NOTABLE EVENTS IN NATIONAL POLICY AND FINANCING FOR MALARIA

Malaria Policy Landscape PATH MACEPA JULY 2016 OVERVIEW API 2014 PATH MACEPA has been working in partnership with s Federal Ministry of Health (FMOH) since 2007 and the Amhara Regional Health Bureau (ARHB) since 2013. Administratively, is divided into regional states, zones, districts (woredas), and villages (kebeles). The country has a decentralized health system that, since 2005, has been strengthened with the establishment and subsequent expansion of the Health Extension Program (HEP), allowing closer monitoring of epidemicprecipitating factors at the local level. Plasmodium falciparum and P. vivax are the two most dominant parasite species in. They are prevalent in all malaria-endemic areas in the country, with P. falciparum representing about 77 percent of the total reported malaria cases according to the most recent Malaria Indicator Survey (2011). 2015 Malaria Indicator Survey results are pending, and should be released in late 2016. In most parts of the country, the peak periods of transmission occur from September to November, following the main rainy seasons (June to September), and from May to June, following the small rainy season (March to May). API 0 Free >0 - <5 Low >5 - <10 Moderate <10 High 2015 2016 NOTABLE EVENTS IN NATIONAL POLICY AND FINANCING FOR MALARIA Development of National Malaria Elimination Guidelines (in progress, Q4 2015 Q1 2016) Update National Treatment Guidelines 2015 Malaria Indicator Survey (MIS) conducted. Development of Advocacy, Communication and Social Mobilization (ACSM) Guide for malaria elimination. Key national malaria planning activities Transmission Season Eth. Minor Transmission Season Transmission Season Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Development of elimination Development of National Malaria Development and launch of National Elimination Guidelines Malaria Elimination Strategy Update to national treatment guidelines to include PQ Development of NMSP 2017 2021 Malaria Indicator Survey 2015 ETHIOPIA MALARIA POLICY LANDSCAPE 2015 JULY 2016 PAGE 1

NATIONAL MALARIA POLICIES AND STRATEGIES 2014 2020 National Strategic Plan goals and targets s malaria strategy is described in its National Malaria Strategic Plan (NMSP) 2014 2020. In the current NMSP, has set the following high-level goals for 2020: Achieve near-zero malaria deaths (defined as less than 1 death per 100,000 population at risk). Reduce malaria cases by 75 percent from 2013 levels. Eliminate malaria (P. falciparum & P. vivax) in selected low-transmission areas. To work toward these goals, has outlined six strategic objectives, with accompanying targets to be achieved by 2020: Strategic objective Objective 1. By 2020, all households living in malaria-endemic areas will have the knowledge, attitudes, and practice toward malaria prevention and control. Objective 2. By 2017 and beyond, 100% of suspected malaria cases are diagnosed using RDTs or microscopy within 24 hours of fever onset. Objective 3. By 2015 and beyond, 100% of confirmed malaria cases are treated according to the national guidelines. Objective 4. By 2015 and beyond, universal access of the population at risk to at least one type of globally recommended anti-vector intervention is ensured and maintained. Objective 5. By 2020, zero indigenous transmission of malaria in 50 selected districts is achieved and sustained. Targets 100% of people living in malarious areas recognize/know the importance of using an LLIN. 100% of people living in IRS-targeted malarious areas recognize/know the importance of having their house sprayed. 100% of people living in malarious areas recognize/know the importance of early diagnosis and prompt treatment (within 24 hours of fever onset). 100% of health posts in malarious kebeles provide malaria-related outreach services, social communication, and mobilization. 100% of health facilities in malaria risk areas will provide RDTs and/or microscopy diagnostic service to sustain universal coverage of diagnosis. 100% of laboratory professionals at health facilities will receive training on malaria laboratory diagnosis. 100% of health extension workers (HEWs) will be trained on malaria diagnosis and treatment as part of iccm. 100% of health centers and hospitals shall be equipped with microscopes and other malaria laboratory commodities. Two university instructors of laboratory professionals will be trained from each university on malaria laboratory diagnosis to improve pre-service training. Community-level case management 100% of HEWs have the necessary skills and capacity to properly assess, classify, and manage common childhood illnesses. 100% of woreda health offices have the capacity to coordinate iccm. 100% of sick children targeted through the iccm approach will be managed as per the iccm guideline and protocol. 100% of HEWs will receive training on malaria diagnosis and treatment as part of iccm. Health center-level and hospital-level case management 100% of health facilities in malarious areas will be provided with ACTs and other anti-malarial medicines to sustain universal coverage of treatment. 100% health professionals in malarious areas will receive training on malaria diagnosis and case management. Long-lasting insecticidal nets Provide LLINs to all target population to reach and maintain 100% ownership of LLINs (100% of households in LLIN targeted areas own at least one LLIN per two persons). Achieve and maintain levels of use above 80% by all age and biological groups. Encourage local production of at least 3 million LLINs per year. Indoor residual spraying Achieve and sustain 100% coverage of IRS in targeted woredas or kebeles; Maintain 100% coverage of households sprayed in targeted woredas and kebeles. Larval control 100% of the breeding sites will be identified by HEWs and health development armies (HDAs) in the target communities. 100% of important breeding habitats in targeted areas will be eliminated or controlled through larval control methods. Zero indigenous malaria transmission achieved and sustained in the 50 selected districts. ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 2

