Closing the Financial Gap against Malaria

As Nigeria joined the rest of the world to mark this year’s World Malaria Day, Martins Ifijeh and Kuni Tyessi write on the need for increased funding to tackle the public health challenge.

At a point, the whole world battled with malaria which is a serious disease that causes chills, fever and death. It is passed from one person to another by the bite of mosquitoes, particularly the anopheles specie. However, in 1970, Europe and America were able to defeat the parasite.

Economies like India and China, with populations of close to two billion people have both been able to control theirs to insignificant percentages.

But Nigeria has not been fortunate to achieve same feet despite concerted efforts by the federal government and agencies saddled with tackling the public health issue in the country.

Presently, the country still has the highest number of malaria casualties worldwide, with about 300, 000 deaths occurring annually, while at least 100 million Nigerians are still at risk of the disease. It contributes to an estimated 11 per cent of maternal deaths, and it accounts for 29 per cent of global malaria burden.

Nigeria, with a population of about 190 million and a fast growing economy has placed a bench mark to replicate same progress made by other countries in the elimination of malaria. It is expected that if the parasite cannot be totally defeated by 2020, then it should be less than five per cent prevalent.

As Nigeria, yesterday, joined the rest of the world to mark this year’s World Malaria Day, tagged: ’Ready to Beat Malaria’ with the slogan ‘Together We Can’, the federal government believes it is possible to achieve the dream even in the face of losing N300 billion annually to treatment and prevention, including loss of man-hours annually to the disease.

It is in addressing this that the Nigerian Government renewed its efforts to secure $300 million (N108 billion ) in new financing from the World Bank, Islamic Development Bank and African Development Bank to help finance its national malaria strategy.

This came on the heels of the Commonwealth Health Ministers’ launch of the Commonwealth Nations Initiative at the Malaria Summit London 2018, where they agreed to eradicate malaria by half by 2023.

The Nigerian Government also pledged an additional $18.7 million, while the United Kingdom pledged £50 million on malaria programme in Nigeria. It also pledged £9.2 million to fund new research on development of new triple Artemisinin Combination Treatments.

The World Health Organisation, (WHO) believes collective efforts by nations, if achieved, would prevent 350 million malaria cases and save 650,000 lives predominately children and pregnant women who are most at risk annually.

In addition, African Leaders Malaria Alliance (ALMA), in line with the African Union’s Catalytic Framework to end AIDS, TB and Eliminate Malaria by 2030, committed to supporting member countries to introduce and strengthen the use of national and sub-national malaria scorecards and action trackers, with robust community engagement; to support increased domestic funding from both the public and private sector; and to continue its work with Heads of State and Government in Africa to monitor progress towards this goal.

Malaria No More committed to expand efforts to mobilise action and resources to end the disease through engaging leaders, building new partnerships, expanding reach and raising the profile of malaria.

2017 World Malaria Report, a publication by the WHO has shown that Nigeria faces a financial gap of N504 billion ($1.4 billion) to implement its national malaria strategy by 2020.

The former Minister of Health, Ethiopia, Dr. Kesete Admasu, in an exclusive interview with THISDAY recently, said for Nigeria to tackle malaria, it requires funding, adding that this is required to deliver life saving interventions to the Nigerian populations and fully implement its national malaria strategic plan between now and year 2020.

He said so far, the Nigerian Government would require at least US $1.5 billion over the next three years, adding that such money should come from variety of sources, both internationally and domestically.

According to him, malaria is still a leading cause of mortality for children under five in Nigeria, even though the government’s efforts have been credited with reducing mortality rates among children under-five by 18 per cent since 2011. Adding that Borno State, for example, malaria is currently claiming more lives than all other diseases combined.

He explained that, at the turn of last century, almost all countries in the world were malaria endemic. “Today, the number of malaria endemic countries stands at 91, of which 44 have less than 10,000 cases per year – meaning that malaria elimination is within reach. All this shows that ending malaria is possible for any country, even one with a high burden of the disease.

“For Nigeria, there will be lessons to be learnt from other countries that have tackled malaria, but no exact model to copy. Perhaps the first place to start will be in scaling up the malaria surveillance system, which currently only detects 16 per cent of cases. Without adequate surveillance malaria control efforts are blind.

“Nigeria also needs a strong political commitment to tackle the issue. This is a prerequisite for any successful action against malaria, and this needs to translate into additional resources to strengthen the health sector overall and malaria efforts in particular. Today, less than five per cent of national budget in Nigeria spent on health, of which only 0.8 per cent supports malaria, according to the estimates from the Global Fund to Fight AIDS, Tuberculosis and Malaria.

He noted that the private healthcare system provides care for a substantial proportion of the Nigerian population, adding that through Global Fund, the international community is working to increase Nigerian citizens’ access to all the needed WHO-recommended anti-malarial treatments.

The public health expert notes that Nigeria has a great opportunity to be a leader in the fight against malaria, for Africa and for the global community, explaining that the world cannot defeat malaria without Nigeria. “I believe that, with leadership at all levels – from federal down to the local level – Nigeria can do what it takes to end one of the oldest and deadliest diseases in human history and, in doing so, unlock opportunities for its economy and its people.”

Speaking earlier in the week in Abuja to commemorate the World Malaria Day, Dr. Perpetua Uhomoibhi of the National Malaria Elimination Programme (NMEP), said that strategies have been put in place to meet up with the date as it has led to the death of many, especially for children.

