Ethiopia Malaria Financial Landscape

Ethiopia Malaria Financial Landscape PATH MACEPA DECEMBER 2015 MALARIA FUNDING IN ETHIOPIA AT A GLANCE The total estimated cost to implement Ethiopia s National Malaria Strategic Plan (NMSP) for 2015 2017 is $451,843,460. Total committed malaria funding for 2015 2017 is estimated to be approximately $438 million. 1 The US President s Malaria Initiative (PMI) estimates that at projected funding levels Ethiopia will face a long-lasting insecticidal net (LLIN) gap of approximately 3.8 million in 2017. PMI estimates that at projected funding levels there will be surpluses of artemisinin-based combination therapy (ACT) supplies and rapid diagnostic tests (RDTs) for each year from 2015 2017. The Government of Ethiopia plans to commit $66,065,284 or nearly 15 percent of the total funding requirement toward malaria control and elimination activities for 2015 2017. Ethiopia s domestic malaria spending has increased significantly over the past 15 years. Projected 2015 malaria funding of $21,321,519 represents a 247 percent increase over the 2010 spending level of $6,144,036 and a more than tenfold increase over the 2001 spending level. BACKGROUND The funding requirements for the Government of Ethiopia s National Malaria Control Program are based on the goals and objectives included in its 2014 2020 National Malaria Strategic Plan (NMSP). 2 Ethiopia s 2014 2020 National Malaria Strategic Plan Goals (1) By 2020, to achieve near zero malaria deaths (no more than 1 confirmed malaria death per 100,000 population at risk) in Ethiopia. (2) By 2020, to reduce malaria cases by 75 percent from baseline of 2013. (3) By 2020, to eliminate malaria in selected low-transmission areas. 2014 2020 National Malaria Strategic Plan Objectives (1) By 2020, all households living in malaria endemic areas will have the knowledge, attitudes, and practice toward 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 2015 and beyond, 100 percent of confirmed malaria cases are treated according to the national guidelines. (4) By 2015 and beyond, ensure and maintain universal access of the population at risk to at least one type of globally recommended anti-vector intervention. (5) By 2020, achieve and sustain zero indigenous transmission of malaria in 50 selected districts. (6) By 2020, 100 percent complete data and evidence will be generated at all levels within designated time periods to facilitate appropriate decision-making. The 2014 2020 NMSP also identifies priority interventions in the areas of community empowerment and mobilization, diagnosis and treatment, prevention/vector control, surveillance, monitoring and evaluation, and malaria elimination, including: Diagnosing all suspected malaria cases. Sustaining universal coverage of effective and efficacious treatment as per national guidelines. Achieving universal coverage and improving utilization of long-lasting insecticidal nets. Improving immediate notification, case and foci investigation, and classification. Reducing number of active foci and locally acquired cases to zero, and halting and sustaining zero local transmission in selected areas. 1 All dollar values represent US dollars. 2 Federal Democratic Republic of Ethiopia, Ministry of Health. National Malaria Strategic Plan 2014 2020. ETHIOPIA MALARIA FINANCIAL LANDSCAPE 2015 DECEMBER 2015 PAGE 1