NATIONAL MALARIA POLICIES AND STRATEGIES (continued) Strategic objective Objective 6. By 2020, 100% complete data and evidence will be generated at all levels within designated time periods to facilitate appropriate decision-making. Source: NMSP 2014 2020. Targets Control phase 100% of health facilities and health offices engaged in malaria control phase send weekly malaria report to the next higher level. 100% of health facilities in epidemic prone areas adhere to the national epidemic and response plan. 100% of health facilities in epidemic prone areas have developed epidemic thresholds defined by time period using all available past data of confirmed cases. 100% of health facilities and woreda health offices using epidemic monitoring charts based on confirmed cases. 100% of all detected malaria epidemics properly controlled per the national epidemic and response plan within two weeks of onset. Elimination phase 100% of facilities in the selected elimination districts will have standardized data capturing tools. 100% of the clusters/kebeles in selected elimination districts will have a trained functional surveillance assistant. 100% of health facilities in selected elimination districts will report weekly malaria data using rapid reporting system. 100% of index cases family and neighbors will be traced and tested. 100% of health facilities, district health offices in selected elimination districts will have at least one health worker trained on surveillance and rapid reporting system. 100% of health posts in selected elimination district will use malaria monitoring chart and cluster mapping to trace focal infections. 100% of selected elimination districts will prevent resurgence/reintroduction of malaria after maintaining zero local transmission. National strategies/policies revision timeline* Document Status Timeline for development/ revision National Malaria Treatment Guidelines National Strategic Plan for Malaria Prevention, Control and Elimination in 2014 2020 Annual Malaria Elimination Operational Plan Health Sector Transformation Plan V Most recent edition, 3 rd edition, released Q1 2012. Several revisions were circulated to health personnel in Q2 2016. N/A Process for development/revision FMOH along with Malaria Control Support Team (MCST) and Technical Advisory Committee (TAC); Current for 2014 2020 N/A Malaria control support team (MCST) and Technical Advisory Committee with leadership and coordination of the FMOH; contributions from EPHI, WHO, UNICEF, USAID-PMI, ICAP, The Carter Center, Abt Associates, The Earth Institute, PATH MACEPA, Malaria Consortium, civil society, regional health bureaus, universities, and others New document Q1 2016 and annually thereafter FMOH and Malaria Elimination Taskforce (MACEPA is a member) Current for 2016 2020 NA Last updated in 2015, the FMOH is currently in consultation with partners Anticipated changes Q2 2016 update highlights: PQ radical cure included for P. vivax in areas targeted for malaria elimination. sldpq recommended for P. falciparum infections. No G6PD testing required for PQ or sldpq use. AL now recommended for infants < 5 kg with uncomplicated P.f. N/A Define activities what, where, how and budget needed for implementation. N/A ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 3

*See Page 6 for chart of FMOH structures relevant to malaria interventions. to develop a new version (Heath Sector Development Program V) ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 4

