We need govt to mobilise resources for malaria – IHVN
Dr Aderonke Agbaje, who manages IHVN GF programme and Oluyomi Lekan-Opesusi, programme officer for community management of malaria, tell Daily Trust how Nigeria has fared in dealing with the disease. What was your experience giving out rapid test kits?Agbaje: Because it was a relatively new intervention, people needed to understand how it works, use it, […]
Dr Aderonke Agbaje, who manages IHVN GF programme and Oluyomi Lekan-Opesusi, programme officer for community management of malaria, tell Daily Trust how Nigeria has fared in dealing with the disease.
What was your experience giving out rapid test kits?
Agbaje: Because it was a relatively new intervention, people needed to understand how it works, use it, accept quality intervention, because it is not every fever that’s malaria. Acceptance was a major challenge. We did it with intensive mentoring and supervision and helping them explore other causes of fever. A lot of people that didn’t have malaria were actually taking antimalarial. Another was availability. In phase one, we were only able to deliver in five of the 10 local governments we were working in.
Are you looking at upscaling?
The National Programme, with support of other programmes as World Bank, DFID, was able to do a national quantification of the requirements and then we are scaling up as a country with experiences gained. We are covering all the local governments we are working on and matching our RDT and ACT targets.
With human resources, are we able to use them for what they are meant for?
We won’t give test kits to people who have not been trained.
What strategies did you use to distribute the long-lasting insecticide treated nets?
It started with a household listing, and the National Programme did a line listing of households in areas, and then apportion two nets per household. On day of distribution, all households were mobilised to distribution points in each local government, and as much as possible women were encouraged to come-with their net cards to get the net. Some people didn’t believe it, they thought these government people have come with their story again, and they didn’t come to redeem their nets. About a month or two down the line, we try to do a mop-up. What the GF has done in Phase Two is to increase the resources available to the country, but when they do that, they are indirectly telling the country to increase its counterpart funding. The nets distributed in 2009, 2010 are due for renewal. Now they use routine distribution using hospitals, so when pregnant women go to hospital, they get nets.
Is your target separate from that NMCP is working toward?
We are working with the national target. What NMCP has done is to apportion targets per state. When you come in as a subrecipient, you take on the target of those states.
Nets given during ANC visits and routine immunisation count as well?
There are outstanding states to be covered in mass campaigns. But as households increase, new additions to the family should be covered. That’s why you have routine distribution, and to ensure that those who for whatever reason miss the campaign are covered.
A lot of the data you get on malaria comes from monitoring and evaluation. How strong is the ability to collect reliable data, collate, analyse and pass it on?
It varies from state to state. Lagos, for instance, is highly cosmopolitan, but in some states the higher cadre of staff will be a community health worker. For those kinds we tend to put in more energy in mentoring. Over time, it gets better but the challenge we have is staff attrition-you train two staff in a facility [10 facilities per local government], one is transferred, the other retires, that creates a gap. Those can weaken the reporting system.
How does that affect Nigeria’s dealing with malaria?
The quality of reporting is very key to informing decision. We really need to invest in reporting, so we can make informed decision. Any time you get incomplete or poor quality data, it affects quality of decision. In Nigeria, it is not perfect but I say we are doing well. In phase one, we were sure we trained two people in each facility we covered, but the programme was only covering 10 facilities per local government, so what happens to the others? It is expected that the government should take them on, but those resources have not been forthcoming. Generally, we may not be getting the full report as a country.
How do you run ACT distribution?
NMCP takes the drugs to the state central medical stores. IHVN use third-party distribution agents to pick the drugs from the states and take them to facilities, and ensures the facilities reports consumption. We assist in distribution and reporting.
This is where community management of malaria comes in?
Lekan-Opesusi: This is where we try to bring treatment to vulnerable people in the community, children under age five. We get role model caregivers and attach them to facilities. They go there to get the drugs. We liaise with community leaders to ensure only children age zero to five are treated in the community. As soon as a woman notices her child is running a temperature, she goes to the caregiver (they have stickers on their door) to get the ACT, and 24 hours later, the caregiver has to go back and check on the child. A lot of people don’t have opportunity to go to hospital, and will want to wait-that’s when the complications set in. But if the child is treated as early as possible, that reduces mortality.
How many role model caregivers do you have?
We have two per ward, two per facility, and 20 per local government.
What exactly do you train them to do?
We use NMCP guidelines-what they should look out for, how to know when a child is running temperature. We have retired matrons, but still we have some people not in health related fields at all but they still can know if a child is running temperature, so they still need to know what to look for and the dosage to be given.
As soon as the ACT is distributed, we get in touch with community based organisations, which in turn get in touch with the caregivers to get the ACT, and they report back to the facility what they have given. They have the ACTs at home so it is easily accessible.
They have the test kits too at home?
The national policy for now still restricts them to facility because it involves blood and pricking, but there is ongoing research looking at what cadre of people can use it in the community. Also the national policy for treatment for under-five does not insist on diagnosis. You can treat them based on symptoms, but for adults you need to diagnose.
What challenges do you see in dealing with malaria?
Just like RDTs, there is shortage of drugs-patients in the community are having symptoms but there are no drugs. And when there are drugs, we have issues where some people want to take things into their hands and elevate themselves as community doctors-that they have become big people. But it has actually helped. When you have access and with more awareness, it has actually helped.
Working with ACTs has improved. When you don’t know why you are doing something it is difficult. People still think why they should go to someone who isn’t a doctor to give them drugs. Later role model caregivers started coming back to say their drugs were not sufficient. But initially, people who could afford to go hospital would go, meanwhile the drugs are next door.
We realise when you involve community people, they feel elated to belong, to be part of something they think was only meant for educated people. They are motivated. They go around to market places to say they have these drugs at home, please if your child has this [fever] come to me.
Agbaje: For IHVN working with NMCP in public sector, ACTs are free both in facility and community. For proprietary patent medicine vendors working with Society for Family Health, it goes for different rates from N50 to N120.
Government commitment at state and local level is a setback for me. We need government to mobilise resources for health, and a key component is malaria. We should also focus on awareness-what are the basic things that can be community level, environmental management, cleanliness, making sure there isn’t stagnant water. That’s why we used to have environmental officers; we need to revive it. We also need to scale up community management for vulnerable groups that cannot afford to go hospital. Funds, people, manpower, and commodities.
Some states are not even aware of the guidelines, some are using monotherapy, buying chloroquine.
Why is that?
Because there is a gap between those controlling the resources and those with the technical knowhow. In decision to procure antimalarial for a state, who does the state involve?