The National Health Policy . A means to combating the malaria scourge in Nigeria

Table of Contents

Introduction

The Nigerian war on Malaria

National Health Policy on Malaria - “Viewing the Score Board”

Conclusion

Introduction

According to the Federal Ministry of Health (FMoH) report (2005); it is estimated that over 100 million people are at risk of malaria every year in Nigeria. The statistic further revealed a prevalence rate of about 50% of the adult population in Nigeria experience at least one episode yearly while the under five children have up to 2 - 4 attacks of malaria annually. The grim implication of malaria is even far reaching negatively as it puts a huge toll bordering on the cost of treatment, transport to source of treatment, loss of productivity, quality of education and overall, on economic growth and development indices.

In Nigeria, the economic burden of malaria is largely conspicuous, a major cause for concern. Every year, the nation loses billions of Naira of taxpayers’ money from cost of treatment and absenteeism from work, schools and farms, according to a report by the Ministry of Health.

Notably, malaria remains the number one cause of hospital attendance in all age groups in all parts of Nigeria. It is also one of the four commonest causes of childhood mortality in the country, the other three being acute respiratory infection (pneumonia), diarrhoea and measles (World Health Organization (WHO) Atlas of African Health Statistics, 2016). Malaria has also been reported to negatively impact maternal health and birth outcomes (maternal anaemia, increases miscarriage and low birth weight) (FMoH, 2005).

Nigeria unfortunately is one of several African countries worst hit by the tropical disease. Therefore, in view of its wide spread prevalence and far-reaching negative consequences around the globe; international organizations like the WHO, World Bank among others have jointly launched a number of programmes to tackle this plague. The gazette containing the Millennium Development Goals (MDGs) highlights areas where research and resources are crucially needed. Malaria, HIV/AIDS amongst other diseases were included as an integral part of the MDGs (MDG-6) (WHO Atlas of African Health Statistics, 2016).

In spite of these laudable efforts from the international communities, developing countries especially in the African region are still left behind. The WHO report for instance, on the progress on the MDGs set a target based on certain strategic approaches to reduce the incidence of malaria in Africa and the rest of the world by 75 % between 2000 and 2015. However, by 2015, Africa had the lowest of 42 % while the Europe had 100 % malaria incidence reduction (WHO malaria report, 2014). In fact, the global health monitoring body (WHO) had flagged in its report setbacks with respect to the percentage of children Under-five years sleeping under insecticide treated bed nets and percentage of children Under-five years with fever being treated with anti-malarial drugs in the African region, 2007 – 2013; of the 80 % target coverage, Nigeria scored low 17 % and 33 % respectively through this period (WHO, 2015). These health outcomes reflect much deeper problem among the countries (in African region), in addition to the endemic nature of the disease.

From a national scale, amongst its malaria parasite variants; Plasmodium falciparum has been identified as the most predominant parasite specie accounting for about 98% of malaria cases in the country. P. malariae usually occurs as a mixed infection with P. falciparum. Meanwhile, Anopheles gambiae is the main vector of malaria in Nigeria, but Anopheles funestus and Anopheles arabiensis are also commonly encountered. Anopheles melas is found in the coastal areas. Notably, malaria transmission is higher in the wet season than in the dry season and this seasonal difference is more striking in the northern part of the country.

Epidemiological data revealed that Nigeria is situated (FMoH report on malaria, 2008) between 4° and 13° Northern Latitude (FMoH report on malaria, 2008) which has a suitable climate for malaria transmission throughout the country. The only exception is the area South of Jos in Plateau State where some mountain peaks reach 1600 meters and the altitude of settlements lies between 1200 and 1400 meters. This area can be considered of low or very low malaria risk.

Furthermore, the five ecological strata from South to North define vector species dominance, seasonality and intensity of malaria transmission: mangrove swamps, rain forest, guinea-, Sudan- and Sahel-savannah. The duration of the transmission season decreases from South to North from perennial in most of the South to only 3 months or less in the border region with Chad. A summary of the entomological inoculation rates (EIR) reported in 86 studies from Nigeria suggests that EIR for A. gambiae ranges from 18 to 145 infective bites per person per year and for A. funestus from 12 to 54.

Mores so, as shown below (Figure 1) on the distribution of projected malaria prevalence rates in the country. The figure basically depicts malaria endemicity is highest around the two river valleys. Taking into account this distribution as well as the population density, it can be estimated that approximately 30% of the population live in areas of high to very high transmission intensity and 67% in the moderate transmission zone and these proportions have been used in the calculations. These results in an estimated number of fever and malaria episodes per person and year of 3.5 and 1.5 respectively for children under 5 and 1.5 and 0.5 for those 5 years and older and a total of 70-110 million clinical cases per year. The current malaria related annual deaths for children under 5 years of age are estimated at around 300,000 (285,000 - 331,000), and 11% of maternal mortality.

