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