Change of strategy is required for malaria elimination: a case study in Purworejo District, Central Java Province, Indonesia.
BACKGROUND
Malaria has been targeted for elimination from Indonesia by 2030, with varying timelines for specific geographical areas based on disease endemicity. The regional deadline for malaria elimination for Java island, given the steady decrease of malaria cases, was the end of 2015. Purworejo District, a malaria-endemic area in Java with an annual parasite incidence (API) of 0.05 per 1,000 population in 2009, aims to enter this elimination stage. This study documents factors that affect incidence and spatial distribution of malaria in Purworejo, such as geomorphology, topography, health system issues, and identifies potential constraints and challenges to achieve the elimination stage, such as inter-districts coordination, decentralization policy and allocation of financial resources for the programme.


METHODS
Historical malaria data from 2007 to 2011 were collected through secondary data, in-depth interviews and focus group discussions during study year (2010-2011). Malaria cases were mapped using the village-centroid shape file to visualize its distribution with geomorphologic characteristics overlay and spatial distribution of malaria. API in each village in Purworejo and its surrounding districts from 2007 to 2011 was stratified into high, middle or low case incidence to show the spatiotemporal mapping pattern.


RESULTS
The spatiotemporal pattern of malaria cases in Purworejo and the adjacent districts demonstrate repeated concentrated occurrences of malaria in specific areas from 2007 to 2011. District health system issues, i.e., suboptimal coordination between primary care and referral systems, suboptimal inter-district collaboration for malaria surveillance, decentralization policy and the lack of resources, especially district budget allocations for the malaria programme, were major constraints for programme sustainability.


CONCLUSIONS
A new malaria elimination approach that fits the local disease transmission, intervention and political system is required. These changes include timely measurements of malaria transmission, revision of the decentralized government system and optimizing the use of the district capitation fund followed by an effective technical implementation of the intervention strategy.
Center for Tropical Medicine and Department of Parasitology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia. herdiana.elsa@gmail.com.
E Elsa Herdiana
EE
Murhandarwati
Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia. anisfuad@ugm.ac.id.
Anis
A
Fuad
Department of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia. sulistyawatisuyanto@gmail.com.
Sulistyawati
Center for Tropical Medicine and Department of Parasitology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia. dikafkugm@yahoo.co.id.
Mahardika Agus
MA
Wijayanti
Politeknik Kesehatan, Kementrian Kesehatan Kupang, Kupang, Indonesia. michaelbia07@gmail.com.
Michael Badi
MB
Bia
Cartography and Remote Sensing Department, Faculty of Geography, Universitas Gadjah Mada, Yogyakarta, Indonesia. barandi@geo.ugm.ac.id.
Barandi Sapta
BS
Widartono
District Health Office of Purworejo, Purworejo, Indonesia. drkuswantoro@yahoo.co.id.
Kuswantoro
Eck Institute for Global Health, University of Notre Dame, Notre Dame, IN, 46556, USA. neilflobo@gmail.com.
Neil F
NF
Lobo
Center for Tropical Medicine and Department of Parasitology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia. supargiyono@gmail.com.
Supargiyono
UNICEF, Jakarta, Indonesia. byh0@cdc.gov.
William A
WA
Hawley
D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D006801:Humans; D015994:Incidence; D007214:Indonesia / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000453:epidemiology* / Q000517:prevention & control*; D008875:Middle Aged; D062206:Spatial Analysis; D055815:Young Adult