Control of disease is center to country's health strategy.
Progress includes declines in deaths, cases, and admissions.
World Bank and partners working to close gaps in fighting disease.
April 24, 2008—Approximately 53 million Ethiopians (63 percent of the population) live in malaria-risk areas. Of these, 33 million – almost 40 percent of the total population – are in endemic areas, and nearly one quarter of Ethiopians reside in endemic-prone areas.
Malaria is a leading cause of death in children and adults. In 2000 alone it killed over 29,000 children, equivalent to almost 80 children per day. In a country where 81 percent of the population lives on less than two dollars a day, reversing the spread of malaria and its destructive impact on poor households and their livelihoods is a formidable challenge.
The Ministry of Health has taken on that challenge
In the past five years, the Government of Ethiopia has put malaria control at the heart of its health sector strategy, with a scaled-up approach adopted in 2005. In a country the size of France and Spain combined and with terrain that stretches across rocky mountains, arid desert, and rainforest, and which, at times, faces political uncertainty, this is no mean feat.
A recent WHO rapid impact assessment (November/December 2007) in four main regions in Ethiopia recorded the following findings for 2001-7 for children of all ages.
There has been a 67 percent decrease in confirmed malaria outpatient cases,
a 54 percent decline in malaria admissions, and
a 55 percent decrease in malaria deaths.
The decrease in malaria cases can be compared with results of non-malaria incidences in this table:
Table 1. Weighted mean percentage of malaria cases in children 2001-2007, Ethiopia
Historically, since malaria has accounted for a large proportion of deaths among children below the age of 5, these recent achievements have meant that thousands more children are reaching their fifth birthday than in previous years.
This success may also mean that in the near future there may be a shift in Ethiopia’s malaria transmission status from moderate-low to very low. Moreover, achieving control over malaria epidemics will free up resources for improving healthcare service delivery elsewhere in Ethiopia, helping the country to meet its other health-related Millennium Development Goals.
Which activities did Ethiopia undertake to achieve this?
Ethiopia’s malaria control program took a three-pronged approach.
Insecticide-Treated Nets (ITNs) Less than five years ago, Ethiopia was lagging behind many countries in Africa, with less than 5 percent of households owning even a single mosquito bed net. In 2004 the Government set itself an ambitious target: to ensure every household in a malaria-risk area owns two long-lasting, insecticide- treated nets (ITNs) – a total of 20 million nets. At an estimate of an average of five members per household, this intended to achieve almost 95 percent coverage by mid- 2008. By January 2008, Ethiopia had exceeded this target. As of March 2008, 20,492,318 ITNs have been distributed. This represents a three-fold increase in bed net distribution since 2005. Every one of the nine regions or city-states receiving nets met its goal and in five of the regions/city-states these were exceeded.
Artemisinin Combination Therapy (ACT) In mid-2005, the Government embarked on administering six million doses of the anti-malaria drug Coartem. This will cover up to 2.2 million newly identified malaria cases. ACT has been made available to all health facilities and communities and no stock outs have been reported.
Indoor Residual Spraying (IRS) Up to the end of 2005 this was the primary intervention for vector control with coverage of 30 percent of the population at risk. Today the impact of IRS is even greater because it is working in tandem with both ITNs and ACTs. However, implementing IRS is difficult, partly because of Ethiopia’s terrain. Spray technicians often use horseback or donkey in order to reach the most remote households.
“Malaria control is really improving, especially compared with the last three years,” according to Dr. Daddi Jima, head of the Government’s National Malaria Control Program. “The overall declining trend in the epidemic situation is showing a very significant decline.”
Sources: Ministry of Health, Ethiopia. Note that Addis Ababa is not a malaria-prone area and therefore is not covered in the national ITN distribution program.
How has Ethiopia achieved such success?
Leadership. Meeting ambitious targets demands commitment and effective management. The success of the malaria initiatives can be attributed to the exceptional leadership of the Government. In the face of political, logistical, and financial difficulties, enormous strides in progress are still possible.
Partnership. The Government’s malaria initiative has been fully supported by donors and it is this joint approach with a ”can do, will do” attitude that has contributed to the success. Multilateral and bilateral donors are working together to align with the Government’s system, provide technical support, particularly in logistics and planning and to fill resource gaps wherever necessary. This was only possible because of guidance from the Ministry of Health and it remains very much a Government-led process.
Pragmatism. The Government has undertaken a realistic assessment of the country’s capacity for health service delivery. To fulfill its pledge to combat malaria, the MOH has temporarily outsourced some delivery of malaria-prevention services to those with an increased ability to handle it, while national capacity for service-delivery is built.
Dr. Daddi notes that the decline in malaria prevalence “directly correlates with the scale of [anti-malaria] interventions, of Coartem [an ACT], and ITN distribution.”
This scale-up corresponds with the introduction of the multi-million-dollar, multi-donor Protection of Basic Services (PBS) project. In 2006, several donors (AfDB, CIDA, DFID, EC, Irish Aid, KfW, Netherlands, and the World Bank) committed around eight hundred million dollars for the PBS project, while Government also scaled up its financing for services. The majority of this money is channeled to local districts, to support the provision of basic education, agriculture, water and sanitation, and, of course, health services. In the PBS donor-partners have agreed to harmonize their reporting and financial management requirements around country systems. Around US$80 million of World Bank and other donor resources have been assigned via the PBS to support the federal government in fulfilling its responsibilities in health service delivery. This delivery is primarily for the purchase of commodities, including ITNs, ACTs, indoor spraying services, medical equipment, vaccines, and contraceptives, as well as capacity building. Donors have provided over $22 million for malaria control alone, and this has enabled the IRS program to be revitalized, the free distribution of Coartem, as well as free distribution of over 3 million bed nets so far.
The World Bank’s contribution to reducing malaria in Ethiopia
The World Bank is committed to supporting the Government to meet its malaria control goals. The World Bank has provided over US$11 million via the PBS for anti-malaria commodities. In addition, in late 2007, a sudden gap in financing for malaria commodities came about, when expected resources were not forthcoming. The Bank was able to step in to bridge this gap by providing a further US$12 million for malaria via the PBS. This demonstrates the Bank’s responsiveness and the joint approach of the international community, which works to cover gaps in financing in order to ensure the Government is fully supported. As the PBS project reaches its second phase in the latter half of 2008, the World Bank and other partners will continue to work in a unified way under Government leadership to help Ethiopia meet its targets to combat malaria.
Where do gaps still exist?
Impact evaluation and monitoring of the healthcare system
Epidemic surveillance and response system: this needs to be restructured, but should improve when the new Health Monitoring Information System is functional.
Improving access to treatment
Scaling up Indoor Residual Spraying (IRS) to cover all regions
Ensuring the quality of IRS and improved targeting of spray areas, and the use of Insecticide-Treated Nets
Linkages within the health system. Targeting malaria demands attention to other aspects of health and poverty reduction.
Ensure provision of primary health care services, particularly by expanding the number of health extension workers (HEWs). The target is to deploy 30,000 HEWs by the end of 2009. The Government is on track. Over 24,000 HEWs were in place by February 2008.
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