MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

CONCLUSION
Overall, this assessment presents a mixed picture of the prospects
of malaria elimination on Zanzibar. On the one hand, it shows
that it is possible to completely eliminate malaria from the
islands with currently available interventions. At the same time, it
concludes that it will be operationally and financially challenging
to prevent the reintroduction of malaria following elimination
if importation risk remains high. In that way, Zanzibar’s
elimination ambitions are tied to the fate of malaria control
on the mainland: as malaria rises and falls in coastal Kenya and
Tanzania, the difficulty and cost of sustaining elimination on
Zanzibar will similarly increase and decline. This suggests that
the MOHSW should engage in active dialogue with the relevant
mainland Ministries of Health as it pursues further exploration
and/or planning of malaria elimination. Yet even if importation
is reduced through such collaboration, Zanzibar should expect
to be able to only modestly reduce its annual expenditure on
malaria.
This core conclusion–that elimination is feasible but very
challenging–also indicates that the success of a potential
elimination program will, in many respects, ultimately be
determined by will: will to mobilize and sustain additional
resources, will to overcome enduring systemic challenges, and
will to pursue elimination of malaria above other health priorities,
among others. Whether this will can and should be generated
and therefore whether malaria elimination should be pursued is a
decision that can only be taken by the MOHSW. It is hoped that
this assessment will be a resource in that process.
As the MOHSW deliberates this decision, it is important to bear
in mind the long time horizon associated with both elimination
and sustained control. The technical feasibility analysis revealed
that the earliest elimination that could reasonably be achieved
would be 2020 and interventions will need to be sustained for
several decades from now regardless of the strategy that the
MOHSW pursues.
This longer time horizon presents challenges that are generally
different from or more acute than short-term scale-up efforts. An
essential conclusion of this assessment is that one of the most
critical of those challenges is financing. Regardless of whether
Zanzibar pursues elimination or sustained control, ensuring
adequate funding to maintain interventions will remain essential
but will become increasingly difficult. The great majority (>90%)
of funding for Zanzibar’s malaria effort currently comes from
international donors whose priorities and systems are aligned
towards short-term reductions in disease rather than long-term
maintenance of disease absence (as is the case with elimination
and sustained control).
10
PERCENTAGE OF INDIVIDUALS INFECTED
ESTIMATED RESURGENCE OF MALARIA FOLLOWING RELAXATION OF
VECTOR CONTROL MEASURES
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
1 51 101 151 201 251 301 351
ABOUT 35% COVERAGE (RC=3.4)
ABOUT 50% COVERAGE (RC=1.5)
ABOUT 55% COVERAGE (RC=1.3)
DAYS
As shown in the figure above, even a modest decline in financing
and therefore intervention coverage could lead to a devastating
resurgence of malaria. Such resurgence is not speculation on
Zanzibar: it has happened twice before on the islands when
elimination campaigns were halted, taking a terrible toll on the
people of the region. As such, although it may take several years for
this challenge to become pronounced, we urge the MOHSW and
its donors and partners to immediately begin work on potential
solutions, including increases in domestic financing of malaria
and mechanisms such as endowment funds and earmarked taxes,
to provide a more secure financing base for the ZMCP. Perhaps
more than any other factor, continued progress in freeing the
Zanzibari people from malaria will depend on success in this area.