In recent years, Zanzibar, a semi-autonomous archipelago that is part of Tanzania, has made huge gains towards malaria elimination. Having a strong malaria surveillance system in place—defined as the people, procedures, and tools to generate information on malaria cases and deaths—is central to a countries’ ability to sustain progress and ultimately achieve elimination. In fact, surveillance systems are so important that the World Health Organization views them as a core malaria intervention.
As countries move toward malaria elimination, the tools for conducting malaria surveillance change. As transmission decreases, as has been happening in Zanzibar, malaria becomes isolated to certain geographic areas, and the intensity and frequency of reporting increases. In these situations, surveillance systems must evolve from reporting aggregate case data by month over large geographical areas (e.g., districts) to reporting near-real-time individual case data in small areas called foci.
RTI has worked closely with the Zanzibar Malaria Elimination Programme (ZAMEP) since 2006 to strengthen its malaria surveillance system, supporting the development of a case-based surveillance system (known as Coconut Surveillance), a mobile software app that district malaria surveillance officers (DMSOs) use on tablets to capture and respond to real-time cases at the facility and household level.
With funding from the U.S. Agency for International Development (USAID)-led U.S. President’s Malaria Initiative (PMI), we continue this work through the Okoa Maisha Dhibiti Malaria (OMDM)—Save Lives, End Malaria (2018-2023) Activity by promoting integration and local ownership of data systems and strengthening the use of malaria data for decision-making to move Zanzibar and Tanzania closer to elimination.
Here are a few of our takeaways from designing, implementing, and integrating these data systems.
1. Understand the ecosystem
When implementing technology on global health projects, we are big believers in (and endorsers of) the Principles of Digital Development. These are a set of best practices endorsed by 250 organizations for designing and developing digital technology in international development. One of these principles is to understand the ecosystem. To us, understanding the ecosystem means knowing what information systems are already in place and having a sense of the local capacity to use and maintain new systems.
In Zanzibar’s case, the Malaria Early Epidemic Detection System (MEEDS) is the original system that helped health facilities report aggregate case data through mobile phones, enabling ZAMEP to identify epidemic outbreaks within two weeks. In 2012, MEEDS was updated to support individual case reporting, but the malaria officers that would respond to reported cases still needed a systematic way to collect additional information and supply the exact geographic location of the case.
To fill this need, RTI worked with ZAMEP to develop Coconut Surveillance, an app that would run on the malaria officers’ tablets, collect all necessary data when they investigate individual cases, and guide them through an active case response protocol. For all of this to work, this app would need to be easy to use, work offline (as malaria knows no network coverage boundaries), and most importantly would need to be interoperable with MEEDS and the District Health Information Software (DHIS2), the main platform that the Ministry of Health uses to collect all public health data at the national level.
See the figure below for how Coconut fits into the broader malaria surveillance ecosystem in Zanzibar.