MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

community needs to be aware that fever testing and malaria
treatment are supposed to be free so that abuse or non-compliance
can be reported.
Access to Health Professionals
Although geographical access is considered to be very good on
Zanzibar with 95% of the population living within a 5km radius
from a public health facility, this is only the case at certain hours
of the day. Not all facilities are open all hours of the day/ all
days of the week, and even the official opening hours are often
not respected. This is partly due to the fact that not all facilities,
especially PHCUs, are fully staffed. In theory a PHCU should
have 9 staff members, but in reality very few are fully staffed.
Most, but not all, have 4 staff members (2 technical (medical) and
2 support staff). Unfortunately, no official figures are available
on the actual staffing per facility (Hussein Hamsi, personal
communication). The reasons for the human resource gap in the
public sector are multiple and beyond the scope of this report.
Nevertheless, it is important to point out that the gap is not only
due to the fact that insufficient numbers of health professionals
graduate every year but also because of:
�� Better salaries in the private sector (informal interviews
indicate up to 50% higher);
�� A preference to work in the different vertical programs where
there are more opportunities in terms of workshops, travel,
training and per diems; and
�� An unequal distribution between urban and rural areas and
even between morning and evening shifts and an apparent
misuse of the “light duty” option that excludes night shifts.
Several projects funded by DANIDA, USAID and ADB are
trying to address the different challenges related to human
resources in the public health care sector based on the Human
Resources for Health 5 year development plan (Revolutionary
Government of Zanzibar, 2004). Although a more detailed
assessment of the current situation in terms of access at any given
time is desirable, a number of general recommendations can be
made with the information available. These recommendations
assume that geographical access of facilities is sufficient (no new
infrastructure needs to be built), but that these facilities will
need to operate more frequently if the goal of universal malaria
diagnosis and treatment is to be achieved. We also suggest taking
advantage of the plan to increase the number of facilities that
will be providing emergency obstetric care (24h/7d) in selected
facilities (Bijlmakers et al., 2007).
�� Before starting the elimination program, all public health
facilities should be at least partly staffed (4 minimum) on a
daily basis to guarantee access during normal opening hours.
�� Train the nurses on duty for emergency obstretic care on the
use of RDT for malaria diagnosis.
In addition, facilities should have the necessary means of
communication (mobile phone) so that they can notify the
relevant people in case of a positive malaria test. It will be
paramount to properly inform the catchment population of these
facilities.
2 | Operational Feasibility
Access to Specialized Care
As the number of malaria cases goes down, the proportion of
severe cases with cerebral malaria will increase due to decreased
immunity in the population (Greenwood et al., 2008). A
functioning referral system including means of transport to
higher-level facilities will be essential to deal with these cases in
a timely manner. This approach will require adequately trained
staff that can both recognize/diagnose severe malaria and provide
pre-referral treatment. The availability of a vehicle rather than
distance will be the main challenge for quick referral. Today
the referral systems are not organized at all and we therefore
recommend that the recommendations made in the Review
of Essential Health Care Package in Zanzibar (p 80-81)
(Bijlmakers et al., 2007) are implemented before elimination
efforts are started.
Access for Minority Groups
Access to health care is not only a matter of financial and
geographical access but can also be compromised if specific
groups are excluded or have more difficulty accessing the system.
Anecdotal evidence suggests that certain minority groups have
experienced difficulties in getting bed nets from mass distributions.
These are of course rare exceptions and the ZMCP has strongly
acted against these practices but when going for elimination
the message must be clear: everyone, including all possible
minority groups, immigrants, and even tourists, should
have access to free fever testing, and free malaria treatment if
necessary. In addition, the provision of these services should
never lead to any form of prosecution. For example, an illegal
immigrant should receive malaria treatment when necessary
without having to fear being reported to immigration services
and/or the police. If this is not the case, illegal immigrants might
delay or even avoid seeking health care and as such pose a serious
risk for the reintroduction of malaria on the islands. Although it
will be required to notify the authorities of all cases and a follow
up is likely to be done for an epidemiological investigation, the
systematic reassurance of these minority groups will be the only
way to over time ensure that all cases, regardless of who the
patients is, will be detected.
Access to Quality Supplies
Access to treatment and diagnostics requires the continuous
availability of supplies in all health facilities (including some
private facilities). The procurement and supply management
of these essential items will, due to the nature and aims of an
elimination program, experience an important shift of focus
from treatment to diagnosis.
The fact that ideally all fever cases should be tested means that
the need for diagnostic tests such as RDT and supplies such as
Giemsa will increase over time and eventually reach a plateau only
influenced by population growth and potentially a reduction in
other diseases that present with fever. For treatments the volume
will reduce over time to negligible levels during the maintenance
phases. Nevertheless, every facility will be required to have ACTs
for all age groups in stock so that they can treat any positive
case without delay. Because ACTs have a short shelf life, stock
management of these rarely-used drugs poses specific problems.
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