Scaling up malaria control in Nigeria: challenges and opportunities - - PowerPoint PPT Presentation

Scaling up malaria control in Nigeria: challenges and opportunities

Kelechi Ohiri and Ndukwe Ukoha Health Strategy and Delivery Foundation (HSDF) June 22, 2015

1

Contents

▪ Overview of Nigeria Health System ▪ Epidemiology of Malaria in Nigeria ▪ Key interventions and outcomes ▪ Opportunities, renewed approaches and initiatives

2

Nigeria is a federation with 6 zones spanning 36 state and a diverse population of over 160 Million people

3

4

Nigeria has a demographic profile, with a high dependency ratio (Proportion of non-working age

• ver working age)

SOURCE: US Census Bureau: International Database

Indonesia Thailand Nigeria 1980 2011 2020

50 100

2020

• 41%

2000 1980

50 100 1980 2000 2020

• 45%

50 100

2020 2000 1980

• 3%

Dependency ratio

5

At current growth rates, Nigeria’s population is projected to double in 20 years and increase by 146% to ~400 million by 2050 making it the 4th most populous country

SOURCE: United Nations Population Division, Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm,Sunday, August 28, 2011; 12:59:25 PM

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

150 50 100 300 350 200 400 450 250 Mexico Brazil Indonesia Bangladesh Pakistan +146% Russia Nigeria USA

Estimated growth trends in the 10 most populous countries (India, China not in chart) millions

6

The Federal Constitution divides responsibility for healthcare across the three tiers of government

The 1999 Constitution: Placed Health on concurrent list Then there was no explicit delineation of responsibilities amongst tiers of Government 2004 Health Policy: Primary Health Care (PHC) became the entry point and cornerstone of the National Health System. It became the core strategy for ensuring access to health for all Nigerians PHC service delivery targeted mostly towards the rural population

▪ Local government authorities are responsible for

direct delivery of PHC services to the communities

▪ The State Governments are responsible for

providing secondary care and deploying additional financial resources, skilled manpower, regulation, supportive supervision for PHC

▪ The Federal government promotes development

and provide overarching policy guidelines, technical support, resource mobilization monitoring and evaluation

▪ In addition, the Federal Government is responsible

for Tertiary Care delivery.

Nigeria’s health system is beset with several challenges and suboptimal health outcomes

7

SOURCE: Nigeria Demographic and Health Survey, 2008, 2013

▪ Maternal mortality rate is

545/100,000 live births = 33,000 women each year

▪ 1 in 9 maternal deaths

worldwide

▪ Infant mortality rate is

69/1,000

▪ 8% of the global total, ▪ An estimated 70% of these

deaths are preventable

▪ Under 5 mortality rate is

128/1,000 = ~1 million deaths per year

▪ ~10% of the global total ▪ ~23,000 health facilities

(estimated 14,000 PHCs) but with different levels of functionality

▪ Poor quality of care ▪ Shortage of critical human

resources

▪ Supply challenges

– Inadequate power or

water supply

– Commodity stock-outs – Equipment inadequacy – Weak standards

▪ Demand for critical services

very low, largely driven by a loss of confidence in the system e.g.

– Only 38% of women

have skilled births; Only 58% have ANC

Within the country, significant inequity in access to services exists

10 20 30 40 50 60 70 80 90 100

• Med. Treatment of

Fever

• Med. Treatment of
• Ac. Res. Inf.

Oral Rehydration Thereapy Antenatal Care

• Att. Delivery

Full Immunization

Lowest 20% of Population Highest 20% of Population SOURCE: 2008 Nigerian Demographic and Health Survey

Use of primary maternal and child health care services among Lowest and highest population quintiles Percentage

8

For instance, ITN coverage in Nigeria ranges from 18% to 82% despite a national campaign efforts

18 24 25 25 26 33 34 34 37 38 42 43 43 44 45 46 49 49 52 52 54 56 56 57 57 57 58 59 59 60 67 69 70 71 73 73 82 Bauchi Imo Gombe Adamawa Benue Osun Kogi Kaduna Nasarawa Edo Sokoto Cross River Yobe Plateau Zamfara Anambra Bayelsa Borno Niger Ondo FCT Rivers Kwara Kano Delta Katsina Ebonyi Jigawa Abia Taraba Kebbi Oyo Ogun Ekiti Akwa Ibom Lagos Enugu

LLIN coverage, 2013 % of households with at least one LLIN

SOURCE: Nigerian Demographic and Health Survey 2013

9

However, most of the expenditure on healthcare is spent on curative services…

SOURCE: A. Soyibo et al. 2009; National health accounts: structure, trends and sustainability of health expenditure in Nigeria