FINANCIAL LANDSCAPE The total estimated cost to implement 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, will face a long-lasting insecticidal net (LLIN) gap of approximately 3.8 million nets in 2017. PMI estimates that at projected funding levels there will be surpluses of artemisinin-based combination therapies (ACTs) supplies and rapid diagnostic tests (RDTs) for each year from 2015 2017. The government of plans to commit $66,065,284 nearly 15 percent of the total funding requirement toward malaria control and elimination activities for 2015 2017. s domestic malaria spending has increased significantly over the past 15 years. Projected 2016 funding of approximately $22 million represents an increase of more than 250 percent over the 2010 spending level of $6,144,036, and a more than tenfold increase over the 2001 spending level. Historical contributions to malaria control, 2009 2014 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 - - - 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% The Global Fund to Fight AIDS, Tuberculosis and Malaria Key Contacts Fund Manager Key Country Coordinating Mechanism (CCM) members Current Malaria Grant Grant: Scaling-up and Sustaining Anti-Malaria Interventions in (ETH-M-FMOH) Grant Details Principal Recipient: Ministry of Health of Signed: $115,599,987 President s Malaria Initiative Key Contacts Matthew Murphy, PMI Team Leader (interim) Key Documents Malaria Operational Plan FY16 Malaria Operational Plan FY15 Malaria Operational Plan FY14 Malaria Operational Plan FY13 Sai Pothapregada Dr. Kesetebirhan Admasu Berhane, Chair Dr. Meshesha Shewarega Gebretsadik, Vice Chair Dr. Kebede Worku Admassu, CCM Main Contact Complete member and contact list here. 1 All dollar values represent US dollars. ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 5

HEALTH SYSTEMS LANDSCAPE Health system structure (relevant to malaria) Summary of health facilities by type and provider,, 2011 Facility type Functional Number Health posts 16,447 Health centers 3,547 Public hospitals 189 Total 20,183 Health facility strata Tier 1: Primary health care unit District hospital (covering 60,000 100,000 people), health centers (1 per 25,000 people) and their satellite health posts (1 per 5,000 people) Tier 2: General hospital Covering catchment population of 1 1.5 million people Tier 3: Specialized hospital Covering a population of 3.5 5 million people Source: Malaria Operational Plan FY16 Health Personnel Overview (Relevant to Malaria) Service provider Health development army (HDA) Training received Function Role in MACEPA work (if any) General overview from MOH, RHB, District Health Office, and Primary Health Care Units (PHCUs); currently no formal training Increase contact with each household through networking one to five households to deliver health information. HDA does all IEC/BCC work in country. MACEPA provides malaria messages to be incorporated into HDA community outreach work, as well as the organization of community coffees to sensitize communities around malaria activities. ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 6

HEALTH SYSTEMS LANDSCAPE (continued) Service provider Training received Function Role in MACEPA work (if any) Surveillance assistants (SAs) Health extension worker (HEW) Health center staff District health officer High school graduates in good standing in their community. Not part of national health system; recruited (have to pass a test and have a recommendation from their community). Training focuses on strengthening knowledge about malaria as well as the use of mobile phones for data reporting. Training on malaria surveillance as an intervention. One year of training after high school diploma; paid FMOH staff; almost 99% women. Training on malaria surveillance as an intervention. 20-day training, which includes malaria prevention and control activities, including treatment of severe malaria. Use of DHIS 2 for monitoring malaria in their respective catchment areas. Training on malaria surveillance as an intervention. Use of DHIS 2 for monitoring malaria in their respective catchment areas. Training on malaria prevention and control activities, including treatment of severe malaria. Members of the community they serve, SAs work alongside community-based health extension workers and within the HDA using mobile phones to collect and report data on malaria cases and commodities needs. Deliver 16 selected health packages, including one health package on malaria; confirm and report malaria diagnoses among clinically evaluated acutely ill patients using RDTs; supervise seasonal activities, including social behavior change communication and mass vaccination campaigns; supervise IRS spray teams and door-to-door mobilization for IRS. Typically can provide inpatient services for up to two malaria patients, and they are equipped with injectable artesunate for severe malaria treatment. Manage malaria component of the HEW portfolio; supervise SAs. Manage malaria component of the HEW portfolio; supervise SAs. MACEPA supports the use of SAs to implement all MACEPA activities including rapid reporting, focal test and treat (FTAT), mass test and treat (MTAT), and other work. SAs are also mobilized in their village catchment areas to support major seasonal activities such as IRS and other health campaigns without compromising their rapid reporting, routine surveillance, and seasonal activities. Set of two in every health post; MACEPA develops and supports the malaria component of their training; HEWs supervise SAs. MACEPA provides basic malaria guidance information, malaria surveillance as an intervention, and training around use of DHIS 2 for local monitoring and decisionmaking. MACEPA provides basic malaria guidance information, malaria surveillance as an intervention, and training around use of DHIS 2 for local monitoring and decisionmaking. Zone malaria officer Training on malaria surveillance as an intervention. Use of DHIS 2 for monitoring malaria in their respective catchment areas. Training on malaria prevention and control activities, including treatment of severe malaria. Manage malaria component of the services of all districts under its catchment. MACEPA provides basic malaria guidance information, malaria surveillance as an intervention, and training around use of DHIS 2 for local monitoring and decisionmaking. Training on malaria surveillance as an intervention. ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 7

