The Global Elimination of Lymphatic The Story of Zanzibar

WHO/CDS/CPE/SMT/2002.15 ACKNOWLEDGEMENTS

The lymphatic filariasis (LF) elimination programme in Zanzibar is the story of the hard work and commitment, primarily of the people of Zanzibar. This document is an attempt to portray the dedication of the many people who were convinced of the importance of the LF programme and made the campaign a success. WHO is indebted to those who are mentioned within the pages of this publication, and also those not mentioned who nevertheless saw a vital role for themselves in making a difference to the health of their communities.

This publication has been made possible by a contribution from the Bill and Melinda Gates Foundation.

© World Health Organization 2002 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. The Global Elimination of Lymphatic Filariasis The Story of Zanzibar

WORLD HEALTH ORGANIZATION WHO Tanzania Country Office

WHO AFRO Regional Support

WHO HQ Social Mobilization Team (CPE/SMT)

WHO HQ Country Technical Support Team (CPE/CEE) Contents

Letter from the WHO LF Support Team (HQ) 4 Lymphatic filariasis and the strategy for its elimination 6 Living with lymphatic filariasis 8 The partnership 9 Zanzibar profile 11 What is the value of eliminating LF? 12 The plan 14 The cost/value calculation 16 Personal sellers 18 Whose campaign is this? 20 Supporting the personal sellers 21 Radio script 23 The best laid plans... 24 Decision to postpone or continue 26 Politics 28 The vital link 30 F-Day 32 The Mop-Up Day 35 Keys to success 36 Partnerships: thinking global... and acting local 38 The future 40 Letter from the WHO LF Support Team (HQ)

Zanzibar was a challenge. Almost everyone in prevalence of LF parasite in the country is one Zanzibar, nearly a million people, needed to be of the world’s highest. Around 15% of people convinced that they had to swallow free but carry the parasite. In some villages, infection potent drugs. And they all had to do it on the rates were well over 30%. The social environ- same day, Saturday, 27 October 2001. It would ment also presented special challenges to a be one of the largest mass drug administrations drug distribution programme. Prior to October, ever attempted. And if it worked, then 27 research revealed the presence of widespread October would be the beginning of the end for misconceptions about LF — that the disease the stigmatizing and incurable was caused by witchcraft or eating green coco- known as lymphatic filariasis (LF), the world’s nuts. Once the campaign was launched, second leading cause of disability. And with the rumours began circulating that the free tablets elimination of LF, , the disfiguring were a form of birth control or had disease caused by the filariasis parasite, would unknown side-effects. If this wasn’t enough, vanish over time as well. logistical and financial problems arose that threatened to sink the entire effort. In fact, the No longer would people be anchored in life by drugs themselves arrived in Zanzibar too close giant legs or other horrors of the disease. to 27 October, "F-Day".

If the majority of the population did take the What follows is the story of the LF campaign in drugs once a year for at least five years, then Zanzibar. It is one of the most unusual health would essentially be stopped. campaigns ever. The risk was that if the target was not reached, the exercise would largely be a waste of time, In Zanzibar, we were reminded again that effort and money. WHO is a technical agency. We supply, primarily, expert advice. But no matter how good our The challenges in Zanzibar were enormous and, advice is, if a health campaign is to be success- quite frankly, more than we expected. The ful it is because thousands of ordinary people

4 work very hard to improve the health of their neighbours. It is also because a few people, like senior political and religious leaders, com- mit themselves in a public way to personally improving the nation’s health. These personal commitments were abundant in Zanzibar. So, although the programme did not go entirely the way it was planned, the success was more than was hoped for.

Given all the frantic activity and eventual success in Zanzibar, we should not lose sight of how special this moment is. After 4000 years of physical and psychological suffering inflicted by LF, we now have the tools to eliminate this disease. If nations seize this opportunity with vigour and commitment, in the way that Zanzibar did, we not only can put an end to this terrible affliction, but also can break the chains that have bound millions of people to poverty. Zanzibar shouts at us that this can be done. But it can be done only if we work hard, work in partnership and, now with the example of Zanzibar, work with the certainty that we all can make a difference.

5 1. The vector 2. Microfilariae Lymphatic filariasis 3. Adult worm and the strategy for its elimination

M ore than 120 million A thread-like worm causes the disease reproductive organs and lower limbs people are infected with the lymphatic that is spread by mosquitoes. which are characteristic of hydrocoele filariasis parasite. The lives of 40 mil- LF parasites are found in more than and elephantiasis. lion people are limited and disfigured 80 countries around the world, which by the disease. For them, there is no means that 1000 million people are at As this process of destruction conti- cure. The remaining 80 million infected risk. nues, the mature worms produce off- people risk the same fate. These spring. It is these immature parasites people have impaired immune systems Efforts to eliminate the disease began (microfilariae), which circulate freely in and are at risk of developing the gross with an understanding of the parasite the blood, that are picked up by a deformities. itself. Once injected by the mosquito and passed to the next into a human victim, the adult worm person. The efficiency of transmission Lymphatic filariasis does not kill, but lives for several years, producing is quite low in LF. One bite from a in most countries of the world it millions of immature worms called -carrying mosquito can trigger inflicts an enormous physical and microfilariae. The worms can lodge in the disease, but it takes several hun- psychological destruction. LF hits the , a network of dreds of bites to infect someone with hardest among the poorest people nodes and vessels that delicately LF. Once the infection is established, and, because its victims are rendered regulate the fluid balance between the the cycle continues endlessly, from unable to work, they are shackled in tissues and blood. Damage to the person to person, forever. even more desperate poverty. lymph system causes the swelling of

