Closing gaps in fight against malaria

Malaria is a public health challenge in Nigeria. However, without handling poor health financing, self-medication, ignorance and bad health-seeking behaviours among Nigerians, experts say it will be difficult to win the fight against malaria, reports Moses Emorinken

 

Globally, 228 million people were afflicted with malaria in 2018, with sub-Saharan Africa contributing about 231 million of this staggering figure.

According to the World Health Organisation (WHO), 405,000 people died from malaria globally in 2018. As usual, children and pregnant women were the most affected.

It further showed that children under five were the most vulnerable group affected by malaria, accounting for 67 per cent (272,000) of all malaria deaths worldwide.

More disturbing is the fact that Nigeria accounts for about 58 million of people afflicted with malaria; pregnant women and children under the age of five being the most affected.

If ranking highest in the global burden for morbidity and mortality from malaria gives a country a gold medal, then Nigeria will comfortably win the trophy because it contributes about 25 per cent of global burden of malaria, rivalled only by the Democratic Republic of the Congo at 12 per cent.

Although Nigeria has recorded some remarkable progress in its fight against malaria, the disease still ravages the people. A 2018 report of the National Demographic Health Survey (NDHS) showed that the country’s burden of malaria dropped from 42 per cent in 2010 to 27 per cent in 2015, and then dropped further to 23 per cent in 2018. While rating this a an appreciable progress, the report however concluded that a lot still needs to be done as malaria is still on the rise.

Malaria is caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. Plasmodium falciparum is the most prevalent malaria parasite in Africa and is responsible for most malaria deaths globally.

Malaria is often implicated in the morbid statistics of Nigeria’s childhood mortality rate of 132 per 1,000 live births and maternal mortality rate of 512 deaths per 100,000 live births.

Experts said pregnancy reduces a woman’s immunity to malaria, making her more susceptible to infection and at greater risk of illness, severe anaemia and death.

Maternal malaria also interferes with the growth of the fetus, increasing the risk of premature delivery and low birth weight – a leading cause of child mortality.

 

Addressing poverty, poor health-seeking behaviour

 

A huge challenge in addressing malaria is in the way people perceive and understand the illness. In Nigeria, many people trivialise malaria, thinking it is not a big health challenge. Yet, malaria is among the top killers of men, women and children in the African continent.

According to the Chairman, Coalition for Maternal, Newborn, Child and Adolescent Accountability Mechanism (C4MAN), Dr. Ejike Orji, malaria waxes stronger in Nigeria because of poor health-seeking attitude of many people.

“Health-seeking behaviours of Nigerians are very poor. Our people do not see real value in visiting hospitals for preventive health care. Most people will rather go to a chemist shop and ask that the chemist mix drugs for them, instead of visiting the hospital. Unfortunately, when mixing those drugs, they cause more harm than good to the patient.

“Because people spend small amounts every day self-medicating, they do not realise that they would have spent a lot more on an aggregate for a period of time.

The reason most Nigerians lack proper health care is largely driven economically, and Nigerians are one of those that spend highest per capital in terms of out-of-pocket health expenses, which is about 60 per cent compared to other countries,” Orji said.

While speaking with The Nation, Dr. Ugwu Odo, president of the Association of General and Private Medical Practitioners of Nigeria (AGPMPN), explained that Nigerians are dying of malaria, “not because we do not have the capacity to treat it, but because of gross ignorance.”

He listed self-diagnosis and self-medication among Nigerians as deep-seated problems that make the fight against malaria difficult to succeed.

“Some make diagnoses for themselves and begin to treat themselves at home; taking the wrong dosage of the right drug, or take the right drug for a shorter time. But once they start getting well, they discard the drugs and don’t follow through with prescribed dosage.

“All these will lead to complications, including adverse effects, multiple organ effect, and can finally lead to death. When little children have malaria, instead of some mothers taking their children to the clinic, they self-medicate or give herbs and all manner of things.

By the time they get to the clinic, their health is already compromised and they die. So, ignorance is part of the problem. Poverty is also part of the problem. Nigeria has failed to allow health insurance to stand.

A person, who is down with malaria but cannot afford to visit the clinic, goes to the local chemists or herbalists because they are cheaper, is doing more harm than good to himself or herself. A simple fever will get complicated and destroy the liver, red blood cells, and kill the man.

But those who go to the clinic early and see the doctor early have a very high potential of getting well,” Odo said.

 

Closing the funding gaps

 

According to the WHO, inadequate funding also remains a major barrier to future progress in the fight against malaria. In 2018, total funding for malaria control and elimination reached an estimated $2.7 billion, falling far short of the $5 billion funding target of the global strategy.

Also in Nigeria, there is still a huge deficit in the amount of funding required to fully cover and intervene in the 36 states of the country, including the Federal Capital Territory (FCT).

The National Coordinator, National Malaria Elimination Programme (NMEP), Dr. Audu Mohammed, also admitted that efforts to roll back malaria nationwide had been stymied by paucity of resources.

It is so bad that Nigeria is unable to cover even a third of its people with necessary intervention programmes, leaving the giant of Africa to the mercy of international donors, he said.

