Thanks to mosquito-control efforts as well as improved diagnostics and treatment, the Solomon Islands has cut its malaria cases in half over the past 20 years. But with its 650,000 people living on more than 900 islands spread across almost 1.5 million square kilometres of ocean, progress varies widely. While some islands are moving towards eliminating malaria, others are still battling to control it. Despite major progress following reorganizations and fresh funding of its malaria programme in the early 1990s and in 2006, the disease has since 2014 staged a dramatic comeback. Incidence nationally remains one of the highest in the Asia-Pacific.

Mr. Albino Bobogare, who for 14 years has been Director of the Ministry of Health’s National Vector Borne Disease Control Program, shared in an email interview, his thoughts on the importance of continued commitment from donors and the government, engaging the community and targeting strategies that move more of the Solomons from controlling malaria to eliminating it.

What challenges does the Solomons’ wide geography and dispersed population pose to deliver anti-malaria efforts to the community and how are you overcoming them?

This affects our logistical and infrastructure capacity, which may not always be available to sustain our efforts to ensure malaria commodities are always available, especially in remote and hard-to-reach health facilities. This has a huge effect in delaying reporting from health facilities and getting supplies to communities. Due to the remoteness of the islands, health workers—including nurses and malaria officers—are not keen to be posted out to these health facilities, as accommodation and other essential services are not available there.

We are privileged to have support from the Global Fund to pay for some of these logistics and infrastructure requirements, including transport (outboard motors, canoes and vehicles). The government of the Solomon Islands also passed a Role Delineation Policy (RDP) in 2015, which aims to provide universal coverage. We are still waiting for it to be fully implemented but have full faith that it will improve our health system by strengthening our primary health care services. We are working very closely with our nurses to improve reporting and supply management to and from health facilities. We are also working closely with APLMA to train our officers and nurses to introduce a surveillance and response strategy for malaria elimination, revive our planned National Advisory Committee for elimination, and get support from our national leaders and the community.

What are the main factors behind malaria’s comeback in recent years in the Solomons?

In the past, donor-funded indoor residual spraying was one of the main vector-control interventions—alongside active case detection and treatment—for targeting malaria hot spots. This intervention ceased in 2015/2016, which affected our malaria control efforts. Now, we conduct bed net distribution as a core activity. Other important approaches, such as monitoring of mosquito population bionomics to guide decisions and appropriate vector-control interventions, are not being implemented due to alternative priorities and a lack of well-trained human resources.

Traditionally, donors and partners funded the programme heavily. Now donors have reduced support for the vertical approach as our ministry has encouraged an integrated one. This is a drawback, as our health system is still not strong enough to support quality reporting (access to communication tools) from health facilities or management of supplies (logistics-transport and infrastructure) to them. In addition, technical refresher trainings for malaria officers, especially field officers (entomologists and microscopists), in the provinces has become irregular, particularly due to COVID-19 travel restrictions. As a result, staff are not always up to date with new strategies planned by the national team with donor partners. This is especially true for our malaria elimination strategies and road map.

Distributing long-lasting insecticidal nets (LLINs) to households is a key part of your programme. What are some of the hurdles to that and how important is community involvement?

Community engagement has played a critical role in ensuring effective LLIN distribution, particularly in hard-to-reach areas. It relies heavily on support from our community workers, including Civil Society Organizations (CSOs) and faith-based groups. Community leaders select the community members who distribute the LLINs to make sure each household has sufficient nets and that the occupants know how to use them. So, the malaria programme trains the community leaders, who in turn train the community participants, on how to carry out mass distribution. In addition, behaviour change communication, targeting the behaviour of individuals in the household, is a critical component of the LLIN distribution.

Distribution is conducted under the close supervision of malaria program officers. Each group consists of five community workers and one or two malaria officers. Despite that, there are issues: delays in the arrival of LLINS, under-trained community workers, unclear selection process of CSOs and faith-based groups, and logistic issues that hinder access to remote communities that require special transportation such as motorboats or heavy vehicles to reach. Daily communication has improved due to the extensive reach of mobile phone networks, but most of the costs of using them is borne by the staff due to a lack of alternative communications and budget implications.

What are some of the key issues that need to be addressed as you shift from controlling malaria to eliminating it on more islands?

It is critical that we first focus on strengthening our primary health care systems, which lack basic infrastructure, particularly in remote locations. It is therefore important to ensure successful implementation of the Role Delineation Policy to strengthen health information and communications (internet access), supply chain management, infrastructure (including staff accommodation and transportation), skilled human resources at clinics and accountable and transparent financial management at the provincial level. This will help us implement critical malaria elimination interventions such as real-time data collection and reporting, supply chain management, timely response and case management and training of provincial health service directors, managers, and frontline health workers. This includes training in the 24-7 surveillance and response strategy as the core elimination activity, which will be piloted in one or two provinces before being rolled out to the rest of the country.

It is also essential to put in place policies that support elimination efforts, such as making malaria a notifiable disease. We are working towards establishing a National Advisory Committee for Malaria Elimination to monitor, advise and guide the implementation of the elimination plan and adapt our responses to the ongoing COVID-19 response. For us to successfully roll out the elimination plan, there is a need to understand the urgency of the situation and win both political and community support.

The Solomon Islands aim to eliminate malaria nationwide by 2034. How do you think your programme needs to be strengthened, nationally and sub-nationally, to achieve that?

The pandemic has shifted our priorities, and subsequently our focus, from routine programmes such as malaria. It is critical that we ensure our commitment towards malaria elimination is continued. As a country, we have limited resources and so we need to ensure that they are utilised effectively. We need to ensure that our policies reflect our elimination needs and that our programme has a clear governance structure with well-defined responsibilities to ensure accountability all the way down to the level of individual health facilities. We also need to ensure that our staff are well-trained and equipped to carry out malaria control and elimination activities.

There is a lot to do if we truly want to defeat malaria by 2034, but we are determined. With the right areas in place, I believe we can achieve it.

This interview has been edited for length and clarity.