MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

CHAPTER 2: OPERATIONAL FEASIBILITY
INTRODUCTION
Historically, operational feasibility has been described in terms of
administrative and practical feasibility. Administrative feasibility
was defined as “the possibility to create a national organization
that can carry out a malaria elimination program with a strong
long-term governmental commitment, a conducive legal
environment for malaria elimination control activities especially
spraying and surveillance, and the availability of sufficient funds.”
Practical feasibility meant “country wide access for personnel
and materials, sufficient human resources for the malaria control
program and the health facilities, and cooperation of the general
public” (Pampana, 1969). Financial feasibility is discussed in
Chapter 3, and here we focus on requirements related to the
implementation of the activities recommended in the previous
chapter to achieve and maintain elimination.
The operational feasibility component of this assessment mainly
focuses on whether the interventions needed to achieve and
sustain elimination can be implemented given the capacity
of the national malaria program and the health system. The
main recommendations from the technical feasibility chapter–
continued high levels of prevention coverage, building up a
robust surveillance system, creating an efficient rapid response
team, and the testing of (ideally) all fever cases–are the backbone
of this chapter. This chapter describes these aspects in detail
and provides recommendations for strengthening of the
surveillance system, strengthening of the health system, moving
of the Zanzibar Malaria Control Program (ZMCP) to a Zanzibar
Malaria Elimination Program (ZMEP), fostering community
involvement, and evaluating the potential legal implications of
an elimination program.
One cross-cutting theme is the need for continuous and
aggressive communication to the population. People will need
to be convinced and reminded that all fever cases must be tested,
and everybody needs to comply with the preventive measures
necessary to achieve and maintain elimination. In addition,
certain activities such as re-active case detection and IRS will
require full collaboration from the population. Strong IEC/
BCC campaigns are therefore a recurring recommendation
throughout the different sections of this chapter. In general, we
believe that any future IEC/BCC activity should be based on a
strong communication strategy adapted to the prevalent malaria
situation and thus regularly reviewed throughout the elimination
process.
The operational feasibility of malaria elimination in Zanzibar will
ultimately depend on whether the government can or is willing
to meet the necessary programmatic requirements and create
an enabling environment to facilitate the elimination process
(Moonen et al., 2009). The Government of Zanzibar has already
2 | Operational Feasibility
shown strong political commitment to move towards elimination.
This commitment will need to be translated into solid political
support for the Zanzibar Malaria Elimination Program, not only
within the Ministry of Health, but also from other ministries and
departments such as immigration, education, agriculture, and
even the judiciary. The speed required for the execution of the
elimination activities will not allow for a protocol heavy decisional
process. Strong political leadership from the highest level and
an efficient coordination mechanism will empower the ZMEP
and facilitate inter-departmental collaboration respectively. We
therefore strongly recommend the set-up of a technical advisory
committee, ideally appointed and given a mandate by either the
Minister of Health or even the President and a National Malaria
Elimination Steering Committee 1 , with representation from
all relevant ministerial departments and key partners, chaired
by the Director General or the Permanent Secretary (see From
ZMCP to ZMEP). We propose a technical advisory committee
composed of between eight and ten independent international
experts , to be invited by the Minister of Health. The committee
should meet at least once a year to review the progress of the
elimination program and to provide independent technical advice
to the ZMCP. The purpose, composition/structure, authority,
frequency of meetings/reporting, and budget should be specified
in a charter much like the charter for the Advisory council for the
elimination of Tuberculosis in the USA (Department of Health
and Human Services, 2007).
The success of elimination and the feasibility of its maintenance
will also depend on further reduction of the malaria burden in
mainland Tanzania (see Chapter 1). The ZMCP should therefore
ensure strong links with Tanzania’s National Malaria Control
Program (NMCP) with regular information sharing from both
sides. Although the technical feasibility working group did not
identify specific high-risk countries that are potential import
sources of infection, cross-border collaboration might become
necessary if further research indicates this might be the case.
Imported cases of P. falciparum in Oman, for example, were
mainly coming from Zanzibar. A drop in malaria prevalence
on the islands means that today almost no cases originate from
Zanzibar.
1 The committee could be chaired by the Zanzibar WHO representative and
should consist of experts from research institutes from the mainland and other
countries. To safeguard its independence, the committee should not have any
members related to any of the main donors of the ZMCP.
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