Strengthening capacity of surveillance and monitoring and evaluation activities, and undertaking routine and periodic data collection and analysis. Ensuring timeliness, completeness, and quality of data. 3 ETHIOPIA S MALARIA FINANCING REQUIREMENTS The total estimated cost to implement the 2014 2020 NMSP is $973,884,080, which would amount to approximately $139,126,000 annually if spent evenly across all years. 4 The 2014 2020 NMSP estimates that $336,214,359 (34.5 percent) will be allocated for long-lasting insecticidal nets, $280,681,801 (28.8 percent) for indoor residual spraying; $163,877,879 (16.8 percent) for diagnosis and case management, $92,321,189 (9.5 percent) for advocacy, communication, and social mobilization, $61,698,360 (6.3 percent) for program management, $14,995,686 (1.5 percent) for elimination activities, and $24,094,806 (2.5 percent) for monitoring and evaluation and surveillance. Commodity procurement is estimated to account for nearly three-quarters (74.5 percent) of the total cost. 5 Ethiopia s 2015 2017 Global Fund Concept Note for malaria states that the total estimated cost to implement the NMSP for 2015 2017 is $451,843,460. 6 It is estimated that over 50 million Ethiopians or approximately 60 percent of the population live in areas of malaria risk. 7 Given the large at-risk population, NMSP implementation involves substantial commodity, health system, and program management costs. Ethiopia requires approximately 40 million LLINs to carry out the planned 2015 mass distribution campaign in at-risk areas and to fund continuous LLIN distribution in 2016 and 2017. The NMSP objective to provide prompt diagnostic testing for all suspected malaria cases is estimated to require approximately 36.3 million RDTs for 2015 2017, while the objective to treat all confirmed malaria cases according to national guidelines will require the procurement of more than 8 million ACT courses. 8 ETHIOPIA S MALARIA FINANCING COMMITMENTS HISTORICAL Ethiopia s domestic malaria spending has increased significantly during the past 15 years. Projected 2015 malaria funding of $21,321,519 represents a 347 percent increase over reported spending of $6,144,036 in 2010 and a more than tenfold increase over reporting 2001 spending of $2,119,140. 9 Ethiopia receives financial support for the prevention, control, and elimination of malaria from donor partners, notably the Global Fund and PMI. Other historic supporters include the World Bank, World Health Organization (WHO), and UNICEF, as seen in Table 1. PMI support PMI began operating in Ethiopia in 2008, and since then has contributed between $20 million and $45 million annually to Ethiopia s malaria efforts. 10 PMI s proposed budget for Ethiopia in Fiscal Year 2016 is $40 million. 11 3 For the list of priority interventions, see National Malaria Strategic Plan 2014 2020, Federal Democratic Republic of Ethiopia, Ministry of Health. 4 Federal Democratic Republic of Ethiopia, Ministry of Health. National Malaria Strategic Plan 2014 2020, p. XIII. 5 Federal Democratic Republic of Ethiopia, Ministry of Health, National Malaria Strategic Plan 2014 2020, p. XIII. Regarding funding for elimination activities, the NMSP states that the key objective of the strategy is the development of elimination methodologies to be implemented in 50 target Woredas. This activity is planned for and costed with 25 Woredas in 2015 and another 25 in 2017. The total cost is $15 million including all diagnosis and treatment supplies. Federal Democratic Republic of Ethiopia, Ministry of Health. National Malaria Strategic Plan 2014 2020, p. 53. 6 2015 2017 Global Fund Concept Note submission for Ethiopia, pgs. 12, 23. 7 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, p. 12. 8 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, pgs. 25, 41, and 42. 9 World Health Organization. World Malaria Report 2012. Annex 3, Funding for Malaria Control, 2000 2011. 10 US President s Malaria Initiative. FY 2015 Ethiopia Malaria Operational Plan, pgs. 5 6. 11 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, p. 6. ETHIOPIA MALARIA FINANCIAL LANDSCAPE DECEMBER 2015 PAGE 2

Global Fund support The Global Fund began funding malaria control activities in Ethiopia in 2003. As of 2015, it has disbursed approximately $513 million in support of malaria control efforts in Ethiopia. 12 Table 1. Historical Contributions to Malaria Control, 2009 2014 13 Year Domestic PMI/USAID Global Fund World Bank WHO UNICEF 2009 $3,456,244 $22,500,000 $121,000,000 $10,090,000 $280,000 $5,000,000 2010 $6,144,036 $33,500,000 $28,300,000 $9,900,000 $210,960 $1,297,858 2011 - $41,400,000 $51,900,000 - $171,357 $27,243 2012 - $41,500,000 $23,800,000-0 - 2013 $19,705,028 $43,770,000 $113,140,000 - $111,677-2014 - $45,000,000 $9,890,472 - - - MALARIA FINANCING COMMITMENTS 2015 2017 Ethiopia is projected to commit $66,065,284 toward malaria control and elimination activities for the period 2015 2017. 14 The funding is expected to cover more than $10 million for indoor residual spraying (IRS) activities; $34 million for advocacy, communication, and social mobilization (ACSM); and $20 million for program management (see Table 2). Domestic financial commitments will be used to assure the distribution and utilization of LLINs, promote community engagement to support IRS implementation, promote program management and administration, and procure antimalarial drugs. 15 Table 2. Total Projected Domestic Commitment, 2015 2017 16 2015 2016 2017 Total Indoor residual spraying (IRS) $3,917,217 $3,416,628 $3,539,865 $10,873,710 Antimalarial drugs $180,385 $118,206 $42,657 $341,248 Advocacy, communication, and $10,670,166 $11,695,380 $12,117,230 $34,482,776 social mobilization (ACSM) Program management $6,553,752 $6,789,453 $7,034,347 $20,377,551 Total $21,321,519 $22,019,667 $22,734,098 $66,075,284 Figure 1. Total Projected Domestic Commitment by Intervention Type, 2015 2017 Program Management 31% IRS 16% Antimalarial Drugs 1% ACSM 52% 12 Global Fund website, Ethiopia page. http://portfolio.theglobalfund.org/en/country/index/eth. 13 World Health Organization. World Malaria Report 2013. Annex 3, Funding for Malaria Control, 2008 2012. World Health Organization. World Malaria Report 2014. Annex 3, Funding for Malaria Control, 2011 2013. World Health Organization. World Malaria Report 2015. Annex 3, Funding for Malaria Control, 2012 2014. 14 15 16 2015 2017 Global Fund Concept Note submission for Ethiopia, p. 17. ETHIOPIA MALARIA FINANCIAL LANDSCAPE DECEMBER 2015 PAGE 3

