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

Abstract

BackgroundLow 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.MethodsThirty-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.ResultsIncidence 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.ConclusionsIn 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.

The economics of malaria control and elimination: a systematic review

“…In the Philippines declining marginal expenditures were observed from control to POR, where costs per PAR were more than halved [57]. Similar findings have been reported in three Namibian regions in a recent study published after the initial search was conducted [78]. In contrast, Ruberu’s analysis in Sri Lanka suggested that the high short-term cost of elimination is exceeded by long-term investments in control and the resulting consequences of productivity losses [46].…”

Moving towards malaria elimination: trends and attributes of cases in Kavango region, Namibia, 2010–2014

“…Furthermore, access to health facilities and malaria preventive measures are thought to be poor at most health facilities in Angola. 9 This underscores the need for neighbouring countries to work together to implement malaria control activities.…”

Individual- and Household-Level Risk Factors Associated with Malaria in Mutasa District, Zimbabwe: A Serial Cross-Sectional Study

“…23 Similarly in Namibia, the highest risk of malaria was found along the border with Angola, which is considered malaria endemic. 24,25 The increased risk of malaria transmission along international borders has been attributed to poorer access to health care, differences in malaria endemicity, the porosity of borders, frequent human population movement, and suitable climatic conditions for malaria transmission. 26 Interestingly, proximity to a health facility was not associated with malaria.…”

“…29 The movement of parasite-carrying individuals from the higher transmission setting of Mozambique may be undermining malaria control in eastern Zimbabwe, as suggested by studies in other countries where malaria resurgence has been attributed in part to frequent human population movement across international borders. 24,30 Regionally, several intercountry collaborations have been developed to address cross-border malaria, including the Lubombo Spatial Development Initiative between Mozambique, South Africa, and Swaziland, 31 the Trans-Kunene Malaria Initiative between Namibia and Angola, 25 and the Trans-Zambezi Malaria Initiative between Angola, Botswana, Namibia, Zambia, and Zimbabwe. 24 The success of these regional initiatives has been hampered, however, by lack of political will, limited funding, slow mobilization of resources, and poor coordination.…”

“…24 The success of these regional initiatives has been hampered, however, by lack of political will, limited funding, slow mobilization of resources, and poor coordination. 25,32 The strong relationship between malaria and proximity to the ZimbabweMozambique border provides yet another argument for the importance of regional collaborations in controlling malaria. Stronger intercountry collaborations will be especially important as malaria goals shift from control to elimination.…”