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