Abbildung in dieser Leseprobe nicht enthalten

Figure 1: Distribution of projected malaria prevalence rates

Source: FMoH (2008)

The Nigerian war on Malaria

Historically, Nigeria in 1996 developed its first National Malaria Control Policy. A yearly plan of action was developed for 1997 and 1998 and a three-year Plan of Action was also developed for 1999– 2001. Malaria Control units in the Nigerian states were revitalized or reestablished and awareness to funding malaria activities was created. The highest advocacy between 1996 and 1998 was the celebration of the National Social Mobilization Day when the Malaria Control logo was launched by the then Minister of Health, Rear Admiral Jubril Ayinla. The National Technical Committee was also resuscitated in 1998 comprising the National, State and some LGA malaria programme managers and officials, as well as representatives from the private sector and international agencies (FMoH, 2008).

The fierce tackle on the plague of malaria in Nigeria has been ongoing since the latter part of the 20th century. One of such effects culminated in the Roll Back Malaria (RBM) initiative (FMoH, 2005). It was initiated in 1998 through a joint partnership of WHO, UNICEF, UNDP and the World Bank.

RBM consists of two phases - the inception phase and the implementation phase. After the Consensus Building Meeting for countries in West Africa in March 1999, Nigeria started the RBM inception phase. Nigeria drew attention of the world to problems of malaria control in Africa by hosting and co-financing the African Heads of State Summit on RBM in April 2000. The Summit was also attended by the four founding agencies (WHO, UNICEF, World Bank & UNDP) and other development partners. The Summit concluded with the signing of the Abuja Declaration and Plan of Action. By signing the Declaration, Africa rededicated itself to the principles and targets of the Harare Declaration of 1997 and gave commitment to intensify efforts to halve (50 %) the malaria mortality in Africa by the year 2010 through implementing strategies and actions of Roll Back Malaria. Some of the activities of the Nigerian FMoH in accordance to the RBM approach and Abuja Declaration include (a) Consensus building meeting nationally and in all the six geopolitical zones. A three year National Plan of Action which also contained the States Plan of Action was developed. (b) Partnerships have been developed with stakeholders (private and public sectors) and NGOs and International developmental agencies (WHO, UNICEF, DFID USAID, etc.). (c) Deskwork analysis of the malaria situation was completed (d) Malarial situation survey was carried out to assess the actual situation of malaria in the country to fill the gap created from the deskwork (d) A National strategic plan was developed to guide implementation from 2001 to 2005.

Specifically, the objectives of the national health policy on malaria were tailored to reduce morbidity; halt the progression of uncomplicated disease into severe and potentially fatal disease, and thereby reduce malaria mortality; reduce the impact of placental malaria infection and maternal malaria-associated anaemia through intermittent preventive treatment; minimize the development of anti-malarial drug resistance (FMoH, 2005, 2008). Furthermore, in line with the National policy on malaria; several strategies have been launched; one strategy that has been consistently used in the last three and a half centuries is chemotherapy hence the national anti-malarial treatment policy in 2005.

Essentially, malaria control in Nigeria is based primarily on early recognition and prompt and appropriate treatment. However, in recent times this effort has been dampened by anti-malarial drug resistance – a global phenomenon. Briefly, the development of resistance has been stated as the ‘ability of a parasite strain to multiply or to survive in the presence of concentrations of a drug that would normally destroy parasites of the same species or prevent their multiplication.’ Unfortunately, problem of drug resistance have continually pose a threat to the usefulness of the presently available antimalarial drugs leading to drug failure. Drug resistance has led to an increase in morbidity and mortality; delay in initial therapeutic response; and an increasing cost to the anti-malarial drugs.

In other quarters, in bid to eliminate the scourge of malaria in the country, the national anti-malarial treatment policy also incorporated some strategies. One of which is the education of the communities and health workers on taking preventive measures; improving on their recognition/diagnosis of malaria and the use of anti-malarial drugs rationally; monitoring and evaluation of the FMoH strategic plan on malaria and continual expansion of malarial research capacity in Nigeria.

It is important to mention at this juncture that in Nigeria, research efforts have been centered mainly on studies designed to evaluate efficacy and safety of anti-malarial drugs even though it’s on a disproportionately low scale compared to the rate of the disease transmission.

With respect to financing the national health policy, funding for malaria control had majorly been undertaken by the Federal, State and Local governments. Others sources of funds include international and local non-governmental development agencies / organizations, communities and philanthropic individuals. The policy also enlisted an increase in budgetary allocation to health by governments at all levels envisaging the 15% set out by Abuja Declaration.

What is the status of the work done with respect to the Nigerian health policy on malaria?

