Zambia’s Ministry of Health has been at the forefront of the fight against malaria, demonstrating early success in reducing malaria illnesses and deaths by rapidly scaling up delivery of proven tools to prevent and treat the disease. Now the country has an ambitious new goal: to begin work to end malaria transmission once and for all. PATH staff recently sat down with Dr. Elizabeth Chizema Kawesha (photo below) to discuss Zambia’s new strategy. Dr. Elizabeth Chizema is the director of Disease Control, Surveillance and Research, at the Zambia Ministry of Health.
Your early career started at the district level. How has that early experience shaped the national surveillance work you do today?
My interest in pediatrics began in the late 1980s when I attended medical school. I started my medical career in a peri-urban area called Kalulushi as its first district director of health. When I arrived, there were very few clinics and even fewer basic health services. To diagnose malaria, I had to send patients 20 kilometers away, which meant an additional financial burden to cover transport. Eventually, I was able to set up a lab for blood tests and other primary health care services. I went on to help improve primary health care in clinics at Kitwe, a larger district, before the government requested me to help with national malaria control efforts from the capital, Lusaka. I continue to remain focused on what works in the communities.
Zambia has demonstrated incredible country ownership for malaria control. Why did Zambia decide to take on this leadership role?
At one time, malaria was considered a “notifiable” disease in selected districts—meaning that the government received an alert about any case because it was an uncommon occurrence, thanks to investment in malaria control programs. But then the copper industry, a staple in Zambia, ran into difficult economic times, and the government decided to cut funding for some of the malaria programs. We learned the hard way that this only exacerbated our economic difficulties.
Beyond the devastating mortality due to malaria in children less than five years old and in pregnant women, morbidity due to malaria also takes its toll on the population. In Zambia, mining companies in the Copperbelt were seeing high rates of absenteeism, increasing rates of injury at work due to workers being weak from malaria, and higher costs in general associated with hiring replacement staff. As a result, many companies developed their own malaria prevention and treatment programs and documented their success.
The demonstrated success of these interventions in the private sector was part of the inspiration behind the Zambian government’s malaria programs. The Roll Back Malaria Partnership and PATH Malaria Control and Evaluation Partnership in Africa (MACEPA) were among the first partners who came on board to help strategically plan, followed by other partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria; World Bank; and President’s Malaria Initiative.
What does Zambia’s national malaria control program look like?
For preventing malaria, we focused on bednet distribution in rural areas and indoor residual spraying (IRS) in urban areas. In some homes we find both interventions, which we see as an encouraging sign that our coverage is thorough. Today, I am proud that we have achieved 75 percent coverage with bednets and IRS, but there are also new challenges to overcome. We need to invest in newer chemicals because of the parasite’s increasing resistance to existing ones. Currently, we are compensating for the resistance by spraying twice a year with shorter-lasting chemicals in some districts, rather than once a year, but we need to find a more cost-effective, long-term solution.
For treating malaria, we have also improved case management tools and practices. Previously, we reacted to every fever as malaria, but with new rapid diagnostic tests, we can make more informed decisions.
One of our most successful programs is preventing malaria in pregnant women by distributing malaria medicines during pregnancy. We’ve seen a remarkable drop in maternal mortality numbers from malaria.
What are the next steps for malaria control in Zambia?
Before we scaled up these malaria control interventions, we couldn’t even talk about elimination. Now, thanks to our government and partners’ commitment, it is possible.
We’ve conducted four national malaria indicator surveys that show transmission rates high in certain areas and very low in others. We decided on our vision of national elimination of malaria, starting in the successful pockets to wipe out malaria completely, zone by zone. Our goal is to create five malaria-free zones by 2015. With MACEPA’s support, we will implement the three-step approach to clear away the parasite in asymptomatic individuals and quickly identify the source of the problem when we find a case of malaria.
Why should donors and policymakers invest in malaria?
So much has already been written about the economic benefits of malaria control, and in Zambia we’ve seen it firsthand. In Africa as a whole, US$12 billion is lost every year due to malaria. If we defeated malaria, that $12 billion could be freed for many other things; for example, it could strengthen health systems to prevent other diseases.
As you know, the theme of this year’s World Malaria Day was “Invest in the future; defeat malaria.” What is the one ask you would make of the global malaria community as we aim to accomplish this goal?
I would say that now is not the time to stop. In fact, now is the time for those who are not part of the malaria fight to join in, because we are making progress. Malaria is preventable and treatable, and it is money well-spent.
I would also like to express my gratitude to all the partners. I appreciate their efforts to help us document best practices, develop strategic plans, and openly communicate with country governments. Our success is contingent upon their unique and complementary roles and perspectives.