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