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GLOBAL HEALTH GROUP

Southern Africa - Country Support

The Malaria Elimination Initiative, in partnership with the Clinton Health Access Initiative (CHAI), leads the Southern African Malaria Elimination Support Team (SAMEST). SAMEST, comprised of a small team of management experts based in the region, currently supports the NMCPs in Namibia, South Africa, and Swaziland. Team members work with the NMCPs on a daily basis, contributing to the development of national and cross-border elimination plans, conducting baseline and gap assessments, identifying and resolving key bottlenecks, catalyzing rapid scale up of critical interventions, developing monitoring and evaluation frameworks, conducting operational research, and mobilizing critical resources, primarily through developing funding proposals and convening technical experts. The current objectives of SAMEST are to:

  • Ensure all malaria cases are effectively diagnosed and treated
  • Build robust surveillance systems to rapidly detect and respond to all malaria cases and to maximize the impact of key elimination interventions and increase resource efficiency

Botswana

Beginning in January 2008, SAMEST worked with the NMCP to support the development of Botswana’s elimination strategic plan and malaria advocacy and communications plan. Following the development of the elimination plans, SAMEST worked with WHO, UNICEF and Malaria No More, to support the NMCP in developing and implementing an innovative pilot bed net distribution program. The pilot program, which distributed over 38,500 long lasting insecticidal nets (LLINs), was designed to demonstrate that a door-to-door distribution with assisted net hanging and health education campaign could overcome barriers to usage of insecticide-treated bed nets in Botswana’s most vulnerable communities. The survey results indicate that providing direct assistance in the hanging of distributed nets and door-to-door health education visits had a measurable positive impact on the sustained usage of the LLINs.

SAMEST also managed the development and roll out of a pilot in Chobe District in northern Botswana at 16 health facilities to test the use of mobile phones as a potential solution to overcoming challenges to rapidly reporting, managing, and responding to malaria cases. Lessons from both pilot studies have been shared with other Southern African countries to support the development of practical solutions for LLIN distribution and surveillance and information systems in preparation for elimination.

Namibia

SAMEST support for Namibia launched in October 2008 with an initial assessment of the country’s malaria program. The assessment demonstrated to SAMEST and the Namibia NMCP that in order for Namibia to achieve its goal of elimination by 2015, the country required a system to identify precisely where and how much malaria transmission occurs, as well as sustained financial resources to implement elimination activities. Since then, SAMEST has partnered with WHO, the Malaria Control and Evaluation Partnership in Africa (MACEPA), the Malaria Atlas Project (MAP) and others to support the development of, and data collection and analysis for, Namibia’s first Malaria Indicator Survey, allowing the country to identify malaria transmission patterns.

Additionally, the Team has supported the development of Namibia’s Global Fund proposal to mobilize an additional USD $17.4 million for their elimination program, which launched a massive elimination advocacy campaign in 2010. SAMEST led and facilitated the development of a National Malaria Strategic Plan for Namibia for 2010 – 2016 to guide the transition of the country’s malaria control efforts towards an elimination objective. SAMEST is currently working to support the NMCP in strengthening its diagnosis and surveillance plans for malaria elimination.

The Team also supported the NMCPs in Angola and Namibia to develop a cross-border implementation plan for a malaria initiative between the two countries, the Trans-Kunene Malaria Initiative, which was launched on World Malaria Day 2011. As much of Namibia’s malaria transmission lies at its northern border, the TKMI will help Namibia eliminate malaria and will help Angola to control the disease in its southern regions and eventually develop a plan for spatially progressive elimination. Cross-border initiatives such as the TKMI are one of the main objectives of the E8.

In partnership with the Southern Africa Roll Back Malaria Network (SARN), SAMEST coordinated and facilitated the first TKMI Stakeholder meeting, held in August 2011. Priority joint action items were agreed on by Angolan and Namibian partners, focusing on synchronized vector control, operational research, joint training programs, and harmonized strategies to improve delivery of essential commodities and services. With support from SAMEST and partners including NetsforLife, the TKMI is increasing coverage of malaria interventions such as indoor residual spraying and insecticide-treated bed nets in the border regions.

SAMEST is working to support the NMCP in documenting their national and cross-border efforts to allow for other countries to learn from their experience.

