A regional approach to malaria control – the LSDI success story
The Lubombo Spatial Development Initiative (LSDI) was a tri-lateral initiative between the governments of South Africa, Swaziland and Mozambique aimed at accelerating the agricultural and economical development of the Lubombo Mountains region which straddles the three countries. In sharp contrast to the richness in natural resources are the high levels of poverty and general lack of social well-being among the people of this region. Malaria was identified as one of the main threats to the success of the initiative, with large parts of this region classified as endemic or seasonally endemic, with a high prevalence of severe malaria caused by Plasmodium falciparum. The loss of productivity associated with malaria morbidity and mortality in conjunction with the high cost of treatment and control of the parasite and its vectors contributes to economic and social decline and lack of development in the region.
Considering the fact that neither the parasite, nor the vector is restricted by provincial or international boundaries, it was clear that malaria in the Lubombo region was not a problem that could be addressed in a country-specific manner. The need for a regional, intra-country approach to fight malaria lead to the establishment of the Lubombo Malaria Control Programme in October 1999 through the signing of the Malaria Protocol of understanding at ministerial level between the three countries. The purpose of the Control programme was to address cross-border issues of population, parasite and vector movements as well as the development and spread of vector and parasite resistance in the region. The main emphasis of the programme was to establish international collaboration towards sharing and developing of capacity for the co-ordination and implementation of effective vector and parasite control interventions at a regional level. The control programme was coordinated by the Malaria Research Unit (MRU) of the South African Medical Research Council (MRC) on behalf of the Regional Malaria Control Commission (RMCC) which was comprised of scientists, control experts and health specialists from all three countries. The RMCC met quarterly to ensure the progress of the programme and to address any issues.
The project was a show-case for successful Public Private Partnerships (PPP) in malaria control. The programme was initiated in 2000 with funding from private sector, with government contributions from 2003. The majority of funds for the programme from 2003 onwards were provided by the Global Fund to Fight Aids, Tuberculosis and Malaria, with additional inputs by various private and public partners.
With established and successful malaria control programmes functioning in South Africa and Swaziland, the focus of the LSDI malaria programme was extension of effective control into Southern Mozambique. This area is considered as an important reservoir and point-source for the re-introduction of malaria into areas where successful control measures have been implemented and is a significant source of imported malaria cases.
Malaria control in the LSDI programme was based on a strategic, two-pronged, approach aimed at disrupting the malaria transmission cycle. One leg was the implementation of effective vector control through indoor residual spraying (IRS) using insecticides approved by the governments of the individual countries. The other leg was effective case management by means of definitive diagnosis with Rapid Diagnostic Tests (RDTs) and reliable treatment using Artemisinin-based Combination Therapies (ACT’s). The combined use of RDTs and ACT’s assures appropriate treatment of patients where malaria have been ruled out, saves valuable resources, improves cure rates, decrease malaria transmission and potentially inhibits the development and spread of drug resistance.
An essential part of the case management arm was the routine surveillance for molecular markers of resistance to the first and second line malaria treatments. This surveillance was conducted as a means of detecting the emergence of antimalarial drug resistance prior to large scale treatment failures. The first line treatment of an artemisinin combination therapy, artesunate plus sulphadoxine-pyrimethamine (AS+SP) was adopted in 2002, and implemented throughout Maputo province by 2006. Due to the region-wide increased prevalence of markers for sulphadoxine and pyrimethamine, the first line malaria treatment in Mozambique was changed to artemether plus lumefantrine in 2008.
The development and successful implementation of a Malaria Information System (MIS) was central to the management and dissemination of malaria case data for management and research purposes. The MIS included a spatial component that makes use of Geographical Information Systems (GIS) that includes administrative boundaries, population, health facility locations, towns and other relevant information. The MIS was continually customised to minimise end-user skill requirements and to optimise access to different data sets. Input screens mirrored data collection forms and automatic-linking and drop-down lists minimised data errors. The MIS played a key role in the monitoring and planning of spraying activities by providing managers with information on both diagnosed malaria cases and vector control activities.
The implementation of control interventions in Southern Mozambique took place in a step-wise fashion through the delineation of malaria control zones throughout the region. Since the inception of the malaria control programme, malaria incidence rates in South Africa and Swaziland have declined from around 25% to less than 2%. In the control zones of southern Mozambique malaria prevalence in children between the ages of 2 and 15 years of age have been reduced from above 60 - 90% at the baseline surveys to less than 15% in all zones.
Although the initial objective was to extend and implement effective control measures into Maputo Province, which borders on Swaziland as well as KwaZulu Natal and Mpumalanga provinces in South Africa, the interventions was so successful that the project was extended to include Gaza province in Mozambique which borders on Mpumalanga and Limpopo provinces in South Africa. This brought the contiguous area under malaria control by the LSDI malaria control programme to more than 200 000 Km2.
An often over-looked success of the project is the capacity and infrastructure development that was realised through this project. In both provinces of Mozambique, LSDI malaria control offices have been set up in close collaboration with the local Provincial Health Departments. Local candidates have been trained and equipped to coordinate and manage the activities of the programme in the provinces with support from experts from South Africa and Swaziland. The provincial coordinators were supported by vector control officers, database managers and entomologists, all of whom have access to experts in the neighbouring countries to assist with their development and to ensure maximum skills transfer. As far as possible, training was provided when and where necessary. Annual training camps were held for spray operators before the onset of each spray round to ensure competency and consistency on the application of residual insecticides inside dwellings. Training was provided to all spray operators either as a refresher for previously trained spray operators, or as in depth training for new recruits. Training was also provided to healthcare providers to ensure the efficient implementation, monitoring and evaluation of rapid diagnostic tests and artemisinin-based combination therapies. During the annual prevalence survey at all sentinel sites throughout the control zones, programme staff and local health workers were actively involved after receiving the appropriate training. Over-all, the project have made huge strides towards malaria control capacity development in Southern Mozambique, and improving region-wide collaboration and co-operation in the fight of a mutual enemy.
Advancing into its final phases, the malaria control programme progressively integrated with the local Department of Health in Southern Mozambique. This integration followed a carefully developed plan that allowed for the systematic transfer of infrastructure and human resources into governmental health structures. The ultimate goal was to ensure continuity of successful malaria control activities in Southern Mozambique beyond the life-span of the project. The many lessons learned, and experience gained through this project is proving invaluable for the development and implementation of other regional initiatives in Southern Africa. Above all this project has shown that regional collaboration at an international level is not only possible, but is a highly effective tool in the fight against malaria in Africa.