6 Young boy with LF (elephantiasis)

No drug exists to cleanse the body of The theory was so sound that in 1997, all the adult worms, but some WHO committed itself to eliminating veterinary drugs were known to block LF. the reproduction of the parasite. Scientists established that the co- The Chinese validated the concept administration of these drugs was safe when they mixed one of the drugs, and effective in humans. In fact, (DEC), with This saturation level would need to be a single dose of the drugs blocked the ordinary table salt and distributed it maintained year after year for production of microfilariae for a year. to the population. Over a period of the level would need to be maintained time, LF disappeared. China, however, for the entire reproductive lifespan of These findings sparked enormous was a unique situation. Elsewhere, the worm. But when the last adult interest because they suggested a workers do not have worm died in the last infected person, public health strategy that could such direct influence over a popula- the mass drug administration could be eliminate LF. In theory, if the drugs tion. Another approach was required, stopped, and LF would be eliminated. could block the creation of the young and subsequently WHO developed microfilariae in an infected person, the mass drug administration (MDA) The challenge is in implementing such they would not be available to be strategy. a large-scale intervention. It is not sucked up by mosquitoes. This would known whether such a large stop transmission. And if the microfila- MDA is built around dosing entire percentage of a population – both riae were blocked year after year, until populations at risk with LF drugs once those infected and not – could be the mature parasite lived its full five a year for five years. To be successful, convinced to commit themselves to years of reproductive lifespan, the risk it requires that a substantial propor- take drugs, with potential minor side- of LF would evaporate. tion of a population participate for at effects, for so many years. least five years.

7 Living with LF

Jaku Hassan Ali is a fishmonger and estimates he is about 65 years old although he is not certain. He has had elephantiasis since he was a child and believes he acquired the disease while playing in muddy water.

Today, his left leg is enormous. His toes, which stick out from the folds of his leg, are the only visible sign of feet. His pants are cut off above the knee and ripped through the crotch to accommodate the leg. A doctor recently advised him to have his leg amputated, but he declined because he needs it to ride his bicycle.

Does he feel depressed?

- "No," he says. "This is God's plan. It is from God, so I will endure it."

Jaku is one of the lucky ones, he has managed to support a wife, raised a family and now has grandchildren.

For many others, LF has a devastating psy- chological, economic and social impact. According to Kassim Ali, a community health nurse: "They have shame to walk among the people. Working is reduced. Wounds make offensive smell. People tend to isolate themselves."

Jaku Hassan Ali

8 The partnership

The theory of LF elimination was Another pharmaceutical firm, Merck & The Bill and Melinda Gates given a chance to prove itself in 1998 Co. Inc., which was providing its drug Foundation provided enough seed when the pharmaceutical firm (Mectizan”) to help control money to the Alliance to prove whe- GlaxoSmithKline (previously known as river blindness, announced that it too ther or not mass drug administration SmithKlineBeecham) offered to donate would provide its drug in African could work. its product , which in countries where the two diseases exist association with DEC or ivermectin side by side. When nations are committed to elimi- will prevent the production of new, nating LF by working with the Global young worms. The pharmaceutical The agreement between WHO and Alliance, they establish new synergies. company pledged, and reaffirmed its GlaxoSmithKline attracted the support This partnership generally includes commitment in a Memorandum of of dozens of governments, universities, some members of the Global Alliance, Understanding with the World Health UN organizations, international deve- primarily WHO and the drug compa- Organization, to provide albendazole lopment agencies, NGOs and philan- nies, but it is always directed by the for as long as it was needed. And it thropists. They decided to join forces country concerned. would be free. This would likely mean to work towards eliminating LF.This donating 4 to 6 billion tablets over 20 public–private partnership is known as Zanzibar did this and WHO decided to years. The London Financial Times cal- the Global Alliance to Eliminate use the Gates Foundation funds to run led it "the biggest single act of corpo- Lymphatic Filariasis. the programme. Thus, Zanzibar beca- rate philanthropy in any industry." me a high-profile test of the strategy for LF elimination.

9 The government of Zanzibar is part of the United Republic of Tanzania. It lies 6o south of the equa- tor, 35 km across the Indian Ocean from the mainland. Almost a million people live in Zanzibar; they are pre- dominantly Muslim, with a rich Swahili culture. Once the world’s largest pro- ducer of cloves, the islands today attract tourists from all over the world. These visitors enjoy the white sandy beaches, an abundance of coconut palms, emerald green coves and a kaleidoscope of underwater life. Zanzibar is home to the rare Kirk’s Red Colobus monkey, which has its own protected crossing on the main north-south highway, and a wide variety of birds and butterflies.

10 Zanzibar profile

It was also the home of Freddie clinics throughout the islands, and sensitized the population to large- Mercury (born there on 5 September health issues, including LF, have been scale public health efforts. But nothing 1946), the lead singer of the band debated in the country’s House of that depended on the cooperation of Queen. Representatives. The country has parti- so many people on a single day had cipated in a number of national health ever been attempted in Zanzibar. The archipelago consists of the two campaigns including immunization main islands of Pemba and Zanzibar, programmes and a programme to and a collection of smaller, mostly control and soil-trans- uninhabited islands. Zanzibar Island mitted helminths. But the country is Pemba (known locally as Unguja) is 60 miles also familiar with broad, international long and 20 miles wide. The largest health efforts that have failed, inclu- city on these 650 square miles is ding one against malaria. Drug-resis- Zanzibar City with 100,000 inhabi- tant malaria is in Zanzibar. tants. Stone Town, famed for its grand Consequently, people in Zanzibar were

Arab houses with richly hand-carved already accustomed to large-scale Indian Ocean wooden doors, has been designated health campaigns. by the UNESCO as a "world cultural heritage site". In a sense, Zanzibar is ideal for mass Zanzibar (Unguja) drug administration. It has rigid boun- In public health terms, Zanzibar has daries. The public health system is an extensive infrastructure of health strong and previous campaigns have

11 What is the value of eliminating LF?

When people were first told about saved from the disease. Also, funds now the free drug programme for LF, used by the Ministry of Health for LF will they often asked: "Why are you giving be freed for other pressing public health us drugs for this when malaria is needs. killing us?" As the LF campaign in Zanzibar unfol- Indeed LF does not kill suddenly, but ded, it became clear that the implica- it kills slowly, gradually reducing life tions of ending LF extend far beyond expectancy. And while it has been public health. shown elsewhere to inflict a drain on that nation’s economy amounting up to Political leaders in Zanzibar acknowledge $1 billion annually, in Zanzibar only that if LF is pushed out of the islands, anecdotal reports link LF to erosion of faith will be revived in health initiatives personal income. based on collaboration with internatio- nal agencies and commercial donors. Still, ending LF will have important Also, the LF campaign could help to instil benefits to the country’s health system. a medically-based sense of why disease The most obvious is that children will be develops and how it can be cured.

