With less than one month left until the end of 2020, Nigeria is yet to meet its six-year targets for malaria control, which focused on creating a malaria-free Nigeria.
The 2014-2020 National Malaria Strategic Plan (NMSP) had ambitious goals, including reaching pre-elimination status for the disease (less five per cent which can be interpreted as less than 5000 cases per 100,000 people) and zero mortality from the disease.
But these targets are far from being met, with COVID-19 taking them more off-track.
According to the World Health Organization (WHO), Nigeria still accounted for 25 per cent of the world’s malaria cases in 2018, with 53 million cases.
Children are the worst affected. The prevalence of malaria (according to microscopy) among children aged 6-59 months was 23 per cent that same year; down from 42 per cent in 2010, with an average decline of 2.3 per cent per annum, according to the 2018 National Demographic and Health Survey (NDHS).
For 2020, it cannot be said with certainty whether these numbers have further declined and if targets have been achieved or not because the COVID-19 pandemic prevented the Malaria Indicator Survey being conducted. However, judging by the most recent NDHS, these targets are unlikely to have been met.
And nowhere is this more evident than in Kebbi State.
Kebbi State as a case study
Malaria rates in Kebbi are the highest in the country, especially in children, with NDHS data showing that 52 per cent of children under 5 were infected in 2018.
The northwestern Nigerian State has had the highest number of malaria cases in the country for the past five years, though numbers have shown some decline in that time.
There are many reasons for this burden, including a lack of government support, cultural attitudes towards the disease and now the COVID-19 pandemic.
A health expert in Kebbi who pleaded anonymity for fear of victimisation, added that the high cases of malaria in the state are attributable to the lack of skilled health workers and irrigation farming (this creates a breeding ground for mosquitoes), as well as socio-cultural factors like illiteracy and poverty leading to poor understanding of the disease in local communities.
This last point defeats target four of the strategic plan, which aimed to provide adequate information to all Nigerians such that at least 80 per cent of the populace habitually takes appropriate malaria preventive and treatment measures as necessary by 2020.
Amina Aliyu, a community health extension worker at Primary Healthcare Ambursa in Kebbi, said the people of Kebbi struggle with malaria, especially the children. The community has received Artemisinin Combination Therapy (ACT) from the government over the years as treatment, she said, but has not received mosquito nets for over two years. Patients are advised to purchase their nets from the marketplace by health workers at the clinics.
While the local government does supply Rapid Testing Kits (RDTs) to diagnose malaria, most of the time, clinics and laboratories are buying them for themselves because the supply from the local government is irregular, especially in this year.
“We buy them ourselves out of our pockets”, said Mubarak Dahiru, lead laboratory technician at PHC Ambursa. He added his facility last received supplies from the government in July.
The outbreak of COVID-19 also led to a reduction in the number of patients visiting primary care clinics because of fear of contracting the disease. Health workers were also afraid, Mr Aliyu explained, and often referred people to other, bigger facilities. This increased the influx of people in secondary health institutions and in turn led to a lack of bed spaces.
“Compared to pre-covid period, malaria cases increased a lot with the advent of the pandemic,” said Usman Mohammed, Principal Medical Officer at the Hajiya Turia Yar’adua General Hospital Zauro in Kebbi.
As of November 21, Kebbi had a total of 93 cases and eight deaths from COVID-19, according to data from the Nigerian Centre for Disease Control. Numbers of malaria cases are likely to have been significantly more.
Another problem is that many people in the community see the hospital as the last option for treatment, said Mr Mohammed.
Most of the time, these children are brought in severe conditions because their parents do not bring their children to the hospital until they have exhausted every other available option, he explained.
“Sometimes they try the pharmacy, traditional medicine and all they can. When all of these fail, that is when they think of coming to the hospital. The hospital is usually their last option”, Mr Mohammed said.
