With malaria elimination in sight, CHAI wraps up work in Botswana

As CHAI exits Botswana, the former country team reflects on our efforts to build sustainable systems to help the Botswana government reach malaria elimination.

At CHAI, we like to say that we are “working ourselves out of our jobs,” in the countries where we operate. In our place, we hope to leave sustainable, government-led health systems. Often, this seems like a faraway reality, but at the end of 2020, the Botswana malaria team handed things over to the National Malaria Program.

CHAI first supported the Botswana government from 2008 to 2011, then returned in 2015 to assist the country to achieve an ambitious goal: eliminating malaria.

Malaria cases predominantly come from six districts in the northern-most part of Botswana: Bobirwa, Boteti, Chobe, Ngamiland, Okavango, and Tutume. However, in recent years, Palapye district in the central eastern part of the country has also reported a significant number of cases. CHAI came in to help the Botswana National Malaria Program better understand and combat malaria in these hot spots with effective tools, systems, and targeting.

Vector control, primarily through indoor residual spraying (IRS), was and remains Botswana’s key strategy to not only reducing malaria transmission but achieving elimination. Case management is another key strategy. While surveillance is one of the tenets of the country’s strategic framework, in practice there was plenty of room for improvement.

The last, most difficult mile

When elimination is in sight, the number of malaria cases are extremely low. Ironically, the closer a country gets to wiping out the disease, the more difficult it can become. Ministries of health need to establish strong surveillance systems to find and prevent malaria in those last endemic pockets – hot spots where there is still ongoing transmission. Stronger surveillance systems are also needed to keep an eye on areas that have not reported a case in the last 12 months to ensure they don’t backslide.

Our strategy was to help the National Malaria Program set up a robust surveillance system to capture and report cases quickly, build a culture that used data for decision-making, and improve national and regional planning and budgeting for malaria.

CHAI put together a team that focused mainly on the six endemic districts, where our staff worked together with the district teams in those locations.

Picture showing predicted malaria incidence in Botswana

Map showing predicted malaria incidence in Botswana.

What we measure, we improve

Comprehensive and detailed data is critical, not only to find and understand the drivers of transmission at both the macro and micro-levels, but also to make decisions about which interventions to deploy where. The program needed granular information about local mosquitos and how they react to the malaria interventions in the ministry’s toolbox.

In Botswana, we helped develop and operationalize this kind of data.

We developed national guidelines, training materials, registers, and reporting tools to establish the program’s entomological surveillance program (the study of mosquitoes, their behavior, and environment) and strengthen data collection nationally and at district level. We trained 33 environmental health officers across the country to perform basic entomological surveillance. From this training, officers were able to collect and study the mosquitos and their habitats to understand what was causing the malaria cases in specific hot spots.

Leungo Motlhabane, an associate formerly based in Ngamiland shares: “In my district, I vigorously advocated for investigations in active areas across the district. As a result of the investigations, the Regional Health Management Team [RHMT] distributed nets to a remote settlement in the Okavango Delta, Xaxaba, and procured equipment to continue the investigations even after CHAI leaves.”

‘CHAI was that irritating voice in the back of their minds’

To reach elimination, it’s important to ensure the right interventions are going to the right places at the right time and in the right way. To do that, we need the data to make those informed decisions. IRS is the key vector control intervention in Botswana, but there was little data available to track its effectiveness.

CHAI supported two spray quality assessments in 2019, a first for Botswana, in Chobe and Okavango districts. The assessments evaluated whether spray operators were using the right spraying techniques and applying the right dosages on people’s walls. The results were used to improve spray operator training and purchase appropriate spray tank parts for the 2020 IRS campaigns of several districts. The National Malaria Program plans to conduct regular spray quality assessments moving forward.

Not only is it important to collect and use data for decision-making, but to do so routinely. CHAI worked with our government counterparts to establish regular data review meetings. These meetings were important to help district management health teams think critically about the efficiency of their malaria programs. As Leungo says, “[CHAI] was that irritating voice in the back of the RHMT’s mind saying, ‘Let’s gather the data and meet in-person to discuss this issue and forge a way forward as a collective.’ ”

IRS spray operators

IRS spray operators at the back of a land cruiser preparing to go in the field.

Microplanning was one way to help RHMTs think critically about their IRS operations. Microplanning is a very granular operational plan that lists the when, where, what, how, and who for deploying an intervention – in this case, IRS. By establishing this practice of planning down to the ‘micro’ level, it allowed decision makers visibility into the financial and logistical need for the upcoming spray season and prevent any hurdles along the way.

We created a variety of tools for other malaria work streams including case management to institutionalize a culture of data reviews to monitor progress against program targets.