12 "It has a social value," says Dr H. Principal Secretary of Zanzibar’s Ministry Nyanga, the zonal medical officer for the of Health and Social Welfare. "They will Island of Pemba. "We would like to get come to conclude that government is rid of the idea that filariasis is a result of more caring of them." witchcraft. We would like to eradicate that idea. It is a belief that affects other Faith in government. Faith in internatio- diseases as well, such as cerebral mala- nal health campaigns. Faith in medicine. ria and strokes. If we eliminate this idea, More funds for other diseases. Healthier we will have more hospital attendees. children. And a more robust economy. People will be coming to the hospital All this and more is riding on the LF instead of going to witch doctors." campaign in Zanzibar.

And if the Zanzibar government is able to put an end to LF, it could also help rebuild the people's faith in their government."If it works, it will show the people that government takes care of their health," says Omar Mussa,

"If it works, it will show the people that government takes care of their health,"

Omar Mussa, Principal Secretary of Zanzibar’s Ministry of Health and Social Welfare. 13 Zanzibar Airport The plan

Never before had a health To persuade people to take the medi- campaign ever attempted to motivate cine requires a well-informed public. nearly a million people to participate, But LF experts in Zanzibar warned that by personally swallowing tablets for a there were long-held and widely belie- disease they may or may not have. ved misconceptions about the disease. To do that, people would have to be For example, a substantial number convinced that the disease was a risk believed it resulted from witchcraft. for them and their families. They And many people thought that would also have to believe that the elephantiasis of the legs and of the drugs, which have potential minor genitals were two different diseases. side-effects, would be effective and safe. To help develop a social mobilization plan, WHO sent two social mobiliza- "This is more difficult than curative tion experts to Zanzibar in late June medicine," said Dr. Hyanga Nyanga, 2001 to work with the local the zonal medical officer for the island authorities. One of the advisers had of Pemba. "If somebody is not sick originated a marketing strategy for and then you tell them to swallow promoting health behaviours known drugs, they will not be willing." as COMBI (Communication-For- Behavioural-Impact).

14 One of the markets in Zanzibar.

The other adviser had experience The campaign consisted of many Zanzibar was not 900,000 but using the COMBI approach for a tasks, each of which needed to be 800,000 persons. This meant that to campaign in her homeland of performed in the right sequence and protect the entire population, LF drugs “Somaliland”. at the right time. If it worked, it would had to be taken by all of the eligible be a human symphony. A big failure population. The LF campaign would COMBI begins with an intimate could capsize the project. If the cam- have little room for error. appreciation of the "customer". At the paign failed to get enough people to heart of COMBI is an intimate unders- participate then the size of the remai- A lot would be riding on the success tanding and appreciation of the ning reservoir of infected people of COMBI. perspective of those who will benefit would be too large to interrupt the from the programme. That is what’s cycle of transmission. The campaign Zanzibar was split into 10 operational different about this. COMBI also would fail. units. A team of four people headed identifies the barriers and constraints by a District Supervisor were respon- that may prevent people from taking One of the complications facing the sible for planning, implementation and up the treatment. planners was that not everyone would co-ordination of the campaign for be eligible to take the drugs. About their districts. Zanzibar’s health, media and govern- 100,000 people would be unable to ment officials working with WHO staff participate. They included the very The highly populated urban areas, and consultants, designed a broad young and very sick, pregnant women including Stone Town, were further social mobilization campaign. and women in the first week of split into three zones. lactation. So the target population in

15 The cost/value calculation

To better understand their custo- Unless people felt a personal risk, it child which has a greater urgency mers, the WHO social mobilization would be hard to motivate them to than the risk to oneself. Moreover, in advisers began what they called take the drugs. Many people did not countries where the polio campaigns "walking around research". They tra- know that LF came from mosquitoes. were operating, polio was a visible velled to villages and talked with lea- With this understanding, the WHO risk. Everyone was aware of it, and ders, knocked on household doors and team met with members of the aware that his or her children were at asked to chat. One of them met ministries of health and of education, risk. Consequently, because the risk people while jogging, and they also and began to outline a potential was perceived as real and a risk to interviewed taxi drivers and campaign. their children, the "cost" (time, effort, restaurant waiters. They studied the money) of going to a health centre culture, politics and history of Zanzibar An initial proposal suggested establi- was low. and what people knew about the shing drug depots, like those that had disease. While they found there was a been used in the polio The cost/value calculation for LF was general awareness about the disease, programme, where people could go to just the opposite. The value of the they also found something that was get their LF drugs. WHO advised that drugs was already perceived to be low deeply troubling. "I didn’t get a sense this would not work. According to the since most people felt they were not that people felt they were at risk of COMBI theory, individuals made deci- at risk or they could avoid the risk the disease," recalls one of WHO’s sions based on "cost versus benefit" altogether by not eating green coco- advisers. calculations. Distribution centres had nuts or taking other preventative been a success in the polio campaign, steps. The "cost" of acquiring these but with polio the risk was to one’s drugs would be high if people were

16 Discussions with villagers in Mkunguni Kizimkazi Health Centre

required to leave home. The high disease was caused by parasites The people of Zanzibar had to coverage threshold would not be delivered in the bite of a mosquito, understand that the drugs could kill reached, the WHO social mobilization that it could lie dormant for years, the parasites but in order to protect experts said, if it relied on drug that the disease was incurable when the entire community, everyone had depots. it appeared, and most importantly to take the drugs. that everyone was at For the LF campaign to succeed, the considerable personal risk. perceived cost had to be lowered. WHO advised and the Zanzibari authorities agreed that delivering the free drugs directly to the home would entail the lowest possible cost. With home delivery, the only need was to Staff at Kizimkazi Health swallow the tablets. Centre, headed by Mr Kasim Ali, Community Health Nurse. In addition to lowering the cost, the campaign needed to increase the Also present are perceived value of the drugs. The Mr Khalfan Mohamed, government/WHO team decided that LF Programme Manager, and Mr Mohamed Mkenga, LF information had to reach into the Acting Director for Health home. People had to know that the Education Unit, MOH

17 Personal sellers

build giant corporations including but also in how to communicate with Hoover and Avon. Similarly, the FPAs others in their homes. They had to be would play the most critical role in the able to engage people inside the LF campaign. homes they visited.

