Mohammad Alhabsyi

Despite decades of malaria control efforts in Indonesia focused exclusively on curative treatment, Dr. Mohammad Alhabsyi has shifted practices in eradicating malaria to a collaborative, preventive approach across government agency and local community sectors.

In 2003, an outbreak of malaria struck many villages in South Halmahera, Indonesia claiming 267 lives. In light of this, Dr. Moh realized that eradicating malaria and communicable diseases is everyone’s responsibility. Through the Malaria Center, he developed an integrated system that connects communities and different government offices in the pursuit of malaria prevention and treatment. He has transformed the way the government addresses malaria control by flipping the strategy from top-down to bottom-up. His strategy begins with individuals and neighborhoods, and his treatment now has community members taking the lead in controlling the mosquito-borne disease and engaging government offices to take part in the effort.

Through this new process, Dr. Moh created a new role for individuals in villages, empowering them with the tools and methods to identify potential outbreaks of disease and begin prevention at a hyper-local level. Dr. Moh developed Village Malaria Committees, a system that educates community members not only about what causes malaria and on how it is transmitted, but how to recognize signs and symptoms, improving preventive collective practices and ingraining treatment-seeking behaviors. He also created channels to connect the local needs to the appropriate government offices, which has successfully prevented outbreaks over the past three years, especially for vulnerable populations, such as infants and pregnant women.

Dr. Moh and his colleagues pushed the provincial and district governments to issue regulations that force key government institutions to collaborate in eradicating malaria. Through the development of a curriculum for kindergarten and primary school students, Dr. Moh is educating Indonesian youth about malaria. He has also lobbied local governments and the District House Representative to ensure that 40 percent of annual village budgets are dedicated to eradicate malaria at the local level. To date, Malaria Centers have been set up in seven districts across North Maluku province. Currently, Dr. Moh and his colleagues are working on the replication of his methods in Eastern Indonesia islands, where South and West Sulawesi provinces have already started the model. The Ministry of Health and the Global Fund have replicated the model in eight and five provinces, respectively.

Malaria remains a major cause of morbidity and mortality in tropical and subtropical regions of the world. Nearly half of Indonesia’s 240 million residents live in malaria endemic areas, with the Eastern provinces having the highest incidence of disease. Despite decades of malaria control efforts by the government, a 2009 World Health Organization report found more than 500,000 deaths from the disease (with an estimated 900 people dying per 100,000 cases) According to the same report, 90 percent of those deaths were children. For children who survive an episode of severe malaria, they suffer from learning impairments and brain damage; repeated episodes often lead to poor childhood physical and mental development. Mothers and their unborn children also face serious risks from malaria.

In the province of North Maluku, with a population of around 1 million, people lack information and a scientific understanding about the disease—they do not know where illness came from, could not recognize its signs or symptoms and they did not know how transmission of the disease occurs. For hundreds of years, this population has linked the symptoms of malaria to myths and superstition. Patients turned to traditional healers for explanation and treatment, neither of which was true or efficacious. Due to costly geographic barriers, which result in high transportation costs, people do not seek treatment. Healthcare centers in these villages, when they exist, do not have the capacity to treat patients and lack medical equipment to perform blood tests for diagnosis. There are only 30 centers serving populations across 400 islands in the district of South Halmahera alone. These conditions make it almost impossible to eradicate malaria in these areas.

Since the 1950s, government intervention to control malaria took a curative approach, focusing only on symptomatic treatment and not on preventative measures. Despite government efforts, malaria-prone sites still exist across neighborhoods, especially in coastal and swampland areas, like South Halmahera, which are the perfect breeding sites for Anopheles mosquitoes. The government’s top-down approach to provide infrastructure and services, such as sanitation and roads, were uncoordinated and left out the people, so they were ineffective against malaria. Furthermore, lack of communication and monitoring by government offices (i.e. Public Works and Fisheries) has made it difficult to create a comprehensive health solution.

Finally, systemic poverty and other economic effects are serious consequences of malaria. Not only does the disease affect one’s health and well-being, but it also exacerbates already limited resources.

Dr. Moh’s strategy to eliminate malaria in rural Eastern Indonesia is three-fold: (i) coordinating of government agencies to address malaria prevention (ii) treatment (iii) working with local communities to educate, end stigma, and superstition. He does this by increasing awareness of malaria’s causes and providing incentives, equipment, and knowledge to supplement existing medical services in villages.

Key to Dr. Moh’s strategy is understanding how to gain buy-in from the government. Through the Malaria Center, Dr. Moh educates local governments on an integrated approach to address malaria, primarily through the cooperation of different government offices (District Planning Bureau, Village Development Bureau, Fisheries District office, Public Works office, Education office and Health office), coordinated under the district mayor’s office. The identification of mayors as “leaders” was a key strategy. The mayor is the lead politician in every district. Civil servants in his district must follow his directions. When malaria rates dropped precipitously following the implementation of the Malaria Centers, the mayor reaped the positive media coverage and credit for success. However, the program is not tied to any particular Mayor, so when new mayors are elected each must continue the tradition of the government-mandated centers. The Malaria Center regulates how each office should coordinate and respond to the community needs. For example, to minimize mosquito-breeding sites, villagers work together with fishery and mining offices to shift unused mining holes, or with the agriculture office to convert unused paddy fields into fishponds. The Ministry of Public Works and Electric Power will follow up with village proposals to implement sanitation and roads projects, including drainage constructions improvement. Alternatively, for the coastal areas, Public Works will build water embankments to restrain seawater from coming in and staying after the tides in to prevent the build-up of stagnant water, a breeding-ground for mosquitoes.

