ZANZIBAR'S switched to ACTs in 2004, after growing resistance to chloroquine, previously the most commonly used drug. At Wete District hospital, Sheikh Makame, recalls that once he was so sick with malaria that he had been unable to move.

"But when I was brought here and given ACT, I recovered fast. That's why I've brought my child who is also suffering from malaria," he says. The man at the helm of Zanzibar's Malaria Control Programme , Abullahi Ali, says they want to distribute a further 70,000 treated bed nets, taking the total figure to 300,000.

Zanzibar's strategy to fight malaria was closely modelled on the World Health Organisation's Roll Back Malaria initiative. Efforts to combat the disease have seen the prevalence rate come down from 35 per cent before 2008 to below 1 per cent, but health officials are worried the gains could be reversed.

"Despite the achievements in reducing malaria, a lack of funds for awareness (raising), indoor residual spraying and surveillance, is a challenge. Also, we have a problem with people's resistance to behavioural change, particularly in keeping the environment clean and in the use of mosquito nets," said Mwinyi Msellem, head of the diagnostic unit at the Zanzibar Malaria Control Programme (ZMCP).

As malaria prevalence heads towards zero, the population is also losing its natural immunity to the disease, meaning that population screening will become increasingly important, said Msellem. Malaria prevalence was below one per cent, according to the Roll Back Malaria Indicator Survey of 2007.

ZMCP interventions include case management through the treatment and training of health workers and integrated vector control through the use of insecticide-treated bed nets, environmental hygiene and indoor spraying.

The programme hopes to cover 95 per cent of the island's estimated 280,000 households in this way as against 60 per cent at present. The prevention of malaria in pregnancy has also been a key malaria control intervention although the use of prophylaxis medication by pregnant women is low at 40 per cent against a target of 85. "Most pregnant women attend clinics when they are close to delivery so they just get the last dose," he said.

Two doses are recommended. Along with past interventions, emphasis is on new case monitoring and research. "When you get this kind of success you have to increase surveillance," he noted.

A Malaria Early Epidemic Detection System has also been established to monitor new cases at 52 of Zanzibar's 150 health facilities. "Weekly, they [the health centres] send text messages to our server indicating the number of patients, those tested for malaria and the number diagnosed with malaria," said Msellem.

Comparisons are then drawn against previous weekly reports. "If an increase is noted, we have to investigate and check breeding grounds," he said. The health centres reported 1,671 confirmed malaria cases in 2009, of which 618 were children under five.

According to the Ministry of Health and Social Welfare, health centres have been showing 2-3 per cent malaria prevalence, with no change noted since the short March-May rains. Challenges are, however, emerging in disease monitoring, behaviour change and funding.

Among the problems is difficulty in getting monitoring data from the health facilities, he said. Mobile phone technical errors sometimes also interfere with data collection. "Each district also needs its own surveillance and response team and there is a need for more trained personnel," he said.

"To set up this system you also need a lot of money." Refusal to test and be treated for malaria has also been noted as cases decline, raising the risk of onward transmission or even death. This is because some people believe malaria has already been eliminated, said ZMCP. Mariam Mussa, 34, a small trader and mother of three in Tunguu village south of Unguja, one of Zanzibar's constituent islands, said: "I thank God that the last time one of my children had malaria was in May (2009). In the past we used to have malaria frequently."

"Although malaria is down, the situation remains fragile. Sustainable commitment by the government, including having its own funds for the anti-malaria programme and awareness.

For Zanzibar, which has been a good example to Kagera Region, the Island was the first country to receive assistance from the President's Malaria Initiative (US) and the World Health Organisation and the Italian Cooperation Agency are also partners. ZMCP interventions included case management through the treatment and training of health workers and integrated vector control through the use of insecticide-treated bed nets, environmental hygiene and indoor spraying.

The programme hopes to cover 95 per cent of the isles' estimated 280,000 households in this way as against 60 per cent at present. He says the prevention of malaria in pregnancy has also been a key malaria control intervention although the use of prophylaxis medication by pregnant women is low at 40 per cent against a target of 85.

"Most pregnant women attend clinics when they are close to delivery so they just get the last dose," he said. Two doses are recommended. Along with past interventions, emphasis is on new case monitoring and research. "When you get this kind of success you have to increase surveillance," he noted. Early epidemic detection system For the Isles, a Malaria Early Epidemic Detection System has also been established to monitor new cases at 52 of Zanzibar's 150 health facilities.

"Weekly, they (the health centres) send text messages to our server indicating the number of patients, those tested for malaria and the number diagnosed with malaria," said Zanzibar Malaria Control Programme (ZMCP) Manager, Mr Abdullah Suleiman. Comparisons are then drawn against previous weekly reports.

"If an increase is noted, we have to investigate and check breeding grounds," he said. The health centres reported 1,671 confirmed malaria cases in 2009, of which 618 were children under five.

According to the Ministry of Health and Social Welfare, health centres have been showing 2-3 per cent malaria prevalence, with no change noted since the short March-May rains. The National Strategy for Growth and Reduction of poverty (NSGRP)11 launched in April this year, also confirms the same in its reference to malaria prevalence at health centres.

Infact, it notes that life expectancy has increased to 55 years, but that neonatal mortality has increased only marginally due, partly, to little improvements in maternal deaths which is also attributed to malaria incidences, among others.

It notes that in 2007/8, malaria prevalence in children stood at (6-59 months of age) ranged between 5 per cent and 30 per cent. But it now notes that there has been a decline in malaria transmission, malaria in-patient admissions and the proportion of fever cases due to malaria.

The document attributes this to improvements in the coverage of insecticide-treated nets (ITNs) even though, it adds, that the coverage is still lower in rural areas than urban areas. It cites other interventions as introduction of 'highly effective artemisinin based combination therapy (ALU), Rapid Diagnostic Test (RDTs), larviciding and Indoor Residue Spraying.