I. EXECUTIVE SUMMARY
When it was launched in 2005, the goal of the President’s Malaria Initiative (PMI) was to reduce malaria-related mortality by 50% across 15 high-burden countries in sub-Saharan Africa through a rapid scale-up of four proven and highly effective malaria prevention and treatment measures: insecticidetreated mosquito nets (ITNs); indoor residual spraying (IRS); accurate diagnosis and prompt treatment with artemisinin-based combination therapies (ACTs); and intermittent preventive treatment of pregnant women (IPTp). With the passage of the Tom Lantos and Henry J. Hyde Global Leadership against HIV/AIDS, Tuberculosis, and Malaria Act in 2008, PMI developed a U.S. Government Malaria Strategy for 2009–2014. This strategy included a long-term vision for malaria control in which sustained high coverage with malaria prevention and treatment interventions would progressively lead to malaria-free zones in Africa, with the ultimate goal of worldwide malaria eradication by 2040-2050. Consistent with this strategy and the increase in annual appropriations supporting PMI, four new sub-Saharan African countries and one regional program in the Greater Mekong Subregion of Southeast Asia were added in 2011. The contributions of PMI, together with those of other partners, have led to dramatic improvements in the coverage of malaria control interventions in PMI-supported countries, and all 15 original countries have documented substantial declines in all-cause mortality rates among children less than five years of age.
In 2015, PMI launched the next six-year strategy, setting forth a bold and ambitious goal and objectives. The PMI Strategy 2015-2020 takes into account the progress over the past decade and the new challenges that have arisen. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s Strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and ending extreme poverty. It is also in line with the goals articulated in the Roll Back Malaria (RBM) Partnership’s second generation global malaria action plan, Action and Investment to defeat Malaria (AIM) 2016-2030: for a Malaria-Free World and WHO’s updated Global Technical Strategy: 2016-2030. Under the PMI Strategy 2015-2020, the U.S. Government’s goal is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.
Ethiopia was selected as a PMI focus country in fiscal year (FY) 2008.
This FY 2017 Malaria Operational Plan presents a detailed implementation plan for Ethiopia, based on the strategies of PMI and the National Malaria Control Program (NMCP). It was developed in consultation with the Federal Ministry of Health (FMOH), NMCP, Oromia Regional Health Bureau (ORHB), and with the participation of national and international partners involved in malaria prevention and control in the country. The activities that PMI is proposing to support align with the National Malaria Strategic Plan (NMSP 2014-2020) and build on investments made by PMI and other partners to improve and expand malaria-related services, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) malaria grants. This document briefly reviews the current status of malaria control policies and interventions in Ethiopia, describes progress to date, identifies challenges and unmet needs to achieving the targets of the NMCP and PMI, and provides a description of activities that are planned with FY 2017 funding.
The proposed FY 2017 PMI budget for Ethiopia is $38 million. PMI will support the following intervention areas with these funds:
Entomologic monitoring and insecticide resistance management:
Insecticide resistance in Ethiopia is a concern and Ethiopia is currently updating its national resistance monitoring and management strategy. The goals are to minimize insecticide selection pressure, ensure vector control interventions are guided by evidence, develop and implement a national plan for insecticide resistance monitoring and management, and provide timely analysis and interpretation of data. From 2014-2016, PMI supported entomological resistance monitoring of 11 insecticides from 4 insecticide classes in 8 permanent sites and mosquito behavior studies in 3 sites. The insecticide resistance monitoring test results show that local vectors are generally resistant to dichloro-diphenyltrichloroethane (DDT) and pyrethroids. With FY 2017 funds, PMI plans to continue the support of insecticide resistance surveillance and support the coordination of insecticide resistance data for more timely reporting and analysis of data.
Insecticide-treated nets (ITNs):
As per the NMSP 2014-2020, the FMOH conducted a mass campaign in 2015, distributing 29.6 million long-lasting insecticidal nets (LLINs) to protect all Ethiopians living in areas with ongoing malaria transmission, representing 60% of the total population. The Global Fund contributed the majority of the LLINs with PMI supporting the remaining gap. PMI cumulatively procured over 20 million LLINs between 2008 and 2015. With FY 2015 and FY 2016 funds, PMI plans to procure 6.2 million LLINs for distribution to high risk communities to replace lost nets and protect new households and new household members. With FY 2017 funds, PMI plans to procure an additional 4 million LLINs for distribution as part of Ethiopia’s 2018 universal coverage campaign. PMI also plans to support the development of a LLIN distribution tracking system and ensure all LLINs are reaching their intended users.
Indoor residual spraying (IRS):
The FMOH’s NMSP aims to provide 100% IRS coverage as a key malaria prevention measure in areas where malaria burden is high and in highland fringe areas with the potential for malaria outbreaks. According to the NMSP’s malaria stratification, which is based upon annual parasite incidence, about 17% of the population in the country will be targeted annually for IRS. PMI has been implementing IRS in Ethiopia since 2008 and has supported a comprehensive range of IRS-related activities, including targeting and enumeration of areas for IRS operations, improved logistical planning and support, environmental compliance monitoring, entomological surveillance, and technical assistance and operational support. The PMI-supported IRS program protected between 1 million to 2.9 million people annually since its launch. In 2015, PMI supported the spraying of 704,945 structures and protected 1,655,997 people from malaria in 36 districts of Oromia Region, achieving a 99.5% coverage rate. With FY 2017 funding, PMI will continue to support safe and effective IRS implementation within 36 high burden districts in the Oromia Region, in addition to continuing to provide limited IRS support to 34 graduated districts.
