Pretoria, August 2015 - WHO has called on the global health community to urgently address gaps in prevention, diagnosis and treatment of malaria. South Africa has a Malaria Elimination Strategic Plan (MSP) which aims to achieve zero local malaria transmission in South Africa by 2018. With WHO country office assistance, the Mid-Term Review was held to assess the implementation of the interventions, strategies and activities in the three year period 2012/13-2014/15 of the current MSP and to propose changes required to achieve elimination of malaria in South Africa by 2018.

An internal review was conducted followed by verification, discussions and recommendations by an external team from WHO’s Inter-country Support Team for East and Southern Africa. The internal review was conducted by an independent consultant who undertook field visits to each endemic province (Mpumalanga, Limpopo and KwaZulu-Natal), the non-endemic province of Gauteng and the National Programme to review their progress towards elimination. There were also interviews conducted with the main stakeholders including members of the South Africa Malaria Elimination Committee representing the main interventions such as case management, vector control, surveillance and health promotion.

Challenges

With respect to surveillance and monitoring and evaluation, currently there is no well-functioning system for notification of cases within 24 hours and therefore case investigation might be delayed. Malaria mortality audits are currently conducted. The yield of (pro) active surveillance is very low. The endemic provinces all have a Malaria Information System (MIS) that feeds into a national system, but this is not functioning well. GIS capacity for mapping is limited in KwaZulu-Natal and Gauteng.  Entomological surveillance capacity is limited, especially in KwaZulu-Natal and Mpumalanga, but partners are taking on several of the activities. There are some areas where larvaciding is conducted. The National Institute for Communicable Diseases is assisting with parasite prevalence surveys, insecticide resistance monitoring and drug resistance monitoring. Although epidemic thresholds have been developed at national level, these are not used in practice to inform the response. No malaria early warning system is currently in place.

Recommendations 

The recommendations/activities below should move the programme towards elimination from 2015-2018:

To reorganise the national & provincial teams/organograms for elimination: sufficient core technical staff, joint planning between national/provinces, sufficient resources.
Put in robust performance management plans for staff at NDoH and provinces.
Change the mind set towards elimination on all levels.
Conduct an annual national review meeting to address country challenges.
Costing (data) should be aligned to the activities in the strategic plan.
All reporting (provincial, national) should be aligned to the activities and indicators in the strategic and M&E plans, as well as to external reporting requirements.
Focus on sub-district/district phased approach to elimination. Prioritise activities accordingly in the provinces; identify the quick wins of some of the challenges that are identified in the SWOT analyses and monitor and track if they have been implemented.
Have a functional national malaria information system at NDoH including all relevant indicators for malaria elimination. Have a 24 hour reporting system in place linked to the MIS which stimulates outbreak response / 7 day case investigation.
Improve field detection of parasites through the introduction of e.g. Lamp/PCR and make treatment in the field possible. IV-AS and primaquine need to be registered for easy access.
Strengthen supervision and monitoring of indoor residual spraying management and implement additional vector control measures.
Increase funding and staff for health education on malaria elimination through health promotion. Conduct a KAP survey to inform messaging.
Integration with other units within NDOH (e.g. CDC, TB, HIV) and outside DoH (Tourism, Agriculture, Education), external partners (chiefs and traditional healers; private sector e.g. mining, agriculture; partners for technical assistance and operational research).
Strengthen cross-border collaboration to combat imported malaria.
The next step is to review the objectives and activities, align indicators to the objectives and make the relevant changes as discussed during the review. WHO will support by reviewing the final update of the strategic plan. The activities will be prioritized by the Department and WHO will support the quarterly review in order to track implementation over the next three years.