MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

These obstacles clearly demonstrate that the Zanzibar health
system needs substantial strengthening. Nevertheless, there are
also signs that the health system has improved considerably over
the last couple of years, with important reductions in childhood
and infant mortality and a good performance for both the malaria
and tuberculosis programs (MOHSW, 2007). Unfortunately,
the PER does not provide details on the performance of the
health system in terms of timely delivery of quality health care in
general. An overall improvement of the health care system would
benefit the move towards malaria elimination. However, the
health system does not need to be perfect. Important areas that are
essential when going for malaria elimination are discussed below.
HEALTH SYSTEM STRENGTHENING FOR
ELIMINATION
ACCESS
Financial Access
To ensure that all fever cases are tested within 24 hours, people
must have access to diagnostic services and any barriers to
treatment be reduced to an absolute minimum. The 2007 RBM
survey revealed that 32% of children under five years old do not
seek medical care for febrile illness within 24 hours. Some of
these children will eventually seek care but others will not. Table
11 gives an overview by region on the proportion of people that
are not seeking medical care when they feel ill and the stated
reason for not doing so. Although the relatively wide range seen
in some of the results might indicate a flawed methodology, the
data show that, unlike many countries, geographical access is not
a primary barrier to public sector care in Zanzibar. The major
reason for not seeking care is that people feel that there is no need
to do so. This attitude is problematic in an elimination setting
where all fever cases must be tested. Increasing people’s health
seeking behavior, especially for fever, will need to be increased
through IEC/BCC and community involvement (see below). In
addition, financial access seems to be an issue that will need to
be addressed. These data include the private sector so we cannot
conclude that the public sector is too expensive. Nevertheless, an
important proportion of people do not seek care because they
feel that costs are too high. We therefore recommend that fever
testing and malaria treatment should be absolutely free in
both the public and private sector to ensure maximum access.
TABLE 11: REASONS FOR NOT SEEKING HEALTH CARE BY REGION
(OCGS, 2006)
Reason Kaskazi Kaskazi Kati Kusini Magharibi Mjini Wete Micheweni Chake Mkoani Total
Cost-sharing or user fees, although mentioned in the Health
Sector Reform Strategic Plans, have not been officially introduced
but do exist at all levels of the public health care system (Simai
et al., 2007). Anecdotal information suggests that consultations
48
A
B
Chake
No Need 69.0% 73.8% 61.5% 79.9% 67.0% 70.0% 54.5% 36.2% 59.5% 69.0% 60.8%
Too
Expensive
22.5% 14.7% 4.4% 9.8% 18.1% 28.2% 36.7% 58.0% 23.3% 22.5% 27.5%
Too far 2.2% 2.0% 5.0% 1.8% 2.8% 0.7% 2.4% 4.0% 9.9% 1.5% 3.5%
Other 6.9% 9.5% 28.9% 6.9% 12.0% 2.0% 6.4% 1.5% 5.6% 4.9% 7.7%
and malaria-related diagnostic testing are free of charge in
most facilities, but patients are commonly charged for certain
laboratory tests (mainly glucose, hemoglobin and pregnancy
testing) and other services. These services include referrals which
are potentially important for malaria treatment.
These “unofficial” charges vary between facilities and no attempt
has been made to standardize practices. User fees are mostly
collected at the point of service (for example, the patient pays
the lab technician for a test). Only in Chake Chake Hospital
are fees collected at a central collection point where the patient
receives a receipt that has to be taken to the actual service point
(pre-payment). If user fees will be officially implemented, it
will be important to guarantee free testing of all fever cases and
no charges for a malaria-related consultation and anti-malarial
drugs. Additional “hidden” charges will reduce access to health
care and should be avoided. For example, if a patient, regardless
of the pathology he/she presents with, has to pay for health care
provision (as is done in many primary health care settings), the
service will not be perceived as “free,” even though the RDT and
the ACT will be provided gratis. The same goes for consultation
fees. If clinicians keep on charging fees for the actual “consults,” in
the assumption that the malaria diagnosis can only be made after
having seen a clinician, malaria-related services will not be truly
free of charge. We therefore recommend doing a more detailed
analysis of the current de facto cost-sharing practices in the
public sector in order to make more practical recommendations
to ensure free fever testing and malaria treatment.
Guaranteeing financial access will be challenging as many cases of
fever will present at the health facility (requiring a test), but few
(almost none) will be positive for malaria during an elimination
program. In Nigeria, for example, it was clearly demonstrated
that poorer households have higher rates of self-diagnosis for
malaria suggesting that user fees for malaria diagnosis influence
health seeking behavior, especially for the poor (Uzochukwu
& Onwujekwe, 2004). We therefore suggest the following
pragmatic steps to ensure that the goal of free malaria
diagnosis and treatment is achieved:
�� Triage in the waiting rooms to identify cases of fever or
patients with a history of fever to be tested for free (microscopy
or RDT). In places where fees are collected at a central point
before any services are provided, triage will need to be done
before patients are required to pay;
�� Positive cases need to been seen immediately without charging
a consultation or any other fee;
�� Free provision of treatment for positive cases, not only ACTs
but also any other drug required including for associated
pathologies; and
�� Clear communication towards the patients on which services
are supposed to be free.
The MOHSW will need to include these recommendations in
the necessary policy documents and communicate them to health
professional at all levels of the system. The implementation
of these recommendations will require strong supervision to
ensure that facilities comply with these recommendations. The