Understanding malaria resurgence in the Amhara Region, northwestern Ethiopia: a qualitative study of perceived drivers from stakeholder and community perspectives

Abstract

Abstract Background Ethiopia has experienced a marked resurgence of malaria, with confirmed cases rising from 1.0 million in 2018 to more than 7.3 million by October 2024. This resurgence is particularly pronounced in the Amhara Region and threatens national elimination goals. This study explored perceived drivers and contextual determinants of malaria resurgence from the perspectives of frontline health workers and community members in the Amhara Region. Methods Between 1 and 28 February 2025, we conducted 28 semi-structured key informant interviews, two focus group discussions (n = 20), and 12 in-depth interviews. Participants were purposively selected based on professional roles or community leadership. Data were collected in Amharic, audio recorded, transcribed verbatim, and translated into English, then analyzed inductively using reflexive thematic analysis. The Health Belief Model, which focuses on risk perception and care-seeking behavior, was used as a sensitizing framework to interpret behavioral findings. Results Participants perceived malaria resurgence as increasingly widespread, with near year-round transmission, expansion into previously low-risk highland areas, and a rising burden among children under five years and pregnant women. Perceived ecological drivers included irregular rainfall, land use change, irrigation schemes, and construction-related water storage. Reported health system challenges included recurrent stockouts of antimalarials and diagnostics, delayed or incomplete vector control, and reliance on passive surveillance. Behavioral factors such as low perceived susceptibility and severity, reliance on traditional and religious healers, misuse of insecticide-treated nets, and weak regulation of private providers were seen to delay care-seeking and undermine prevention, particularly in conflict-affected and remote areas. Conclusions Stakeholders and community members perceived malaria resurgence in the Amhara Region as arising from interacting ecological change, health system fragility, and behavioral dynamics, exacerbated by conflict and recent public health emergencies. These hypothesis-generating findings suggest that locally tailored, equity-focused interventions, integrating behavioral insights with strengthened supply chains, surveillance, and community-centered vector control, could inform efforts to address resurgence and support Ethiopia’s elimination goals.