10

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…although the burden of disease is largely driven by preventable infectious and parasitic diseases

CMPN: Communicable, Maternal, Perinatal and Neonatal conditions SOURCE: WHO Department of Measurement and Health information 2009. Based on 2004 DALYs

2004 Injuries NCDs CMPN* 5,249 16,648 55,793 77,690

55,792 33,887 8,146 8,940

3,218 Nutrition 1,601 Total Respiratory infections Infections/ Parasitic Maternal Perinatal

2,954 16,178 4,124

Cancers Digestive Cong anomalies 1,457 Resp 1,578 Sense

• rgan

disorders 1,670 CVD Neuro- Psychiatric 1,274 1,233 Diabetes /Endo 1,124 Others 764 Total

5,249 2,587

Total RTAs 1,231 Intentional injuries 1,431 Other unintentional injuries

Estimated total DALYs (000s) by cause

In summary, the health system, despite recent improvements, still faces the following four challenges

• High maternal, newborn and child mortality rates
• Inequalities in health outcomes and utilization by socioeconomic status, urban/

rural and by regions across the country Suboptimal health

• utcomes
• Persisting vaccine-preventable diseases, such as Polio, Measles and Meningitis
• Rising burden of non-communicable diseases
• Significant burden of injuries and trauma-related deaths

Triple burden

• f disease
• Poor quality of health care services in public and private facilities that is

unresponsive to the needs of the population

• High rates of outward migration for health care services for those who can afford

it Poor quality of health services

• Health insurance coverage is minimal. Most payment remains out of pocket
• National health insurance scheme currently covers only the formal sector

Lack of protection from financial risk

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Contents

▪ Overview of Nigeria Health System ▪ Epidemiology of Malaria in Nigeria ▪ Key interventions and outcomes ▪ Opportunities, renewed approaches and initiatives

13

Nigeria is strategically important to global malaria control efforts

Global ¡ ¡

¡

¡Africa ¡ ¡

¡

Nigeria

1 2 3

▪ An estimated 3.3 billion people are at risk of malaria ▪ 25-30% of global malaria-related mortality is attributable to Africa ▪ Africa still bears over 80% of the global burden, despite recent declines in

morbidity

▪ Nigeria and the DRC account for 40% of the continental burden ▪ An estimated 97% of the country’s 176 million people is at risk of malaria. ▪ About 11% of all child deaths worldwide are estimated to occur in Nigeria. ▪ Annual financial loss due to malaria in Nigeria is estimated at132 billion Naira (≈USD

800,000)-cost of treatment, prevention, loss of man-hrs. etc.

SOURCES: World Malaria Report 2008,2009,2010, 2011,2013, 2014; Nigeria National Indicator survey 2010, Nigerian Demographic and Health Survey 2008 and 2013

14 ¡ ¡

The drivers of malaria prevalence in Nigeria are environmental, socio-economic and health systems-related factors

Key ¡factors ¡ Malaria ¡ Prevalence ¡ Implica5ons ¡in ¡Nigeria ¡

▪ Vector ¡Distribu-on ¡

– Rainfall ¡ – Temperature ¡ – Land ¡Use ¡ – Land ¡cover ¡

▪ Nigeria ¡has ¡different ¡dis-nct ¡clima-c ¡zones ¡

(arid ¡deserts ¡in ¡the ¡north, ¡to ¡rainforest ¡and ¡ mangrove ¡swamps ¡in ¡the ¡south) ¡

▪ Variability ¡in ¡vector ¡distribu-on ¡across ¡states ¡

in ¡Nigeria ¡

▪ Human ¡Vector ¡Contact ¡ ¡

– behavioral ¡factors ¡ ¡ – occupa-onal ¡factors ¡ ¡

▪ Human-­‑host ¡related ¡factors ¡

– Popula-on ¡movement ¡ – Educa-on/Income ¡ – Sanita-on ¡

▪ Poor ¡quality ¡of ¡care ¡ ¡ ▪ Complex ¡opera-onal ¡structure ¡ ▪ Weak ¡program ¡coordina-on ¡ ▪ Poor ¡health-­‑seeking/care ¡

prac-ces ¡ ¡

▪ Health ¡educa-on ¡and ¡knowledge ¡ ¡ ▪ The ¡use ¡of ¡personal ¡protec-on ¡measures ¡

