MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

conditions. Health worker motivation is based on a range of
core health system issues, including compensation and working
conditions, which are well beyond the scope of this assessment.
However, as motivation will be a central factor in the achievement
of malaria case management targets for an elimination program,
we recommended that the MOHSW explore additional means
of motivating health workers at the peripheral level, including
through innovative approaches such as use of mobile phone
money transfer technology to provide performance-based
incentives.
Training
The shift from presumptive treatment of frequently malariapositive
fever cases to strong differential diagnosis in an
environment with little or no malaria will require important
changes in both pre-service and in-service training of health
workers. As malaria cases become rare, health workers will lose
their experience in diagnosing and treating the disease. Yet
continued ability to recognize and appropriately treat malaria
will be critical even after elimination due to the continued
imported cases and potential outbreaks. Training programs will
therefore need to include modules on malaria that give the
disease a more prominent position than it would merit based
on its prevalence.
One of the drivers of the current frequent presumptive treatment
of fever with anti-malarials is that it is considered unacceptable
to miss a malaria case due to the potential rapid and severe
consequences. While this attitude may be justified in holoendemic
settings, the negative impact of overtreatment (i.e.,
mortality from other severe febrile illnesses treated with antimalarials)
will often be greater than that of untreated malaria
infections in an elimination environment. As such, all training
programs, guidelines, job aids, diagnostic tools, and supplies
will progressively need to be adapted to ensure that health
workers have the knowledge, tools, and necessary supplies to
identify and treat non-malaria-related fevers.
Changing Patient Perception
Patients need to be informed about the fact that when they present
with fever, the likely cause will be not malaria but something else,
something that will not always have a name. This might give the
impression that their fever is not taken seriously, and that they
are not really sick. Qualified and confident health workers will be
able to deal with this but it will be equally important to include
adapted messages in IEC/BCC campaigns and materials
to address this challenge. These messages should explain the
importance of malaria testing for all fevers, the fact that most of
these will be negative, and they should also provide an overview
of the alternative illnesses that can cause fever (and potential
treatment). Changing the patient’s perception or preconceptions
in regards to fever–fever often being a synonym for malaria–will be
as important as changing the health care workers behavior. This is
further discussed in the section on community involvement and
on the restructuring of the ZMCP.
2 | Operational Feasibility
The Private Sector
While often overlooked, quality of care in the private sector will
also need to be considered and addressed. As discussed, there is
little existing evidence in this area. An assessment of the private
sector funded by the African Development Bank (Revolutionary
Government of Zanzibar, 2004) only evaluated its current
status and looked at opportunities for the private sector in the
overall health system. Anecdotal evidence suggests that quality of
care varies considerably in this sector depending on the type of
facility and its staffing. Regulatory bodies are in place, but their
mandate does not necessarily include on-the-job supervision to
evaluate the quality of care provided. The table below provides
suggestions on how quality of care could be defined and achieved
at facilities of a particular type in the context of an elimination
program.
TABLE 12: QUALITY OF CARE IN PRIVATE FACILITIES
Type of
Private
Facility
Shops
(informal
outlets)
Targeted Service Quality How to Achieve
All fever cases encouraged to
get tested
No anti-malaria drugs sold
OTC
Pharmacies All fever cases encouraged to
get tested
ACTs only sold based on an
official prescription
Clinics All fevers are tested
Only positive cases are
treated with anti-malarials
Severe cases are recognized
and immediately referred
All positive cases are
immediately notified
Hospitals All fevers are tested for
malaria
Only positive cases are
prescribed (or treated with)
ACTs
Severe cases receive adequate
treatment
All positive cases are
immediately notified
IEC/BCC material available
at the shops; incentives for
referral to public facilities
Impose by law; mix of
enforcement and incentives to
ensure compliance
IEC/BCC material available in
the pharmacy
Introduction of “official”
prescription papers
Potential subsidized supply of
RDTs
Training of health workers;
potential subsidized supply of
RDTs
IEC/BCC Campaigns targeting
both patients and health
workers
Appropriate training; incentives
for clinics that properly refer
Incentives for clinics that notify
all cases
Training of health workers
IEC/BCC Campaigns targeting
both patients and health
workers
Requirement of available
equipment for treatment of
severe cases
Referral system in place for
severe cases that cannot be
treated in the facility and
incentives to refer
Incentives for clinics that notify
all cases
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