MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

elimination will raise two major financing challenges. The first
will be to secure sufficient funds to implement the initial increase
in interventions to achieve elimination. The second will be to
ensure that funding is both long-term and consistent. This
second requirement is not specific to an elimination program—
maintaining the high level of intervention coverage that Zanzibar
has recently achieved will require a steady source of long-term
financing as well. In either scenario, a significant withdrawal of
financing—and an accompanying easing of vector control and
surveillance—could trigger a devastating resurgence of malaria
as discussed in Chapter 1. Unfortunately, the incentives and
mechanisms of the international health financing architecture
are not currently structured to support this requisite sustained
funding in the context of a low level or absence of disease. As
such, regardless of what strategy Zanzibar chooses to pursue, it
is imperative that it begins working with its donors and partners
to address this challenge, including through the development of
innovative financing mechanisms.
COSTING SUSTAINED CONTROL
Although it is now an established concept in malaria program
planning, there is no precise definition of sustained control.
The term “sustained control” implies that malaria is kept steady
at a low level of malaria prevalence through the consistent
implementation of a package of interventions. There is currently
no guidance on what such an “acceptable” level of prevalence
should be or what level of coverage of key interventions should
be targeted on an ongoing basis. Given this absence of clear
definitions, we, for the purposes of this exercise, established a
definition of sustained control on Zanzibar in order to enable an
effective cost comparison.
As described in Chapter 1, Zanzibar has already achieved a high
degree of control, achieving a prevalence rate of around 1%
and IRS coverage of 96% of households. This situation could
qualify as an effective sustained control baseline. However,
Zanzibar is already planning on building on this success through
the implementation of an additional grant from the Global
Fund (Round 8). Specifically, with the support of that grant
and funding from other donors such as the President’s Malaria
Initiative (PMI), Zanzibar will aim to:
�� Achieve universal LLIN distribution (100% coverage, >80%
usage) through tri-annual mass campaigns;
�� Continue IRS coverage of 100% of households for two more
years. IRS would be progressively scaled back to eventually
only be used in outbreak control;
�� 100% of malaria cases treated with an ACT;
�� 100% of fever cases presenting in the public sector are
diagnosed for malaria;
�� 100% of pregnant women receiving ANC receive IPT;
�� Expand the Malaria Early Epidemic Detection System
(MEEDS) to all public health facilities.
Since Zanzibar’s strategic plan still has a goal of control and the
morbidity targets through the enhanced activity in the new grant
do not yet approach elimination levels, we decided to define
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sustained control (SC) on Zanzibar as the achievement and
maintenance of the objectives outlined above. While arbitrary,
these levels have been set by the ZMCP following careful
planning and are clearly at or near the threshold at which further
intervention would only be warranted if the goal were to fully
interrupt malaria transmission. Moreover, as the purpose of this
feasibility assessment is to help the MOHSW determine whether
to pursue elimination and therefore increase its activities and
investment accordingly, it makes most sense to use its current
plans as the baseline. This increased level of control activity
already entails substantially higher annual expenditure than in
recent years (the grant will provide an average of $2.7 million
each year), which it is important to consider when interpreting
the final analysis.
The most important activities under SC from both a programmatic
and cost perspective include the universal coverage with LLINs
(i.e., 80% usage) and the prompt and effective diagnosis and
treatment of malaria-related fever. IRS constitutes an important
proportion of the current budget (> 40%), but consensus has been
reached that plans will most likely only include full coverage of
IRS for two years, followed by three years of targeted spraying in
malaria “hot spots” (North B, Central and Micheweni districts),
followed by focal spraying of clusters if an outbreak is detected.
Other activities that currently contribute more modestly to
expenditure, but are important aspects of the program include
behavior change communication (BCC) and surveillance.
Surveillance activities under sustained control include seven
sentinel sites around the islands and the expansion of the Malaria
Early Epidemic Detection System (MEEDS), currently
implemented in 52 facilities, to all public health facilities. The
analysis of data collected from sentinel sites as well as the
collection and analysis of data gathered through a strengthened
HMIS are also costed as part of sustained control (these are
included under M&E). ZMCP objectives for BCC beyond
communicating the importance of early treatment with ACT
and continued usage of LLINs include increasing usage and
adherence to confirmed diagnosis.
The total cost of managing a sustained control program is based
on the detailed gap analysis and a costing exercise of these
activities, conducted by the ZMCP when preparing the Global
Fund proposal. The RBM Needs Assessment estimated the total
needs for the sustained control program to vary from $5 to $5.5
million between 2006 and 2014. However, this estimate includes
both universal coverage with LLINs and IRS, a scenario that is
neither recommended in the technical feasibility chapter nor
likely to be implemented in a sustained control program given
current conversations with donors. After the initial 2 years, when
IRS is no longer recommended, we deducted IRS from the total
estimated need. This resulted in an average cost of sustained
control of roughly $2.9 million per year, which was used as the
baseline against which to compare the costs of an elimination
program over the next 25 years.