In addition to tackling challenges with the natural environment, Dr. Moh’s strategy focuses on educating the most vulnerable populations in rural areas. As children are at the highest risk for malaria, Dr. Moh channels the Education Office to help village primary schools run local curricula on malaria. Led by Dr. Moh and his team, they develop the curriculum together with health officers, primary school teachers, university lecturers, and UNICEF. Once passed through the curriculum, students through grades 2 to 5 are able to identify malaria mosquito larvae and their breeding sites, and understand how to eradicate malaria. Most importantly, children share these prevention actions with their parents. Proud parents, especially mothers, spread the word to other adults in the community. To date, Dr. Moh has introduced the program in 250 primary schools in South Halmahera district.

Dr. Moh’s strategy also takes into account the community at-large. Dr. Moh guides the establishment of Village Malaria Committees to provide community-based malaria control. Before establishing a committee, Dr. Moh meets with village leaders to discuss strategies for preventing outbreaks and controlling the spread of disease. If the village is interested, they send two village representatives to participate in a training program, similar to the youth-based Village Malaria Fighters, where they learn about malaria, its types, causes, prevention, and medical treatment. Using a human body-mapping exercise, the villagers identify the signs and symptoms throughout the body. The village-mapping exercise teaches the representatives to identify the breeding sites in their own village. The training also includes direct observations of breeding sites and larvae taken from water samples. With the findings, villagers, led by the village committee, including village midwife or nurse, find ways to stop the life cycle of larvae in order to reduce the transmission of malaria. Other activities include a weekly Friday village puddle clean-up to prevent breeding grounds from forming and a public campaign focused on malaria awareness through a football match. In the event that preventive measures are unable to contain an outbreak, villagers are educated on various health services options and how to best seek medical treatment. In addition to spreading the innovative learning model to other districts and provinces, Dr. Moh is currently applying this model to address the epidemic spread of HIV/AIDS in the region.

The third prong of Dr. Moh’s strategy focuses on augmenting existing medical services and treatment for malaria with better strategies, facilities, and knowledge. One challenge Dr. Moh is successfully navigating is low immunization participation rates among pregnant women and infants in villages. Dr. Moh’s strategy integrates malaria prevention into already existing maternal and child health services in the village by creating incentives for families to ensure their children have immunizations. In partnership with UNICEF and village health posts, Dr. Moh provides free insecticide mosquito nets to pregnant mothers receiving prenatal care and for children under five with full primary immunizations. Malaria detection is often one of the biggest challenges rural medical centers face. As such, Dr. Moh’s Malaria Centers assists rural village health centers with the provision of a rapid diagnostic test. To improve the performance of health service providers at different levels, Dr. Moh provides training in standard operating procedures and using microscopes for malaria blood testing through the Health Office. The Health Office also improves health services at the Health Centers through an apprenticeship program, setting out four centers as the model for others; improved Health Clinics will ideally provide assistance to the village health posts.

Finally, Dr. Moh has taken steps to advocate for the adoption of his strategy, including funding to scale and institutionalize his methods. This strategy fits recent budgetary changes in Indonesia—a decentralization of budgeting to local areas from the center. To secure funding and guarantee sustainability for his Malaria Centers, Dr. Moh advocated for a District Budgetary regulation, which stipulates that 40 percent of the annual Village Fund Allocation must fund proposals from the Village Malaria Committee. The Malaria Center will also coordinate funding from other sources, for example with the government poverty-alleviation program of PNP, the Mandiri budget and the district offices’ budgets. To date, sixteen government institutions have engaged and supported village level proposals to eradicate malaria. The provincial government has also pledged that every district should have a Malaria Center. In addition, Dr. Moh facilitates relationships between village malaria committees and micro finance services to set up cooperatives and run Internet café businesses. Not only does the profit sustain the village endeavors, the Internet connection helps build the information system for Malaria Centers.

Dr. Moh was born and raised in the city of Ambon, Maluku as the seventh of nine siblings. His father, although originally from Ambon, was born and raised in Java. When his father joined the military, they assigned him to a station in Ambon, where he met Dr. Moh’s mother and they raised their family. After retiring from lecturing at Pattimura University, his father returned to Java. Dr. Moh was taught empathy and social values from his father, who made an effort to share with those less fortunate regardless of how little his own family had.

When Dr. Moh was still in primary school, he dreamed about becoming a doctor, wanting to help as many people as possible. When his grandfather was ill, he had to travel four hours to find a doctor. This experience moved him to create opportunties for all people to be healthy. He learned perseverance and dedication from his father, who gave him his full support while he enrolled in medical school. During college, Dr. Moh learned from the local communities; feeling the magnitude of how people suffered from health problems. Every holiday season at school he organized his medical school friends to go to remote areas to serve the community. His impartial attitude has made him welcome by the Islamic students’ organization and other Islamic organizations.

After graduation, Dr. Moh became the head of a sub-district health post in the Sula Islands—a remote district where he was the only doctor. He faced a politicized environment and chose not to align with any one political group, but instead form broad connections. From working within communities, he found that in addition to the need for equal access to health care facilities, people needed to have a role in improving their own health. He was then assigned as a civil servant in the Communicable Diseases department of the Provincial Health Office. While there, a huge outbreak of Malaria occurred in 2003. In one area, sixty people died in six days. Suddenly Dr. Moh realized that this outbreak was not only a health problem. He became determined to end the “not my department” mentality of government. From the inside, he began to change the bureaucratic culture. Dr. Moh and his colleagues took the initiative to address the problem. Knowing that the outbreak was the culmination of long-standing problems at the community level as well as the government level, Dr. Moh made an important breakthrough by setting up the Malaria Center. The democratic process he applies at the community level stems from his upbringing: his father always let him decide and pursue his dreams. To further develop and spread his idea, Dr. Moh has taken a five-year leave from his assignment at the health office.