Malaria in pregnancy (MIP):
The FMOH’s NMSP does not support IPTp with sulfadoxine-pyrimethamine due to the relatively low intensity of malaria transmission in most of Ethiopia. Malaria in pregnancy in Ethiopia is addressed through improving prompt access to diagnostics and treatment, prioritization of LLIN use by pregnant women, and enhanced social and behavior change communication (SBCC) activities targeting pregnant women in malaria endemic areas. With FY 2016 funds, PMI will provide pre-service training for midwives and health extension workers (HEWs) to improve malaria case management services for pregnant women. With FY 2017 funds, PMI will continue to strengthen malaria case management of pregnant women at both the facility and community levels and ensure access to LLINs.
The NMSP aims for robust coverage of high quality diagnostic and treatment services universally, especially at public sector health facilities in rural areas in order to diagnose 100% of suspected malaria cases within 24 hours of fever, and treat all confirmed cases according to the national guidelines. Since the launch of PMI, a total of 6.24 million RDTs and 12.34 million ACT treatment doses have been procured. In addition, in collaboration with regional and district health offices, PMI has supported health worker training, mentoring and supervision for quality malaria diagnosis using microscopy, and the management of malaria at district-level health centers and community-level health posts through integrated community case management (iCCM). Coordinating with Global Fund, no additional procurement of ACTs with FY 2017 funding is planned. With FY 2017 funds, PMI plans to procure 513,000 RDTs and other non-ACT antimalarials, will continue to strengthen case management activities in the public and private sector in microscopy strengthening, and will conduct therapeutic efficacy monitoring.
Health systems strengthening and capacity building:
As outlined in the NMSP, substantial resources are needed to strengthen health systems and to provide capacity building for malaria control in Ethiopia. PMI has historically strengthened the health systems in Ethiopia through support to pharmaceutical management and logistics systems, including quantification of malaria commodities (through the micro-plan), strengthening routine malaria surveillance systems, and building the capacity of health staff through both pre-service and in-service training. Additionally, PMI has supported the training of Ethiopian Field Epidemiology Training Program (EFETP) residents in outbreak investigation and response. With FY 2017 funds, PMI will provide coordination support for ORHB as well as nationally, EFETP training and pre-service training of HEWs for malaria prevention and control activities.
Social and behavior change communication (SBCC):
In the NMSP 2014–2020, the SBCC objective states that “By 2020, all households living in malaria endemic areas will have the knowledge, attitudes and practices towards malaria prevention and control.” In order to achieve this objective, the NMSP will utilize HEWs, health development armies (HDAs), and model family households to deliver SBCC interventions. In 2013, through the USAID/Ethiopia Local Capacity Development program, PMI initiated and supported two local organizations’ community-based malaria SBCC activities that targeted school children and religious leaders. In addition, starting in July 2015, PMI funded SBCC activities that utilized an integrated campaign platform, which organizes health messaging including malaria in a coherent and coordinated way through multiple channels to support community-based health workers. With FY 2017 funds, PMI plans to continue supporting SBCC capacity building, coordination, message harmonization, and schoolbased SBCC activities that promote malaria prevention and control with a focus on migrant populations.
Surveillance, monitoring and evaluation (SM&E):
According to the NMSP, high priority malaria SM&E activities through 2020 for Ethiopia include: national household surveys such as the Malaria Indicator Survey (MIS), strengthening surveillance data management capacity, supporting routine surveillance in 40 districts in Oromia, monitoring LLIN durability, conducting annual program review meetings to examine malaria data, and bi-annual supportive supervision. PMI has historically provided substantial financial resources and technical assistance for many of these SM&E activities, including support for Ethiopia’s Public Health Emergency Management (PHEM) system, the MIS in 2007 and 2011, and the recently completed 2015 MIS. PMI’s ongoing support to routine malaria surveillance aims to enhance reporting from rural health posts where half of all malaria morbidity is detected and treated. The annual micro-plan collects comprehensive malaria burden and commodities quantification data. With FY 2017 funds, PMI will continue to strengthen the PHEM system and epidemic reporting as well as the national malaria microplan.
Operational research (OR):
PMI has supported OR in Ethiopia to address key program bottlenecks especially in building the evidence to improve Plasmodium vivax case management. Through FY 2014, PMI has supported operational research projects including assessments of drug adherence, glucose-6-phosphate dehydrogenase deficiency prevalence, malaria serology studies exploring relationships between schoolbased children and community malaria prevalence by RDT and microscopy and health facility-based surveillance, and the role of serology in MIS in low transmission settings. With FY 2015 and 2016 funding, PMI is planning operational research projects to evaluate targeted mass drug administration and reactive case detection on malaria transmission and elimination in Ethiopia, hematologic monitoring to assess the safety of the use of primaquine radical cure for P. vivax, and monitoring mosquito and human behavior to better understand malaria transmission in agricultural development areas in Ethiopia. No OR is planned with FY 2017 funding.