Namibia's path toward malaria elimination: a case study of malaria strategies and costs along the northern border

Abstract

Background: Low malaria transmission in Namibia suggests that elimination is possible, but the risk of imported malaria from Angola remains a challenge. This case study reviews the early transition of a program shift from malaria control to elimination in three northern regions of Namibia that comprise the Trans-Kunene Malaria Initiative (TKMI): Kunene, Omusati, and Ohangwena.

Methods: Thirty-four key informant interviews were conducted and epidemiological and intervention data were assembled for 1995 to 2013. Malaria expenditure records were collected for each region for 2009, 2010, and 2011, representing the start of the transition from control to elimination. Interviews and expenditure data were analyzed across activity and expenditure type.

Results: Incidence has declined in all regions since 2004; cases are concentrated in the border zone. Expenditures in the three study regions have declined, from an average of $6.10 per person at risk per year in 2009 to an average of $3.61 in 2011. The proportion of spending allocated for diagnosis and treatment declined while that for vector control increased. Indoor residual spraying is the main intervention, but coverage varies, related to acceptability, mobility, accessibility, insecticide stockouts and staff shortages. Bed net distribution was scaled up beginning in 2005, assisted by NGO partners in later years, but coverage was highly variable. Distribution of rapid diagnostic tests in 2005 resulted in more accurate diagnosis and can help explain the large decline in cases beginning in 2006; however, challenges in personnel training and supervision remained during the expenditure study period of 2009 to 2011.

Conclusions: In addition to allocating sufficient human resources to vector control activities, developing a greater emphasis on surveillance will be central to the ongoing program shift from control to elimination, particularly in light of the malaria importation challenges experienced in the northern border regions. While overall program resources may continue on a downward trajectory, the program will be well positioned to actively eliminate the remaining foci of malaria if greater resources are allocated toward surveillance efforts.

Figure 1

P. falciparum transmission and predictions of receptive Pf PR _2–10 . Map of Namibia showing the spatial limits of P. falciparum transmission and predictions of receptive P. falciparum parasite rate (for age range 2–10 years, or PfPR_2–10) at health district within the stable limits. The receptive risks were computed as the maximum mean population adjusted PfPR_2–10 predicted for the years 1969, 1974, 1979, 1984 and 1989 for each health district [13].

Figure 2

Malaria program organization. Within the Government Republic of Namibia Ministry of Health and Social Services, the National Vector-borne Diseases Control Programme is part of the Directorate of Special Programmes (DSP). At the national level, the program supervises malaria activities at the regional and district level, providing them with trainings and supplies for vector control. The Central Medical Store provides all medicines and clinical supplies required to carry out malaria case management. Regional DSP Programme Administrators and Environmental Health Officers organize and support activities at the regional and district levels.

Figure 3

Reported malaria cases from health facilities, 2001–2011. Source: Health Information System, MoHSS Note: Region populations for 2002–2004 were not available. Calculated by taking difference between 2005 and 2001 populations, dividing by 4 and adding amount to each year. Note: Based on regional names and boundaries as of July 2013. The selected study regions are shown in color. Neighboring regions are shown for comparison. PAR = population at risk; ACT = artemisinin combination therapy; LLIN = long-lasting insecticide-treated nets; RDT = rapid diagnostic test.

Figure 4

Malaria program expenditures in study regions, 2009–2011. PAR = population at risk; CLM = controlled low-endemic malaria; M&E = monitoring and evaluation. All figures are reported in 2011 USD. Note: Figures A, B, and C contain different scales in US$ per PAR.