MALARIA CONTROL PROGRAMS

Group six
October 24, 2020
Addis Continental Institute of Public
Health(ACIPH)
GROUP MEMBERS

• Megdelawit Mengesha • Michael Kefyalew

• Mengesha Girmay • Mulu Bekele
• Mengistu Tefera • Mulugeta Gebremariam
• Meron Tekeba • Fikremelekot Temesgen
• Mesale Solomon • Gadise Bekele
• Meseret Tefera • Hana Sime
• Messay Tesfaye
SUB TOPICS

• Epidemiology
• Objectives
• Strategies
• Organization and funding
• Achievements
• Challenges
• Way forward
• References
EPIDEMIOLOGY
EPIDEMIOLOGY

• Even though the transmission significantly decreased since 1959,

malaria is still a major public health problem in Ethiopia.
• ~68% of the total population is estimated to be at risk.
• P. falciparum and P. Vivax as major species in Ethiopia make the
control effort difficult.
EPIDEMIOLOGY: MALARIA VECTORS

1. Geographic distribution

• A. Arabinesis – major vector with wide geographical

distribution and peaks during the rainy season.
• Other vector forms- An. funestus, An. pharoensis and An. nili
have limited distribution.
• An. stephensi is widely distributed and established in eastern
Ethiopia.
EPIDEMIOLOGY: MALARIA VECTORS

2. Breeding trend

• An. Arabiensis -> small, temporary, and sunlit water

collections such as rain pools.
• An. Pharoensis and An. Funestus -> large, permanent water
bodies with emergent vegetation, such as swamps and the
edges of lakes.
• An. Nilli-> brackish water with localized distribution.
EPIDEMIOLOGY: DYNAMICS OF
TRANSMISSION

• Generally, malaria transmission in Ethiopia occurs in areas

located at altitudes below 2,000m above sea level, which is
the target area for antimalarial interventions.
• low-hypo-endemic transmission-> highland fringe areas and
semi-arid regions.
• high-endemic perennial transmission-> lowland regions and
valley floors
EPIDEMIOLOGY: DYNAMICS OF
TRANSMISSION

• In most parts of the country, transmission is seasonal, major

transmission being from September to mid-December,
following the main rainy season (June-August), and minor
transmission season during March-May.
• As a result, malaria transmission pattern in Ethiopia is
seasonal and unstable often characterized by highly focal and
large-scale cyclic
EPIDEMIOLOGY: DYNAMICS OF
TRANSMISSION

• Transmission of malaria in highland fringe and semi-arid areas

of the country is found to be sharply decreasing over recent
years.
• Despite, reduction in overall incidence of malaria, malaria
transmission has expanded to highland areas due to recent
temperature warming in these highlands.
EPIDEMIOLOGY: STRATIFICATION AND
MAPPING

High malaria endemic areas –areas of stable and intense malaria

transmission with altitudes below 1000 meters eg. in Gambella,
Benishangul Gumuz, Western Oromia, Amhara, some parts of
South Nations and Tigray regions.
Hot humid tropical climate with mean annual temperature of
25.4°C (range: 22–28°C) and mean annual rainfall 935mm (range:
503–1,643mm) -> Perennial transmission
EPIDEMIOLOGY: STRATIFICATION AND
MAPPING

Moderate malaria endemic areas – areas in the midland zones

between elevations of 1,001 and 1,750m with mean annual
temperature ranging between 21°C and 30°C, mean annual rainfall
between 503 - 1,643mm. Transmission is moderate with strong
seasonality (6–9 months) with a tendency of longer transmission
duration and intensity at lower altitudes.
EPIDEMIOLOGY: STRATIFICATION AND
MAPPING

Low malaria endemicity - highland fringe areas are located

between 1,751 and 2,000m altitude with mean annual
temperature 19°C and mean annual rainfall ranging between
1,100–1,600mm.
• Transmission is unstable and seasonal (3–6 months),
• large-scale epidemics that recur at irregular intervals of 5–8
years with localized outbreaks occurring almost every year.
EPIDEMIOLOGY: STRATIFICATION AND
MAPPING

Very low malaria endemicity –arid and semi-arid areas as well as

areas that are located above 2,000 altitude in the country.
• Afar and Somali Regions with altitudes below 1,000m are
characterized by unstable transmission.
• short periods of intense malaria transmission, which lasts only
for about 3–4 months.
EPIDEMIOLOGY: STRATIFICATION AND
MAPPING

The malaria-free areas: areas found in the highlands of the

country where climate hinders development and maturation of
both vectors and parasites making local malaria transmission
impossible.
• However, population movements imported malaria cases.
EPIDEMIOLOGY: MALARIA EPIDEMICS IN
ETHIOPIA