against ¡mosquito ¡bi-ng ¡ ¡

▪ Distance ¡to ¡known ¡breeding ¡sites, ¡type ¡of ¡

household ¡construc-on, ¡household ¡occupancy ¡

▪ Migra-on ¡and ¡internal ¡displacement ¡of ¡

popula-ons ¡

▪ In ¡Nigeria, ¡issues ¡related ¡to ¡quality ¡of ¡care ¡

exist, ¡including ¡but ¡not ¡limited ¡to ¡misdiagnosis ¡

• f ¡malaria ¡

▪ Poor ¡access ¡to/uptake ¡of ¡preven-ve ¡

interven-ons ¡ Issue ¡

▪ Climac-c ¡and ¡

environmental ¡ ¡

▪ Socio-­‑

economic ¡

▪ Health ¡

Systems ¡

SOURCES: NDHS, 2013, J.S Ogboi et al. 2014. Misdiagnosis of malaria using wrong buffer substitutes for RDT in poor resource settings in Enugu, Nigeria.; Multi-indicator cluster survey 2011, NBS Nigeria 15 ¡ ¡

A 2013 study carried out by the NMEP in Nigeria & the INFORM project . § The findings show a gradual shift from hyper-endemic to meso-endemic patterns from 2000 – 2010. § The Nigeria NMEP relies on these findings for all recent decisions relating to the country’s malaria burden – including its recent application for Global Fund NFM in 2014.

The most recent epidemiological analysis suggests a spatio-temporal improvement in malaria epidemiology, with the burden higher in some parts of the country

Binned Predicted Mean PfPR2-10

PƒPR2-10 < 5% ≥ 5% - < 10% ≥ 10% - < 50%

> 50%

SOURCE: A description of the epidemiology of malaria to guide the planning of control in Nigeria (2013). NMEP, Abuja, Nigeria; The INFORM Project; WHO

16 ¡ ¡

Contents

▪ Overview of Nigeria Health System ▪ Epidemiology of Malaria in Nigeria ▪ Key interventions and outcomes ▪ Opportunities, renewed approaches and initiatives

17

The focus and targets of the national malaria program has evolved over time

▪ Shift from prioritizing the vulnerable

as primary target group to universal & equitable access of all the population.

▪ Priority on preventive interventions

for all households in the country, to achieve SUFI.

▪ Community involvement in malaria

control activities & involvement of

• ther sectors/ civil society orgs./Faith

based orgs.

▪ Integration of malaria programs at all

levels, into general health activities to seek synergies/increase cost- effectiveness.

▪ Operational research out to improve

understanding of malaria and how best to implement programs.

▪ Build capacity to deliver malaria

control/elimination interventions at national, state and LGA levels.

▪ Strengthen programme coordination

at national & sub national levels.

▪ Improve unified annual planning

among all stakeholders.

▪ Develop a comprehensive strategy

for private sector engagement.

▪ Strengthen reporting of malaria

control efforts + dissemination of all reports/research findings to relevant stakeholders.

SOURCES: Nigeria National Malaria Strategic Plans: 2006 – 2010; 2009 – 2013; 2014 - 2020

▪ Malaria intervention efforts

focused on u-5s and pregnant women.

▪ Parallel malaria control efforts

hence synergistic opportunities were missed.

▪ Poor community involvement and/

• r civil society organizations.

▪ No private sector involvement. ▪ No robust operational research to

ascertain the country malaria epidemiology.

2006 – 2010 2009 - 2013 2014 till date

Targeted coverage for the most vulnerable Scale Up for Impact Universal coverage Year/period

Focus

Target population Scale/scope

• f

interventions Stakeholder involvement Non- state actors Evidence based programing

1 2 3 4 5

18

The current strategic shift from control to elimination reflects renewed determination to curb the disease with aspirations towards elimination

The country’s aspiration to attain pre- elimination by 2020 has implications. This is indicative by the following: 1. Transmission intensity remains very high across the country – 97% of approx. 178 million people are at risk of malaria. 2. A summary of entomological inoculation rates (EIRs) reported in 86 studies from Nigeria suggest that rates for A. gambiae species range from 18 to 145 infective bite per person per year, and for A. funestus species, from 12 to 24 infective bite per person per year. 3. Studies have also shown that the asymptomatic malaria parasitaemia population is high in Nigeria.