Zanzibar’s personal sellers had to be So, as part of the design of the special. People taking the drugs had training programme, the FPAs were to to have confidence that the drugs participate in role-playing exercises. were safe and effective, and that, in This would help them understand turn, depended on the confidence they what a customer might be thinking. would have in the drug distributors. In fact, half their training was To establish trust, they had to be seen designed to be in repeated role- Delivering the tablets to the as a neighbour but more than a playing exercises. home would require thousands of neighbour. They had to be of good people. A quick calculation revealed character, respected in their communi- Finally, they had to be identified as a that if one person was to reach 50 ties and committed to eliminating LF. part of the LF campaign with LF homes in one day, then the campaign The FPAs also had to be knowled- badges, tee shirts and caps. And they would need to recruit and train 3,000 geable about the drug and disease, would be supplied with tools for their Filaria Prevention Assistants (FPAs). which meant they had to be trained, work including tape measures (since The FPAs were like the door-to-door and trained not only in the technical the number of drugs given was based "personal sellers", who have helped aspects of the disease and the drug on a customer’s height) and note-

18 “I am happy to protect my people from this disease.”

Issa Hassan Haji, age 20 Filaria Prevention Assistant. Kiembisamaki, West District

books to record who participated happened, they said, it would mean (vital for validating the total number the drugs were working to clear the of participants). For nearly a week’s parasites. Mostly importantly, the FPAs worth of work, the Ministry of Health would listen and respond to the decided the central players in this concerns of their "customers". programme would be given the equivalent of US$16 for food and On the second visit, two weeks before transportation. This would consume F-day, the FPA would go over the nearly half of the campaign budget. same messages, give each family member a pencil with the F-Day logo The third visit, on F-Day, would be to The FPAs would make three visits to and date as a reminder, and show the deliver the drug and leave behind a each home. The first visit, three weeks tablets. Showing the tablets was small flag to display to the community before Filaria Day or "F-Day", was to important so that people could see that this household had played it’s establish a bond, to register eligible and hold the tablets they would be role to keep everyone healthy. family members and explain the taking on Filaria Day. On this second purpose of F-Day. They would inform visit too, the FPAs would inform those people that everyone would need to in the home that each FPA would be take the tablets every year for the next required to watch each person five years. They would also talk about swallow their tablets, as well as possible side-effects like headache or answering any questions or concerns. pain in the stomach or genitals. If this

19 Whose campaign is this?

The World Health Organization supplied technical assistance, negotiated with pharmaceutical companies to have the drugs provided without cost, and channelled the Gates Foundation’s donation to finance the project.

Beyond that, this programme belonged to Zanzibar.

This is an important key to success. It helps explain why the LF programme team worked far into the night to overcome the obstacles that arose. And it explains why thousands of drug distributors visited 50 to 90 homes time and again, even when the reception was sometimes hostile.

"They were motivated," says Zanzibar’s Principal Secretary of Health, Omar Mussa. "They felt this project was their own. It was not owned by WHO. This was our project."

And the benefits, including building a stronger relationship between the government and the governed, are Zanzibar’s as well.

20 The banner reads:

Fight the disease of filaria and the in Zanzibar on the 27th October 2001.

Remember that anyone can get filariasis. To get rid of it, take the tablets.

Supporting the personal sellers

The messages delivered by the that they had done this, the parents FPAs during the home visits could be were to sign the fact sheet and the reinforced by the media, advised the student would return it to the teacher. WHO consultants. A series of radio, and television messages was planned. The plan also established two "Filaria The campaign also called for banners Prevention Riders Bicycle Touring to be stretched across roads and Teams" for the country’s two main dangled from lamp-posts. The COMBI islands. Each team, comprising ten advisers said that for new product riders, would be dressed in orange, the introductions to be effective, the F-Day colour. The teams would circle consumer had to be hit with a pro- each island, stopping in as many duct-related message about six times villages as possible where they would a day. That would be the goal for the be greeted by local political leaders, Zanzibar campaign. called Shehas, and the religious leaders (Imams). The riders would Schoolchildren would provide a mingle with the audience and conduit to funnel LF messages into distribute F-Day information sheets. the home. Teachers would distribute They would also answer questions LF fact sheets to students, and the about the drugs and side-effects. With students would be required to read luck, the media would print and the material to their parents. To verify broadcast reports about the rides and

21 Community Meeting: Mchangani shehia

thus deliver another LF message into broadcast the news of Zanzibar’s the home. President swallowing the tablets himself. A lottery was also included in the

Mrs Riziki Selele plan. During the second home visit of Not to be announced, but still part of District Supervisor, Urban West District the FPAs, residents would be allowed the strategy, was a "mopping up" to enter their names in a lottery. Those day, on the day following F-Day, to get selected and their FPAs would receive at those people who had somehow prizes of donated colour television been missed. sets, bicycles and mopeds. That was the plan. It was built around Closer to F-Day, a new series of events personal sellers who were backed by a would be launched. The village broad advertising campaign, commu- political leaders would be asked to nity leader involvement, promotional spread the LF messages at community incentives and intense media meetings. Imams would be asked to coverage. include a mention of the programme as part of their sermons in the mosques on Friday, the day before F-Day. Sound trucks would announce that F-Day had arrived. And on F-Day itself, radio and television would

22 Radio script

"LF is endemic in our country. Everyone is at risk. Our health workers will come to your home with the About 15% have the parasites, worms, which are pills, which will destroy the worms that cause Filaria. transmitted from one infected person to another by These pills are free. They are usually very expensive, mosquitoes. You know the problems of the disease. but the World Health Organization is making them Once you have the disease there is no cure. These available to us free. They are small tablets, easy to worms in the body cause the disease, and the worms swallow. Yes, like every drug you take, some people can exist in your body without any effect on you for may have some side-effects such as headache and years. You will be as normal as everyone else, even nausea. These are all temporary and will go away. with the worms in you. But a person infected with the People who are infected with the worms will proba- worms will most likely get the first signs of filaria in bly experience more of the side-effects as the drugs about five years or longer. If we kill these worms, then begin their effect of killing the worms. Everyone must we don’t get the disease...We should assume that we join in taking the pills. If only some do, the mosqui- all have the worms in us. If we can eliminate all the toes can still transmit the worms from the infected worms in everyone in our community, then we can who did not take the pills to those who did take the get rid of the disease. We have the drugs to do just pills. this. For adults, just four tablets taken once a year for On Filaria Day, welcome our health workers, take the five years will destroy the worms, which cause Filaria. pills and swallow them. Protect yourself and your "The Ministry of Health will begin a campaign to family and your neighbours from the disease of Filaria eliminate Filaria on 27 October. and destroy the Filaria worms."

