MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

COMMUNITY INVOLVEMENT ON ZANZIBAR
Zanzibar had a relatively successful community-based health care
program in the early 1990’s. Since that time, however, there has
been a significant increase in the fragmentation of communitylevel
services and the interface between communities and the
health system. On the upside, this means that a number of
skilled and experienced people and structures are already present
at the community, but on the downside that coordination of
activities has become increasingly complex resulting in inherent
duplications and inefficiency of delivery (Suleiman and Borg,
2008). As the recent proposal for health systems strengthening
to the Global Fund noted, “at the level of local communities,
activities are often conducted in an ad hoc and uncoordinated
manner… currently, priority programs are employing multiple
community health strategies that respond to programmatic needs
but not necessarily to the needs of communities or individuals
within those communities.”
Of importance for the community health strategy is that at
the community level the country is divided in administrative
units, called Shehias (currently 299 in total). While at the
district level the District Commissioner (a Presidential
appointee) oversees civil services, at the Shehia level the Sheha
(a Regional Commissioner’s appointee)-assisted by a ten member
Shehia committee-is responsible for the administration at the
community level. The Sheha is reporting directly to the District
Commissioner on public affairs and is also responsible to
maintain a register of vital statistics. A Shehia can contain up to
3 villages and varies in population size.
Current practice of national health programs does tend to
bypass the district level and will contact the Sheha directly on
community interventions. It then depends on the interpretation
of the Sheha for how further contact with the community is
established. Moreover, several programs tend to establish their
own community “interface” and channels including “extension
workers”. This means that several health-related community
committees can exist at the same Shehia level. It can be argued
that this has led to undesirable fragmentation of health services
supply at this level. As a by-product of this fragmented approach
a plethora of structures exist at the community level, which
make intervention less efficient and effective through a lack of
coordination.
Suleiman and Borg (2008) have proposed one single Shehia
Health Custodian Committee (SHCC), to replace/transform
existing community involvement structures with their varying
roles (in most cases initiated by different national programs and
external donors).
COMMUNITY INVOLVEMENT IN MALARIA ELIMINATION
Community involvement in the GMEP of the WHO has, to our
knowledge, been relatively poorly documented and described.
The only direct reference to community participation we found
was related to the use of volunteers for spraying activities initiated
by a group of students in Pakistan as part of their program of
community social service and subsequently used mainly to reduce
2 | Operational Feasibility
costs in resource limited settings (Afridi, 1956). The evaluation
of this scheme did not only show results in terms of cost
reductions, higher coverage and impact on malaria prevalence
(demonstrated through reduced spleen rates) but also concluded
that community participation (described as “self-help”) can be
used to bear a considerable part of the human resource burden
for the labor intensive spraying activities.
More recently the WHO and the RBM Partnership have
extensively promoted community participation in malaria
control, but we were not able to find recommendations related
to community participation in elimination programs in any of
the recent elimination guidelines. For a disease that will become
increasingly rare, involving the community to ensure ownership
and buy-in will be essential to achieve the necessary coverage of
preventive measures and acceptance for activities such as active
case detection or IRS. On Vanuatu, an island group in the
Southwest Pacific, a high level of community participation was
identified as a key factor in the success of the elimination program.
Community involvement resulted in a high acceptance of mass
drug administration and bed net ownership and use, without
which elimination would not have been achieved (Kaneko et
al., 2000). Other elimination efforts in the Southwest Pacific are
planning to have strong community involvement based on the
above-mentioned results in Vanuatu (Andrew Vallely, personal
communication).
Although no guidelines exist on community involvement in
malaria elimination, the RBM Partnership has proposed a set of
objectives related community participation to malaria control
(WHO, 2002). These objectives are equally important for malaria
elimination and we believe that the community can actively
contribute to their achievement. The table below proposes a
number of activities for each of these (control) objectives that
could contribute to achieving and maintaining elimination.
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