She enlightens on the use of treated mosquito nets and the acceptable and prescribed medication for pregnant women. She said current strategic plans were expected to lead Nigerians to pre-elimination period by the year 2020, adding that this means the national prevalence will be less than five per cent of malaria when the national survey is carried out. “From there, we will begin to work towards a total malaria-free Nigeria.”

“The first strategy is the universal use of treated mosquito nets and everybody is encouraged to make use of it. Our aim is that two people per household have access to at least one net and that is the universal coverage. So if there is a household of six people, it is expected that three nets should be given to them.

“The other strategy is test before treatment. So every symptom of malaria should be tested and confirmed that it is malaria and the proper treatment which are the ACTs must be given. Those are two of the strategies. We also have the one of prevention of malaria in pregnant women, which is the use of IPTP which is the using of Intermittent Preventive Treatment for malaria in pregnancy. It is used for pregnant women and there are many others as well,” Uhomoibhi said.

National Coordinator, National Malaria Elimination programme, Dr. Audu Bala Mohammed, is also optimistic that the parasite can be eradicated at the given time. He says ’malaria elimination in 2020 is possible. When you do the right thing, you will get the right result. Several other countries were able to crash down their malaria challenges within a spate of five years and Nigeria can do it. If we work religiously with what we have put down in the 2014- 2020 strategy and with availability of funds and workmanship, we can achieve it.”

He revealed that the ban on mono-therapy for the treatment of malaria was agreed to be from November 2014 after the National Council for Health meeting. The meeting gave a guideline that Artemisilin-based Combination Therapy should be used and that is what works.

He further explained that, “using the mono-therapy does not work for malaria and it creates resistance when the ACT is used. A memo was made to the council and it was approved that there should be a ban on the use of mono-therapy for the treatment of malaria because it is not effective. Now the guideline is that we should use the combination therapy and that is the ACT.

“In pregnant women, it is recommended that they use quinine because in the first trimester of pregnancy, the effects of the ACT might not be very suitable for them and they can use it only when there is no suitable alternative. If not, they are advised to use quinine. But from the second trimester, it works very well and has less harmful effect on the unborn child and so it is quite good to make use of it. However, sometimes, it may be necessary to use it in the first trimester if there’s no alternative and life of the mother must be saved.”

Mohammed also revealed that there were two strategies in fighting and eliminating malaria which include the use of treated mosquito net and ensuring that everybody makes use of it. “The aim is that two people per household have access to at least one net and that is the universal coverage.

“The other strategy is test before treatment. So every symptom of malaria should be tested and confirmed that it is malaria and the proper treatment which are the ACTs must be given. Those are two of the strategies and then we also have the one of the prevention of malaria in pregnant women which is the use of IPTP which is the use of Intermitent Preventive Treatment of malaria which is used for pregnant women and there are many others as well.”

On whether or not the ban is working, Mohammed explained that the issue was that the national programme is not an enforcement agency as it is set to educate, create awareness and sensitise people.

“It is one of the reasons we are going to the field to make people know and understand that the medicine is no longer in use. You don’t need to use chloroquine for the treatment of malaria. It is non effective and will not give good result. Some of the mono-therapy drugs have been linked to several heart conditions, and so they are not recommended for the treatment of malaria.

“Medicines like malarech, amalar, and many of them are for pregnant women and not for the treatment of uncomplicated malaria. Some of the pregnant women might react to the drugs but that is for few percentages of people. We advise that if one has reacted to it in the past, it should not be taken anymore and if there are cases of such reaction among family members, we advise such people to stay away from it.”

He said Rapid Diagnostic Test for now was one of the best diagnostic tools available for community and family use and that it is a one step procedure where blood is taken using a pin prick. “This is then applied to the cosset and it gives you a positive result. When you have one line, it is negative’ two lines mean it is positive, and anybody can buy and use it. It is referred to as a point-of-care diagnosis. What this means is that when you feel that a person is sick, a person trained on how it is used can actually use it, irrespective of profession.‎”

There are many other factors that can be responsible for fever and not just malaria because it is just one of the many conditions that would lead to fever in an individual. Mohammmed advised that there is the need to do tests, as every individual that presents symptoms of malaria or fever must be tested‎ before they can be given anti-malaria medicine if they test positive.

He also called on patient medicine vendors and community pharmacists to try as much as possible to know the new position of the country so as not to stock mono-therapies or one that will have just Artesunate which is not recommended.

“Any medicine used in the treatment of malaria must have a combination which must include an Artemisulin product. So, treating malaria with one medicine is unacceptable,” he noted.

On the efficacy of herbal medicine and ongoing research for more malaria medications, Mohammed stated that malaria programmes are evidence-based, adding that there was nothing adopted that is not based on evidence. “Artemisunin itself is an herbal product. It is a leaf ‎and it’s a product we encourage. Until one is able to bring to fore, other specimen and studies done on them, we cannot say otherwise. It is found that they can work in Nigeria and can work anywhere. It is not about somebody going into the room and concocting something presented to the world with claims that it treats malaria. It must be proven by using international standards before we can say this medicine is good enough. The malaria-curing leaf was a herb that was used by the Chinese over several years. It was tested and found to be good as a treatment for malaria and has been adopted globally.