There is no doubt that some measure of progress has been made. Yet it should be said that in spite of the effort of the RBM programme in Nigeria; transmission of malaria remains a major public health issue according to the FMoH. Situation analysis on the fight against malaria revealed the following:

- The perception of the cause of malaria is poor and very few people in the community link mosquito to malaria.
- 80% of malaria cases are inadequately managed at community level by the facility and home based caregivers.
- 96% of caregivers initiated actions within 24 hours but only 15% of their actions are appropriate due to inadequate dosage.
- 60% of mothers had no knowledge of the current management of convulsions. Only 5% referred such cases to hospital while most either go to traditional healers or use traditional home made concoctions.
- Improper use of parenteral anti-malarials
- Only 5% of anti-malarial drugs are produced in Nigeria
- 85% of health facilities surveyed in rural areas had stock-out. None had prepackaged drugs.
- 51% of mothers obtain drugs from Patent Medicine Vendors, 89% of the drugs were found to be substandard and 43% of syrups unsatisfactory.
- Non-availability of treatment guidelines in sampled health facilities.
- Poor laboratory support in diagnosis of malaria.
- 40% of patients with severe malaria die due to poor quality care.
- Treatment of malaria illnesses accounted for 46% of the curative health care cost incurred by households with a mean of N330.00 per month.
- Reporting of malaria is poor in the country.

National Health Policy on Malaria - “Viewing the Score Board”

In the year 2000, the world launched Millennium Development Goals (MDGs) and Goal 6C was to halt and reverse the incidence of malaria by 2015 (United Nations, 2014; Aribodor et al., 2016). Following the end of MDG, the World Health Organization member states, Nigeria inclusive, in 2015 agreed a new global malaria strategy for 2016-2030 (WHO, 2015). The strategy aimed to reduce the global disease burden by 40% by 2020, and by at least 90% by 2030. It also aimed to eliminate malaria in at least 35 new countries by 2030. Notably, between 2000 and 2013, the global malaria mortality rate dropped by 47% (WHO, 2014). A major expansion of the WHO-recommended core package of measures – vector control, chemoprevention, diagnostic testing and treatment – proved both cost effective and efficient.

In spite of the strategic control against malaria, it appears millions of people are still unable to access malaria prevention and treatment. In addition, most cases and deaths continue to go unregistered and unreported. In 2013, malaria killed an estimated 584 000 people with over 2 million cases (WHO, 2014). According to a WHO report (2012), Nigeria was reported to have contributed about 25% of the world malaria burden.

Briefly, some of the setbacks to achieving the malaria elimination in Nigeria as highlighted in a study by Aribodor et al. (2016) include the following.