HEALTH SYSTEMS LANDSCAPE (continued) Commodities and Delivery Strategies Commodity/strategy Standard in National treatment policy P. falciparum Uncomplicated 1 st Line: AL + sldpq with no G6PD testing 2 nd Line: Oral quinine Severe IV or IM artesunate (preferred); IM artemether (alternate); where not available, stabilization with rectal artesunate (children < 6 years only) or IM quinine and referral to next appropriate health facility. Malaria in Pregnancy Oral quinine in the first trimester of pregnancy and oral AL in the second and third trimesters for uncomplicated malaria, IV artesunate is the first line treatment for severe malaria. P. vivax Uncomplicated 1 st Line: Chloroquine (and PQ for patients with limited risk of malaria infection in the future [i.e., not living in malaria-endemic areas]). No G6PD testing required, but with close follow up. 2 nd Line: Oral quinine Malaria in Pregnancy Chloroquine all trimesters for uncomplicated malaria, IV artesunate is the first line treatment for severe malaria. Mixed infection (Pf + Pv) Uncomplicated 1 st Line: AL (and PQ for patients with limited risk of malaria infection in the future [i.e., not living in malaria-endemic areas]). No G6PD testing required, but with close follow up. 2 nd Line: Oral quinine Severe IV or IM artesunate (preferred); IM artemether (alternate); where not available, stabilization with rectal artesunate and referral to next appropriate health facility. Malaria in Pregnancy Oral quinine in the first trimester of pregnancy and oral AL in the second and third trimesters for uncomplicated malaria. IV artesunate is the first line treatment for severe malaria. National diagnostic policy Multi- species RDTs are the main diagnostic tool at the health post level; microscopic diagnosis the standard of diagnosis in health centers and all levels of hospitals. All patients with suspected malaria should receive a diagnostic test before treatment is prescribed. National Strategy for IRS Goal: increase and maintain IRS coverage at 100% in IRS-targeted districts by 2020 Selected based on FMOH s new NMSP malaria stratification based on API. Only 17% of districts will be targeted for IRS, and not all communities within a specific district will be targeted for spraying. Community selection will be refined every year within targeted districts. Insecticides used In 2014, PMI-supported districts performed IRS using bendiocarb, while FMOH spraying used both bendiocarb and propoxur. In 2015, PMI piloted pirimiphos-methyl CS spraying in 8 out of 36 PMI-supported districts, to draw lessons to inform its future use on a larger scale. Selection of insecticides for IRS use in will be determined annually based on the insecticide resistance pattern of the vectors and other factors. National Strategy for LLIN coverage Goal: ensure universal coverage by distributing 1 LLIN per 1.8 persons living in malarious areas and improve utilization and care through behavior change communication activities. Continuous distribution of LLINs through HEWs in communities will replace worn out/deteriorated or lost nets, cover new household members in targeted communities. Procurement planning for continuous distribution of LLINs for 2016 and 2017 will be based on 8% and 20% estimated loss of LLINs in the first and second year respectively. ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 8

