THE PROBLEM
Malaria in Ethiopia is one of the leading causes of death (21.8 percent), consultation in outpatient departments (17.8 percent) and hospital admissions (14.1 percent) (Reference Adhanom, Deressa, Witten, Getachew, Seboxa, Berhane, Haile-Mariam and Kloos2;14). To overcome this problem, the Malaria Control Program (Federal Ministry of Health) has designed a community-based malaria treatment approach that played key roles in malaria epidemic control and community mobilization as well as vector control operations. In this approach, Community Health Workers (CHWs) and Village Malaria Workers, volunteers selected by community and trained on malaria diagnosis and treatment as well as indoor residual spray for few days (Reference Temiess16). However, sustainability of this approach has been a challenge to the malaria control program. Thus, institutional arrangements in which every Kebele (the smallest administrative unit of 5,000 people) has a health post staffed by two Health Extension Workers (HEW) as part of the country's health system is a breakthrough to strengthen malaria control. A study has shown that more than half of the patients with fever visit CHWs and private health facility services (Reference Deressa, Ali and Enqusellassie4).
In Ethiopia, unlike in many parts of Africa, Plasmodium vivax accounts for 30–40 percent of the confirmed malaria cases reported annually (Reference Gebre-Mariam8;14;Reference Tulu17). This makes confirmation of cases crucial to render appropriate and effective malaria treatment at health facilities, including health posts. For the treatment of P. vivax, chloroquine is still effective and widely used (7;13;Reference Teka, Petro and Yamuah15). The provision and scaling up of artemisinin-based combination therapies (ACTs) along with rapid diagnostic tests (RDTs) at the village level in Ethiopia has been implemented through HEWs over the past 3 years. There are now more than 30,000 HEWs with formal basic primary health care training deployed throughout the country. Two HEWs are assigned for every 5,000 people, and they are fully integrated with the health system as part of the regular workforce (Reference Kong and Brown11;Reference Temiess16).
Low health service utilization and inadequate diagnosis and treatment of malaria could be attributed to the following: (i) Many malaria cases are treated outside the formal health sector, for example, in shops and open markets, and given ineffective non-ACT treatments; (ii) Private pharmacies and drug stores may sell counterfeit artemisinin-based combination therapies (ACTs), as ACT price is high and not widely available; (iii) There is inadequate follow-up and supportive supervision of HEWs generally, and particularly for malaria prevention and control (Reference Kitaw, Ye-Ebiyo, Said, Desta and Teklehaimanot10). As a consequence, accurate diagnosis with RDTs and recognition of the clinical symptoms of malaria is often not adequate; (iv) Supportive supervision to strengthen disease management and diagnosis with RDTs by both HEWs and health facilities has not been well coordinated; (v) There are not adequate mechanisms and systems for quality assurance of malaria microscopic diagnostic procedures by health facilities or diagnostic procedures by HEWs using RDTs; (vi) Community initiatives to improve awareness and health seeking behavior through HEWs (or other means) are not widely implemented; and (vii) Although there are now more than 2,000 private clinics and pharmacies across the country, the role of the private health sector and reporting mechanism is not explicitly defined in the current national malaria diagnosis and treatment guideline. Working with the private sector has a large potential in scaling up and achieving universal access to ACTs, if done properly.
POLICY OPTIONS
Three policy options that could improve access to ACTs are as follows: (i) rescheduling ACTs to be over-the-counter, (ii) engaging the private sector, and (iii) follow-up and supportive supervision of HEWs. These three options are described in Table 1.
Table 1. Policy Options
Home-based malaria treatment as part of the malaria control strategy in Ethiopia was challenged with the shift to ACTs in 2004 (Reference Teka, Petro and Yamuah15). Evidence of treatment-seeking behavior of malaria patients because the switch to ACTs is limited. However, previous studies found that a considerable portion of the population practiced self-treatment of malaria in rural areas (Reference Deressa, Shelleme and Olana5). Thus, it is particularly important to improve access to ACTs in these areas. Another study before the switch to ACTs found a major reduction in under-5 years of age mortality through teaching mothers to provide home treatment (Reference Kidane and Morrow9). A study in northern Ethiopia supported by WHO and Novartis evaluated the effect of deployment of ACTs with simple RDTs at the community level. The results were promising, especially for the rural poor who live far away from a clinic or health post (Reference Enserink6). Scaling up of home-based management of malaria has also been found to be feasible and effective in other settings (Reference Marsh, Mutemil and Willetts12;18).
