Abstract
BackgroundParts of Zambia with very low malaria parasite prevalence and high coverage of vector control interventions are targeted for malaria elimination through a series of interventions including reactive case detection (RCD) at community level. When a symptomatic individual presenting to a community health worker (CHW) or government clinic is diagnostically confirmed as an incident malaria case an RCD response is initiated. This consists of a CHW screening the community around the incident case with rapid diagnostic tests (RDT) and treating positive cases with artemether-lumefantrine (AL, Coartem™) in accordance with national policy. Since its inception in 2011, Zambia’s RCD programme has relied on anecdotal feedback from staff to identify issues and possible solutions. In 2014, a systematic qualitative programme review was conducted to determine perceptions around malaria rates, incentives, operational challenges and solutions according to CHWs, their supervisors and district-level managers.MethodsA criterion-based sampling framework based on training regime and performance level was used to select nine rural health posts in four districts of Southern Province. Twenty-two staff interviews were completed to produce English or bilingual (CiTonga or Silozi + English) verbatim transcripts, which were then analysed using thematic framework analysis.ResultsCHWs, their supervisors and district-level managers strongly credited the system with improving access to malaria services and significantly reducing the number of cases in their area. The main implementation barriers included access (e.g., lack of rain gear, broken bicycles), insufficient number of CHWs for programme coverage, communication (e.g. difficulties maintaining cell phones and “talk time” to transmit data by phone), and inconsistent supply chain (e.g., inadequate numbers of RDT kits and anti-malarial drugs to test and treat uncomplicated cases).ConclusionsThis review highlights the importance of a community surveillance system like RCD in shaping Zambia’s malaria elimination campaign by identifying community-based infections that might otherwise remain undetected. At this stage the system must ensure it can meet growing public demand by providing CHWs the tools and materials they need to consistently carry out their work and expand programme reach to more isolated communities. Results from this review will be used to plan programme scale-up into other parts of Zambia.
Highlights
Parts of Zambia with very low malaria parasite prevalence and high coverage of vector control inter‐ ventions are targeted for malaria elimination through a series of interventions including reactive case detection (RCD) at community level
Study site Choma, Pemba, Namwala and Kazungula Districts in Southern Province were selected for review because they represent three waves of community health worker (CHW) training, each with slight modifications to content and/or duration that might affect the ability of CHWs to carry out the programme and other implementation barriers (Fig. 1)
Key issues noted by programme staff as needing to be addressed prior to scaling up the programme include obtaining additional funding to expand the role of CHWs, addressing community concerns to increase local acceptance of CHWs to test and treat malaria, expanding marketing of the programme and improving coordination among the Government of the Republic of Zambia and its partners to better ensure an uninterrupted supply chain of essential commodities at the local level. Both integrated community case management and many disease-specific programmes in low- and middle-income countries rely on CHWs to reduce the number of maternal and childhood deaths in hard-to-reach communities [21, 22]
Summary
Parts of Zambia with very low malaria parasite prevalence and high coverage of vector control inter‐ ventions are targeted for malaria elimination through a series of interventions including reactive case detection (RCD) at community level. Of 106 countries and territories with malaria transmission in 2000, 102 have reversed the incidence of malaria [2], and 55 are on track to meet the roll back malaria and World Health Assembly targets of reducing malaria case incidence rates by 75 % by 2015 [1] Despite such progress, the 55 countries with decreases of >75 % in malaria incidence accounted for only 13 million (6 %) of the total estimated cases. The Zambian government with assistance from several partners is working to create malaria-free zones through a number of initiatives These include mass distributions of long-lasting insecticide nets, indoor residual spraying campaigns and effective case management at facility and community level. More novel approaches are being attempted under operational research to reduce community parasite reservoirs that remain in the presence of vector control methods, including mass test and treat or mass drug administration campaigns in areas of low to moderate transmission [6]
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