The community-based malaria control programme in Tigray, northern Ethiopia. A review of programme set-up, activities, outcomes and impact.

Tigray, the northernmost state of Ethiopia, has a population of 3.5 million, 86% rural, and 56% living in malarious areas. In 1992 a Community-Based Malaria Control Programme was established to provide region-wide and sustained access to early diagnosis and treatment of malaria at the village level. 735 volunteer community health workers (CHWs) serve 2,327 villages with a population of 1.74 million, treating an average of 489,378 patients yearly from 1994 to 1997. Recognition of clinical malaria is similar for CHWs and health staff at clinics where there is no access to microscopy. In 1996 a pilot community-financing scheme of insecticide-treated bednets was well accepted, but re-impregnation rates fell in 1998 because of war-related social upheaval. Indicators from health institutions show a progressive increase in malaria morbidity from 1994 to 1998. Repeated mortality surveys show a 40% reduction in death rates in under-5 children from 1994 to 1996 and a 10% increase from 1996 to 1998. These trends may be related to increased malaria transmission with water resources development, increased seasonal labour migration to malarious lowlands, prolongation of the transmission season with climate changes, and increasing chloroquine resistance throughout Ethiopia. Progressive extension of CHW services to ensure better coverage of women, children, migrant workers and communities near water development projects, change to first-line treatment with sulfadoxine-pyrimethamine, extension of the impregnated bednet initiative, and development of a regional warning system for epidemics should result in a greater impact on morbidity and mortality.