SOURCES: WHO malaria elimination continuum. World Health Organization, 2014; National malaria strategic plan 2014 – 2020, NMEP, Abuja Nigeria

Nigeria is currently in the control Phase …but aspires to attain pre-elimination by 2020

19

Priority interventions in Nigeria have focused on prevention and case management

SOURCES: Nigeria National Malaria Strategic Plans – 2006 – 2010; 2009 – 2013; 2014 – 2020; NDHS 2008, 2013; NDHS 2008, 2013

1 2 3 4 5 6 7 8

▪ Long ¡Las-ng ¡Insec-cidal ¡Nets: ¡ ¡~100 ¡million ¡LLINs ¡distributed ¡across ¡states ¡in ¡Nigeria ¡between ¡

2009 ¡-ll ¡date. ¡ ¡

▪ Indoor ¡Residual ¡Spraying: ¡ ¡~1% ¡of ¡Nigeria’s ¡en-re ¡households ¡covered ¡with ¡IRS ¡in ¡4 ¡states ¡

(Anambra, ¡Bauchi, ¡Jigawa ¡and ¡Lagos). ¡ ¡

Preven5on: ¡

▪ Larval ¡Source ¡Management: ¡This ¡is ¡planned ¡to ¡be ¡implemented ¡across ¡the ¡en-re ¡country. ¡ ▪ Intermi^ent ¡Preven-ve ¡Treatment ¡in ¡pregnancy: ¡Given ¡free ¡of ¡charge ¡to ¡pregnant ¡women ¡through ¡

ANC ¡services ¡at ¡public ¡health ¡& ¡non-­‑governmental ¡facili-es, ¡using ¡an ¡approach ¡of ¡directly ¡observed ¡

• therapy. ¡ ¡

Case ¡management: ¡

▪ Rapid ¡Diagnos-c ¡Test ¡kits: ¡RDTs ¡are ¡used ¡in ¡detec-ng ¡evidence ¡of ¡malaria ¡parasite ¡in ¡human ¡blood, ¡

in ¡public ¡and ¡private ¡facili-es ¡across ¡country. ¡

▪ Microscopy: ¡ ¡iden-fies ¡different ¡malaria ¡causing ¡parasites. ¡Mostly ¡available ¡in ¡secondary ¡and ¡

ter-ary ¡facili-es ¡in ¡Nigeria. ¡

▪ Seasonal ¡Malaria ¡Chemoprophylaxis: ¡Deployed ¡so ¡far ¡in ¡4 ¡out ¡of ¡the ¡9 ¡sahel ¡region ¡states ¡in ¡the ¡

country ¡( ¡Bauchi, ¡Borno, ¡Jigawa, ¡Katsina, ¡Kano, ¡Kebbi, ¡Sokoto, ¡Yobe, ¡Zamfara). ¡

▪ Artemisinin ¡Combina-on ¡Therapy: ¡ACTs ¡remain ¡the ¡first ¡line ¡treatment ¡for ¡uncomplicated ¡malaria ¡

in ¡Nigeria. ¡

20 ¡ ¡

1a) LLINs: Over 100 million LLINs have been distributed in all states across Nigeria via different distribution channels with modest increases in ownership and use

National net ownership trends and usage levels among children under the age of five years and pregnant women.

SOURCES: Nigeria Demographic and health surveys – 2003, 2008 & 2013, Nigeria malaria indicator survey 2010, Nigeria Standardized Monitoring & Assessment of Relief and Transition (SMART) survey, 2014 53 50 15 10 25 6 1 17 17 12 5

SMART 2014 NDHS 2008 NDHS 2003 NDHS 2013 %use by pregnant women %net ownership %use by under fives I n d i c a t o r s f o r measurement: Ownership: % of household with at least a net in their homes. Usage in under 5 : % u-5 children that slept in a net the night before the survey. Usage in pregnant w o m e n : % pregnant women that slept in a net the night before the survey. Civil society free or subsidized LLINs Public sector free LLINs Commercial sector (subsidized or unsubsidized)

▪ Mass campaign

distributions

▪ Community based

distribution for “mop up

▪ Mass campaign

(integrated or stand alone)

▪ Routine

distribution (ANC) and (EPI) services

▪ Retail market

(through PPMVs, pharmacy stores etc.)

▪ Institutional sales

1 2 3

Intervention…… …..Impact

21

1b) LLINs: Surveys have shown that a number of factors affect the usage of mosquito nets in states across the country

SOURCE: Survey on mosquito net ownership and usage in Nigeria; Ukoha et al. 2014– unpublished article

Factors that affect net usage in Nigeria

22 ¡ ¡

2) IRS: About 300,000 households in the country have been sprayed using indoor residual insecticides between 2009 and 2013 with some positive effects reported

SOURCES: Africa Indoor Residual Spraying report, Nigeria 2014 www.africairs.net; Nigeria Epi-analysis report NMEP, Abuja

1 1 1 1 2 2

Nationa l Rura l Urba n MIS 2010 NDHS 2013 % of households sprayed with residual insecticide in the past 12 months before survey Recorded impact of IRS on malarial infection (btw June & Dec. in Misau & Giade general hospitals in Misau & Giade LGAs of Bauchi state.