• Epidemic prone areas-> areas where there is low and unstable

malaria transmission, and people have low or no immunity.
• 1958-> major epidemic claimed 150,000 lives.
• Since then epidemic occurs every 5 to 7 years.
• Since 2003 no major malaria epidemic, except smaller-scale
outbreaks and seasonal case build-ups.
EPIDEMIOLOGY: MORBIDITY AND MORTALITY
TRENDS
EPIDEMIOLOGY: MORBIDITY AND MORTALITY
TRENDS

2500

2000

1500

1000

500

2012 2013 2014 2015 2016 2017 2018 2019

Trend of malaria-attributed deaths in Ethiopia from 2012 to 2019, NMEP,
Ethiopia
EPIDEMIOLOGY: MORBIDITY AND MORTALITY
TRENDS

7000000
6611801 6471958
5913799
6000000 5403951

5000000
4000000
3000000
1718504
2000000 1530730
962087 904495
1000000
0
2016 2017 2018 2019

Suspected versus confirmed malaria cases

GOALS AND OBJECTIVES
GLOBAL MALARIA CONTROL STRATEGY
HISTORY

• 1950: Focused on parasite eradication using (DDT)

trichloroethane
• 1960: Incidence decreased but was not sustained because the
rigidity of the eradication program which was vertically
structured & failed to consider regional differences in malaria
epidemiology & public health infrastructure.
• Malaria resurged in the following decades & the goal of malaria
eradication was declared a failure & abandoned.
ROLL BACK MALARIA(RBM)

RBM partnership was established in 1998, the first in three

decades. The goal was to halve the number of deaths due to
malaria by 2010 through these 4 strategies:
1. Disease management through prompt and affordable access to
effective treatment including ACT
2. Disease prevention through “personal and community
protective measures,” primarily increased access to insecticide-
treated bed nets
3. Targeted disease control and prevention for pregnant women
4. Epidemic control through early detection and response
NATIONAL MALARIA STRATEGIC PLAN
(ETHIOPIA)

 STRATEGIC PLAN (2006-2010)

 STRATEGIC PLAN (2011-2015)

 STRATEGIC PLAN (2014 – 2020)

 STRATEGIC PLAN (2017 – 2020)

 STRATEGIC PLAN (2021 – 2025)

2006-2010 NATIONAL STRATEGIC PLAN

 aimed to rapidly scale-up malaria control interventions to

achieve a 50% reduction of the malaria burden, in line with
RBM objectives.
NATIONAL MALARIA STRATEGIC PLAN
2011-2015

1. Community Empowerment & mobilization

2. Diagnosis & Case Management
3. Prevention: The two main major vector control IRS & LLINs
4. Active Surveillance & Epidemic Control

Had 2 goals & 7 objectives.

The objective of the 2011-2015 plan is to consolidate the
achievements of that of 2006-2010 & sustain its impacts
NATIONAL MALARIA STRATEGIC PLAN
2011-2015

GOALS

1. By 2015, achieve malaria elimination within specific

geographical areas with historically low malaria transmission.
2. By 2015, achieve near zero malaria death in the remaining
malarious areas of the country.
NATIONAL MALARIA STRATEGIC PLAN,
2017-2020

• The national malaria strategic plan goals and objectives for the 2017-2020 has
3 goals and 6 objectives.
• The NMSP is updated for 2017-2020 incorporating Malaria Indicator Survey
(MIS)2015 findings & the most recent Global funding request application.
NATIONAL MALARIA STRATEGIC PLAN,
2017-2020

GOALS

1. By 2020, maintain near zero malaria deaths (no more than 1

confirmed malaria death per 100,000 population at risk) in
Ethiopia.
2. By 2020, reduce malaria cases by 40percent from baseline of
2016.
3. By 2030, eliminate malaria from Ethiopia
NATIONAL MALARIA STRATEGIC PLAN,
2017-2020

STRATEGIC OBJECTIVES

1. By 2020, all households living in malaria endemic areas will

have the knowledge, attitudes, and practice to adopt
appropriate health-seeking behavior for malaria prevention
and control.
2. By 2017 and beyond, 100 percent of suspected malaria cases
are diagnosed using RDTs or microscopy within 24 hours of
fever onset.
3. By 2017 and beyond, 100 percent of confirmed malaria cases
are treated according to the national guidelines.
NATIONAL MALARIA STRATEGIC PLAN,
2017-2020

STRATEGIC OBJECTIVES

4. By 2017 and beyond, ensure that the population at risk of

malaria has universal access to one type of globally
recommended vector control intervention.
5. By 2020, malaria elimination program will be implemented in
239 districts.
6. By 2020, 100 percent complete data and evidence will be
generated at all levels within the nationally designated time
periods to facilitate appropriate decision-making.
ETHIOPIA MALARIA ELIMINATION
STRATEGIC PLAN: 2021-2025

The national malaria strategic plan goals and objectives for the
2021-2025 has 2 goals and 6 objectives.
ETHIOPIA MALARIA ELIMINATION
STRATEGIC PLAN: 2021-2025

GOALS

1. By 2025, reduce malaria morbidity and mortality by 50 percent

from baseline of 2020.

