MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
A key challenge will be that as an elimination program progresses<br />
a growing proportion of slides will be negative. Once elimination<br />
has been achieved, laboratory technicians will no longer see<br />
positive cases and will lose experience in detecting malaria,<br />
particularly when the patient has low parasitaemia. Frequent<br />
quality control of negative slides and RDTs will therefore be<br />
important. In addition, laboratory technicians will need to<br />
be regularly trained on malaria diagnosis to make up for<br />
the lower exposure to the disease on the job. Quality control<br />
of tests can, as has been done in Oman, be centralized to the<br />
national reference laboratory, but we would only recommend this<br />
for the later stages of the elimination program when the volume<br />
of tests has declined.<br />
Medical Supplies<br />
Treatment and diagnosis can only be as good as the quality of<br />
the supplies that are used. A system for quality assurance for<br />
diagnostic tests (RDTs, PCR reagents and equipment) will<br />
need to be established. For both the public and private sector,<br />
the responsibility for drug quality assurance falls under the<br />
Zanzibar Food and Drug Regulatory Body (ZFDRB), part of the<br />
Procurement Unit of the Central Medical Stores of the MOHSW.<br />
Currently, quality testing is often limited to scrutinizing the<br />
importation documents, and laboratory testing is not routine.<br />
The ZFDRB recently received mini-kits for drug quality testing,<br />
but insufficient resources in other areas (e.g., staff) will impede<br />
progress in this area. The unsuccessful HSS component of the<br />
latest GFATM malaria proposal, addresses some of the weaknesses<br />
of the ZFDRB, including building a more rigorous system<br />
of drug quality testing. Unfortunately, as long as there is no<br />
funding, these services will remain inadequate. The ZFDB is also<br />
responsible for the supervision of private facilities and checking<br />
if standards for infrastructure, staffing and drugs are respected.<br />
They have the authority to, after a series of warnings, close any<br />
facility that doesn’t meet the necessary requirements. Especially<br />
in the private sector, substandard quality drugs remain a concern<br />
and additional funding will be necessary to allow for batch<br />
quality control of incoming medicines through the provision of<br />
laboratory equipment and reagents for the Government Chemist<br />
Laboratory. If the MOHSW decides to eliminate malaria, it<br />
will be paramount to ensure that these systems are adequately<br />
funded to guarantee quality diagnostics and treatment.<br />
CONCLUSION<br />
The Zanzibar Health Care System will need considerable<br />
strengthening before embarking on malaria elimination. Passive<br />
case detection, case notification and case management–the heath<br />
care system’s main tasks–will need to be near perfect. Health<br />
facilities therefore need to be able to provide quality diagnosis<br />
and treatment, ideally free of charge to ensure access for all. On<br />
Zanzibar, geographical access to public health facilities is good,<br />
but the necessary human resources are not always in place to<br />
ensure access to treatment for the population. Ensuring the<br />
necessary human resource capacity, in terms of both skills and<br />
numbers, at all levels of the health care system will be the main<br />
challenge. The MOHSW will also need to clarify its current<br />
policies and future strategies in regard to user fees. These fees are<br />
2 | Operational Feasibility<br />
officially not in place but in reality a barrier to access. In addition,<br />
the necessary mechanisms need to be put in place to ensure that<br />
minority groups, including tourists and illegal immigrants, have<br />
access to free malaria treatment.<br />
Assuring high quality diagnosis and treatment will be equally<br />
important. This will not only require motivated and regularly<br />
trained staff, but it will also require that the necessary quality<br />
supplies are available at any given time at all levels of the health<br />
care system. Training and motivating health workers alone cannot<br />
achieve this. The patient will also need to be informed that in<br />
an elimination setting getting tested for malaria for any fever is<br />
extremely important, and both health providers and receivers<br />
need to be convinced that not every fever is a malaria fever. We<br />
also suggest using a new algorithm for malaria diagnosis that is<br />
simultaneously relatively easy to implement and of high enough<br />
quality for an elimination setting.<br />
We are not arguing that the Zanzibar Health System needs to be<br />
perfect before embarking on a malaria program. Certain activities<br />
will need to be executed with a high(er) degree of perfection.<br />
These activities will require important investments, mostly in<br />
terms of human resources. The implementation of important<br />
recommendations from important strategic documents such as the<br />
essential health care package and the human resources for health<br />
reports will substantially facilitate achieving and maintaining<br />
malaria elimination. Their progressive implementation will be a<br />
first and essential step in Zanzibar’s move towards elimination.<br />
53