The nuts and bolts of cross-border malaria elimination

Trucks lined up at the DRC/Zambia border. PATH/Felix Masi

Trucks lined up at the DRC/Zambia border. PATH/Felix Masi

By Christopher Lungu, Monitoring & Evaluation Officer, MACEPA Zambia

Chirundu, Zambia, is a dusty border town nestled between dry Zambian hills and a sprawling Zimbabwean game area. Scores of trucks and crowded busses pass through here, waiting for hours—or sometimes days—to clear customs. Since Zambia is a landlocked country sharing borders with Zimbabwe, Malawi, Mozambique, Namibia, Tanzania, Botswana, DR Congo, and Angola, its roads are the lifeblood for trade and commerce. But they are also vectors for disease transmission, such as HIV and malaria. Zambia and all of its neighbors are malaria endemic, making cross-border transmission of malaria not just a national but a regional concern.

Cross-border malaria transmission can be a complex challenge for any country trying to eliminate the disease. Political borders mean nothing to parasites, but funding for ongoing malaria control efforts are often bound to them. Mosquitoes can travel up to three kilometers and people often cross borders for work, living in one country but working in another, complicating a malaria program’s work. In some areas of southern Zambia for example, clinics are often overwhelmed with malaria cases that may have originated in Namibia, Botswana, or Zimbabwe. Planning for vector control becomes less precise as well, as neighboring countries could be using different insecticides and drugs just a few kilometers from each other. Sometimes malaria programs don’t fully account for the transient nature of some populations, such as fishermen and semi-nomadic groups. A better way of tracking infections and halting them at the border is needed.

A truck drives down a dirt road past a village of grass-roofed huts in Zambia. PATH/Gabe Bienczycki

A truck drives down a dirt road past a village of grass-roofed huts in Zambia. PATH/Gabe Bienczycki

Cross-border malaria elimination requires cooperation with neighboring national malaria control programs, but different operational realities can make this challenging. Each country has a different health agenda, different geographies, different levels of malaria prevalence, and even different types of mosquitoes and malaria parasites to combat. Most major donor-funded projects are country-specific, operating on different funding cycles, implementing different control strategies and measuring success differently. Reconciling all of these competing and approaches is an ongoing process, as is finding a common way of measuring progress against commonly agreed benchmarks.

In March 2009, the Ministers of Health of several southern African countries met in Windhoek, Namibia, to found what would become the E8 (for Elimination 8): eight countries committed to working toward malaria elimination including Swaziland, Namibia, Botswana, Angola, Mozambique, Zimbabwe, South Africa and Zambia. Zambia has reprioritized cross-border elimination activities in the draft National Malaria Elimination Strategy 2016–2020 and has taken part in several of five regional cross-border malaria initiatives with its neighbors.

Since the inception of E8 in 2009, surveillance strategies for malaria elimination has become a key discussion area. A strong regional surveillance system that aggregates and feeds back evidence to inform targeted and evidence-based implementation was identified as a key strategic objective of the E8 partnership. Furthermore, the partnership identified the development of an E8 regional surveillance database as a key activity. This partnership holds promise for slowing and eventually halting malaria transmission across borders, and can strengthen each country’s malaria elimination efforts. In Zambia, the National Malaria Control Centre is the focal point or node for the E8 network, which has made strides in developing ways to measure progress in malaria elimination in different parts of the country. Zambia’s creativity and shoulder-to-shoulder partnership with Zambia’s neighbors will slow down and eventually halt cross-border malaria transmission and strengthen the region’s malaria elimination efforts.

UPDATE: In November 2015, the E8 provided a roadmap to eliminate malaria in southern Africa, with Botswana, Namibia, South Africa, and Swaziland projected to eliminate malaria by 2020. Angola, Mozambique, Zambia, and Zimbabwe expect to eliminate by 2030.

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