Total reduction

10,130 2011 14,949 2012 4,819 Number of reported malaria cases

553 553 920 Total reduction

2011 2012 Number of reported malaria cases Reduction (in%) = 67.67 Reduction (in%) = 39.89 A: Misau general hospital B: Giade general hospital

reported cases for all age group btw June &

• Dec. for the two years

reported cases for all age group btw June &

• Dec. for the two years

23

4) IPTi: There has been marked improvements in the use of Intermittent Preventive Treatment in pregnancy between 2008 and 2013, however the numbers remain low, nationally

SOURCES: Nigeria Demographic and Health survey 2008 & 2013

% of pregnant women who received IPT during an ANC visit

21 9 23 4 25 6 24 10 15 12 23 10

NDHS 2008 NDHS 2013 South West South South South East North East North Central North West

% of pregnant women who received 2+ doses, and at least

• ne during an ANC visit

17 7 12 3 17 4 18 5 10 6 11 6

NDHS 2008 NDHS 2013 South West Nort West North East North Central South South South East

24

5&6) RDT & Microscopy: Adherence to guidelines for treatment of malaria is largely uncommon

SOURCE: Epidemiological analysis for malaria in Nigeria, 2014, NMEP Nigeria

Percentage fever, fever reported within 24 hours and fever tested by RDT & microscopy among children under the age of five years

22 37 35 20 11 5 6 8 10

201 3 201 1 201 2 % under fives with fever cases tested by microscopy % under fives with fever cases who reported within 24 hou % under fives with fever cases tested by RDT

25

85 94 98 98 80 82 55

Itinerant Drug Vendor General Retailer Drug store (PPMV) Public Health Facility Pharmacy Private for-profit health facility Private Not for-Profit facility

7) ACTs: In spite of the high penetration of ACTs since its adoption as first line treatment in 2006, alternative treatments are still widely used

Percentage of anti-malarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2013. Among all outlets with at least one antimalarial in stock, across survey rounds.

2013

SOURCE: ACTwatch, Nigeria outlet survey 2013

65% of pharmaceuticals in 2013 were purchased from drug stores (Patent Proprietary Medicine Vendors or PPMV) 35% 65% Drug store (PPMV) Others

Market share (2013)

26

8a) SMC: This has been successfully deployed in only 4 out of the 9 states suitable for the intervention

Orange-red areas, identified as suitable for SMC based on >60% of annual rainfall in 3 months Yellow areas, identified as suitable for SMC in Nigeria.

SOURCE: Carins et al. 2012. Estimating the potential public health impact of SMC in African children.

Presently, 4 (Katsina, Zamfara, Jigawa & Kano) out of 9 states have benefited from this intervention

A: Map of Africa (orange coloration indicating areas suitable for SMC) B: Map of Nigeria (yellow coloration indicating areas suitable for SMC)

28

8b) SMC: Preliminary studies in Katsina state indicate a dip in number of malaria cases which may be linked to the introduction of SMC in children under the age of five years

100 200 300 400 500 600 700 800 900 1000 Jan Feb March April May June July Aug Sept Oct Nov Dec MALARIA CASES MONTH

Total monthly malaria cases by year, in LGAs that received 2 SMC Rounds (2013/14)

2012 2013 2014 100 200 300 400 500 600 700 800 900 Jan Feb March April May June July Aug Sept Oct Nov Dec MALARIA CASES MONTH

Total monthly malaria cases by year, in LGAs that did NOT receive any SMC

2012 2013 2014

SOURCE: Report on effect of SMC,Support for the Nigerian Malaria Programme – Support for National Malaria Program (SuNMaP), Malaria Consortium , DFID 2014.

29

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§ Nigeria still contributes disproportionately to the global malaria burden…this is, to a large extent due to the population size, ecological landscape and the complexity of the country’s demography. § In spite of the high malaria burden, the response to malaria in Nigeria has not matched the challenge as a result of § 1). poor data-to aid clearly articulated decisions for wide scale implementation; § 2). complex governance/oversight-state programs have substantial autonomy and exercise considerable authority over allocation and utilization of their resources…limiting the influence

• f the national program, and

§ 3). Very limited funding-with no sustainable framework for projected targets. § The shift in focus from control to elimination, has implications that need to be carefully considered and articulated in a way that is realizable in the country within a realistic timeframe. § Following large scale implementation of preventive and case management strategies, the effects remain relatively low across states and regions in the country…an area worth investigating…to understand the human behavioral dynamics that may directly influence uptake etc.

