This blog is the fifth in a seven-part series examining the nature and reasons for the near elimination of malaria in Zanzibar since 2000. This question forms the basis of a major new research project and big conversation about malaria led by the Zanzibar Research Centre for Socio-Economic and Policy Analysis (ZRCP). A link to the full report from ZRCP can be found here. This blog follows from Part Four: A Delicate Balance: What are the Policy Implications of Moving Towards Malaria Elimination in Zanzibar?

Malaria in Zanzibar: a recap

Malaria is spread to humans through mosquito bites, with symptoms ranging from mild (fever, chills and a headache), to more severe (coma, severe anaemia, seizures, and difficulty breathing), and in too many cases death. Infants, children under 5 years, and pregnant women are at higher risk of severe infection. 

In the early 2000s, the World Health Organization (WHO) estimated there were between 300 and 500 million global cases of malaria a year, resulting in between 700,000 and 2.7 million deaths annually. During that time, 90% of the malaria disease burden was located in Africa. 

New evidence on the economic and human cost of malaria in the 1990s helped inspire a renewed global elimination effort. A big push backed by global leaders, funders, and researchers and in Africa governments, health care professionals, volunteers, statisticians, and households was launched in the early 2000s, leading to a dramatic global reduction in the incidence of malaria, and after 2012, the successful trial and later in 2022 the scaling up of a malaria vaccine. After 2015 the WHO verified the complete elimination of malaria in a succession of countries.

Across Africa after 2000, the most successful countries were those that reduced the incidence of and mortality from malaria by 50%. Zanzibar went much further, to near elimination.

Malaria in Zanzibar: A Striking Public Policy Success

The near-elimination of malaria in Zanzibar represents a striking public policy success, not just reflecting global donor commitment, but also the sustained, targeted, scientifically-empirically-politically driven domestic commitment by the government of Zanzibar (see Blog 2). The success was achieved despite the stubborn presence of malaria in mainland Tanzania and the importation of this through Zanzibar’s status as a tourist destination and wider economic dependence on the mainland. Reflecting on this achievement despite difficult conditions, in 2022 the WHO Country Representative in Tanzania said, 

“The evidence of an ever-decreasing rate of malaria in Zanzibar proves that with collaboration and efforts at community, facility and policy level, we can achieve goals that may seem elusive”. 

Closely involved in the anti-malaria effort in Zanzibar are the Roll Back Malaria Partnership (RBM) who declare that one of their main functions is to, “facilitate peer learning on delivering or implementing new tools or approaches through sharing of experiences, lessons learned and best practices” and to “facilitate South-South learning, and to generate lessons from operational and implementation research”. The RBM declares that the, 

“RBM Partnership will be a “bridge” for feeding the evidence and experience of endemic countries and affected communities back into global forums on policy, guidance and financing”.


But Where are the Lessons from Zanzibar: International Partners?

The stated importance of learning lessons from malaria organisations can be contrasted with their near complete failure to do so in practice. This surprising lack of reflection on the success of efforts to (nearly) eliminate malaria in Zanzibar can be seen in reports from multi-lateral organisations. 

In a 2023 report examining public service provision the World Bank mentions health care in Zanzibar twenty times but fails to mention malaria once. Another example is the 2023 WHO Joint Evaluation Exercise (JEE) to evaluate the implementation of the 2005 international health regulations. The mission examined Zanzibar’s capacities in 19 technical areas through a consultative process between international and national experts. 

The JEE praises Zanzibar’s effort in relation to non-malaria disease (ignoring malaria), “Case management guidelines/SOPs are available for some highly infectious diseases (COVID-19, Ebola virus disease, cholera) which were disseminated and oriented/trained from national to health facility levels”. (p49-51). The JEE rates Zanzibar as having “developed capacity” in relation to vaccine coverage and sustainable capacity in relation to “national vaccine access and delivery” (p3). The JEE derives this favourable assessment from an understanding of immunisations where they note that, “Zanzibar has a robust Expanded Programme on Immunization (EPI) which was established with the primary aim of protecting children from VPDs, and an overall goal of contributing to the reduction of infant and childhood morbidity and mortality rates.” (p28-30). More widely the JEE notes that in Zanzibar there is “a strong health system with wide and adequate distribution of the health facilities that have a good coverage. Access to the health services is free and there is strong commitment from the government and partners to support health service delivery. Zanzibar has available expertise for health case management and have policy documents, guidelines, and SOPS to facilitate health service provision. There is a strong health management information system (HMIS) in place and an essential package of health services for health emergencies.” (p49-51). There is no discussions of how this capacity was built up in the context of the anti-malaria campaign. 

In the 2023 report the JEE is less flattering about testing, rating laboratory testing and quality capacity as “no capacity” (p3). In 2022, only a year before the WHO had declared that Zanzibar offered “brilliant rate of testing before treatment using rapid tests”. The JEE rates the capacity of Zanzibar to increase its health workforce “during a public health event” as “no capacity” and the “human resources for implementation of international health regulations” as of “limited capacity”, though concedes “workforce training” shows “demonstrated capacity” (p4). The JEE recommends urgent attention to mapping existing human resource skills and to develop human resources to cope with public health emergencies. There is no mention of the malaria campaign in any of this assessment (p4).