OPERATIONAL RESEARCH Studies completed this period (Jan June 2016) Title Assessment of G6PD variant prevalence Malaria serology as a MIS biomarker Start date End date 01/2014 03/2015 03/2014 10/2015 Ongoing and planned studies Funding Countries Partner institutions in $90,000, PMI Public Health Institute (EPHI), CDC $70,000, PMI Public Health Institute (EPHI), CDC Summary of objectives and findings Objective Analyze genotypic prevalence of G6PD deficiency in. Findings Only G6PD genotype detected was G6PD*A, no samples were positive for the clinically significant A- or Mediterranean variants. Study findings suggest a low expected frequency of drug-induced anemia from primaquine antimalarial therapy among ns. Objective Assess the utility of serologic testing to collect additional biomarkers in household surveys in settings where malaria transmission is very low and/or seasonal. Title Rapid reporting: Strengthening malaria surveillance using computer and mobile technology Epidemic Prognosis Incorporating Disease and Environmental Monitoring for Integrated Assessment (EPIDEMIA) system Combining indoor residual spraying and long-lasting insecticidal nets for malaria prevention: a cluster randomized controlled trial in (Maltrials) Routine case investigation and reactive case detection for malaria in Amhara region, Start date End date 2011 2017 12/2013 11/2018 09/2014 09/2016 2015 2017 Funding Countries Partner institutions in BMGF via PATH MACEPA Senegal Zambia FMOH PATH MACEPA NIH FMOH Bahir Dar University, Research Council of Norway BMGF via PATH MACEPA Addis Ababa University (PI) Hawassa University FMOH PATH MACEPA Summary of objectives and findings Objectives To improve the availability, quality, and use of timely malaria case and commodity data Objective Develop and implement a malaria early warning system forecasting future disease outbreaks in the Amhara Region of based on environmental risk factors. Objective Assess whether the combined use of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) increases protection against malaria Objective To provide evidence in order to design surveillance system components, evaluate screening criteria for reactive case detection, and optimize case investigation strategies in low transmission settings ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 9

OPERATIONAL RESEARCH (continued) Ongoing and planned studies (continued) Title Combining indoor residual spraying and long-lasting insecticidal nets for malaria prevention: a cluster randomized controlled trial in (Maltrials) Quantifying malaria endemicity in : Implication for moving away from control towards elimination and eradication Evaluation of radical cure primaquine for P. vivax Evaluation of the roll out of single-dose primaquine for P. falciparum Documenting and maintaining zero malaria transmission in elimination settings Chloroquine prophylaxis for pregnant women with P. vivax pregnancy Start date End date 09/2014 09/2016 05/2015 09/2016 10/2015 10/2016 10/2015 09/2017 Funding Countries Partner institutions in Research Council of Norway Special Program for Research and Training in Tropical Diseases (TDR) $150,000, PMI $500,000, PMI 2016 BMGF via PATH MACEPA 03/2016 03/2017 $200,000, PMI Addis Ababa University, ; Hawassa University, Jimma University, Summary of objectives and findings Objectives Assess whether the combined use of LLINs and IRS increases protection against malaria. Measure malaria incidence and transmission and insecticide resistance across. Assess whether LLINs result in an age shift in malaria morbidity. Measure cost-effectiveness of combined interventions Objectives To quantify and describe malaria endemicity using three different techniques (spleenometry, parasitemia and antibody test) and to compare the result to identify best fit method to the context To determine the level of hemoglobin and anemia among children included in the study (2-9 years) and examine its relationship with malaria infection and splenomegaly To predict malaria endemicity from mean hemoglobin level and asses utility of the prediction model as alternative tool to measure malaria endemicity Modelling the Prevalence and the age-dependent Force of Infection Directly from Antibody Levels FMOH Objective Evaluate the roll-out of primaquine radical cure for P. vivax in hospital and health center settings. FMOH Objective If primaquine is implemented for first-line treatment of P. falciparum infections in elimination districts, this study will evaluate its roll-out. Senegal Zambia FMOH PATH MACEPA Objectives To assess exposure to malaria in the population using malaria sero-prevalence and infection prevalence, describe historical changes in malaria transmission, identify best operating sampling strategy, maintain a malaria surveillance system and prevent reestablishment of transmission. FMOH Objective Evaluate use of weekly suppression of P. vivax in pregnant women using chloroquine. Evaluation of 10/2016 $400,000, FMOH Objective reactive case 09/2017 PMI Assess administration of presumptive treatment to detection and all household members of an index case as a presumptive strategy to halt local transmission, clear malaria treatment of the transmission foci, and reduce locally acquired cases index households to zero. Sources: MESA Track, PMI Malaria Operational Plans FY15, FY16 ETHIOPIA MALARIA POLICY LANDSCAPE JULY 2016 PAGE 10