2. By 2025, achieve zero indigenous malaria in districts with

annual parasite incidence less than 10 and prevent
reintroduction of malaria in districts reporting zero indigenous
malaria cases.
ETHIOPIA MALARIA ELIMINATION
STRATEGIC PLAN: 2021-2025

STRATEGIC OBJECTIVES

1. By 2025, achieve adoption of appropriate behaviour and

practices towards antimalarial interventions by 85%
households living in malaria endemic areas.
2. By 2021 and beyond, conduct confirmatory testing for 100% of
suspected malaria cases and treat all confirmed cases
according to the national guidelines.
3. By 2021 and beyond, cover 100% of the population at risk of
malaria with one type of globally recommended vector control
interventions.
ETHIOPIA MALARIA ELIMINATION
STRATEGIC PLAN: 2021-2025

STRATEGIC OBJECTIVES

4. By 2021 and beyond, conduct cases or foci investigation,

classification and response in districts currently having API
less than 10 and prevent reintroduction of malaria into areas
reporting zero indigenous malaria cases.
5. By 2021 and beyond, generate 100% evidence that facilitates
appropriate decision-making.
6. By 2021 and beyond, build capacity of all levels of the health
offices to coordinate and implement malaria elimination
interventions.
ORGANIZATION & FUNDING TO
CONTROL MALARIA PROGRAM
IN ETHIOPIA
ORGANIZATION AND FUNDING TO CONTROL
MALARIA
Organizational Structure
ORGANIZATION AND FUNDING: ROLE AND
RESPONSIBILITY

MOH Level
• Provision of policy and strategic guidance to RHBs and partners
for malaria prevention, control and elimination activities.
• Resource mobilization from the global community
ORGANIZATION AND FUNDING: ROLE AND
RESPONSIBILITY

Regional Level
Guide the lower levels of the health system in
• Planning and execution of plans,
• Disseminating and cascading policies and strategies,
• Resource mobilization and allocation, and
• M&E of malaria control and elimination activities
and programme outcomes.
ORGANIZATION AND FUNDING: ROLE AND
RESPONSIBILITY

Zonal Level
provide technical support for Woreda malaria staff in
• planning, follow-up and supporting implementation
of planned activities,
• Ensuring the continuous availability of adequate
supplies required for the different strategic
approaches of malaria programme and M&E of the
programme outcomes.
ORGANIZATION AND FUNDING: ROLE AND
RESPONSIBILITY

Woreda (District) Level:

planning, implementing, M&E of all interventions including
• LLINs distribution,
• IRS operation,
• case management,
• surveillance,
• IEC/BCC and LSM activities,
• stratification of the Kebeles/villages,
• providing resources,
• Conducting supportive supervision, and guiding intervention activities.
• Collaborate with Woreda council and other sector organizations to monitor and contain
epidemics, collect and report all relevant information.
ORGANIZATION AND FUNDING: ROLE AND
RESPONSIBILITY

Health Facilities (Hospitals, Health Centers and Health Posts):

• Diagnosing all suspected cases and treating all confirmed
malaria cases as per the national guidelines.
• Responsible to participate on malaria programme activities
conducted at community level. They will work by using the
established PHCU linkage for referral and reporting of relevant
data and feedback.
ORGANIZATION AND FUNDING: ROLE AND
RESPONSIBILITY

Community level:
• The health extension worker (HEW) works and lives within or
near the community.
• HEW in collaboration with the WDA uses the community
structures and networks to mobilize the community on malaria
programme activities (e.g environmental management, LLINs
distribution and utilization, etc)
ORGANIZATION AND FUNDING

MALARIA PROGRAM FUNDS

Ethiopia receives significant funding from development partners
for the health sector including the NMEP.
• Domestic funding for the health sector are largely allocated for
covering recurrent expenditures, such as salaries and human
resource development (including, notably, the training and
salaries )
• Development partners have largely financed fixed costs and
commodity inputs (e.g. ITNs, ACTs, RDTs, etc.).
ORGANIZATION AND FUNDING: TYPES