But Where are the Lessons from Zanzibar: The Government of Zanzibar?

We would expect to see Zanzibar, particularly the government, publicly celebrating this success and integrating the implications for near-elimination into their medium term economic planning. Tourism for example has a significant presence in government planning documents, but there is no discussion of how the near elimination of malaria can boost tourist arrival numbers. In Greece and Spain (1930s and 1940s) and Jamaica (1958) the elimination of malaria was a pre-condition for the development of large-scale tourism. 

Vision 2050 is all but completely silent about malaria. Malaria gets two mentions in Vision 2050. One mention dismisses the success with faint praise, 

“Though efforts to control HIV/AIDS, malaria and gastro-intestinal diseases have been relatively successful, there is an increasing concern of emerging non-communicable diseases (NCDs) as well as perinatal, neonatal and infant mortality” (p35). 

The second references malaria in terms of a climate change induced threat, 

“Ecological stability is further threatened by climate change, which could potentially affect future livelihoods, with children in particular at greater risk of food and water scarcity; vector and water-borne diseases, such as malaria, dengue and cholera as well as air pollution” (p62). 

By comparison the health plan in Kenya for 2023 to 2027 includes detailed discussion and analysis of malaria. Malaria is mentioned in the report 41 times. There are detailed presentations of data showing how the prevalence of and mortality from malaria declined in different geographic regions as well as the roll out of vaccines (p32). The prevention, diagnosis, and treatment of malaria is ascribed the status of ‘strategic goal’ (p43). There are clear annual targets to reduce the incidence of malaria for every year between 2023/24 and 2027/28 (p45) and targets for the number of ITNs distributed, coverage of IRS in target areas, vector surveillance reports completed, procurement of anti-malarial medicines and malaria diagnostic kits (p66) and the project is fully costed (p122).

A Puzzle and a Potential Answer

It is a puzzle, why Zanzibar and its international partners in public health are not more publicly celebrating the success of the two-decade long anti-malaria campaign. In part this can be explained because no-body has undertaken the research necessary to think through the likely economic benefits from the (near) elimination of malaria (see Blog 3). More broadly, it seems evident that Zanzibar should be loudly proclaiming this success to boost its image in relation to potential tourist arrivals. 

Another, more speculative reason for the relative neglect of thinking about malaria is the dominance of the good governance paradigm in thinking about economic development. 

In the early 1990s, the World Bank explained the relative economic failure of many African economies over the past few decades,

“The main factors behind the stagnation and decline were poor policies – both macroeconomic and sectoral – emanating from a development paradigm that gave the state a prominent role in production and regulating economic activity”. 

Despite substantial policy reform in the 1980s and 1990s, there was no apparent economic revival. Policy reforms, they argued, weren’t generating good economic outcomes because they were implemented in a context of ‘bad governance’. The World Bank and IMF shifted attention from good policy to good governance, which included aspects related to the functioning of government administration–transparency, accountability, fairness, participation, and ownership–and to those impacting economic transactions, such as the registration, protection, and tradability of property rights. Consequently, the development debate became tightly focused on the role of good governance and institutions. 

The focus on good policy and its link to good governance and institutions is clearly reflected in Zanzibar, where Vision 2050 was structured around four pillars. Of those four, three were related to “good policy”: economic transformation (industry, trade, tourism, blue economy, oil and gas, creative and digital economy, finance and investment); infrastructure (housing, transport, seaports, airports, energy, ICT); and social welfare (education, health, sanitation, social protection, heritage and sports). Good policy is defined in a conventional manner throughout, as making markets work better, improving incentives, allocating resources more efficiently, boosting investment, and increasing exports. The final pillar is good governance, which provides the context to ensure that good policy leads to economic success. Good governance in Zanzibar is discussed in globally conventional terms,

“The RGoZ has consistently acknowledged the role of good governance in facilitating development in its previous national plans. The establishment of an accountable, transparent, responsive and effective system of governance that is resilient to developmental pressures cannot be emphasised enough”. 

Jeffrey Sachs wrote that this conventional set up of good policy being framed by good governance left the development debate “dangerously simplified”; if the economy was performing poorly and efforts to implement good policy were not generating desired economic outcomes, the blame could always be placed on the governance or institutional framework. The implication of this debate has been to distract attention from the undoubted success of the campaign to near-eliminate  malaria in Zanzibar and the likely economic benefits. In thinking about economic development in the years to 2050, Zanzibar remains committed to this “dangerous simplification” whereby good policy in a framework of good governance are the only objectives that a government needs to focus on.

Look out for Part Six: It is Like a Horror Film, the Villain Keeps Coming Back to Life: The Risks of a Malaria Revival in Zanzibar