In summary…

Contents

▪ Overview of Nigeria Health System ▪ Epidemiology of Malaria in Nigeria ▪ Key interventions and outcomes ▪ Opportunities, renewed approaches and initiatives

31

This health system response to malaria has been beset with three principal challenges: 1) Limited data; 2) complex governance and oversight; 3) Limited funding

Poor data for decision making Complex governance and oversight Funding gaps

• More strategic use of data and

information is needed to help financiers invest in the most appropriate technical strategies suited to the local context

• Sub-national malaria programs
• perate as “vertical” programs,

and have little involvement with wider health sector strategic planning

• Inconsistent international

financing and inadequate domestic funds threaten longer term success…recorded achievements are uneven and fragile

1 2 3

32

SOURCE: Nigeria District Health Information system (DHIS) Platform 2

¡ 10 20 30 40 50 60 70 80 90 100

Reporting rate - NHMIS January 2013

These figures represent data from public sector facilities only

1a). Data: Low rates of routine data reporting limits the information available to health systems managers to act on

33

1b). Data: Sometimes, available data on malaria epidemiology in Nigeria are conflicting

Malaria Indicator Survey for Nigeria; 2010. (percent children age 6 -59 months testing positive for malaria by blood smear) Malaria Atlas Project, Oxford University; 2010 (spatial distribution of PfPR2-10 malaria endemicity map in 2010) Nigeria NMEP & The INFORM Project ; 2013 (spatial distribution of PfPR2-10 malaria endemicity map from 2005 - 2010)

SOURCES: Malaria indicator survey for Nigeria, 2010; MAPS 2010 http://www.map.ox.ac.uk/explore/countries/NGA/; The INFORM project 2013. A description of the epidemiology of malaria to guide the planning of control in Nigeria

34

▪

Sets policies and national strategy at the federal level, but usually in collaboration with the states.

▪

Plans for the program nationally.

▪

Uniformly deploys malaria interventions in states.

▪

Application for grants and loans for programming is mostly handled by this tier of government.

2a). Nigeria’s tiered structure presents a local challenge to implementation

Implementation

▪

Nigeria operates a 3 tier government (Federal, state & LGA). Each tier has some responsibility as it pertains to health care in the country.

– Structures differ from one state to another as well as priorities. – Decision making is not always based on data at the state and LGA levels. – Fragmented structure, planning and execution btw the NMEP & SMEP. – Some states rely heavily on partners for implementation.

▪

Responsible for overseeing malaria programs at the state (and in many cases, Local Government level)

▪

Priorities and areas of emphasis may differ from the the Federal level.

▪

Use of data is still a challenge.

▪

A total of 37 state programs running in parallel to the national program makes it difficult to coordinate.

▪

Tier of government charged with implementation at the community level.

▪

Community involvement vary greatly from one area to the

• ther.

▪

Capabilities vary across the country, but is typically weak at this level.

▪

Cohesion in planning and execution with the state program is weak. National Program State Programs LGA/Community

35

The National Malaria Elimination Programme (NMEP) is the secretariat of the Technical Working Group (TWG) malaria while the branches of the NMEP serve as the secretariat for the six technical sub-committees. The key mandates of the TWG include: § Jointly assess the status of the national programme § Support NMEP & other malaria stakeholders to identify areas for improvement; provide needed financial, technical and material support for improvement on the national response. § Support NMEP to design and implement operation research and use the findings to suggest options for policy formulation and implementation. § Mobilize resources from the public, private and other stakeholders based on approved plan and budget by the national programme. § Regularly explore areas of collaboration and harmonization with other disease TWGs and Health systems group of FMoH. § Provide regular reports to ATM task force of FMoH.

2b). Complex governance and oversight: While federal-level programming is under an independent malaria elimination program….

• Hon. ¡Ministers

Permanent ¡ Secretary Director ¡of ¡ Public ¡Health ¡ Na5onal ¡ Coordinator ¡NMEP AIDS, ¡TB, ¡Malaria ¡ (ATM) ¡Task ¡Force Malaria ¡ TWG

Administra5on

Internal ¡ Audit

IVM CASE ¡ MGT

M&E

Finance ¡ / ¡IT ¡ ACSM

PSCM

PROG ¡ MGT

36

2c). …. state-level governance and structures differ by state, with potential implications for program performance

• Hon. ¡Commissioner ¡of ¡

Health Permanent ¡ Secretary Director ¡of ¡ public ¡health ¡ Deputy ¡Director ¡ public ¡health Technical ¡ Working ¡Group/ Advisory ¡ commiRee State ¡malaria ¡program ¡ manager State ¡level ¡ partners’ ¡ forum IVM ¡

