Malaria control in Eritrea: a success story International PHC Conference Ouagadougou, Burkina-Faso 28 – 30 April 20

1. Malaria control in Eritrea: a success storyInternational PHC Conference Ouagadougou, Burkina-Faso 28 – 30 April 2008 By Dr. Tewolde Ghebremeskel Head, National Malaria Control Program Ministry of Health, State of Eritrea

2. Presentation Outline Country Profile Burden of Malaria in Eritrea Interventions Achievements Lessons learnt Challenges/Concerns Conclusion

3. Country Profile Area: 124,320 sq. km Population: 3.6 million Population distribution <5 years old: 15% pregnant women: 5% Rural: 80% Urban: 20%

4. Burden of Malaria in Eritrea • 3 epidemiologically distinct strata: • Coastal plains (0-1000m) • Western lowlands (700-1500m) • Highlands (1500-2000m and above) • 67% (2.4 million) of population live in malaria risk areas • Parasite distribution: P. falciparum (84%), P. vivax (16%) • Main vector:Anopheles arabiensis

5. Burden of Malaria in Eritrea….Contd • Malaria is seasonal, focal, and unstable. - 2 main transmission seasons: • September – November (central, southern, western lowlands) • January – March (coastal plains) • High malaria epidemic risk • Displaced populations due to border conflict • High population mobility/movement • Low immunity • Drug resistance

6. INTEGRATED MALARIA INTERVENTIONS CASE MANAGEMENT IVM EPIDEMIC PREVENTION M & E CAPACITY BUILDING HEALTH PRHOMOTION OPERATIONAL RESEARCH HFs CHAs Larviciding ITNs IRS Source reduction REDUCTION IN MALARIA MORBIDITY & MORTALITY

7. Case management • First line treatment of uncomplicated malaria: • Chloroquine (Until 2001) • Chloroquine plus SP (2002-2007) • Artesunate plus Amodiaquine (since August 2007) • Approximately 80% of all febrile cases were managed by CHAs • CHAs were trained in the utilization of the guidelines for referrals • Pull system of drug distribution from catchment health facility to the CHAs.

8. Integrated vector management • Insecticide Treated Nets/Long lasting insecticidal Nets (ITNs/LLINs) • Free distribution of ITNs to vulnerable groups • Tax exemption of importation of malaria control commodities • Above 90% ITN re-treatment rate at no cost to the beneficiary • Indoor Residual Spraying (IRS) in high endemic areas • Source Reduction or Elimination of breeding sites. • Larviciding

9. Capacity building • Training of CHAs on case management, referral and integrated vector management: • Bring services closer to the population • Strengthen the linkage with health facilities • Promote community empowerment, ownership & sustainability of malaria control interventions. • Strengthening of referral health facilities through regular training & refresher courses for • health workers to manage complicated malaria cases, • laboratory technicians for detection of malaria parasites, • Zonal/district malaria technicians who are part of district health team. • Strengthening of institutional capacity for • Equitable distribution of malaria supplies and equipment • Equitable distribution of health services • Provision of affordable services including drugs

10. Operational Research • Drug /insecticide efficacy studies. • Regular yearly drug efficacy study for monitoring purposes • Analysis of non response of febrile cases referred by CHAs and confirmed as malaria • Analysis of weekly report and trends of malaria cases at sentinel sites. • Quarterly review of malaria morbidity trends including treatment failure rates from health facilities by a technical committee. • Participatory drug efficacy studies in low endemic areas for policy change.

11. Health Promotion • Community empowerment, ownership & use of CHAs for positive behavioral change • Involvement of Eritrean social marketing group. • Operates at grass root level • Provides services at no cost • Distributes ITNs at affordable cost • Annual National Malaria Campaign weeks. • Use of various channels of communications • Mass media • promotional materials • Interpersonal communication • Drama, malaria related films, folktales,

12. Supervision, Monitoring & Evaluation • Monitoring & supervision • Regular supervision of CHAs by public health technicians • Routine utilization of supervisory check list by PHT • Monitor the operationality of Malaria Sentinel sites • Conduct regular quarterly review meetings • Follow up status of implementation of recommendations. • Evaluation • National annual review meetings (RBM partners meeting) • Dissemination of annual reports • Midterm and final evaluation of strategic plan

13. Promotion of partnerships • Coordination mechanisms • Map out who does what & where • Strong & functional Zonal/District malaria control teams • HIV/AIDS, Malaria, Sexually Transmitted Disease and TB (HAMSET) steering committee meetings at national and district levels • Integrated multi-sectoral approach initiated by the Government to manage HAMSET Project • Mobilization & utilization of resources. • Effective internal & external resource mobilization • Good financial accountability • Effective utilization of available human and material resources

14. Eritrea’s achievements against applicable Abuja Targets

15. 2000 ARI Diarrhea Malaria Anemia Septicemia TB HIV/AIDS Heart failure Burns Soft tissue injury Trends of malaria mortality among top-10 diseases in children <5 years 2007 • ARI • Anemia & malnutrition • Diarrhea • Septicemia • Perinatal respiratory problem • Slow fetal growth, Malnut etc • Intrauterine Hypoxia/Birth Asphyxia • HIV/AIDS • Malaria • TB, all types Source: NHMIS * Source: Eritrea Health Profile, 2000

16. Trends of malaria mortality among top-10 diseases in ADULTS 2000 • Malaria • TB • Anemia & malnutrition • ARI • HIV/AIDS • Diarrhea • Hypertension • Other liver diseases • Diabetes Mellitus • Septicemia 2007 • ARI • Anemia & malnutrition • HIV/AIDS • Diarrhea • Septicemia • TB, all types • Perinatal resp. problem • Hypertension • Other liver diseases • Diabetes Mellitus * Source: Eritrea Health Profile, 2000 Source: NHMIS

17. Lessons Learnt • High political commitment, promotion of community ownership and empowerment play a significant role in malaria control. • It is possible to achieve the Abuja targets through the implementation of integrated and comprehensive interventions. (free distribution of ITN, community based case management by CHAs, integrated community based vector management) • Regular operational research is important for evidence based decision making & policy change. • Improved coordination of partners and sectors during planning, implementation, Monitoring & Evaluation is crucial for the success of malaria control programs. • Proper and accountable management of available financial and material resources enhances program effectiveness and donor confidence

18. Challenges • Complacency due to current achievements. • Utilization of ACTs by CHAs. • Health seeking behaviour • Competing priorities • Skilled human resource • Cross border transmission.

19. Conclusion Eritrea has moved towards malaria pre-elimination phase primarily due to • Strong Political commitment • Commitment of MOH staff and other relevant sectors • Involvement of community including the use of CHAs in planning, implementation, monitoring and evaluation • Better coordination of partners • Proper management of available resources

20. Kill Mosquito! Control Malaria

21. MERCI THANK YOU YEKENYELEY SHUKREN