a) Drug Resistance and Treatment Failure: Drug resistance till date remains a major cause for concern in the strategic control of malaria. Chloroquine used to be the drug of choice against malaria but chloroquine resistance that swept across endemic countries in the 1980s was the reason for treatment policy change that gave rise to the use of Artemisinin-based combination therapy (ACT) as the current drug of choice. Unfortunately, drug resistance to Artemisinin has also been reported in major parts of southeast Asia and worldwide (Ariey et al., 2014; Hien et al., 2012; Phyo et al., 2012; Kyaw et al., 2013; WHO, 2014, 2015). With suspected cases of treatment failures which drug resistance could be a factor, it is doubtful if Nigeria has research-based data on the status of ACT, vis-à-vis resistance to P. falciparum and any role in treatment failures, hence a challenge to overcome. In addition, a number of factors have been attributed to the malaria treatment failure including incorrect dosing, non-compliance with the duration of dosing regimen, poor drug quality, drug interaction, and improper or misdiagnosis.
b) Insecticide resistance: The control of the Anopheles vectors of malaria relies on the use of Long-Lasting Insecticide Nets (LLINs) and Indoor Residual Spraying (IRS). The benefits of the use of these methods have been recorded in many countries (Hemingway et al., 2000). However, this success is being impeded by the development and spread of insecticide resistance malaria vectors in Africa, which has compromised the use of these vector control strategies. Only 4 classes of insecticide (carbamates, organophosphates, organochlorines and pyrethroids) are available for IRS, whereas the use of LLINs depends exclusively on pyrethroids. In Nigeria, the Anopheles vector resistance to DDT (Dichlorvos) and pyrethroids has been reported (Awolola et al., 2002, 2003, 2005, 2007, 2008). Hence, there is a strong need for the development of appropriate tools to monitor resistance in field populations of the Anopheles mosquitoes in order to benefit from the contributions of the appropriate use of chemical insecticides in malaria elimination in Nigeria.
c) Global Warming and Climate Change: Available data suggest that the temperature of the world is increasing, with the last decade recorded as having the highest temperature (Craig et al., 2004; Ezenduka et al., 2014; Craig et al., 1999; Tanser et al., 2003). This increase in global temperature mainly as a result of human activities, including burning of fossil fuel and deforestation leads to global warming which in turn affects the country’s climate. Malaria has been identified as one of the most climate sensitive diseases [Githeko et al., 2000] with studies suggesting significant associations between temperature and malaria incidence (Li et al., 2013). Climatic factors have been reported to play important roles in the spatial and temporal distribution of malaria (Hay et al., 2002; Paaijmans et al., 2009). The relationship between climatic variables and malaria transmission has also been reported in many countries (Gagnon et al., 2002; Kim et al., 2012; Paaijmans et al., 2009; Hay et al., 2012; Craig et al., 2004). In addition, relative humidity (Githeko et al., 2000; Li et al., 2013) and rainfall (Zucker et al., 1996; Craig et al., 1999) have also been associated with malaria transmission. Climate change expressed through changes in temperature and precipitation may influence habitat suitability and can potentially shift the geographical range of malaria (Aribodor et al., 2016). Warmer temperatures accelerate physiological processes of the mosquito vector, leading to increased activity such as biting rate, growth, development and reproduction. Extreme temperatures may also decrease survivorship of vectors, leading to a convex relationship between temperature and mosquito performance [Hay et al., 2002; Shanks et al., 2005; Artzy-Randrup et al., 2010].
d) Conflicts, terrorism, insurgency, internally displaced persons and migration: The negative cost of civil and tribal includes the destruction of civil infrastructures and the loss of human lives (Pasquale et al., 2013). Notably, the health status of the surviving victims is predictably impacted negatively - in addition to the loss of productivity in such region. The infection with the malaria parasite in these regions cannot be exempted owing to the high malaria transmission intensities with inherent high morbidity and mortality rates (Ross, 2009). Furthermore, the massive movement of non-immune people across areas infested with the malaria vector is one of the consequences of such wars. The malaria control situation is threatened by the impact of refugees, returnees, internally displaced populations, and natural disasters, i.e. flooding, that put added strain on an already weakened system from years of conflict and that may destabilize whatever gains that have been made. The situation is aggravated by an increase in population due to refugees, returnees and internally displaced persons. Nigeria today is plagued by conflicts, terrorism, insurgency, migration and internally displaced persons. Virtually all regions of the country are affected, with the Northeast bearing the highest burden.
e) Attitude and Behaviour Change: Perceptions about malaria illness, particularly households’ perceived susceptibility and beliefs about the seriousness of the disease, are important preceding factors for decision-making concerning preventive and curative actions (Rakhshani et al., 2003). The understanding of the possible causes, modes of transmission, and individual preference and decision-making about the adoption of preventive and control measures vary from community to community and among individual households (Adongo et al., 2005). Misconceptions concerning malaria still exist (Aribodor et al., 2014) and practices for the control of malaria have been largely unsatisfactory (Aribodor et al., 2014; Alaii et al., 2003; Laveer et al., 2001; Obol et al., 2011). It is important in Nigeria to understand the culture and traditions of malaria endemic communities, as these form the basis of community members’ values, which shape community members’ attitudes on topics like malaria control and elimination. Often these local beliefs influence community members’ action or inactions more than any other factor in the fight against the disease.
f) Political will, leadership and funding: An important action for mobilizing and encouraging governments to continue to support malaria programmes is to generate political commitment. Since 2000, there has been an increasing political drive to eliminate malaria (Roll Back Malaria, 2011). The transition from sustained control to elimination demands a shift in focus. It requires significant national commitment, and sustained investment and financial support (Whittaker et al., 2014). To maintain a malaria-free status, a country must show that it has the necessary political will and vision, has created the required legislative and regulatory framework and has adequate financial and administrative resources, personnel and technological capacity (Moonen et al., 2010; Ejov et al., 2014). The most important challenge in battle against malaria in Nigeria is the lack of political will (Aribodor et al., 2016) and until this is overcome, achieving elimination may be a mirage. It is important that the community should take responsibility for their own health and that community leaders should be involved in malaria prevention campaigns (Mlozi et al., 2006).
g) Research: Local governments, states, regional and country-wide research studies are undeniably imperative towards control of malaria in Nigeria. Local produce or novel intervention tools are imperatives for malaria elimination (Aribodor et al., 2016). The malaria elimination surveillance research and development agenda needs to develop tools and strategies for active and prompt detection of infection (Bennett et al., 2011; Slutsker, 2012).

Conclusion

Malaria elimination in Nigeria is a realistic possibility. In fact, as highlighted in this discourse, the Roll Back Malaria initiative has been immensely instrumental to achieving reducing mortality and morbidity arising from malaria. However, this upwards movement has - and is currently being threatened by contributory elements such as lack of political will, drug resistance, conflicts, poor funding, global warming, the prevalent attitude of the people to mention a few. All these militating elements need to be tackled, as the elimination and eradication of malaria will require a complete integration of people, resources and policy to achieve the desire target of a malaria-free society.

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