• fficer

M&E ¡

• fficer

Local ¡Government ¡malaria ¡focal ¡persons ¡(one ¡person ¡per ¡LGA) ¡ ACSM ¡

• fficer

PSCM ¡

• fficer

The malaria program structure in State B The malaria program structure in State A

The ¡Execu5ve ¡ Governor ¡ The ¡Special ¡Adviser ¡to ¡the ¡Governor ¡on ¡ malaria, ¡community ¡& ¡primary ¡health Director ¡of ¡ community ¡& ¡PHC ¡ State ¡malaria ¡ program ¡officer State ¡malaria ¡M&E ¡

• fficer

Local ¡Government ¡malaria ¡focal ¡persons ¡(one ¡ person ¡per ¡LGA) ¡ Health ¡facility ¡in-­‑charge ¡across ¡the ¡ communi5es Technical ¡ Working ¡Group State ¡level ¡ partners’ ¡forum A B

$403m $76m $94m $2m ¡ $814m $671m ¡ $584m $1,023b ¡ Estimated need (USD) Existing commitmen t (USD) Funding need, commitment and gap (USD) 2017 ¡ 201 6

• 738m
• 1,002b ¡
• 578m

201 4 201 5

• 181m

Funding gap (USD)

• 3a. Funding challenges, which present a huge gap for implementation

National malaria program financials (2014 – 2017)

SOURCE: Financial gap analysis for the malaria programme in Nigeria, NMEP, Abuja 2015

6% Health Other 94% 82% 18% Recurent expenditure Health ¡programs ¡

Breakdown of Nigeria’s average budget per year $1.7bn (on the average) Appropriation of Nigeria’s health budget 37

• 3b. There is no sustainable funding framework for the projected cost of interventions

SOURCES: World Malaria Report 2014, National malaria strategic plan 2014 – 2020, NMEP Abuja, Nigeria

2014 – 2017 budget by service delivery

39

Evidence for decision making & opportunity For large scale impact Improved governance and oversight Funding and multi-sectorial collaboration Locally tailored approaches for implementation

• pportunity

brief description

▪ Nigeria contributes over 20% of the global malaria burden…hence strategically important to

global malaria control. Improved access to quality-assured and program-relevant evidence on malaria epidemiology, transmission, emerging risks, best practices etc. is needed to inform national malaria plans as well as implementation and investment plans for malaria.

▪ The malaria landscape is complex, but the institutional architecture offers opportunities for

better use of evidence in malaria programming

▪ PHCUOR ▪ The collective power of political leaders, technicians, civil society, the private sector and donors,

if properly informed by evidence can be focused on making the changes needed to bring about more durable malaria results…with better value for money achieved.

▪ Basket funds and results-based financing ▪ While the global evidence based norms and standards remain relevant and should be adopted,

local data and information should be used to adapt these standards and establish a technical strategy to the local context…

▪ Increased role of the private sector, given the mixed health system. However, some opportunities exist which can potentially improve malaria outcomes across states in the country

40 ¡ ¡

Text

▪ Short-term priorities and

• bjectives

▪ Clear goals and targets ▪ Defined accountability ▪ Quarterly delivery cycle

and progress reviews Delivery Aspirations

▪ Clear health outcome

aspirations (e.g., reduce mortality ratio)

▪ Clear operating

performance objectives

▪ Improved quality of care ▪ National health priorities and

long-term objectives

▪ Region-specific health priorities

and performance objectives

▪ SAML ‘Big 5’ priorities

Strategy

National MOHSS Strategic plan State Strategic plans

+

‘Big 6’

Objectives Actions Reviews Reports Delivery cycle

This new approach must go beyond strategies and plans, and focus on successful delivery of results

41 ¡ ¡

“Perhaps the greatest challenge for any government is successfully implementing its policies…. ... Many a government has come unstuck from failing to deliver, even when its ideas and policies were potentially sound… ….As one former prime minister lamented

• n leaving office, 'We tried to do better but

everything turned out as usual”

Sir Michael Barber1

There is a chiasm between great plans and tangible impact. Successful delivery is the bridge

1 Previous head of the Prime Minister’s Delivery Unit in the UK

42 ¡ ¡

|

One initiative in Nigeria that is aiming to do this, is the Saving One Million Lives Initiative which has malaria elimination as one of its key pillars

1 million lives saved by 2015 Logistics and supply chain Innovation (Private sector engagement) and technology (ICT)