Aliyu Yahaya, a farmer whose five-month-old son was in a critical condition from malaria at Hajiya Turia Yar’adua General Hospital Zauro, at the time of this report, told PREMIUM TIMES the child showed symptoms of being sick about a week ago. He was taken to a healthcare facility in their immediate locality where the doctor administered treatment to the child, but it didn’t work.
“We took him back to the doctor who directed us here and that is how we came here,” said Mr Yahaya.
According to Mr Mohammed, the medications given to the child probably did not work because most times, the community health workers, who members of the community refer to as doctors, treat the symptoms and not the cause (problem) itself. For example, treating fever or headache in a patient instead of testing to determine if malaria is to blame.
In April, the WHO published figures on the possible effects of COVID-19 disruption on malaria cases and deaths in sub-Saharan Africa.
For Nigeria, the data suggested that deaths from malaria could increase by up to 192,358 this year (a worst-case scenario) compared to over 95,000 deaths in 2018, an increase of more than 100 per cent.
In Nigeria, COVID-19 has diverted resources and attention away from other diseases and left the Nigerian health system overwhelmed just like in other parts of the world.
But Nnenna Ogbulafor, the Head of Case Management on the National Malaria Elimination Programme (NMEP), said her team has responded with a triple counter-force of testing, treatment and data tracking to match the increase in cases.
“What we did was to push out rapid malaria testing in the country so that people will know when it was malaria or COVID-19, or if they were coexisting as both infections had similar symptoms,” said Ms Ogbulafor, adding that this makes for better management of cases.
The programme also worked hard to make sure certain treatment programmes went ahead as normal, such as seasonal malaria chemoprevention, where full treatment courses of antimalarial medicines are given to children in areas of highly seasonal transmission before the malaria season.
“Seasonal malaria chemoprevention for children under five in the Sahelian states, started in July and continued through October,” she said. “Similarly, the Insecticide Treated Nets (ITNs) distribution campaign has begun in some states who did not receive during the previous distribution campaign.”
‘Behind on targets before the pandemic’
But Nigeria was behind on targets long before the pandemic arrived, said Tim Obot, Deputy Director Programme Management, NMEP, adding that the programme knew it could not meet its target of pre-elimination and zero mortality.
According to Mr Obot, the programme was probably too ambitious with its targets because of the support it had received in the previous years from donor organisations. The current plan did not receive the same level of support, as donor programmes had ended.
As well as the key targets around prevalence and deaths, the current programme hoped to ensure at least 80 per cent of target populations were using appropriate preventive measures by 2020, that all suspected malaria cases are tested with RDTs or microscopy tests by 2020 and that at least 80 per cent of health facilities in all local government areas (LGAs) would report routinely on malaria by 2020.
There is no data available in public space to show if these targets have been met on time, but if existing data from 2018 and current regional insights are anything to go by, then these goals are far from being achieved.
However, Bala Audu, National Coordinator of NMEP, told PREMIUM TIMES that the reductions in malaria prevalence in Nigeria from 42 per cent in 2010 to 27 per cent in 2015 and 23 per cent in 2018 represents the sterling achievement of the programme to date.
But he highlighted the continued decrease in health allocation for malaria interventions as a challenge in meeting new targets. “The allocation to health as a total of the federal budget has declined from 5.6 per cent in 2014 to 4.7 in 2019. This means too that the allocation to malaria keeps reducing. The low allocation has a ripple effect on programme implementation,” he said.
“We have gone ahead to source innovative financing through the World Bank and Islamic Development Bank alongside advocating for an increase in budget allocation,” Mr Audu said.
On Kebbi, Mr Audu said the programme has come up with new strategies to tackle malaria in the state in the coming year. Some of these strategies include the distribution of new generation nets as resistance from mosquitoes to previously distributed nets has been noticed.
But as it stands, there are many hindrances to meeting the goals of achieving a malaria-free Nigeria.
(This story was produced by PREMIUM TIMES. It was written as part of Reporting Malaria, a media skills development programme run by the Thomson Reuters Foundation. The content is the sole responsibility of the author and the publisher).