23 The best laid plans...

The WHO advisers had finished the participants, the dangle banners and, most difficult part of their work and most importantly, the lottery. left the island. Now it would be up to the people and government of Government officials would later Zanzibar to discuss, adapt and execute explain that the nation had just the plan, with continued support and finished an intense political campaign advice from the WHO team. that did not use any of these promo- tional activities. What, they asked The COMBI plan had been developed themselves, would people think of by members of the Zanzibar communi- such an extravagant effort to provide ty, staff members of the Ministry of tablets to them? The officials worried Health, and the technical advisers that such an intense effort might itself from WHO. Senior government officials create suspicion. ("If the programme endorsed the plan, but dropped some was so good, why spend so much of the proposed activities. effort?") And they didn’t want to confuse a health campaign with The areas dropped were thought of as political trappings. the "glitter" components of the plan. They included the cycling tour, the flags to be hung from houses of

24 Finally, they thought that several of the funds lagged behind the need Perhaps most threatening of all, with aspects of the plan would produce a to fund activities as F-Day rapidly less than two weeks to go before festive atmosphere rather than approached and the budget break- F-Day, the drugs had not arrived. sensitize people to fight an unpleasant downs submitted were not detailed Actually, they had been transported to health situation. enough. The system was also jammed Dar Es Salaam, but they were held when estimates for printing posters there for a month. When the shipment More threatening was bureaucracy. seemed to be extraordinarily high. was finally cleared, the drugs were put Typically, requests for funds are pas- Dialogue, cooperation and on a boat for Zanzibar. But when the sed through a series of intermediaries transparency between WHO and the regular ferry arrived, no drugs were on from the country to WHO headquar- Ministry of Health has since ensured board. In fact, the drugs had been ters in Geneva; the money itself flows that a new system is in place which sent on another boat and when no through these same intermediaries promises clarity and speed in financial one claimed them at the dockside, from Geneva back to the country. The accountability. they were returned to the mainland. system of accounting procedures is More telephone calls followed, and designed to prevent abuse and waste, For a time, the LF campaign was the shipment finally arrived in and those involved in financial matters unable to purchase anything. Just Zanzibar to be claimed the following (WHO and counterparts) need to have three weeks before F-Day, there were day, just 11 days before F-Day. an understanding and comply with no posters, banners, tee shirts, badges, these procedures. In this case, the flow or balloons. And the FPAs were also left without the tools they had expected.

25 Decision to postpone or continue

When one of the WHO advisers A bigger problem was the impact on by distributing the information sheets returned to Zanzibar in early October, the FPAs. They did not have their tee and balloons to pupils under 10. No two-thirds of the COMBI plan had not shirts and caps to identify them as balloons or information had been been completed. Immediately, she was part of the LF campaign in their com- printed, however, because of the asked if F-Day should be postponed. munities. They also were not provided disbursement snag. Members of the But first she conducted an assessment with the registration books to record Task Force and Technical Committee of her own, by meeting with FPAs the names of individuals eligible for visited the main Islamic institutions from rural and urban areas and fin- the treatment. in the country and won their support ding out what people knew of the as well. programme. However, items in the campaign that didn’t require a cash payout had been The work of selecting and training The Zanzibar media campaign was accomplished. A National Task Force drug distributors had been completed. going well. The radio station, for was formed along with a National Many were teachers, which led to example, had done several talk-shows Technical Committee. The Task Force some professional jealousy with about the campaign and regularly set 27 October as F-Day. It was a regular health staff. Because initial mentioned the campaign just before Saturday, so most people would be at estimates of households were based and just after the regular, widely home. The Zanzibar LF team met with on unreliable census data, it soon broadcast news programmes as well every community leader, known as became apparent that more FPAs as incorporating it into the most shehas, on both islands. Meetings with were needed. The corps of FPAs, which popular programmes. teachers were held and the teachers was initially set at 3,000 persons, rose agreed to participate in the campaign to 4,077 in October. The training

26 Essential tools for the FPAs being packed at the MOH warehouse before being collected and distributed by the District Supervisors Left page: Mr Ali Rashid, Co-ordinator for Pemba Island and Mr Said Uthman, Social Mobilization Consultant

programme was robust enough to Essentially, the WHO adviser found programme, had already been printed absorb over 1,000 unplanned FPAs, that there was a high awareness of and were waiting to be hung across but the budget remained fixed. These the programme in the country and the roads and junctions throughout the dedicated people then decided among FPAs had carried out the first visit. Islands. Two hundred thousand themselves to keep within the budget So, the decision of those involved in information sheets were produced and by reducing their own reimbursement the programme was not to postpone distributed to schoolchildren (some for expenses from an equivalent of but to rapidly unfreeze the funds, do parents refused to sign them, fearing US$16 a person to just under $12. what could get done, and continue that the tablets were dangerous and In this way, everyone could be paid with F-Day as planned. signing relieved the provider from and the programme would not be liability). FPAs were given the answers jeopardized. The plan was triaged. The most to the questions that had stumped important items were re-ordered into them on their home visits. a list of those items that could be accomplished in the three weeks Everything was now rushed: printing remaining. Quickly 7,000 posters were of extra posters, tee shirts, registration printed and distributed to the urban books, badges and distributing areas only. The posters announced the materials, as well as the drugs. programme and showed a mosquito biting a human and a man swallowing With the critical support and white tablets. The 150 banners, asking facilitation of the WHO office and the people to participate and support the MOH, time lost would be gained.