Essential medicines Malaria PMTCT MNCH Polio/ Routine immu- nization Child Nutrition

218,000 37,000 102,000 73,000 200,000 444,000 Lives saved 43

|

This new approach is premised on the fact that, beyond the usual investment in inputs, there are three factors critical for implementing the initiative

Reliable and available data flow Coordination and alignment

• f programs

Delivery structure/ team Rationale

▪ For determining

number of lives saved

▪ Current data systems

suboptimal Action

▪ Adapt the LiST tool and agree

methodology for baseline

▪ Establish data collecting tools, and

methodology

▪ Clarify reporting process with

implementing agencies

▪ Multiple programs exist

within the country that contribute to lives saved

▪ Poor coordination

among partners and programs

▪ Establish a Coordinating mechanism

with a governance structure that is government-led

▪ Map programs at state/local govt

levels

▪ Involves pubic and private sector

partners

▪ History of challenges in

successfully delivering

• n projects

▪ Capabilities currently

lacking within the system

▪ Set up a fully funded delivery unit

structure

▪ The delivery unit will have a dedicated

lead, and oversee several work streams along the various programmatic areas

• bjectives

• 2. Constitute

• 5. Track

• 4. Implement

• 1. Establish

• 3. Create budgets

1 2 3

44

|

This approach was used in a state in Nigeria, where a steering committee focused on malaria and analyzed gaps in malaria programming

Malaria care continuum State performance, 2013

19 12

% ANC patients receiving IPTp % U5s sleeping under an LLIN

76

100

75

100 Drivers of underperformance SOURCES: District Health Information System 2; State Malaria Elimination Program report; SMART survey Supply chain: RDT stock-outs caused a decline in Oct. 2013 in otherwise exceptionally high rates of testing Demand: Not enough demand for IPT Supply chain: SP stocks causing a decline in IPTp utilization Demand: People are not sleeping inside the nets Supply chain: Campaign nets worn out –

• nly 42% of U5 households have LLINs

98 95 % fever cases tested with RDTs or microscopy % cases of uncomplicated malaria treated with ACTs Prevention Utilization of prevention measures is very low Diagnosis Niger is consistently testing fever cases for malaria and is close to meeting its target for this indicator Treatment Niger is consistently treating malaria with ACTs and is close to meeting its target for this indicator

Target

Provider capability: Closing the gap will require improving case worker capability in ICCM

45

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All critical stakeholders (including the government and development partners) review the data…

46

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..and a menu of corrective actions are developed in order to improve the impact of the program

Supply chain Bottleneck Next steps/Action items Demand Responsible

▪ Not enough channels of

commodity supply for LLIN

▪ Campaign planned ▪ Use of EPI, school and

community channels

▪ SPHCDA to appeal to the

LGA chair/MLG on timely release of funds…

▪ Women do not attend

ANC at which point they will get IPT2

▪ Dependent on season,

use higher during rainy season

▪ People may not be

aware of importance

▪ Awareness creation and

social mobilisation communities

▪ Orientation of HCW on

routine dist. of SPs*

▪ Use campaign planned

as part of campaign

▪ Orientation of HCW on

routine dist. of LLINs and SPs*

▪ Airing different jingles* ▪ Sensitization to 6

primary/secondary schools per LGA* Issue

▪ Increasing

stock-outs

▪ Commodity collection

from state medical stores not timely

▪ Low demand for

IPT2

▪ Low utilization of

LLINs Deadline

▪ NMEP/SMEP ▪ SuNMap ▪ SMEP MNGR.

SPHCDA

▪ SuNMap, ARFH ▪ SMEP ▪ SMEP MNGR.. ▪ NMEP/SMEP ▪ SMEP MNGR ▪ ACSM officer ▪ SMEP and

partners

▪ Nov. 2014 ▪ 2nd -3rd qrt… ▪ May 2014 ▪ Ongoing ▪ Mar 2014 ▪ Nov. 2014 ▪ March 2014 ▪ Mar – Dec ’14 ▪ Quarterly

* SOURCE: State Government 2014 Annual Operational Plan for Malaria Control ILLUSTRATIVE

47

Source: Nigeria District Health Information system (DHIS) Platform 2

¡ 10 20 30 40 50 60 70 80 90 100

Reporting rate - NHMIS January 2013

These figures represent data from public sector facilities only

10 20 30 40 50 60 70 80 90 100

Reporting Rate - NHMIS April 2015

Efforts at increasing data reporting have led to marked improvements in routine reporting rates in most states between January 2013 till date

Other types

• f data also

need to be collected to track progress

49

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