“Our primary area of concern is resources becaus, we are unable to cover one third of the country with adequate malaria interventions.

We depend mainly on donors for the resources we need. With the availability of the resources we received in the past, and what we have quantified in our strategic plan, we have the global fund covering 13 states, while the presidential malaria initiative of the US government covers 11 states. This makes a total of 24 states covered.

“We have additional 13 states that are not covered yet. So we are doing everything possible to get resources so that we are able to cover all our interventions in those states.

You cannot do a partial management of malaria; it has to be comprehensive and aggressive. This is what some other countries did and were able to overcome malaria.

In the strategic plan, we have a gap of about $650million. Through innovative financing, we have contributions coming through the World Bank, African Development Bank (AfDB), and Islamic Development Bank.

We made a request of about $600million but they were able to come up with about $350million. We will judiciously use it.

“Also, costs of commodities are coming down; so we hope that with the fund we can scale up and do a lot of things. Hopefully by March this year, we should get the $350milion from the World Bank.

In the past, we got about $300milion from the global fund. The US government funding varies between $60million and $70million per year; for three years, we calculate about $180million.

The funding from the global fund runs from 2018 to 2020. The fund we are expecting from the World Bank is expected to cover from 2021 to 2022,” Mohammed said.

He added that malaria has an economic impact, which he broke down thus: “When a child is sick, he or she cannot go to school. Also the parents and family members have to rally round when he or she is admitted into the hospital, and there is usually so much out-of-pocket spending.

According to a study, for every dollar you spend on malaria, you get $39; so it has economic importance. There is an urgent need for the government and other stakeholders to address the matter.

“African leaders gathered in Nigeria and took a critical look at the health indices in the country, and saw the need to respect the WHO’s recommendation that at least 15 per cent of the national annual budget should be ceded to health.

Ever since, we have hardly given more than six to seven per cent of our annual budget to health. Health care is a very expensive programme with expensive budgets. Without funding, we cannot follow up. The government needs to obey the same plan they were instrumental to initiating and were part of signing into law – minimum 15 per cent.

Read Also: Nigeria to reduce malaria burden by 13% in 2023 – Official

 

With this, there will be reasonable money to put in place a functional health insurance scheme where we can now benchmark to aspire towards universal health coverage; in which case every Nigerian will have an insurance health cover, such that when he or she is sick, a health emergency will not be an economic emergency.”

 

 Increasing resistance to anti-malaria and insecticides

One of the major difficulties in tackling and ending the grim grip of malaria in the country is the issue of resistance of malaria vector (mosquitoes) and parasites to insecticides and anti-malaria drugs.

Respondents, who spoke with The Nation in the satellite areas in Abuja, claimed it is becoming difficult to treat malaria as the available drugs can hardly completely treat the illness.

They also complained that most insecticides in circulation only weakened the mosquitoes; after sometime, they rise again to start their business of biological terrorism.

In Orji’s words: “Because of the lack of compliance in the use of malaria medicines, some drug resistance have come in. Even when you give out a correct medicine, because the malaria parasite is resistant to that drug, then the person will not be properly treated.

Also, people do not know that when you treat malaria, you also have to treat the aftermath of the disease like fever and pain; so the use, compliance and adherence to use of painkillers are also key.

Some people do not take the correct dose, which makes them relapse. In an environment where there is a lot of poverty, which causes malnutrition, the nutritional level of people are down, especially pregnant women and young children. Therefore, their immune system is low, and it becomes difficult to fight diseases.”

According to Odo, there was a time chloroquine was the first line of treatment for malaria. That was before self-diagnosis and self-medication became widespread in the country. “However, Nigerians became doctors for themselves and prescribe drugs for themselves. They commenced, withdrew, suspended and reintroduced treatment for themselves.

‘’Of course, if you do not manage these drugs the way they are designed to be managed, you merely underexpose the parasite to these chemicals. And rather than the parasites dying, they become weak and undergo hibernation.

After a while they recover and become more virulent, tougher and more dangerous. In such a reconfigured structure, the normal malaria medicine will not affect them.

The more you treat, the sicker the person becomes. It is a matter of drug abuse, poor exposure, wrong treatment, under treatment and mismanagement of the patient,” Odo said.

Mohammed admitted that although malaria vectors are resisting some insecticides and drugs, science is coming up with new insecticides that have been in use in the country and have a double-barrel way of dealing with the mosquitoes.

“We have new insecticides called the PBO, and other new products that we will start deploying to overcome the resistance of the mosquitoes. We also observed that not every fever is malaria.

People need to know that they have to do a diagnosis before treating. We also encourage people to use the Quality Assured Admission Therapy (FCT); once you do the diagnosis and it is confirmed and you take the medicine well, definitely, you will be okay. Our studies show that the efficacy is almost 98 per cent.

“Another area of concern is the importation of substandard drugs because of the porous nature of the country. We know that the national regulatory agencies are doing their best to do sampling of drugs from the chemists to know if the drugs available are fake or genuine.

We are trying our best to see that these drugs are free in public health facilities, and also a reduction in price in private sectors so that it can be affordable to people,” he said.

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