Malaria is one of the major infectious tropical diseases with substantial socio-economic repercussions in the sub-Saharan Africa region. In 2019, WHO’s African Region accounted for about 94% of malaria cases while only six African countries (Nigeria, Democratic Republic of the Congo, Tanzania, Mozambique, Niger, and Burkina Faso) accounted for about 51% of all malaria deaths globally (1). The number of estimated malaria cases in Africa in 2019 were 215 million (1).

Malaria-related morbidity and mortality entail substantial private costs (e.g., direct costs due to clinical treatments, and indirect costs due to reduced labor productivity) and societal costs (e.g., increasing public health expenditure, and effects on labor, investment, and tourism flows) in many tropical countries (2).

Currently, more than 50% of the population in Ethiopia is exposed to the risk of malaria infection (3–5). Despite the range of prevention measures undertaken in the last two decades, malaria remains to be one of the top ten causes of morbidity and mortality in Ethiopia (6) with substantial repercussions for the macroeconomy (7, 8). The effects of malaria propel into the macroeconomy through two main channels. The first is through agricultural labor productivity changes as the malaria transmission seasons (September to December, and April to May) coincide with the main agriculture harvest seasons (5, 7, 8). Agriculture is the main source of employment (≈ 75%) and merchandise export earnings (≈ 80%) in Ethiopia (9). The second way is through government budget allocation and fiscal balance as government is the main health service provider (4). Seen against the forgoing conditions in Ethiopia, even a marginal increase in the risk of malaria has profound socio-economic implications making malaria disease public health as well as economic problem (8).

It is therefore important to assess the status of malaria risk, and to continuously evaluate the prevention and control measures in the country. It is equally important to identify the existing policy and implementation gaps, and emerging challenges that may undermine (or even reverse) the progress made so far. This paper aims to contribute its part in this regard. It briefly discusses the status of malaria risk, the past achievements, gaps, and emerging challenges in fighting malaria in Ethiopia. The study is a narrative overview that aims to briefly synthesize the existing knowledge, and to draw implications for future research and policy makers (10–12).

The remainder of the paper is structured as follows. Section 2 gives a brief overview of the malaria risk in Ethiopia. Section 3 succinctly presents the malaria prevention and control measures followed by the past achievements, the current gaps, and emerging issues related to malaria control measures in Section 4. This is followed by some recommendations in Section 5, and conclusions in Section 6.

Malaria transmission in Ethiopia is seasonal, unstable, and often characterized by highly focal and large-scale cyclic epidemics (1, 7). Areas lying at altitudes between 1600 and 2000 meters above sea level (masl) are in general epidemic prone hypo-endemic zones of malaria (4) although some studies could also detected malaria in areas higher than 2000 masl (5, 7). Altitude, climate, environmental changes (e.g., due to dams, roads construction, agricultural projects), and housing conditions are important determinants of malaria risk and transmission in Ethiopia (3, 7). Overall, more than 50% of the total population in Ethiopia is exposed to the risk of malaria infection (3–5). Every year, four to five million people are affected by malaria (3, 13) while a major epidemic occurs every five to eight years (7).

The reported malaria cases remain higher than one million cases per annum. On an average, about 1.6 million malaria cases (more than 60% is related to the P. falciparum species) are reported between 2010 and 2019 (1, 5). The rate of the P. falciparum species is especially higher in the lowland regions (7).

There are five distinct malaria risk strata classified based on annual parasite incidence (API) per 1,000 population, elevation, and expert opinions (7). According to the latest malaria risk classification, about 18% of the population lives in high (API ≥ 50) and moderate (10 ≤ API < 50) risk strata. Such classifications are important as they facilitate the design and implementation of most appropriate interventions per strata (5, 7, 14). It worth noting here that the latest stratification (7) and percentage distribution of population living under each risk stratum is different from the previous stratifications and percentage distributions such as, for example, the one in 2014 (14). Figure 1 collates the two stratification maps together. See also that the latest stratification adds one more stratum which is very low risk.

Ethiopia has been fighting malaria through formal institutions for more than five decades (5, 13). Today, malaria is one of its top national health and economic development priorities (7). In line with this, especially since 2004, the Government of Ethiopia together with its international partners has implemented a series of malaria prevention, control, and elimination programs (7) including preparing malaria guidelines (15, 16) and strategies (7, 17–19), and conducting surveys (14, 20, 21). The guidelines present detailed procedures on implementing and reporting various malaria vector control, diagnosis and treatment, and surveillance and response activities (15, 16). The periodic surveys produce evidence needed to formulate as well as evaluate different policy measures. All in all, policy wise, Ethiopia is stepping up its efforts to move from controlling (17) to eliminating (7) malaria.

Ethiopia started scaling up prevention and control measures in 2004 (5). Notable large-scale interventions include distribution of long-lasting insecticidal nets (LLINs), and indoor residual spraying (IRS), and introduction of additional diagnosis and treatment mechanisms such as artemisinin-based combination therapy (ACT), artemether lumefantrine (AL), and rapid diagnostic test (RDT) (5, 7, 13). Furthermore, in 2010 it started implementing test-treat policy, i.e., administration of antimalarial drugs based on test results (5). Figure 2 , which is adapted from (5), depicts the timeline for major interventions between 1995 and 2016.

Remarkable progress has been made afterwards. The share of households in malarious areas (≤ 2000 masl) that possess at least one LLINs and received IRS have, respectively, reached 85% and 93% in 2019 (22). The introduction of RDTs in 2004 was a significant step forward in terms of case detection and management (3) since RDTs are easy to use and to deploy in rural areas (23) where 80% of Ethiopians live. These mass scale deployment of malaria specific inputs were also accompanied by the deployment of health extension workers (HEW) in rural areas which conduct home-to-home outreach activities, and provide basic curative, promotive, and preventive services at health posts (24).

The malaria-specific interventions are also complemented with the overall increase in the number of health infrastructure (e.g., public health facilities and professionals) which profoundly improved malaria case management (13, 24). Notwithstanding the limitations, currently, about 68% of the facilities in the country offers malaria diagnosis or treatment (4). Table 1 presents the key trends in public health services, in malaria control measures, and in malaria disease in the past two decades.

Therefore, in order to maintain the momentum of fighting malaria, it needs to scale up measures related to funding, climate services, and vector control. More specifically, it needs to:

Ethiopia has been undertaking a wide range of policy measures to control malaria, especially, after 2004. Consequently, mortality and morbidity attributable to malaria have declined significantly. To keep the momentum of fighting malaria, however, Ethiopia needs to strengthen its institutional capacity pertaining to domestic resource mobilization, diagnosis by microscopy, vector surveillance, and climate information processing and seasonal weather forecasting. These actions need, among others, to layout and enhance cross-sectoral coordination (e.g., with irrigation, hydropower, and climate change), and cross-border cooperation (e.g., for better surveillance of vectors) mechanisms. Future public budget allocation to fight malaria should factor in these and other emerging challenges.

The author confirms being the sole contributor of this work and has approved it for publication.

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.