27 Politics

The LF campaign unfolded during a politically sensitive year in Zanzibar. There were minor misunderstandings between the ruling (CCM) and opposition party, and allegiance to one’s party is high. Hence the government could count on getting less than the majority of the population required to support the programme. However, reconciliation was high on the agendas of both parties.

"We don’t have such bad politics to go so far as to hurt the health of the people," said Ismail Jussa Ladhu, an official with the opposition Civic United Front (CUF). "We want our people to be healthy to take part in the political developments of the country."

The success of the programme rested on the cooperation of both parties and the reconciliation conference that took place during October was the ideal opportunity for a public display of unity. A chance for both parties to show that they had resolved their differences and were working together for the future of their people.

28 "This disease doesn’t know the difference between the opposition and the government," says Uledi Mwita Kisumku, the Ministry of Health’s Deputy Principal Secretary. "It affects everybody. In the war against any disease, we have to collect all our forces. This is not really a political issue. It is a common problem for the whole country."

It is becoming apparent in Zanzibar that public health is an issue outside the boundaries of politics. After working together last year, the Principal Secretary of Health has pledged to give a more prominent role to the opposition in this year’s mass drug administration campaign. In fact, senior members of the ruling party have suggested that both the Chief Minister and the leader of the CUF be televised taking the pills together on the next F-Day.

In its own way, the LF campaign is helping to repair tension in the country’s political system.

29 The vital link

tougher than anyone envisioned. Some FPAs had to cover not 50 homes as planned, but 60 or 70. (On F-Day, some would be asked to reach as many as 90 homes.) The FPAs sometimes ran into hostile sentiments in the homes they entered. And they worked long hours; sometimes walking through rural areas at 11 p.m., to reach all the homes they were responsible for.

Urban District Supervisors "This is the first programme in which The FPAs, originally envisioned as we worked so hard and received so the heart of the project, had indeed little," said one FPA, Mzee Saleh turned out to be the dedicated people Abdalla, a physical therapist from the LF campaign needed. The local Pemba. "But this is our place. This is officials had chosen people who were for the benefit of our people." generally highly regarded in their com- munities, often teachers or health workers. Yet the job they faced was

30 FPAs meet in local schools in Urban West District to discuss progress, problems and clarify issues before F-Day

The FPAs had attended a six-hour A number of activities were message home that the Saturday training programme and they had undertaken to support the FPAs. would be F-Day. During Friday conducted their initial visits. Without sermons (khutbah) in the mosques, funds to pay for the registration The WHO team asked the media to the Imams encouraged people to books, the personal sellers had to use increase their coverage and boost the participate in the mass drug their own funds to buy school exercise number of LF ads running everyday. distribution. books for the record-keeping. The BBC Swahili World Service prepared a report on 22 October for After the first home visits, the FPAs broadcast before F-Day. Press releases found that they needed further trai- produced news stories about the LF ning. They were asked questions they programme and interviews with could not answer. Why are the drugs officials in the Ministry of Health. Even free? Why not test our blood first? the President of Zanzibar followed the Why you, and not a medical doctor? LF programme through the media. Why LF, and not malaria? Why do I have to take the drug in front of the The FPAs conducted their second distributor? What effect would the home visits, still without their tools. drug have on people with diabetes, During the final week, the shehas held high blood pressure, heart problems, extra community meetings about LF. and ulcers? On Thursday, 25 October, all school- children were asked to carry the

31 Dr Felicity Zaweira, WHO, Zanzibar The Hon. Shams Vuai Nahodha, Chief Minister, speaking at the launch ceremony F-Day

Everything was focused on 27 Deputy Minister of Health, the sheha (community) leader for Matude. October. This was the day the pro- Regional and District Commissioners, His daughter, Mwanakheir Hassan, the gramme had to get the majority of the the WHO Representative, and guests local school teacher and a full-time population to participate and take the from other agencies such as UNICEF FPA during the campaign, said: tablets. and the Aga Khan Foundation. The "Everyone took the tablets except one media covered the event, which man. He ran away twice, but I will go The social mobilization campaign did included beating of drums and dances back for him." its job of mobilizing the entire popula- specially commissioned for the day. tion. A substantial percentage of Through-out the day, radio and televi- At the local health centre in Paje, Zaila Zanzibaris had heard the LF messages sion broadcast the message: "Take Abdulfatah Muse, an FPA, and health through radio and television, at your tablets. Support the campaign." worker Amour H. Amour were community meetings, or from their catching up with the situation in their children, and seen the posters and Many other districts had also prepared district. It is lunchtime and Zaila has banners. The people were informed their own ceremonies to inaugurate already visited all her 50 households. and motivated. F-Day. Various political and community "Generally people are accepting the leaders were also seen taking the tablets," she says, "However, some By 9 a.m., the stage was set in tablets. people are suspicious because the Kizimkazi for the official launch of the drugs are free." campaign. Villagers lined the road as Some people had even postponed the officials’ cars streamed past, their journeys until after the distribu- Problems had begun to surface. delivering the Chief Minister, the tion day, according to Himudi Ali, a

32 The Chief Minister The Deputy Minister of Health, The Regional Commissioner Hon. Zainab Shamari

"The main difficulties are that people television. Some of her family and population." By early evening, the are scattered," according to Amour, friends had accepted the programme, radio and television station began "There are people working in hotels but others were reluctant. broadcasting news from the campaign that have not been registered at all." officials that F-Day was formally being His solution was to quickly dispatch By late afternoon, one sheha after extended to the next day. Everyone an FPA to register and distribute the another, in urban and peri-urban dis- would get their tablets. drugs to all workers in the hotels and tricts, were reporting that they had restaurants in the area. Also, seasonal run out of drugs. The FPAs were sitting Later that evening, district supervisors fishermen who were registered in their under trees with no drugs to deliver. met to figure out where there was an home villages with their families, but People were flocking to the health oversupply of drugs and how to get were working on the East coast and centres and sheha headquarters and those tablets to districts that had staying in temporary accommodation leaving empty-handed. This was the exhausted their supply. Cars were also had to be registered and given situation in the urban and peri-urban dispatched to shehas and health their tablets. areas of Unguja. centres to try and estimate the shortages. Khalfan Mohamed, the One woman had walked to her local "The registration did not tally with the MOH Programme Manager, visited the health centre for the drugs because required amount of drugs," said chief pharmacist, who was at home she had been away from home in the Shambani Mwiny Mzee, the leader of having dinner with his family, to morning. She had been visited twice Sheha Fuani. "There are still 2–3000 provide access to the medical stores by her FPA and had also heard about people without tablets. We have alrea- the next day. the programme through the radio and dy run out of tablets to cover the

