MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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Currently, ACTs are not part of the kit-system that is used to<br />
supply the public health facilities, but are instead distributed by<br />
the ZMCP based on demand (pull-system). We recommend<br />
that ACT supply remains the responsibility of the ZMCP.<br />
The teams that will be responsible for case investigation (and<br />
that should visit the facility where a case has been identified<br />
without delay) can be used to re-supply a facility that has<br />
given out a treatment. (Integrated) supervision teams should<br />
be encouraged to systematically check the availability and<br />
expiry dates of ACT at all facilities.<br />
As mentioned above, as malaria cases become increasingly rare,<br />
the proportion of severe cases, especially with cerebral malaria, is<br />
likely to go up. Apart from an efficient referral system discussed<br />
above, severe cases will often require intensive care and treatment<br />
to deal with a variety of complications such as respiratory distress,<br />
kidney failure and coma, to name a few. It will therefore be<br />
important to:<br />
�� Have IEC/BBC activities stressing the importance of prompt<br />
treatment through immediate health seeking behavior for<br />
every fever case.<br />
�� Upgrade the Intensive Care Unit at Mnazi Moja Hospital to<br />
deal with the most common complications of severe malaria.<br />
In addition, the main referral hospital on Pemba should have<br />
adequate capacity to stabilize severe cases before referral.<br />
�� Set up a referral system to send cases that cannot be treated at<br />
Mnazi Moja to Tanzania mainland and abroad (e.g., Kenya)<br />
for live saving treatment. These cases will be extremely rare<br />
but will require a special budget to ensure access to these<br />
specialized services even for the poor.<br />
We do recognize that the above recommendations are not<br />
necessarily elimination specific. Other potentially life threatening<br />
diseases require the same level of care. We therefore did not<br />
include the cost related to these recommendations in the costing<br />
exercise for this feasibility assessment.<br />
The private sector can obviously contribute to increased access to<br />
care, but it would be unreasonable to assume that their services<br />
will be free. However, private structures that will be included<br />
in the elimination program (private hospitals, clinics) should<br />
be provided with free ACTs and diagnostics. Free access to<br />
malaria testing and treatment in the private sector could increase<br />
the likelihood that people would get tested and that they are<br />
treated with a quality drug according to the national treatment<br />
guideline. Private clinics would still charge for physician<br />
consultations (unless the government decided to reimburse<br />
patients for private consultations). The primary challenge to be<br />
addressed with the private sector, however, is the issue of quality,<br />
which is examined below.<br />
QUALITY<br />
Delivery of quality health care is an overarching goal of the<br />
Zanzibar government and as such is not specific to malaria<br />
elimination. However, the success of an elimination program<br />
will depend heavily on the quality of services the health system<br />
provides. If a sufficient level of access to services has been<br />
achieved, poor quality of services will be one the most important<br />
50<br />
barriers to a successful elimination program. Specifically, the<br />
quality of clinical care, diagnosis, and medical supplies must<br />
all be examined and strengthened in preparing an elimination<br />
program.<br />
Clinical Care<br />
To achieve elimination, it will be essential that patients be<br />
provided with prompt, high-quality care for all fever episodes,<br />
not just malaria. An accurate differential diagnosis followed<br />
by appropriate treatment of non-malaria cases must be the<br />
cornerstone of moving the population and health system away<br />
from the old adage of “fever equals malaria”. To achieve that<br />
standard, there must be sufficiently motivated health workers<br />
who are provided with the necessary training and tools so that<br />
they feel confident in their analysis and treatment of non-malaria<br />
fever cases. At the same time, patients will need to be educated<br />
so that they understand that malaria will no longer be the main<br />
cause of fevers and that they will typically need medicines other<br />
than anti-malarials to effectively treat their illness.<br />
We did not find any formal assessments of the quality of care<br />
provided in the public and private sector in Zanzibar. The<br />
“Zanzibar Health Care Worker Productivity Study” conducted in<br />
2007 evaluated how productive health workers are by cadre, but it<br />
did not evaluate the quality of care provided to patients (Ruwoldt<br />
& Hassett, 2007). However, the main challenges identified by<br />
that study-low productivity at the PHCU level and a decline in<br />
productivity over the course of the day-are relevant and important<br />
to malaria outcomes. As a result, it is recommended that the main<br />
recommendations of that study, notably the strengthening of the<br />
Human Resources for Health Technical Working Group and<br />
supervision systems, and the establishment of time management<br />
procedures for health workers, should be implemented as part of<br />
a malaria elimination effort.<br />
Capacity and Motivation<br />
Strengthening supervision of the health facilities was included<br />
in the latest GFATM malaria proposal as a way to increase and<br />
sustain the quality of case management at the periphery of the<br />
health system. Even though the ZMCP has already achieved<br />
strong success in case management through the introduction of<br />
ACTs and training of health care workers (94% of all facilities<br />
have at least one staff member trained in malaria case management<br />
and IMCI), there is still room for improvement, especially at the<br />
PHCU level. This was clearly mentioned in the last Health Sector<br />
Performance Review (MOHSW, 2008), and anecdotal evidence,<br />
including from a visit to a PHCU by the assessment team, confirms<br />
that practices in these facilities can be well below standards and<br />
likely inhibit the quality of care provided to patients.<br />
These weaknesses are due in part to the low motivation of health<br />
workers as well as the consistent understaffing discussed above.<br />
The standard of care that is needed for an effective elimination<br />
program (e.g., careful differential diagnosis, explanation of<br />
illness, and appropriate treatment to patient, etc.) requires<br />
more time workers and precision from health workers than the<br />
current standard of presumptive anti-malarial treatment. As<br />
such, it is important that workers have the necessary motivation<br />
to consistently employ this approach despite often challenging