By Elisabeth Wilhelm
Advocacy and Communications Officer, MACEPA and Global Health Corps Fellow
Mongu, the provincial capital of Zambia’s Western Province, is famed in the region for its fragrant rice, sand, and colorful annual procession of the Barotse Royal Establishment, the Kuomboka. It was also the setting for the province’s first-ever community malaria surveillance training, led by the Zambia Ministry of Health, National Malaria Control Centre, and MACEPA trainers.
Community surveillance—active investigation of confirmed malaria cases led by community health workers (CHWs)—began in Southern Province in 2013 as a way to further bring down malaria cases in the region, and the experience there informed the training of 178 CHWs and 40 Ministry of Health staff in Western Province in March, April, and June. Among the lessons learned in Southern that helped shape the training curriculum in Western was the importance of teaching IT trouble-shooting skills to district staff. Such skills reduce the need for people to travel from Lusaka to remote locations to fix malfunctioning reporting phones, without which, data on community cases goes unlogged.
The training was essential because, as Western Province’s malaria prevalence started to climb from 12.6 to 15.6 percent between 2012 and 2015, provincial health staff realized that a more focal approach to track down infections was needed to stem the tide. But building a large, fast, and accurate response system in Western Province will have its challenges. For starters, sand. White and very fine, it coats everything. In the rainy season it can suck 4×4 vehicles to a halt, making it difficult to reach all the health facilities in this vast landscape bordering Namibia to the southwest and Angola to the west.
The people and their movement patterns are different in Western, too. In a province that is 126,000 square kilometers big with a population just shy of one million—a third larger in area than Southern Province with roughly half the population—the major ethnic group, the Lozi, are cattle-keepers. They sometimes travel considerable distances to follow better farming or grazing, especially when the Barotse Floodplain is flooded by the Zambezi River from December to June. As a result, many people end up crossing national borders to seek healthcare, sometimes carrying malaria parasites with them and taking up scarce staff time and resources in small rural clinics when they fall ill.
Access to malaria interventions across Western Province varies widely. According to the latest Malaria Indicator Survey, 69 percent of all households in the province own one treated bednet, half of all children under five sleep under one, and roughly one out of five households received indoor spraying in the past year. In the southern part of Western Province below the Barotse Floodplain, malaria prevalence tends to be lower than districts to the north. All could benefit from a rollout of the “Step D” approach, training CHWs to test and treat for malaria in people’s homes. Step D is another title for community surveillance and is a critical piece in the government’s stepped strategy to eliminate malaria by 2020; the “D” stands for Detecting and Driving out parasites in communities.
The stakes are high. At the intensive, week-long Step D training of trainers in Mongu where the district staff gained the tools needed to teach CHWs to roll out Step D in their areas, the Acting Provincial Medical Officer, Dr. Muntanga Mapani, reminded them what failure looks like. “Our people are dying of a disease we can completely prevent,” she said. “Every Zambian child who dies cuts away from the future of Zambia so we need to do what we need to do to get rid of malaria.”
The initial blueprint for success is in place. In Southern Province, the Government of Zambia and MACEPA set up near real-time data sharing on malaria cases, diagnostics, and drugs at over 300 health facilities, and in communities more than 2,000 CHWs are now trained on Step D. Because of its success in Southern, the government was keen to roll out this free, in-home malaria testing and treatment to Western Province.
Strong coordination between CHWs, health facility staff, and the district is needed for Step D to work. Focal malaria information, sent weekly from clinics and monthly from community level reporting, informs strategic decision-making by district staff to tamp down on malaria flare-ups and ensure no stock outs of diagnostic tests or treatment. And while some of Western’s natural features pose challenges, committed health workers—chosen by their own communities for this important work—are well-positioned and now trained and armed to keep the province’s unique geography, culture, and people safe from malaria.