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PMI | Africa IRS (AIRS) Project Indoor Residual Spraying (IRS 2) Task Order Four AIRS ETHIOPIA COMMUNITY-BASED IRS MODEL: COMPARATIVE EVALUATION MARCH 2013 Recommended Citation: Africa Indoor Residual Spraying Project. March 2013. AIRS Ethiopia. Community-Based IRS Model: Comparative Evaluation. Bethesda, MD. AIRS Project, Abt Associates Inc. Contract: GHN-I-00-09-00013-00 Task Order: AID-OAA-TO-11-00039 Submitted to: United States Agency for International Development/PMI Prepared by: Abt Associates Inc. Abt Associates Inc. I 4550 Montgomery Avenue I Suite 800 North I Bethesda, Maryland 20814 I T. 301.347.5000 I F. 301.913.9061 I www.abtassociates.com AIRS ETHIOPIA COMMUNITY-BASED IRS MODEL: COMPARATIVE EVALUATION MARCH 2013 The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government. CONTENTS Acronyms .................................................................................................................................... v 1. Pilot of Community-Based IRS ............................................................................................. 1 1.1 Introduction ......................................................................................................................................................... 1 1.2 Health Extension Program in Ethiopia ........................................................................................................... 1 1.3 Definition of Two IRS Models ......................................................................................................................... 2 1.4 Description of the Pilot Program.................................................................................................................... 2 1.5 Results .......................................................................................................................................................... 5 2. Comparative Analysis of CB IRS vs. DB IRS ...................................................................... 6 2.1 Key Advantages of CB IRS ................................................................................................................................ 6 2.2 Additional Advantages of CB IRS .................................................................................................................... 7 2.3 Challenges of the PMI CB IRS Pilot ................................................................................................................ 8 2.4 Future PMI/AIRS Plans to Expand CB IRS .................................................................................................... 8 3. Government-Supported CB IRS in Oromia Region .......................................................... 9 3.1 Jimma Zone, Limmu Kosa District: Description and Brief Analysis ....................................................... 9 3.2 East Shoa Zone, Adama District: Description and Brief Analysis ........................................................... 9 3.3 Challenges and Lessons Learned from the Government-Supported CB IRS ..................................... 11 3.4 Conclusion and Recommendations .............................................................................................................. 11 LIST OF TABLES Table 1: 2012 CB IRS Performance Results in Kersa District ................................................................................ 5 Table 2: Cost-Benefit Analysis of CB IRS vs. DB IRS in Years One and Two of Operation ......................... 7 LIST OF FIGURES Figure 1: Organization of Community-Based IRS ...................................................................................................... 3 Figure 2: HEWs during Training as CB IRS Squad Leaders ..................................................................................... 4 Figure 3: Operation Site with Soak Pit and Wash Areas in a CB IRS kebele ...................................................... 4 ACRONYMS AIRS Africa IRS CB IRS Community-based IRS DB IRS District-based IRS DHO District health office EC Environmental compliance FMoH Federal Ministry of Health GoE Government of Ethiopia HEP Health extension program HEW Health extension worker IRS Indoor residual spraying ORHB Oromia regional health bureau PMI President’s Malaria Initiative PPE Personal protective equipment SOP Spray operator ZHO Zonal health office v 1. PILOT OF COMMUNITY-BASED IRS 1.1 INTRODUCTION In Ethiopia, malaria is generally a seasonal and unstable disease, peaking during and/or following the rainy season for 2-5 months in most of the malaria-risk areas. The malaria control and prevention program in Ethiopia has a history of more than five decades, with indoor residual spray (IRS) of houses as the main component of the program. The aim of IRS is to spray houses at the right time with the right insecticide at sufficient dosages, and at adequate intervals of time so that resting anopheles mosquito vectors will be killed throughout the transmission period. In Ethiopia, IRS was first launched in 1959 as part of the Global Malaria Eradication Program spearheaded by the WHO. After the program was phased out globally in 1969, the Ethiopian government continued spraying campaigns solely with its own funding through approximately 2004. Revived IRS support through PMI began in 2008. In September 2008, Research Triangle Institute International (RTI) began implementation of IRS with PMI funding in 19 districts in Oromia. By 2011 the number of PMI-supported districts had increased to 50, with a total of 858,657 structures sprayed. In 2012, Abt Associates, under a new PMI project, Africa IRS (AIRS), delivered full support to 36 districts and provided limited assistance to 24 districts that had graduated from full PMI support in 2011. Out of 554,063 structures found by AIRS Ethiopia in 36 districts, the project sprayed 547,421 structures, achieving 99 percent coverage. In 24 graduated districts, the project supported government spraying of 428,459 structures, by supplying some personal protection equipment (PPE), and training on IRS and handling of carbamate chemicals, to over 80 health workers from the Oromia region, including participants from the 24 districts. In 2012, AIRS Ethiopia also piloted the feasibility of integrating IRS into the health extension program (HEP) and decentralizing organization of the operation from the district to the community level. 1.2 HEALTH EXTENSION PROGRAM IN ETHIOPIA The Health Extension Program (HEP) is a government-funded health service delivery program that aims for universal coverage of primary health care. The program gives priority to the prevention and control of communicable disease, with active community participation, with the goal of providing equitable access to health services. HEP’s package of services includes basic and essential prevention, promotion, and selected high-impact curative health services. As a preventive program, HEP focuses on four areas of care provided at the community level: disease prevention and control, family health, hygiene and environmental sanitation, and health education and communication. Key health areas that are under the aegis of HEP work are: HIV/AIDS prevention and control, TB prevention and control, malaria prevention and control, and first aid. The program is based on expanding physical health infrastructure and developing a cadre of health extension workers (HEWs) who provide basic preventive and curative health services at the community level. 1 The HEP deploys two HEWs in every village (kebele1) of 5,000 residents, with the aim of strengthening the community-based health care system by promoting prevention behaviors and improving access to health services. The Government of Ethiopia (GoE) typically employs young women who concluded a one-year training course on the HEP package of services to serve as HEWs. Currently, there are about 34,000 HEWs in 15,000 rural kebeles in Ethiopia. For this program, the GoE constructed over 15,000 health posts to have two HEWs assigned to each post. Ethiopia has been implementing HEP since 2005, and it has shown remarkable achievements in the reduction of maternal and child mortality and in the numbers of communicable disease cases. 1.3 DEFINITION OF TWO IRS MODELS Traditionally, IRS in Ethiopia has been planned and implemented by the district health office (DHO) with technical and operational inputs from regional, zonal, and central health offices. We define it as a district-based IRS model (DB IRS). Each district on average includes two operation sites with a soak pit, washing, bathing, and camping area, where the spray team stays for the duration of the IRS campaign. The spray team comprises a team leader, up to four squad leaders and porters, and 16-20 spray operators (SOPs). The number of spray teams depends on the number of structures targeted for spraying in the district. District health staff train temporary-hire SOPs, who are recruited from towns in the same district. The SOPs are stationed in a temporary camp, usually set up near a health center or a school for the duration of the spray campaign. From there, SOPs travel to the villages to conduct the spraying on a daily basis. Moving the spray teams from the district operation sites to the villages requires vehicles. For camping accommodations, tents, mattresses, and other items are required. In most cases, the SOPs are not familiar with the village and not very trusted by the community. Community-based
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