MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

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