South Africa

In 2009, SAMEST launched support to the South Africa National Department of Health (NDOH) for their goal to eliminate malaria by 2018. SAMEST has worked with the Malaria Directorate on proposal development, training, and cross border initiatives, and has supported the development of three critical documents to inform reorientation from malaria control to elimination: a malaria communications and advocacy plan; malaria elimination strategy for 2011-2018, and; a malaria monitoring and evaluation plan. SAMEST also undertook a comprehensive financial analysis to review past expenditure practices to inform more cost-effective financing of malaria in South Africa. SAMEST is providing direct management assistance to the national program as well as South Africa’s three remaining endemic provinces: Limpopo, Mpumalanga and Kwa Zulu Natal.

Swaziland

SAMEST launched support to Swaziland’s NMCP in 2008 through assisting in the development of a successful proposal to the Global Fund for a USD $13.9 million Round 8 grant. SAMEST supported the signing of the grant and then helped to develop Swaziland’s national malaria elimination strategic plan. SAMEST also supported the development and finalization of the country’s national malaria elimination policy – a first for Sub-Saharan Africa, which endorses the national strategic plan and convenes all malaria stakeholders around the central goal of elimination.

SAMEST is now supporting the country to implement the national elimination strategic plan and achieve its major targets. SAMEST facilitated the roll-out of definitive diagnosis for malaria cases through supporting the development of Swaziland’s National Malaria Diagnosis and Treatment Guidelines, providing guidance on rapid diagnostic test product selection, and helping to establish a National Malaria Diagnosis Quality Assurance Program. As a result of these efforts, Swaziland is working towards 100% confirmation of all suspected malaria cases. Additionally, SAMEST supported the establishment of a robust active surveillance program with the goal of investigating all confirmed cases within seven days of being reported. The Team supports the National Malaria Control Program to analyze surveillance data to inform strategies to reduce local transmission and prevent importation from neighboring high endemic areas.

In 2010, SAMEST supported the first-ever national malaria indicator survey in Swaziland, assessing remaining transmission and risk. In this study, the NMCP collaborated with the Malaria Elimination Initiative to pilot new approaches to assess transmission in low-endemic settings. A national cross-sectional study was conducted to characterize national prevalence of parasitemia and past exposure using two novel diagnostic methods, PCR-based pooling and serology. Compared to Rapid Diagnostic Tests, PCR-based pooling provided improved efficiency and diagnostic accuracy, and serological data lent insight into spatial and temporal trends in transmission. Results directly impacted program planning by the NMCP.

SAMEST is also working with the NMCP to document the success of Swaziland’s progress towards elimination and to share best practices with other malaria-eliminating countries.

Elimination Feasibility Assessments

In 2009 and at the request of the Minister and Director General of the Zanzibar Ministry of Health and Social Welfare, SAMEST provided significant support to the Zanzibar Malaria Control Program, to design and conduct a comprehensive assessment of the technical, operational, and financial feasibility of reaching and sustaining elimination on the islands. This feasibility assessment resulted in a series of evidence-based recommendations, and is the first robust analysis on the feasibility of elimination, therefore forming a strong foundation from which strategic decisions and programmatic shifts in Zanzibar can be made.

Following the first comprehensive assessment of the feasibility of malaria elimination conducted in Zanzibar, SAMEST, in close collaboration with University of Florida and Imperial College, is currently working with the World Health Organization Global Malaria Program to refine the methodology and to develop a framework, Elimination Scenario Planning (ESP), for how this type of assessment can be replicated in other countries that are interested in moving towards malaria elimination. ESP, an innovative tool built to support malaria programs make an evaluation of whether elimination or other reductions in malaria represent a feasible and appropriate goal by looking at three linked sets of considerations. These include:

  • Technical feasibility

    Is it technically feasible to achieve elimination within a given timeframe given the baseline level of malaria that occurs within a region? If not, what magnitude of reductions in malaria is technically possible? If so, what fraction of the population theoretically would need to be protected from transmission to achieve malaria elimination? What would technically be required to maintain elimination despite continued importation of infections from neighboring countries?

  • Operational feasibility

    Given real-world operational and administrative challenges, can the technical requirements for achieving and maintaining elimination be implemented? What additional operational requirements, particularly in terms of surveillance, human resources, and legal framework, will be required for elimination to be achieved and maintained?

  • Financial feasibility

    What will be the cost of achieving the operational requirements for elimination and sustaining them over time? Are sufficient funds available to pay for these requirements, and can sustained financing be secured over time?

The tool will continue to be refined based on pilot testing in target settings and broadly disseminated to countries worldwide.