote and under developed areas through a consistent and sustainable system of cooperation.