33 Throughout the day, constant phone The experience of Mzee Saleh Abdalla, calls were made between Khalfan and an FPA from the island of Pemba, Ali Rashid, the Coordinator in Pemba. illustrates the concern. "People were There had been problems related to not ready," he told a WHO staff the selection of FPAs. A substantial member months after the campaign. number were chosen from the ruling "They were opposed to it. Because it party. However, these difficulties were was free, they asked a lot of ques- resolved by the public support from tions. They thought that maybe there

FPA in Bwaje on F-Day the opposition party. was something behind it. They said, "We don’t need these drugs. Please don’t come here. If it is something beneficial to us, you would never bring it to us."

However, phone calls confirmed that the people of Pemba were participa- ting in the programme.

34 “Some people only registered themselves during the campaign. This has caused a problem because the numbers of tablets given to us was based on the initial registers.”

Vuai Ali Haji Sheha Leader The Mop-Up Day

Early on Sunday morning, a motor endorsement of the drug’s safety bike was buzzing through Zanzibar’s and value. One of the benefits of the treatment is biggest city, Stone Town, delivering that it also destroys intestinal worms. drugs. The programme managers had And something else started to hap- In Pemba, some schoolchildren spent the night locating unused pen. Those who had been keeping the discharged intestinal worms through tablets and planning ways to distribu- drugs now swallowed them. And stools and vomiting. This validated the te them, including by motor bike in those who had rejected the drugs potency of the drugs. Most important- areas where the streets and alleys went searching for them. It was a ly, there were no severe adverse reac- were too narrow for cars. mass movement. Crowds surrounded tions that endangered anyone’s life. the homes of many FPAs and local Some people had refused to take the community leaders. They all wanted The number of people with side- tablets the previous day. Their suspi- the drugs. effects in some villages was quite cions were aroused by two compo- high. In Kizimkazi Dimbani (Unguja), a nents of the programme: The drugs As hoped, the people of Zanzibar had place highly endemic with the disease, were free and they were delivered to made a rational cost/value decision at 136 people in a population of 248 the home. On F-Day those suspicions some point between day 1 and day 2. reported to the health clinic with side- had kept this group of people who Zanzibar needed high coverage. Initial effects. However, they had been pre- had been offered the drugs from reports, based on the drug distribu- pared by the FPAs and the mild effects actually taking them. tors’ own registration, indicated that were treated with paracetamol. the majority of the eligible population On Day Two, however, media reports had taken the drugs. An independent "Even now people are asking for the and personal accounts began reaching survey confirmed this number to have tablets," says Saada Ali, the nurse in the reluctant population with word reached 76% of the total population. charge of Kizimkazi Dimbani’s health that national and village leaders had Zanzibar was on its way to elimina- clinic. "This programme should conti- taken the drugs. This was a practical ting LF. nue." 35 Keys to success

The nation’s sense of ownership motivated thousands of people. They were making life better for themselves and their neighbours.

A massive health campaign, based on the COMBI principles and modified to meet cultural conditions, engaged with individuals, families and communities.

Dedicated personal sellers, who visited every home to promote the programme, brought the COMBI lessons into the home.

Involvement of every sector of influence, including district commissioners, religious leaders, widely respected teachers, and the entire public health staff, eventually generated confidence in the campaign.

Political commitment and personal involvement of senior officials in the ruling and opposition parties also built confidence in the safety of the drugs.

And most of all, dedication to making this campaign a success - no matter what the challenges were - compelled people to work long, hard hours to improve the health of everyone in Zanzibar.

36 37 Partnerships: Thinking global…

Public-private partnerships at glo- Today, partnerships that include civil public health systems are poorly equip- bal level have been promoted by WHO’s society, NGOs, academic and research ped to provide even the most basic Director- General, Dr Gro Harlem institutions, governments, UN agencies, health services to meet the main health Brundtland, since the beginning of her private businesses and philanthropists needs of the population. Global partner- mandate. Dr Brundtland is convinced are among the most widely used means ships are therefore entering an arena of that a strong, broad-based partnership to achieve sustainable health outcomes. under-financed health services, with between the private and public sector is poor surveillance and reporting systems. one of the most efficient ways to increa- The Global Alliance to Eliminate Furthermore, economic factors such as se and diversify additional investment in Lymphatic Filariasis has a strong global debt burdens, and adjustment policies public health leading to sustainable commitment, a major component being also contribute to a fragile health infra- health interventions. Influential donors a private–public partnership where two structure. The result is a failure of sus- have come to adopt this view as well, pharmaceutical companies have tainability. Why? Because, critics argue, and the number of partnerships keeps committed themselves to providing programmes are dependent upon exter- multiplying. substantial drug donations to LF nal drug donations, and scarce national endemic countries. The goal is to elimi- health resources could be diverted from In the context of communicable nate the disease within a specific and established priorities and lead to the diseases, a number of global partner- limited timeframe. creation of phantom health agendas. ships are advocating political and public The critics also say that partnerships commitment to eliminate or eradicate often generate vertical programmes, targeted infectious diseases, by giving which do nothing to enhance a nation’s to the poorest in the world greater ...and acting local existing public health infrastructure. access to affordable and effective treat- ments. They also pool research experti- These are legitimate concerns as the se, raise financial resources, and support biggest challenge facing many govern- governments to acquire new tools and However, the resources and ments in developing countries is to find strategies against communicable expertise of global partnerships must be new solutions and strategies to improve diseases. translated into local benefits and the nation’s health, against the ons- actions to have any impact, and the laught of infectious diseases and a challenge is how to translate global background of dwindling resources. promises into local realities. More effective use of national resources, the creation of local partner- Criticisms of partnerships have been ships based on sharing of resources and that, in most developing countries, expertise between private and public

