MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

The current WHO guidelines give recommendations on the
requirements for the different phases of an elimination program
but do not, as such, propose a structure for the malaria program
for each phase. The table below brings together a number of
essential requirements (adapted from WHO guidelines) and
identifies areas where the ZMCP might need to be strengthened
when moving towards elimination. The areas to be strengthened
were not identified based on a robust analysis of the ZMCP but
rather through comparing the current organizational chart (and
competencies in the ZMCP) with the requirements in terms of
HR, infrastructure and equipment for case management, vector
control & prevention, and M&E for an elimination program.
TABLE 13: INTERVENTIONS BY PROGRAM TYPE
(ADAPTED FROM THE WHO, 2007)
The recommendations made in this chapter only try to provide
a general framework for the management of an elimination
program. The actual implementation will depend entirely on key
decisions made by the MOHSW. For example, the MOHSW
might decide that some of the proposed departments should not
sit under the ZMCP or that existing departments apart from the
ZMCP need strengthening to achieve elimination. However, we
strongly suggest that the elimination program, whatever its form
will be, has a robust central management, with a direct link to the
leadership of the MOH and a strong mandate based on a legal
framework approved by the Government of Zanzibar.
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Case
Management
Vector Control
& Prevention
(Pre) Elimination
Requirements
100% parasitological
case confirmation
Strengthening of ZMCP Required
HR (skills
and/or
numbers)
Equipment Infrastructure
YES NO NO
QA/QC YES YES YES
Active case detection YES YES NO
Monitoring drug
resistance
Geographical
reconnaissance
Perfect case detection
system
Reducing vector
capacity (VC) in foci
Outbreak
preparedness and
response
Entomological
surveillance
YES YES NO
YES YES NO
YES YES NO
YES YES YES (??)
YES YES NO
YES YES YES
M&E GIS database YES YES NO
Genotyping YES YES YES
Malaria elimination
database
YES YES NO
4 The WHO insists on “microscopy” confirmed. However, the feasibility
assessment proposes an alternative algorithm for diagnosis using RDTs and
PCR.
5 The QA/QC mechanisms proposed are adapted to the tools used for diagnosis:
RDT, microscopy and PCR.
HUMAN RESOURCES
“The ZMCP is overly reliant on external partners for
particular areas of expertise… and is inundated with
external visiting partners, leaving little time to monitor
activities or integrate them across MOHSW programs.”
–GFATM Round 8 Proposal on “Missing Skill Sets in
the ZMCP”
The ZMCP will need to be strengthened over time in terms
of human resources, not only by increasing/adding positions
but also by changing/adapting the existing skill set within the
program. With no long-term guaranteed funding for a disease
that will become increasingly rare, the ZMCP will need to build
the necessary in-house capacity in terms of technical expertise to
replace the current technical assistance from donor agencies such
as CDC PMI. This will not only contribute to the sustainability
of the program but will also increase the ownership by the ZMCP
of the elimination program.
Over time (and this will depend on how fast elimination will be
achieved), we propose to increase and adapt the human resource
capacity so that the ZMEP will be able to effectively implement
the core activities of an elimination program. The current
structure with four major departments and an administrative
support unit could be retained, but the tasks/responsibilities
would be adapted and renamed to fit the four key activity
categories for elimination. These include:
1. Vector Control Unit
2. Surveillance and Response Unit
3. Monitoring & Evaluation and Operational Research Unit
4. Communications Unit
We suggest creating a separate sub-department for administration,
responsible for the financial and human resource administration
of the program, allowing the program manager to focus more on
the management of the operational units and his/her work related
to reporting/advocacy to senior management in the MOHSW. A
deputy program manager who would lead the Pemba sub-office
would assist the program manager.
The responsibility and human resource requirements for each of
the 4 operational units or cells is further discussed in detail below.
Vector Control Unit
Vector control using IRS and LLINs will initially need to be
continued due to the relatively high vulnerability of Zanzibar.
The ZMCP has demonstrated that with the help of CDC and
partners such as RTI, it is capable of implementing all necessary
IRS activities to achieve high coverage levels. In the later stages of
the elimination program IRS will change from a purely preventive
control tool to a more targeted foci elimination tool and might
need to fall under the responsibility of the epidemiological
response unit instead of the vector control unit. It is up to the
ZMCP to decide which department will ultimately be responsible
for spraying activities, but a strong collaboration between both
units will be paramount in any case. In addition, the more