MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

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