38 sectors, and the widespread inclusion of dy have the disease. Morbidity preven- and poverty. Although no research exists civil society are becoming increasingly tion, control and rehabilitation will be on the economic benefits of the LF vital to address the needs for improved developed with communities and delive- programme in Zanzibar, claims and expanded health care. And this red through active participation of the that LF costs the economy $1 billion a means introducing changes and diversi- patients, households, and the existing year. fying at a pace appropriate to each local health systems. country's capacity, while planning Vital to the success of the programme longer-term improvements. • LF has long been high on Zanzibar's was the strong and committed leader- public health agenda and been debated ship of the government and civil service, The challenge of the Global Alliance is many times in its House of the dedication of health workers, tea- not only to provide resources, but Representatives. When the opportunity chers, and young people, as well as the equally to work alongside governments arose to eliminate LF, a calculated deci- ownership of the programme by local to facilitate and support the formation sion was made by Zanzibar's public communities. A strong foundation has of self-supporting new partnerships and health officials. Moreover, the majority been laid in Zanzibar which can be fur- synergies within countries. Based on the of the programme was paid for by ther enhanced by attracting and tapping experiences of the first year, the LF donor grants, and WHO provided its into local resources, talent and experti- elimination programme in Zanzibar is technical experts without cost so that se, and through creating meaningful poised to make such progress based on national health resources were not partnerships with other stakeholders, a number of features, such as: diverted. The LF programme is also private businesses, individuals and strengthening integration with other social groups. • LF was accepted as a national health services, for example, the intestinal priority when the Zanzibar government parasite control programme and the The personal and collective responsibili- created a special unit to deal with the malaria control programme. ty and ownership shown by the people disease in 1995. Since then, the govern- of Zanzibar in the first year of the ment has undertaken several activities • While the claim on Zanzibar’s programme has to be maintained and to control the disease. The LF elimina- resources was comparatively small, it extended for the next four years. If this tion programme is being delivered was still a significant contribution for happens, and there is no reason why it through the existing health structure, Zanzibar. Through the FPAs more LF suf- should not, LF should be eliminated and an important part of the strategy ferers have been identified and these from Zanzibar in five years, leaving will be the inclusion of activities addres- people can now be helped. The elimina- behind a legacy of an enhanced health sing the prevention and alleviation of tion of LF from Zanzibar could have far- system capable of delivering other morbidity related to LF infection, as well reaching economic implications, given health interventions through mass as the rehabilitation of those who alrea- the perceived link between the disease campaigns.

39 The future

Everyone is excited about the results of the 2001 campaign, and modifications are being made to make the 2002 campaign even better. A total observed coverage rate of 76% of the entire population is an excellent achievement and there are also partner- ships being forged with other programmes.

Much of the success of the 2001 LF campaign in Zanzibar was due to personal commitment. But health workers in Zanzibar have experienced two very different broad public health initiatives and they know that commitments can change.

In the first, an international campaign supported by WHO and UNICEF began focusing primarily on reducing the mosquito population. The programme had spectacular results. Within ten years, malaria rates had plummeted to 7.6% and 1.7% in the two major islands. However, in 1968, the malaria programme stopped most of its activities and the disease quickly rebounded. Today, the rates are high, making malaria one of the major public health problems in Zanzibar.

Secondly, government commitment to the schistosomiasis and soil-transmitted helminth control programme has yielded benefits for a generation of children who are now adults leading active and productive lives. The programme, which began in 1986, with strong collaboration between the Ministry of Health and Ministry of Education, regularly carries out deworming of schoolchildren. The effect has been a reduction in the intensity of infection, improvement in nutritional uptake, and a positive impact. Children are learning better and growing better. As a result, this programme has laid a solid foundation for sustaining health interventions and has changed people’s perceptions namely, a disease without outward signs of illness can be treated.

40 However, people in Zanzibar who have worked in these and other large public health campaigns in the past know that one outstanding year does not ensure continuing success.

Success will only be achieved if commitment is maintained at the political and community level and through the continued support of the Global Alliance Partnership.

"We don’t want the malaria experience to come back," says one experienced health worker. "We are afraid of that. If we stop the programme, the vectors are there (to continue spreading the disease). People fear that this (commitment) will not be sustained."

Zanzibar has completed one year of the campaign and faces four more years. The present high coverage rate has to be maintained. To achieve that, an all-out effort will be required by all the players year after year.

Then and only then can the LF campaign in Zanzibar be declared a success. United Republic of Tanzania

42 Pemba United Republic of Tanzania Zanzibar (Unguja)

43 ABBREVIATIONS

CCM Chama Chama Mapinduzi (The Revolutionary Party) CUF Civic United Front COMBI Communication for Behavioural Impact FPA(s) Filaria Prevention Assistant(s) LF Lymphatic filariasis MDA Mass Drug Administration MOH Ministry of Health WHO World Health Organization

44 Project Manager: Ms Asiya Odugleh

Writer: Mr Dick Thompson

Additional Writing Contribution: Ms Asiya Odugleh

Editorial contributions: Dr Claudio Beltramello, Dr Everold Hosein, Dr Elil Renganathan, Dr Francesco Rio, Dr Nevio Zagaria

Technical input: Dr Claudio Beltramello, Dr Gautam Biswas, Dr Francesco Rio, Dr Nevio Zagaria

Designer: Ms Isabelle Goudal

Photographs: Dr Marco Albonico, Dr Claudio Beltramello, C. Dieutete, Liverpool School of , Ms Asiya Odugleh, Dr Eric Ottesen, Mr Dick Thompson Printed in France THE GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS WEBSITE: http://www.filariasis.org

WORLD HEALTH ORGANISATION

20, AVENUE APPIA, CH - 1211 GENEVA, SWITZERLAND Tel.: +41 22.791.21.11 WEBSITE: http://www.who.int