Before CHAI introduced district-level support, the National Malaria Program had no standardized malaria public education or awareness materials across the country. Community health and mobilization activities were also not tracked. CHAI helped establish reporting tools, strengthen reporting channels between national and district levels, and recommended a bouquet of activities to improve malaria surveillance in all districts, including non-endemic ones, Chebukani Nkobodo, a former national associate, notes.

Working together to achieve elimination

For a country to achieve its goal of malaria elimination, it is important that all actors work together as a single unit and that big goals are broken into simple action items. These are strategies that CHAI used to effect progress faster, particularly for solving operational challenges. Tapiwa Nkhisang, a former malaria associate based in Bobirwa, highlights this in her reflection of her experience:

“District officers often worked in silos. Due to limited communication across the different offices, critical information was not shared. I advocated for the formation of a malaria team consisting of external organizations and key officers across the different work streams to ensure that there was effective communication and coordination of resources for effective decision making and implementation of programs.”

Leungo Motlhabane (left) and Tapiwa Nkhisang (Right) at an IRS Supervisor Training in Francistown, Botswana

Leungo Motlhabane (left) and Tapiwa Nkhisang (right) at an IRS Supervisor Training in Francistown, Botswana.

Program manager Setshwano Gaosenkwe also highlights the importance of breaking tasks into chewable chunks, “Getting buy-in for the introduction of new strategies and tools was a challenge. We were able to overcome this by building onto what was existing and identifying opportunities for tradeoffs. We learned that extensive consultation and breaking down complex tasks into smaller digestible pieces helped to gradually introduce changes and make them less intimidating.”

Picture of Chebukani Nkobodo and Setshwano Gaosenkwe, former Botswana malaria associate and program manager

Chebukani Nkobodo and Setshwano Gaosenkwe after running a marathon in Francistown, Botswana following an IRS training.

CHAI wrapped up our support in December 2020, but we are leaving the National Malaria Program and MoHW better equipped to eliminate the disease.

“As we say goodbye to CHAI I would like to say how grateful I am for the manpower and the services that we received,” said Davies Ntebela, the National Malaria Program manager. “The NMP has definitely improved in its operations because of the partnership that we shared.”

“What I will always miss the most about the CHAI team that worked with the NMP was the positive attitude towards work  they displayed all the time. The team never complained about [the] workload or working beyond normal working hours. CHAI team, you were the star of the NMP Botswana,”  he said.

Malaria is highly concentrated in only one part of the country and new insecticides and drugs are proving effective against the local mosquito population.

With a strong surveillance system driven by evidence-based decision making, skilled healthcare workers at national, district, and facility levels, and better planning tools in place, the MoHW has a stronger foundation to continue its march toward elimination.

While the Botswana CHAI malaria program may no longer exist, we are still present in the region supporting Namibia, Zimbabwe, and South Africa – all countries that border Botswana.

Fond memories from the program team

The CHAI team leaves with cherished memories of their work in the country:

Harvey: “Jogging with the Head of Preventative, who is responsible for overseeing all preventative disease programs in the district, in the evenings after work is definitely one of my fondest memories in the district. He is much older than me, but easily outruns me.”

Tapiwa: “For me, quarterly birthday celebrations with the RHMT staff. For one of these gatherings, I offered that we cook pap and chakalaka at my house. This process took at most an hour and a half, but I learned so much about my colleagues.”

Chebukani: “For me, it is the level of trust the communities have on health personnel for their health and welfare.”

Setshwano: “Taking a road trip with the previous NMP manager on my first day at work to attend an IRS training was a memorable experience. We shared experiences along the way, and I got to the meet the Botswana IRS team members all in one place.”

Leungo: “My fondest memories are of the people I met during trips to the remotest, resource-limited areas of Botswana to serve marginalized, under-serviced communities. The grandfathers wanting to talk about family histories and culture – the way things were done in the ‘old days’, the mothers offering milk or harvest from their fields, and the joy of children who feel seen when you talk to them. These encounters will remain with me forever.”

Picture of former CHAI Botswana Malaria team

From left to right: Leungo Motlhabane, Setshwano Gaosenkwe, Chebukani Nkobodo, Erica Berlin and Harvey Mogojwe en route to Tanzania for the All Africa Regional Malaria Meeting (AARM) in 2019.

While elimination is on the horizon, history reminds us that gains are fragile. Vigilance will be required to ensure malaria is eliminated in the face of limited funding, emerging disease priorities, and climate change.

We would like to wish our colleagues at the National Malaria Program the best in their continued efforts to eliminate malaria in Botswana. With the passionate, talented, and dedicated staff we have worked with at both national and district levels, we are confident the program will eliminate this disease soon.

As we like to say in Botswana, “we part to meet again.”

Le ka moso!