MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

Recommendations:
�� Establish a system using standardized forms to document any
treatment failure reported at the health facility level.
�� Establish a robust methodology for the collection of a random
sample of RDTs to be sent to the Karolinska Institute for
genotyping using PCR as long as the ZMCP does not have
the capacity to perform the tests themselves. (When cases
become extremely rare, all positive RDTs should be re-tested.)
CONCLUSION
As the Zanzibar Control Program progresses from control to
elimination the M&E system will need to be adapted in order
to be able to provide both implementers and policy makers
with the necessary information for informed decision-making.
Apart from routine programmatic monitoring of the different
activities under its responsibility, the ZMCP will also need
to establish a malaria database bringing together all relevant
malaria information from different sources (health facilities,
case investigations, entomological data, laboratory results, etc.).
The MEEDS will be the main supplier of good quality data, but
eventually the routine HMIS system should be made responsible
for malaria data collection and analysis. Routine monitoring
of the speed, completeness and correctness of malaria-related
reporting will be one of the most important tasks of the M&E
unit. In addition, survey methodologies previously used to
evaluate the malaria burden and useful tools to prove absence of
transmission will need to be adapted both in terms of sampling
methods and laboratory techniques. This will also be the case for
drug resistance monitoring.
HEALTH SYSTEM STRENGTHENING
INTRODUCTION
To assess the extent to which the health system needs to be
strengthened in order to achieve and sustain malaria elimination,
we first need to specify what is expected from the health care
system in the different phases of an elimination program and how
these requirements are different from those for the ongoing control
program. The ninth report of the WHO’s expert committee on
malaria defined “minimum requirements of the health service to
support a malaria eradication program” (WHO, 1962), providing
greater specificity than it had previously. These minimum
requirements, although not described in detail, can be summarized
as “adequate coverage of the population with basic health services
in order to detect and treat cases and to provide health education
in support of the eradication program”. This approach–defining
minimum requirements rather than recommending a perfect
health care system–has been used as the overarching framework
for considering health system strengthening issues for Zanzibar as
part of a potential elimination program. While not diminishing
the importance of a strong overall health care system, it is not
necessary for Zanzibar to wait until the health care system is
optimal to successfully pursue elimination. However, some
minimum improvements to basic services and support systems
will need to be made for elimination to be feasible.
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REQUIREMENTS FOR ELIMINATION
In malaria control, the goal of the national malaria program is
to reduce the overall burden of malaria through high coverage
of curative and preventive services. As a program shifts to the
elimination phase, the goal should be to achieve and maintain
interruption of transmission by identifying and treating all
parasite carriers and reducing vectorial capacity (WHO, 2007).
To achieve this we identified two main tasks that the basic health
care system must conduct and that cannot or should not be
substituted by implementing vertical systems:
�� Passive case detection and notification
�� Case management (treatment and follow-up)
It is important to point out that when we talk about the health
care system we are focusing specifically on the provision of care
to patients and not the management of the system. Management
aspects of the malaria elimination program will be discussed
below (From ZMCP to ZMEP). Also, passive case detection is
discussed in detail in the surveillance section.
The services that will need to be available in both public and
private facilities to effectuate these tasks are:
�� Quality diagnosis (microscopy, RDT and/or PCR) to ensure
parasitological confirmation.
�� Prompt and effective treatment (or referral) for both
uncomplicated and severe cases.
These services need to be complemented by a near perfect case
reporting or surveillance system. Health education is not included
because it is felt that, while health providers will be involved
in implementation of behavior change communication (BCC)
activities, primary responsibility will reside with specific IEC/
BCC departments, the ZMCP and the (potential) implementing
agencies.
The support systems necessary to guarantee both the availability
and quality of these services are listed below:
�� Human Resources (skills and numbers)
�� Infrastructure and Equipment (coverage and availability)
�� Procurement and Supply Management
�� Management and Supervision
�� Monitoring and Evaluation (including quality assurance and
control)
None of the above is specific to elimination, but each differs from
control in the level of coverage and precision each requires. To
achieve elimination all malaria cases need to be detected in the
shortest time delay possible in order to avoid onward transmission.
This requires universal access to high quality diagnosis and
treatment complemented by a near perfect surveillance
system. This chapter considers and analyzes each service and
support system component separately to identify essential gaps in
the current Zanzibar health system that will need to be addressed
if the MOHSW decides to eliminate malaria from the islands.