Papua New Guinea is battling the world's oldest pandemic: malaria. How can it get back on track?

With only 1% of the world’s land mass and a population of under 9 million, Papua New Guinea (PNG) is one of the most biologically and culturally diverse places on earth, and home to over 850 active languages. Unfortunately, there are also severe limitations in resources for health delivery, with barely one doctor per 10,000 people (the United States has about three per 1,000); its incredibly rugged terrain has posed continual challenges for economic and social development more broadly (PNG ranks 155^th out of 189 on the United Nation’s Human Development Index). PNG also has the highest malaria burden in the Asia Pacific region – it accounted for nearly a third of cases in 2019. But this was not always the case.

The country had seen a steady decline in malaria cases leading up to 2014, but as data illustrates, this changed rapidly in the span of only five years. In fact, cases increased over tenfold from 50,309 in 2014 to 646,648 in 2019. This alarming resurgence has been attributed to a variety of factors, from reduced government and donor commitment, limited access to key treatment and diagnostic tests, reduced effectiveness of long-lasting insecticidal nets (LLINs), to the challenges of a fully devolved health system. Encouragingly, however, an investment case developed by the University of California San Francisco (UCSF) revealed not only an estimated return of 9:1 on investment in malaria elimination, but also that elimination is technically feasible.

In fact, PNG’s promising progress in managing two other infectious diseases, HIV and tuberculosis (TB), despite limited resources is worth noting. Targeted focus on expanding coverage of antiretroviral therapy (ART) from an estimated 23 to 65% from 2010 to 2020 has resulted in a significant drop in deaths, as has prioritizing TB/HIV linkages in high TB burden provinces.

Despite a myriad of challenges, PNG has successfully built systems addressing complex conditions: whether for chronic disease, in the case of HIV, or in battling acute HIV-associated or multi-drug resistant TB (MDR-TB). In June this year, PNG successfully transitioned out of the World Health Organization (WHO)’s global list of high burden countries for HIV-associated TB.

Building on these successes and getting the country back on track for malaria elimination is critical and will help to save both money and precious resources for the country as it tackles the ongoing COVID-19 pandemic alongside other high-burden diseases.

There are three key things we can do to help bring PNG back on track with regard to malaria:

First, disease-dedicated investment must be linked to infrastructure that meaningfully improves public health. This can be achieved by ensuring governments, foundations and funders support better coordination of health and infrastructure investments in PNG. The country has one the lowest provisions of safe water supply in the world and only an estimated eighth of the population has access to grid-connected electricity. This means that PNG needs power and clean water as much as sophisticated diagnostics or pharmaceuticals.

Take for example vaccine distribution efforts under the COVID-19 Vaccines Global Access (COVAX) facility: Despite the facility securing up to 40 million doses of Pfizer-BioNTech’s cutting-edge vaccine early on, its infrastructure demands, including the need for ultra-low temperature storage, meant PNG could not even realistically receive or dispatch them.

Second, while surging investments in ending malaria are indeed the pathway to eradication and will strengthen PNG's ability to respond to future threats, funding needs to last long enough to do the job. Pouring money into health systems for two or three years as is often the case is insufficient; it takes at least four to five years – with rigorous milestones for progress – to achieve lasting results.

External technical support needs time to earn local trust. Stretching health projects over longer periods and requiring that they involve a greater proportion of local personnel, especially given PNG’s chronic shortage of skilled human capital in the heath sector, will better ensure sustainable results. Funding for local projects should therefore include specific targets for local participation, with a key metric being that of public sector “absorption” of staff into national or sub-national programs.

Finally, there is a need for strong leadership and sustained political will at multiple levels – not solely at the national level, but also at the sub-national and community levels. This is especially true in the case of PNG where the health sector has seen several decentralization efforts since independence, such that Provincial Health Authorities (PHAs) and District Development Authorities (DDAs) have significant budgetary autonomy at the sub-national level. To effectively translate political will into action and impact, sub-national leadership at the district, provincial and state levels is critical. Strong local leadership can support sub-national tailoring of interventions based on locally available data to maximize impact. Joining the dots coherently between all levels of governments, from heads of state right to the hearts of communities, including the most vulnerable and hard to reach, will be key to driving an effective malaria response.

As the Global Fund's 2021 Results Report highlighted, COVID-19 has been the most significant setback in the fight against HIV, TB and malaria in two decades – key programmatic results across these three diseases declined, putting already vulnerable populations further at risk. The pandemic’s silver lining is that it has given global leaders and health policy-makers an extraordinary opportunity to build durable systems instead of applying band-aids.

There has never been a more urgent time to ensure that we invest in the right infrastructure, for long enough and with the right people involved. Only then might we be able to put an end to the over 400,000 preventable malaria deaths annually, and to manage what continues to be the world’s longest-running pandemic.