What We’ve Learned from Ethiopia’s Launch of a National School-Based Deworming Program
In January of this year, the Federal Ministry of Health in Ethiopia announced a groundbreaking national school-based deworming program that will treat over 75% of at-risk children for parasitic worms (namely, soil-transmitted helminths and schistosomiasis) by 2020.
Over the course of the next five years, the Ministry of Health will collaborate with teachers and health extension workers to distribute over 100 million worm treatments to at-risk children in all corners of this vast country.
School-based treatment programs are a reliable method of reaching hundreds of millions of children. At Evidence Action, we provide technical assistance to governments to set up national school-based deworming programs to improve children’s health, access to education and future livelihoods. For the last several years, we have supported the Ministries of Health and Education in Kenya to treat upwards of 80% of school-age children across the country. Earlier this year, with our support, the Indian government launched a national school-based deworming day targeting 140 million children for deworming - the largest deworming campaign in history. We know what a huge undertaking it is for a government to enlist its health and education workers to treat millions of children.
What’s remarkable about the national program in Ethiopia are three key aspects of our work that we didn’t anticipate: 1. the great value of partnership with the Schistosomiasis Control Initiative (SCI), as well as the Ministry of Health, 2. the speed with which the government is launching a national deworming program, and 3. the willingness of the government to elicit lessons learned about launching a successful deworming program at-scale.
1. Partnerships Can Be Catalytic
NGO partnerships are not always effective. Collaborations can be hard, especially when the organizations compete for the same donors. While we’ve always focused on cultivating strong partnerships with governments when working on school-based deworming programs, in Ethiopia we’ve learned how valuable and catalytic a partnership can be with another NGO with complementary expertise and shared goals and values.
Flashback to September 2014, when I began my monthly trips to Ethiopia to determine how we could complement existing efforts to deworm children. From my very first trip, Dr. Mike French of the SCI generously introduced me to representatives at the Ministry of Health. SCI and Evidence Action have complementary skill sets and similar values and missions. We also genuinely like and respect each other. So, a collaboration and mutual commitment to support the government with a high-coverage, cost-effective deworming program made a lot of sense.
SCI and the Partnership for Child Development had already done the hard work of measuring worm prevalence across country - a process that we refer to as ‘mapping,’ an important first step in determining the scope of the worm problem and developing the appropriate deworming schedule and treatment strategy. SCI had also been planning to conduct a first round of deworming to treat children in 95 administrative districts.
Together, we suggested to the Federal Ministry of Health that they expand this initial work. What would it take to treat at least 75% of all at-risk school-age children in the country and to launch a truly national program?
SCI helped Oumer Shafi, the committed and action-oriented Coordinator for Neglected Tropical Diseases in the Federal Ministry of Health, develop a detailed action plan. This entailed sophisticated statistical analysis to determine how many deworming sites would be required to reach at least 80% of kids at risk.
Meanwhile, I worked closely with Birhan Mengistu, an up-and-coming leader seconded from the World Health Organization, and with other Ministry of Health staff. We sat for hours hunched over laptop screens to develop detailed five-year budgets, talking through row after row of spreadsheets and reviewing everything from the cost of fuel for drug transport to the needs of teachers.
Together with the Federal Ministry of Health, we were able to think and act boldly. We are excited to continue to partner with SCI and are seeking other partners who also share common goals and values to rapidly scale school-based deworming in endemic countries.
2. Governments Can Act Fast
When we floated the idea of vastly increasing the scope of the originally proposed deworming rounds to be a truly national plan treating upwards of 75% of all children at-risk, Shafi didn’t flinch.
The speed with which the Ministry of Health agreed to scale up its program impressed me. Shafi was clear about his priorities: achieving the highest treatment coverage possible and improving the quality of data related to a national deworming program. Getting Shafi’s time wasn’t easy; overseeing seven neglected tropical diseases in Ethiopia takes an enormous amount of time. He could have easily de-prioritized the treatment of worms in favor of other urgent competing diseases, as other endemic countries have done. But only a few months later, Evidence Action had memoranda of understanding with the Federal Ministry of Health, formally codifying support.
The Ethiopian Ministry of Health has shown that commitment, backed by hard work, can lead to transformative change in a relatively short period of time. As a result, tens of millions of Ethiopian children will be dewormed over the next five years, and grow up healthier and with improved educational outcomes.
3. Countries Can Learn From Each Other
As a technical assistance provider, we support deworming programs in many countries. All deworming programs need to be customized to the needs of a local geography - no two programs at scale look exactly alike. However, in Ethiopia we’ve found that the Government and Evidence Action have derived a lot of value from learning what has worked in other countries and adapting aspects to meet the local needs. Early on in our partnership, members of Evidence Action’s Kenya team traveled to Addis to share what has worked in the Kenyan National School-based Deworming Program, in areas such as effective governance, program design, training, and supply chains.
Learning went both ways. For instance, the decentralized ‘micro-planning sessions’ used in Ethiopia where region-based Ministry personnel develop their own deworming training budgets and timelines, are proving to be quite applicable to our staff in Kenya where there has been significant financial and decision-making devolution to the County level.
Just shy of a year after the idea of a comprehensive national school-based deworming program was conceived, we had a formal agreement and a well-thought out action plan ready. Several donors have stepped forward with interest in supporting the Ethiopian program though there is still a funding gap. Within the next year, we hope to celebrate the first round of an ambitious, life-changing national program.
Ethiopia is moving forward well, but the global health community of stakeholders has an urgent, vital obligation to share what’s been learned to scale treatment programs. Despite the fact that an effective delivery model exists that treats millions of children for less than 50 US cents per year, globally, only ~35% of at-risk children were treated in 2014.
Oumer Shafi and his team are proving that launching high-quality programs to treat parasitic worms can be done while simultaneously pursuing high coverage programs for other diseases. Worm-endemic countries that are considering national school-based deworming programs can learn from the experiences in Ethiopia, just as Ethiopia itself has benefited greatly from the experience of the countries that went before it.
Jessica Harrison Fullerton is the Associate Director of the Deworm the World Initiative at Evidence Action, a nonprofit organization that scales proven development solutions to benefit millions of people around the world. The Deworm the Worm Initiative, a program of Evidence Action, enables governments to eliminate the public health threat of worms through school-based mass deworming programs.