TYPES OF ORGANIZATION FUNDING MALARIA CONTROL

 Domestic: government budget
 Other Funders
• Global Fund/Malaria
• PMI/USAID
• African leaders malaria Alliance (ALMA)
• Bill and Melinda Gates Foundation
• Catholic Relief Services (CRS)
• Goodbye Malaria
• Malaria no more
• Rotary International
• United Against Malaria
ORGANIZATION AND FUNDING: MAJOR INPUTS

Major inputs for malaria control financing can be split into

two general categories:

1. Federal level program and operational expenditures

(other than commodity procurement and distribution
costs)
2. Regional and woreda level expenditures. Insecticidal
nets and IRS,
Achievements
Mortality and morbidity attributed to
malaria has declined significantly in the
past years
ACHIEVEMENTS: CHANGES IN MORTALITY
10
9
2016
8
0.9 : 100,000 2020
7
0.3 : 100,000
6
5
4
3
2
1
0

Death due to malaria has declined by 67% from 0.9/100,000 population to

0.3/100,000 population at risk between 2016 and 2019.
ACHIEVEMENTS: CHANGES IN PARASITE
INCIDENCE
100
90
2016
80
19 : 1000
70 2020
60 12 : 1000
50
40
30
20
10
0

Similarly, the annual parasite incidence has declined by 37% from 19/1000
population to 12/1000 population between 2016 and 2019.
ACHIEVEMENTS: VECTOR CONTROL

• Various activities have been performed to

control malaria vectors such as distribution
of Long-lasting Insecticide-Treated Nets
(LLITNs) and Indoor Residual Spraying (IRS)
spraying.

• A survey showed that LLITN coverage of

households with at least one net was 64.8%
in 2017 and 67% in 2020.

• IRS coverage increased from 20.0% in 2007

to 92.5% in 2016 in targeted areas
ACHIEVEMENTS: MALARIA CASE MANAGEMENT

• Rapid Diagnostic Tests (RDT) and microscopy

tests for suspected malaria cases has
increased significantly.

• Malaria drug availability has increased over

the years.
ACHIEVEMENTS: Social and Behavior Change Communication

• In the last five years, numerous SBCC

activities have been implemented and
various platforms were used to reach the
community

• “Zero malaria starts with me” campaign was

launched, which renewed the government’s
commitment in the fight against malaria.
CHALLENGES
CHALLENGES

• Suboptimal quality of diagnostic microscopic tests

and limited External Quality Assessment (EQA)
• Delay in procurement and intermittent stock outs
of antimalarial drugs
• Low utilization rate of ITNs;
CHALLENGES

• Low treatment seeking behavior;

• High influx of seasonal migrant workers, internally
displaced people and refugees to malaria areas
• Lack of kebele-level mapping and stratification of
malaria
CHALLENGES

• Inadequate implementation of insecticide-

resistance monitoring and management strategy
• Lack of entomologic database
• Insufficient malaria program organizational
structure and inadequate staffing and capacity at
all levels
WAY FORWARD
WAY FORWARD

• Perform mapping of the geographical distribution of all

malaria vectors and execute appropriate vector control
interventions
• Develop and implement a strategy to address malaria in
special group of people such as migrants, refugees, etc.
• Ensure the implementation of strong quality assurance
for malaria diagnosis and treatment (including using
External Quality Assessment)
WAY FORWARD

• Ensure uninterrupted supply of antimalarial

commodities and good stock control management
practices
• Ensure community ownership and engagement in all
malaria related planning and implementation through
appropriate community sensitization and mobilization
channels
• Conduct operational research projects aimed at malaria
prevention and control to guide program decisions.
WAY FORWARD

• Restructure the national malaria program management

to achieve a higher quality of implementation (e.g.
human resource, finance and logistics)
• Establish a surveillance system to enhance real-time
data reporting and to track the key indicators.
Considering what is achieved so far and future efforts, malaria
could possibly be eliminated from Ethiopia once and for all
THANKS!
References:
1. U.S. President’s Malaria Initiative Ethiopia Malaria
Operational Plan FY 2020. Retrieved from (www.pmi.gov)
2. WHO (2010). Annual Report 2010. WHO Ethiopia's country
office. Addis Ababa.
3. Sheleme Chibsa ( 2007). Malaria Vector Control Efforts and
Challenges in Ethiopia: Ethiopia4thWIN Meeting. Basel
Switzerland.
4. MoH (2013) Report [ Mahalet will complement the source ]
5. PMI 2020
6. Malaria epidemiology and interventions in Ethiopia from
2001 to 2016, Infectious Diseases of Poverty, Hiwot S Taffese
et. Al, Article number: 103 (2018)

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