LSDI

Background

The LSDI is a programme by the governments of Mozambique, Swaziland and South Africa to develop the Lubombo region into a globally competitive economic zone, ensuring sustainable employment and equity in access to economic opportunity in the region. The geographic region targeted by this initiative is broadly defined as eastern Swaziland, southern Mozambique and north-eastern KwaZulu Natal, an area linked by the Lubombo mountains.

Malaria was identified as a critical deterrent to the development of the Lubombo region. This led to the creation of the Lubombo Malaria Control initiative, a cross-border collaboration aimed at the reduction of malaria throughout the LSDI area.

The primary emphasis of the LSDI malaria control programme was to extend malaria control to southern Mozambique and thereby address a number of aspects central to increasing the effectiveness of malaria control in the two highest risk malaria provinces in South Africa and Swaziland.

It was acknowledged that further inroads into controlling malaria could only be achieved through inter-country collaboration and that malaria could no longer be viewed as a country specific problem but should be seen as a regional problem. For malaria control measures to be effective, they need to be co-ordinated and implemented at a regional rather than country-level. The extension of malaria control to southern Mozambique is essential for the effective control of the disease in the Lubombo region (See map)

The devastating effects of malaria on communities in Africa and on development have been well documented. (See Malaria and development) There is also evidence that effective malaria control is a positive precursor to development with the situation prior to malaria control in South Africa supporting this view, given the well-documented negative effects of malaria on tourism and agricultural development in the 1930’s. The LSDI malaria programme was targeted at creating a platform for development, the beneficiaries being communities in areas with the lowest socio-economic development in the region as well as tourism, business and governments.

History of the project

Control measures in Mozambique since independence in 1975 have focused around the major urban centers and consist of indoor residual spraying and treatment for those who report ill to health facilities. Historical data from 1937/8 (Figure3) prior to the introduction of control measures indicate that the high prevalence of infection differs little from the current situation. A house spraying programme was started in 1962 in southern Mozambique and these data indicate a dramatic decrease over the 8 year period of control ( Figure 4 ). However, by 1999, there was no spraying programme in Maputo province, which borders South Africa, outside of Maputo city.

Dual intervention through both parasite and vector mosquito reduction has achieved and maintained a limitation on malaria distribution in Swaziland and South Africa. Insecticide residual house spraying has been the mainstay of malaria vector control in both these coutries.

However, in South Africa, malaria incidence data analysed by the MRC shows that the disease remains at an unacceptably high level in the northern most regions in KwaZulu-Natal bordering Mozambique and Swaziland. It was acknowledged that further inroads into controlling malaria could only be achieved through inter-country collaboration and that malaria could no longer be viewed as a country specific problem but should be seen as a regional problem (Sharp B L and le Sueur D (1997); Need for regional co-operation in malaria research and control. SAMJ. 87(11):1608-1609).

The launch of the Lubombo Spatial Development Initiative in 1999 provided an agreement for cross-border collaboration that a regional malaria control programme could hang on.

In July 1999 President Mbeki, President Chissano and His Majesty, King Mswati III signed the General Protocol which puts in place a platform for regional cooperation and delivery. A brief document was submitted to the three country ministerial meeting in 1998, outlining the negative effects of malaria on development and proposing malaria control. The LSDI malaria control programme was officially inaugurated by the 3 country ministerial signing of a protocol of agreement, during October 1999. The signing of this protocol legally constituted the Regional Malaria Control Commission (RMCC), a commission comprised of malaria scientists, and control and public health specialists from the three countries.

In December 1999, the World Heritage Convention Act was promulgated and the Greater St Lucia Wetlands Park inscribed on the World Heritage Convention list. In June 2000 the three countries signed the Lubombo Transfrontier Conservation and Resource Area Protocols (TFCA).

The aim of the malaria control component is to protect communities in the area, enhance development potential and protect economic investments through the extension of malaria control, including a spraying programme, to Southern Mozambique.

General Objectives include:

extending indoor residual spraying (IRS) to Maputo Province, Mozambique and ensuring effective malaria control was maintained in South Africa and Swaziland.
monitoring and evaluating malaria control in the region and developing a regional GIS-based Malaria Information System (MIS).
providing updated tourist information booklets containing definitive malaria risk maps and prophylaxis guidelines.
monitoring the negative impact of malaria and the beneficial effects of malaria control on communities, tourism and development.
ensuring sustainability of malaria control through appropriate capacity development, fund raising and integration of control activities within the provincial health system in Mozambique.

Since effective malaria control requires both vector control and early effective treatment, the RMCC decided to extend their objectives to ensure that the best malaria treatment based on artemisinin-based combination therapy (ACT) was introduced across the LSDI. Partnership with the University of Cape Town (UCT) Division of Clinical Pharmacology and its collaborators in the SEACAT evaluation facilitated the meeting of this additional objective.

Widespread use of ACT offers the benefits of not only improving cure rates, but, unlike other malaria treatments, of also directly decreasing malaria transmission and potentially slowing drug resistance. To optimise the synergistic effects of IRS and ACTs on reducing malaria transmission and thus disease burden, while minimising programme costs, the implementation of ACTs has been timed to follow the establishment of effective vector control.

Measurable and Specific Objectives of the Lubombo Spatial Development Initiative (SDI) are:

to reduce the incidence of malaria in Maputo province (MP) and thus contribute to its reduction in the adjoining border areas of South Africa and Swaziland;
Reduce malaria incidence in the border areas of South Africa and Swaziland from 250 per 1000 to less than 20 per 1000.
Reduce malaria infections from 625 per 1000 to less than 200 per 1000 within three years after the start of IRS in Maputo Province.
to reduce mosquito vector densities in MP;
to train community members to spray houses for malaria vector control, to recognise symptoms of the disease and to work in concert with health care centres in terms of health education;to ensure a collaborative response to malaria epidemics in the Region;
to establish a plan for continuous monitoring and evaluation of interventions.