MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

THE ZANZIBAR HEALTH CARE SYSTEM
THE PUBLIC SECTOR
The organization of the public health care system is based on
a district model consisting of a network of primary health
care units (PHCU) complemented by a number of secondary
(Primary Health Care Centers, District Hospitals) and tertiary
referral structures. In theory there are two types of primary
health care units: PHCU (basic primary health care services) and
PHCU plus (same plus obstetric, laboratory and dental services).
In practice there is no difference between the two units, with
laboratory and dental services rarely available at the PHCU-plus
level (EHCP, 2007). Primary Health Care Centers (PHCC),
also known as Cottage Hospitals, provide inpatient care (30
beds), some more advanced services such as x-rays, and they
also serve a larger population. The 3 district hospitals are the
second line referral level and have surgical capacity. All 3 are on
Pemba. Zanzibar has 3 tertiary referral hospitals: Mnazi Mmoja
general hospital, Mwembeladu maternity hospital and Kidongo
Chekundu Mental Hospital, all situated in Stonetown. The one
referral laboratory for both islands is situated on Pemba.
TABLE 10: NUMBER OF PUBLIC HEALTH FACILITIES BY LEVEL OF CARE
Unguja Pemba Total
PHCU 55 49 104
PHCU plus 19 13 32
PHCC 2 2 4
District Hospital 0 3 3
Referral Hospital 3 0 3
All of these facilities have malaria diagnostic capacity-RDTs
at the PHCU level and microscopy for PHCC and above-and
dispense ACTs. According to the most recent Malaria Indicator
Survey, almost 95% of facilities have at least one staff member
trained on malaria and IMCI (MIS, 2007). However, the most
recent human resource for health development plan has noted
that there is a misallocation of the few available health personnel,
with the majority of the front line workers earmarked for the
PHCUs and PHCCs placed in referral hospitals in urban areas
(Revolutionary Government of Zanzibar, 2004). Attrition of
qualified health personnel moving outside the islands is also a
persistent challenge. In addition, the 2008 Performance Report
(MOHSW, 2008) states that staff performance at all levels is
inefficient and ineffective. The main reasons mentioned in the
report are unexplained absence, unclear job descriptions, staff
competencies not properly exploited, no reward or disciplinary
system in place, high turnover (especially of highly qualified
staff), lack of commitment, and no culture of mentoring and
managing junior staff.
The public health care system management is organized by level,
with facility management teams at the facility level, district health
management teams at the district level, and the MOHSW with
its different departments and vertical programs at the central
level. Notably, the Zanzibar Strategy for Growth and Reduction
of Poverty (MKUZA) (Revolutionary Government of Zanzibar,
2 | Operational Feasibility
2006) and the Zanzibar Health Sector Reform Strategic Plan II
(Revolutionary Government of Zanzibar, 2006) both describe
the malaria program as a vertical program alongside Reproductive
and Child Health programs. This reality needs to be addressed in
the context of the strength of the health system to move towards
malaria elimination.
THE PRIVATE SECTOR
Zanzibar has a flourishing private health care sector that consists
of 3 private hospitals (all in Zanzibar Town), around 100
clinics or dispensaries providing outpatient care, 60 registered
pharmacies and more that 200 OTC outlets selling over-thecounter
drugs, including malaria treatments. Roughly two-thirds
of these private facilities are in and around Zanzibar town.
Although the proportion of mothers seeking care through the
public sector has been increasing, the private sector remains an
important source of treatment for malaria. One-third of mothers
use a private facility when their child has a fever, while just under
half first visit a public facility (ZMCP, 2007). However, when it
comes to acquiring anti-malaria drugs, three quarters of mothers
get their treatments from the public sector (ZMCP, 2007).
Almost all private facilities, including OTC shops, sell antimalaria
treatments. However ACTs are still expensive and most
treatments sold are mono-therapies (ZMCP, 2007). Testing for
malaria is available at most private hospitals and at almost 2/3 of
out patient clinics. However, there are only 9 facilities where the
laboratory regularly undergoes quality controls checks. Private
pharmacies and OTC shops dispense malaria treatment almost
always based on clinical (self)-diagnosis.
PERFORMANCE OF THE HEALTH SYSTEM
The MOHSW reviews the performance of the health sector
on a yearly basis since 2007. All departments, units, programs
and management teams provide reports for the Minister’s
annual budget speech to the House of Representatives. The
House’s secretariat updates and compiles reports into the annual
performance report. The Performance Report is a part of ongoing
efforts to strengthen the planning and monitoring cycle
in Zanzibar.
The 2008 Public Expenditure Review (PER) identified
the following major obstacles in achieving milestones and
implementing the Plan of Action (MOHSW, 2008):
�� Staff performance at all levels is inefficient and ineffective
�� Back-up emergency and contingency resources lacking
�� Drugs shortages or irregular distribution to health facilities
�� Delays in approval of research proposals
�� Poor integration and coordination between districts and
programs (activities, resources)
�� Planning and reporting processes are suboptimal
�� Central support for and will to achieve the annual Plan of
Action and milestones is not unified or transparent
�� Cost-sharing stalled
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