Indonesia has made a similar bold commitment against another public health threat, that of malaria. The goal to eliminate malaria by 2030 was set out by Indonesian policymakers in 2009 and remarkable progress has been made over the last decade. Malaria cases fell by 47 percent in 2019 compared to 2010 and more than half its districts are officially declared malaria free. Malaria cases are concentrated in the eastern provinces of Papua, West Papua, Maluku and East Nusa Tenggara, with Papua accounting for 86 percent of all cases nationally.

The malaria elimination goal is under threat due to disruptions caused by COVID-19 that led to a decline in testing, interrupted bed-net distribution campaigns and created fear among frontline workers providing malaria services to vulnerable communities. 

Indonesia’s complex geographical terrain, characterized by 17,000 islands (of which around 6,000 are inhabited) with several remote and hard to reach provinces in the eastern region, make health service delivery particularly challenging.

Papua is among the most challenging areas in Indonesia geographically with its population distributed unevenly, many living in isolated and difficult to reach areas. Health facilities and health care providers are limited, affecting quality malaria services.

If COVID-19 has taught us anything, it is that we are only as strong as our weakest link. Until all provinces have the capacity to respond to emergent public health threats, the country remains at risk. If there is any silver lining in COVID-19, it is that it has brought urgent attention on public health preparedness, to reinvigorate the fight against malaria. It is important to bring Papua, West Papua, and other high burden pockets back on track towards malaria control and elimination.

Three factors will be critical: 1. Increased political commitment to the goal of elimination, especially from local government, 2. Greater investments in malaria interventions that will strengthen public health systems, particularly in areas such as surveillance and 3. Ensuring approaches that recognize subnational strategies.

Reaching the last mile of malaria affected communities in the Papua requires strong and lasting political commitment from local government. The national malaria program in Jakarta needs to ensure that adequate political, financial and technical resources are made available to Papua to undertake robust control and elimination activities.

The decentralized system of governance ensures government at all levels – governor, regency heads and mayors – have responsibility for malaria control activities and contribute toward a proportion of the budget for the malaria program.

The rapid roll-out of the COVID-19 vaccine across the country, including the remote eastern provinces has been made possible due to commitments from the highest levels of government in Indonesia.

COVID-19 is reported to have had an impact on malaria in Asia Pacific, with surveyed facilities in seven countries reporting a fall in malaria diagnoses by 56 percent and in malaria treatment services by 59 percent. The malaria program in Indonesia too needs a shot in the arm with a recommitment from the national level to the goal of elimination and a specific commitment to bring Papua back to a modest level of control over the next three years.

Indonesia has demonstrated increasing financial commitment toward malaria elimination. Domestic funding has become a dominant source of financing for malaria, almost doubling in 2020 compared to 2012. The next three years are a critical phase in Indonesia’s journey towards elimination. Budget needs during this period are estimated to be two and a half times greater than the needs in the previous three-year period.

This increase is largely toward greater investments in strengthening surveillance and reporting systems to ensure aggressive testing, diagnosis and treatment and increasing coverage of bed net distribution through community involvement in Papua. 

Domestic contributions from other low-endemic and malaria-free districts are expected to be reasonable due to adequate fiscal capacity. There continues to be, however, a strong need for greater external funding support to provinces like Papua and West Papua to strengthen primary health and surveillance systems, build the infrastructure needed to protect against future outbreaks and pandemics and to ensure we can reach the elimination target.

A critical learning from the significant progress made over the last 10 years on malaria has been the importance of subnational action in a context of increasing decentralized authority. The 2009 Ministerial Decree on malaria elimination spurred action and commitment from provincial, district and municipal leaders, who had the autonomy to develop and implement context-specific malaria interventions. 

To make a dent in the malaria burden in Papua and West Papua province, it is imperative that provincial governors take the lead in implementing the malaria program, with support from Jakarta in the form of political, financial and technical resources. 

Studies have shown that while malaria is geography-dependent, it is also a disease of poverty. Shifting from control to elimination requires not only technical interventions but also social ones. An integrated approach to elimination that brings together health, industry, finance and social affairs, with interventions tailored to the local context, has the best chance of success.

Indonesia is recognized for its strong economic growth and is primed to host the presidency of the Group of 20 Summit in 2022. This is a good opportunity to showcase the progress made across sectors, including health. The investments made in strengthening health systems through the COVID-19 vaccine introduction as well as progress made toward fighting malaria provide a robust foundation for increased regional health security.

Increased attention on the eastern provinces will ensure that the end game of malaria elimination is within reach,  increase economic productivity, and build the resilient health system needed in the new age of pandemics.

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Nafsiah Mboi is a former Indonesian health minister (2012-2014), Sarthak Das and Amita Chebbi are respectively CEO and senior director of Asia Pacific Leaders Malaria Alliance.