Empowering Nigerian Communities to Combat Malaria
As Africa’s most populous country, Nigeria is also encumbered by a proportionately large malaria problem. The World Health Organization (WHO) estimates that more than 150 million cases of malaria occurred in Nigeria in 2006, most severely affecting young children and pregnant women. The Federal and State Ministries of Health are building malaria control capabilities in understaffed, poorly supplied facilities but still fall far short of meeting people’s needs. More than half of community members (80 percent in some states) seeking treatment for malaria currently obtain their drugs from patent medicine vendors operating out of small convenience stores. These vendors, while well intentioned, have little training in dispensing such medicines and little experience to guide the information and advice they dispense with the medicines.
To better equip these front-line providers with important information, MSH, as a partner in the Community Participation for Action in the Social Sector (COMPASS) Project funded by the US Agency for International Development (USAID), has trained patent medicine vendors as well as community health workers and other community-based providers in Nasarawa, Kano, and Lagos states. These workers have been trained in malaria case management, intermittent preventive treatment for pregnant women, and malaria prevention using insecticide-treated mosquito nets (ITNs).
While COMPASS has also invested in training public-sector providers, training private-sector and community health personnel has substantially increased access to malaria control services. In the past year, COMPASS, an integrated health and education project managed by Pathfinder International, has trained more than 1,000 patent medicine vendors and other community members in malaria management and ITN distribution and use. In total, the project has distributed more than 100,000 long-lasting nets, more than 3,000 sets of job aids for community caregivers, and behavior change communication materials for building public awareness of malaria control. The distribution of ITNs was made possible with the help of COMPASS Community Coalitions, parent-teacher associations, and Community Health Promoters and other volunteers.
Struggling in the Face of Drug Resistance and Expensive Treatment
The Nigeria national program follows the guidelines of the Roll Back Malaria Program of WHO and the United Nations Development Program, which endorses the use of ITNs, presumptive treatment of women during pregnancy, and the rapid diagnosis and treatment of cases. Ninety-five percent of malaria cases in Nigeria are due to plasmodium falciparum, the most deadly of the four species of malaria parasites. As in most of Africa, P. falciparum is rapidly becoming resistant to chloroquine, fansidar, and other less costly and well-accepted antimalarials. The recommended replacement treatment is artemisinin combination therapy (ACT) but cost, availability, and lack of experience on the part of caregivers have limited the use of these lifesaving drugs.
A History of Success: BASICS
MSH and partners have been working in Nigeria since 1999 as part of the USAID Basic Support for Institutionalizing Child Survival (BASICS) Project, setting out to improve the functionality of the PMVs in three states: Lagos, Abia, and Kano. The main strategy, drawn from earlier Kenyan initiatives, was to provide training on malaria treatment essentials to patent medicine vendors. A one-day course provided information about malaria transmission, the role of ITNs, early diagnosis, the necessity of treatment with an approved drug, the importance of correct and complete dosing, and referral of complex life-threatening cases to government facilities. Each graduate of the course received educational materials to distribute to those seeking help and a wall ornament to hang in his shop to mark the completion of the course. In Abia State, where most of the vendor training was conducted, 832 medicine sellers serving a catchment area of about 1 million completed the program. Some of the early trainees formed a peer training program that went on to train 1,600 more patent medicine vendors.
An evaluation using “mystery client” surveys, exit interviews, and a cluster survey demonstrated that the percentages of patent medicine vendors giving the recommended dosage of the correct drug improved from 9 percent to 53 percent. The numbers of fever cases referred to clinics also increased, although not as dramatically. The percentage of vendors who imparted information to their customers about the use and value of ITNs increased from 25 percent to 65 percent.
To reach large populations with life-saving drugs and information in a country as vast as Nigeria, enlisting the assistance of its vibrant private sector and fostering community participation are crucial.