Resurgence of malaria in Ethiopia: a national landscape analysis of systemic and operational gaps.

backgroundMalaria remains a major public health threat in Ethiopia, with more than 7.3 million confirmed cases and 1,157 deaths reported in 2024, representing the highest incidence recorded in the past seven years. Persistent regional heterogeneity in transmission, emerging insecticide resistance, and systemic health system constraints continue to undermine national malaria elimination efforts. This study assessed systemic challenges and strategic priorities in Ethiopia's malaria management across six operational domains: preparedness, detection, containment, response, recovery, and prevention.

methodsA national landscape analysis was conducted using a convergent mixed-methods approach. Peer-reviewed literature and relevant policy documents published between 2016 and 2025 were systematically searched across bibliographic databases and institutional repositories. Eligible studies were assessed using predefined inclusion criteria and synthesized descriptively across six operational domains of malaria management. In parallel, structured consultations were undertaken with malaria programme professionals at federal, regional, and facility levels to validate and contextualize findings from the evidence synthesis. These consultations were conducted as part of technical validation and did not constitute primary qualitative research.

resultsThe search yielded 246 records, of which 198 unique documents were screened and 24 malaria-specific primary studies met inclusion criteria. Household surveys reported national insecticide-treated net (ITN) ownership averaging approximately 64%, with substantially lower coverage and utilization documented in several high-burden and urban-adjacent settings, particularly within Oromia and selected densely populated areas. Indoor residual spraying (IRS) was implemented in roughly half of targeted high-risk zones, with operational coverage constrained by logistical delays and reduced effectiveness in areas with documented pyrethroid resistance. Digital malaria surveillance platforms were operational in approximately 80% of health facilities; however, multiple studies reported delayed reporting, incomplete data submission, and weak feedback mechanisms, especially in remote districts. Diagnostic performance was compromised by intermittent stock-outs, expired rapid diagnostic tests (RDTs), and widespread pfhrp2/3 gene deletions affecting HRP2-based RDT sensitivity. Post-outbreak recovery capacity remained limited, with only about half of health facilities reporting timely replenishment of essential malaria commodities within three months and little evidence of routine after-action review processes. Cross-cutting constraints included delayed financing, fragmented digital systems, limited routine entomological surveillance, and insufficient community engagement in prevention activities.

conclusionsEthiopia's malaria programme demonstrates foundational capacity to interrupt transmission but remains constrained by systemic, operational, and equity-related gaps. Strengthening real-time surveillance and data use, adapting vector control strategies in response to resistance patterns, institutionalizing recovery and learning mechanisms, and embedding community-centred prevention approaches are essential to support a resilient and sustainable malaria response.