On World Malaria Day we asked Dr Uchenna Nwokenna, a Medical Epidemiologist and Health Systems Specialist who has spent most of the last year working on Malaria programmes in Nigeria, to reflect on progress made in controlling Malaria.
Saturday was WORLD MALARIA DAY and the theme for this year was “Invest in the Future: Defeat Malaria”. After the celebrations and the speechmaking, this is a useful time to step back and reflect how our actions and inactions in Nigeria have defined our investments.
Malaria remains a major cause of sickness and deaths in Nigeria accounting for 60% of outpatient visits and 30% of hospitalizations among children under five years of age. It is estimated that over 200,000 children die from malaria annually in Nigeria (NPC et al., 2012). Available local statistics show that malaria causes up to 11% of maternal mortality, 25% of infant mortality and 20% of under-five mortality.
In the last decade, since the inception of the Roll Back Malaria campaign, significant progress was made in malaria control in Nigeria by reducing morbidity and mortality rates. These reductions occurred as a result of a major scale-up of vector control interventions (interventions to tackle the anopheles mosquito which is the vector that transmits malaria), treatment with artemisinin-based combination therapies (ACTs) and an expansion of behaviour change communication. Nigeria has ambitions to reach the target of universal coverage of its population with malaria control interventions through economy, efficiency and equity in coverage with appropriate interventions linked to the epidemiology (pattern) of in different parts of the country. If the targets set for universal coverage with prevention and treatment interventions are achieved in Nigeria, it is estimated that this will result in a progressive reduction in malaria specific under-five mortality by 50% by 2017, saving over 134,000 lives annually. In addition, the interventions have the potential of reducing malaria specific maternal mortality by 44% and saving over 1,500 neonates (newborns) annually.
Specifically, parasitological diagnosis for malaria at the point of care has improved from 15% to 40% with improved availability of rapid diagnostic tests. The scale up of ACTs in the public sector and introduction of the Affordable Medicines Facility for malaria (AMFm) in the private sector has improved ACT utilization. Significant strides have also been made in the treatment of severe malaria, with the adoption of artesunate as first line treatment for severe malaria to replace quinine. Little progress was however made on implementing malaria community case management due to limitations of policy and guidance on community health services.
Towards the goal of achieving universal coverage, over 66 million long lasting insecticide-treated nets (ITNs) were distributed in Nigeria over five years from 2009-2013; 60 million of these were distributed through mass campaigns and the remainder through routine maternal and child health clinics and social marketing. Indoor residual spraying (IRS) was conducted in selected Local Government Areas (LGAs) in 8 states with external funding. The proportion of pregnant women using ITNs increased from 12% in 2008 to 16% in 2013. The proportion of pregnant women using ITNs in households with at least 1 ITN was 30%. The proportion of women who received at least two doses of sulphadoxine-pyrimethamine for the intermittent preventive treatment of malaria in pregnancy (IPTp) increased from 5% in 2008 to 15% in the same period.
While, significant investments have been made in malaria control in Nigeria in the last decade, malaria is still highly endemic making it one of the countries with the highest burden of malaria in the world. Current reports suggest that an estimated 97% of the country’s 170 million population is at risk of malaria. In the light of the current global economic downturn, we need to start doing things differently, linked to key lessons that would serve as drivers of our national response.
In the first instance, leadership, coordination and governance at national and sub-national levels remain weak and institutional capacity needs to be strengthened at all levels to achieve effective coordination of malaria interventions.
The use of available and emerging evidence remains central to achieving our goals. As such, epidemiological and risk maps need to be updated regularly to support planning and implementation of activities. We need to continue to support one national health management information system (HMIS) as the reference point for all routine malaria data including the development of tools and training to enable the collection of appropriate data.
There is an emerging need to distribute long-lasting insecticide treated nets (LLINs) to help achieve universal coverage over a shorter time and ensure that significant coverage is attained and maintained to achieve the desired impact. There is also a need to strengthen vector surveillance and bionomics and to map vector distribution and behaviour around the country given the scarcity of up to date vector distribution maps. There are subsisting knowledge gaps around larviciding and LLIN efficacy and durability that require operational research studies, in order to inform policy and guide implementation.
In addition to ensuring adequate supplies of Rapid Diagnostic Tests (RDTs) at all levels of care and public education to increase uptake, the scepticism of health workers towards RDT will need to be addressed.
In order to expand access to prompt treatment, we need to advocate for policies to guide integrated community case management (iCCM) and to mobilize resources to scale up its implementation (including training, equipping and retaining adequate numbers of volunteer community based providers).
In order to ensure the availability of quality medicines throughout the supply chain, more will need to be done to strengthen pharmacovigilance and a post marketing surveillance system. Similarly, with the widespread deployment of the rapid diagnostic tests, existing institutional capacity should be used to establish a quality assurance programme for malaria diagnosis and diagnostics.
While efforts have been made to improve the quality of care for uncomplicated malaria, there is also a need to improve the quality of severe malaria case management through strengthening referral systems, the infrastructure for emergency care and the capacity of health workers in secondary health facilities. In order to monitor progress and performance of implementation of case management activities, surveillance activities need to be strengthened at the sentinel sites. The uptake of intermittent preventive treatment of malaria in pregnancy (iPTP) is hampered by low and late ante-natal clinic attendance. Malaria programmes need to collaborate with maternal health departments to explore innovative delivery mechanism for maternal health services that including IPTP.
Timely availability of quality assured commodities for diagnosis, treatment and communication at all service points is essential for quality of case management. Achieving this requires a strong national supply chain that is streamlined across different commodities and programmes, improved infrastructure for storage of medicines and commodities at facility level and improved visibility of where supplies are going or needed through a functional logistics management information system.
In order to ensure sustainability, Nigeria needs to develop a strategic framework for malaria health financing; and this needs to be supported by intensive advocacy efforts at national and international level to increase financing for malaria interventions.
The task appears daunting, but the progress made so far indicates what might be achievable, if we all lend our voices, our actions and our efforts to tackling this challenge.