Inroads in fighting malaria

COVER STORY

“Reducing the burden of malaria in PNG is vital to achieving the 2030 goal of a malaria-free Asia-Pacific as pledged by former Prime Minister Peter O’Neill, with 22 other heads of state.”

THE release of WHO’s World Malaria Report 2022 provides a timely moment to reflect on the challenges and progress made in the Asia-Pacific region. The data reveals almost 2 million confirmed cases reported in Asia-Pacific in 2021, with PNG accounting for almost 40 per cent of these cases. PNG also continues to shoulder the highest malaria burden in the region, followed by Pakistan, Indonesia and India.
Reducing the burden of malaria in PNG is vital to achieving the 2030 goal of a malaria-free Asia Pacific as pledged by former PNG Prime Minister, Peter O’Neill, with 22 other heads of states. Last year, PNG reported the first decline in malaria cases since 2016. PNG’s strong efforts have been able to ease the burden, but even a 13 per cent case reduction still meant that 650,000 Papua New Guineans contracted malaria leading to 201 deaths in 2021.
With 94 per cent of PNG’s people still at high risk of contracting malaria, the burden is still substantial. We cannot be complacent. This latest data underscores the need to double down and support PNG in its effort to end malaria. Strengthening the country’s malaria response and broader health system is pivotal to saving lives among many vulnerable communities and for boosting malaria progress in the region.
Inroads
PNG’s health sector is already making inroads with their latest National Health Plan (2021-2030), which outlined plans to step up structural and operational foundations to “achieve an efficient health system which can deliver an internationally acceptable standard of health services.”
It laid out three key strategies to reduce the burden of communicable diseases: (1) increasing capacities of the health sector to prevent, promote and treat disease, (2) building capacity of provincial health authorities (PHAs) to improve disease surveillance and (3) raising awareness amongst key stakeholders to enable collaboration and meet the disease elimination targets.
Ending malaria is a feat which can substantially benefit from investments in health sector capacity, surveillance, and management. These three building blocks are essential to get PNG back onto track to elimination.

First, focus on sub-national operational strategies: PNG’s diverse ecosystem — from costal mangrove swamps to tropical rainforest to highlands — reflects the complexity of malaria epidemiology in the country. Among Plasmodium parasites that infect humans, P. falciparum and P. vivax are two of the most-deadly and dominant species, however prevalence rates differ by province: P. falciparum is the most widespread while P. vivax is concentrated within highland areas. Madang, Morobe, and East Sepik rank among the highest-burden provinces.
Changes in biting and resting habits of mosquitoes have also been observed in recent years, which are impacting the efficacy of indoor residual spraying and insecticide-treated nets, two core prevention tools for malaria. Prevalence of malaria in different age groups also vary, infection rates are high in young children and pregnant women in lowlands whereas in highlands, malaria infections are common in all age groups. Given this complex and highly diverse malaria epidemiology, tailoring malaria strategies at the sub-national level according to the specific needs of target groups to bring cases down and subsequently eliminate malaria will be crucial. Strategies will need to account for the continuous monitoring of surveillance data to effectively plan access to everything from diagnostics, treatments, bed nets, staff training, to financing. Funding provincial activities should therefore include detailed plans, developed in collaboration with PHAs and with specific targets that can be tracked.
Second, firmly build surveillance capacity. Since the launch of the e-National Health Information System (eNHIS), malaria surveillance in PNG has switched from aggregated sub-national paper-based reporting to geo-tagged case reporting. While this has enabled access to village level outbreaks with the potential to provide timely information on supply needs, uptake of eNHIS to inform malaria planning remains in need of strengthening.
According to the latest malaria programme review from this year, the programme advisors and Department of Health monitoring and evaluation officers at the national, provincial and district levels need eNHIS training and ongoing support.
In other near-elimination countries such as Laos, the national programmes host weekly management meetings to evaluate malaria trends and inform proactive next steps. They use a standard framework to guide their discussions to identify issues and gaps in implementation. These routine meetings have helped strengthen capacity of provincial and district-level staff to resolve problems at the local level.
A similar mechanism could be helpful in PNG for provincial and district authorities to collaborate monthly on the analysis of malaria data trends to identify and target areas in need of support.
Third, intentionally focus on supporting provincial and district management and leadership: Provincial and district-level governments who are responsible for the bulk of funding and delivery of malaria and indeed all health care delivery remain under-resourced in terms of human resources for malaria programming. Currently, seven provincial malaria supervisor positions remain vacant and there is limited oversight at the district level in the absence of a malaria officer.
Home-based management of malaria (HMM) volunteers at the village level also lack incentives and guidance from local authorities. In Sri Lanka, one key operational feature that was central to ending malaria was the onboarding of 22 highly experienced and dedicated malaria officers.
Each lead a team comprising of public health inspectors, laboratory technicians, field officers, and an entomology team for vector surveillance and vector control at the district level. Given the demographic and cultural diversity of PNG, a dedicated team at the district level can provide the leadership and management the support that the programme is currently lacking, also reflected in the operational and surveillance gaps. Investments in malaria-related human resources for health need not be endless investments; they can also be synergistic with other public health programmes.
Other communicable diseases
Despite the broader health sector challenges, PNG has managed to make substantial progress in other communicable disease areas such as HIV and tuberculosis which are in many ways even more complex infectious threats. In fact, PNG had driven national prevalence to around 1 per cent a decade earlier.
To get back on track and accelerate PNG’s malaria response, Papua New Guinea has the compass and map through the National Health Plan. Ensuring key domestic and international resources, such as Global Fund to Fight TB, AIDS, and Malaria, are coordinated to empower PHAs is critical.
But such an approach, under the aegis of robust national leadership, can secure a malaria-free future for the next generation of Papua New Guineans. It is both a medical and moral imperative to ensure this preventable and treatable disease becomes a relic of history as PNG looks to a future of prosperity and health equity.

• Dr Sarthak Das is Chief Executive Officer of the Communicable Disease Threats Initiative & Asia Pacific Leaders Malaria Alliance, and adjunct lecturer at the Harvard Chan School of Public Health. He has spent the last three decades living and working on infectious diseases, health systems in Africa and Asiaa-Pacific.
• Leo Sora Makita is the Programme Manager, Malaria and Vector-Borne Disease at the National Department of Health, Papua New Guinea.