Table 3. Concept Note Funding Estimate, 2015 2017 17 Funding source Total Percentage of total 2015 2017 funding requirement estimated in Global Fund Concept Note Domestic resources $66,075,284 15% External resources $222,770,447 49% New Funding Mechanism (NFM) allocation request $126,685,556 28% Above allocation $36,312,173 8% Total funding requirement $451,843,460 100% In June 2015, the Global Fund approved a grant of $115,599,987 to support malaria control efforts in Ethiopia during the 2015 2017 period. When in-country cash balances from the previous grant and implementation period are taken into account, the total Global Fund malaria program budget for Ethiopia is $148,752,983. 18 Combining the Global Fund program budget with the Concept Note funding estimates for other partners shows that total malaria funding for 2015 2017 is estimated to be approximately $438 million. Table 4. Total Projected Malaria Funding, 2015 2017 Funding source Total Percentage of total 2015 2017 funding requirement estimated in Global Fund Concept Note Domestic resources $66,075,284 15% External resources $222,770,447 49% (including PMI but not Global Fund) Global Fund $148,752,983 33% Total funding commitments $437,598,714 97% COMMODITY GAP ANALYSES 2015 2017 PMI developed gap analyses for key malaria commodities in its FY 2016 Malaria Operational Plan for Ethiopia. These gap analyses use the 2015 2017 Concept Note commodity requirement estimates as well as the expected Global Fund procurements for 2015 2017 based on the Transitional Funding Mechanism (TFM) and New Funding Mechanism (NFM) malaria allocations for Ethiopia. The tables below summarize the PMI gap analysis estimates for 2015 2017. PMI estimates that at projected funding levels Ethiopia will face a gap of approximately 3.8 million LLINs in 2017. PMI estimates show RDT and ACT surpluses for each year from 2015 2017. 19 Table 5. PMI Long-Lasting Insecticidal Net (LLIN) Gap Analysis, 2015 2017 20 Population targeted for net coverage 53,252,086 54,636,640 56,057,192 Total LLIN requirement 29,584,492 3,135,956 6,956,971 Total LLINs available (all sources) 29,584,492 4,785,000 5,649,044 Estimated LLIN gap (surplus) 0 (1,649,044) 21 3,756,971 17 18 Global Fund website, Funding Decisions page. http://www.theglobalfund.org/en/fundingdecisions/. 19 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, pgs. 25, 41 and 42. 20 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, p. 25. 21 Surplus 2016 LLINs to be carried over for use in 2017. ETHIOPIA MALARIA FINANCIAL LANDSCAPE DECEMBER 2015 PAGE 4

Table 6. PMI Rapid Diagnostic Test (RDT) Gap Analysis, 2015 2017 22 Total number of projected 10,665,023 10,665,023 10,665,023 fever cases Percent of fever cases confirmed by RDT 47% 47% 47% Total RDT requirement 12,102,764 12,102,764 12,102,764 Total RDTs available (all sources) 12,963,540 14,909,950 12,950,762 Estimated RDT surplus 860,776 2,807,186 847,998 Table 7. PMI Artemisinin-Based Combination Therapy (ACT) Gap Analysis, 2015 2017 23 Target population at risk for malaria 59,247,046 60,787,469 62,367,943 Total projected number of 2,331,491 2,069,220 1,742,501 Plasmodium falciparum cases Total ACT needs 2,956,516 2,881,109 2,426,197 Total ACTs available (all sources) 5,054,280 5,889,854 5,532,345 Estimated ACT surplus 2,097,764 3,008,745 3,106,148 22 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, p. 41. 23 US President s Malaria Initiative. FY 2016 Ethiopia Malaria Operational Plan, p. 42. ETHIOPIA MALARIA FINANCIAL LANDSCAPE DECEMBER 2015 PAGE 5