Rescheduling ACTs to Be Over-the-Counter
Allowing over-the-counter sales of ACTs and increasing the number of licensed private pharmacies combined with training private drug retailers and purchasers could improve the availability of ACTs and effective early presumptive treatment for childhood fevers (Reference Abuya, Mutemi, Karisa, Ochola, Fegan and Marsh1).
Engaging the Private Sector
A considerable number of patients seek malaria treatment from private clinics (Reference Enserink6;Reference Temiess16). Not providing the private sector with ACTs has created an environment that is conducive to the distribution and marketing of ineffective and counterfeit drugs. Engaging the private sector by allowing ACTs to be prescribed and then dispensed in public health facilities; and subsidizing the drug price for those institutions that can dispense the drugs would also contribute to early treatment and scaling up the use of ACTs.
Follow-up and Supportive Supervision of HEWs
The Health Extension Program (HEP) in Ethiopia provides a package of basic and essential preventive and curative health services targeting households in a community. The aim is to improve families’ health status with their full participation, consistent with the principles of primary care laid out in the Alma Ata Declaration (3). The objectives or the program of HEP are to improve access and equity in essential health services provided at the village and household levels (Reference Temiess16). Malaria treatment is included as part of the program. Effective malaria treatment requires a correct diagnosis and patients’ adherence to treatment. Supportive supervision, including monitoring and evaluation of the quality of care, and promoting awareness in the community could improve appropriate delivery and utilization of ACTs by HEWs, especially in rural areas (Reference Zuvekas, Nolan and Tumaylle19).
IMPLEMENTATION OF THE POLICY OPTIONS
Barriers to implementing the three policy options and strategies for addressing these are described in Table 2.
Table 2. Implementation of the Policy Options
DISCUSSION
The policy brief summarized here was a result from a 3-day meeting convened in Addis Ababa, Ethiopia, February 18–22, 2008, at the Ethiopian Health and Nutrition Research Institute (EHNRI). The policy actions proposed were widely discussed and agreed among relevant experts in the Federal Ministry of Health and Malaria National Program Officers at the WHO Country Office and other stakeholders. The proposed policy actions, particularly the action related to increasing access to malaria diagnosis and treatment services through trained CHW, has been pilot tested, and there is a great deal of information that will help implement this action. Improving access to effective ACTs over-the-counter at affordable prices, efforts to strengthen the role of the private sector, and strengthening follow-up and supportive supervision of HEW are the other three policy actions that are planned to be implemented.
It is believed that there are sufficient in-country resources from existing Global Fund to Fight Aids, Tuberculosis, and Malaria malaria grants (Round 5 and Round 8) and from other partners to support the initial launch of these policy actions. To further strengthen the resources required for the full implementation of these policy actions, the Federal Ministry of Health will coordinate the essential actions.
CONTACT INFORMATION
Amha Kebede, MSc, PhD (ehnriddirector@ethionet.et), Deputy Director General, Department of Research & Technology Transfer, Adugna Woyessa, MSc, Medical Parasitology (adugnaf@yahoo.com), Malaria Epidemiology Researcher, Kelbessa Urga, MSc (Kelbessaurga@yahoo.com), Director, Department of Vaccine & Diagnostic Production, Tsehaynesh Messelle, MSc, PhD (ehnridirector@ethionet.et), Director General, Daddi Jima, MD, MPH (daddi_jima@yahoo.com), Deputy Director General, Public Health Emergency Management Center, Ethiopian Health and Nutrition Research Institute, Patriots’ Street, P.O. Box, 1242, Addis Ababa, Ethiopia
