Category Archives: Private Sector

The Business Case for Malaria Prevention: Employer Perceptions of Workplace LLIN Distribution in Southern Ghana

Kate Klein as part of her Master of Science in Public Health program in Social and Behavioral Interventions at the Johns Hopkins Bloomberg School of Public Health undertook a study of the potential for private sector involvement in malaria prevention in Ghana. She shares a summary of her work here. During her practicum in Ghana she was hosted by JHU’s Center for Communications Programs and its USAID supported VectorWorks Program. Her practicum she was also supported by the JHU Center for Global Health, and she presented her findings in a poster at the CGH’s Global Health Day on 30th March 2017. Her essay readers/advisers were Dr. Elli Leontsini (Department of International Health) and Kathryn Bertram (Center for Communication Programs).

Malaria is endemic in all parts of Ghana and significantly burdens families, communities, and economies. Malaria remains a leading cause of morbidity and mortality in Ghana; it accounts for eight percent of deaths in the country (The Global Fund, Ghana). It was also responsible for about 38% of outpatient visits, 27.3% of admissions in health facilities, and 48.5% of under-five deaths in 2015 (Nonvignon et al., 2016). In Ghana, the estimated cost of malaria to businesses in 2014 alone was estimated to be US$6.58 million, and 90% of these were direct costs (Nonvignon et al., 2016). Malaria leads to reduced productivity due to increased worker absenteeism and increased health care spending, which negatively impact business returns and tax revenue to the state (Nabyonga et al., 2011).

Although long-lasting insecticidal treated nets (LLINs) are a well-documented strategy to prevent disease in developing countries, most governments, including Ghana, lack the resources needed to comprehensively control malaria. The Global Fund (GF), USAID/President’s Malaria Initiative (PMI Ghana), and the United Kingdom Department for International Development (DfID Ghana) are the main donors for the national malaria control strategy and have worked primarily with the public sector (World Malaria Report, 2015). As government funding remains unable to close the funding gap for malaria, there is an increasing need to revitalize the private sector in sales and distribution of this life-saving technology.

A “Journey mapping” exercise to consider the process of employers buying and distributing nets to employees, created during a PSMP advocacy workshop in December 2016

Ghana is looking to the private sector to encourage a departure from previous dependence on donor-funded free bed nets. The Private Sector Malaria Prevention (PSMP at JHU) project is being implemented in Southern Ghana to increase commercial sector distribution of LLINs. Three case studies served as a situation analysis and exemplified the potential for the PSMP: a rubber producing company, a mining company and a brewery.

All three had experience in malaria control and prevention but only one had specific experience with LLINs (which dovetailed well with its own corporate strengths in logistics management as exemplified by other bottling companies in Africa). Another supported the idea of adding LLINs to its existing indoor residual spraying and community health education efforts, but needed to consider how to develop the flexibility to engage in multiple malaria interventions.

The third had had the right climate and leadership to be able to partner with PSMP, but recently underwent a takeover by a large multinational brewing company and the resulting period of transition could potentially complicate their participation in LLIN distribution efforts from a budgetary standpoint. Generally these companies had the understanding of the potential benefits to the company of situating malaria control within their structure, and thus being early candidates for adoption of the PSMP.

While the three case study companies recognized the business case for malaria, this was not a unanimous opinion among other five companies interviewed. Their concerns ranged from a preference toward treatment interventions to concerns expressed by employees about the difficulty of achieving high levels of net usage due to an array of complaints surrounding sleeping under LLINs. Some of these others had financial constraints.

Through case studies and interviews PSMP was able to identify various challenges moving forward as well as areas where further clarity must be sought. PSMP learned that several companies are pouring their resources into strong treatment and case management programs, and one challenge will be determining how to push for preventative action, such as LLIN distribution, when treatment mechanisms are so established and bias exists.

For those companies who are making tremendous strides in malaria prevention, bringing recognition to these successes through advocacy will be necessary for encouraging future participation and convincing other similar employers of the benefits of starting their own LLIN distribution programs. Finally, PSMP needs to prioritize clarifying viewpoints on LLIN efficacy and use, with a focus on understanding why employers may hold unfavorable views and what it would take to overturn them.

In the future it will be necessary to move beyond the occupational considerations specific to mining and agro-industrial operations and consider how the work has changed the environment into a malaria habitat and the non-traditional work hours that may create more significant Anopheles mosquito exposures. PSMP should gather specific information on lifestyle, housing, and work environments during future visits with employers so that companies that have the most to gain through LLIN distribution are identified and targeted.

Manufacturing Mosquito Nets ‘At Home’

The technology of insecticide treated nets (ITNs) to prevent malaria has been around for over three decades. ITNs have evolved from a process of semi-annual soaking and impregnating nets with a safe insecticide at the household or community level to long lasting insecticide-treated nets (LLINs) where the insecticide is integrated into the nets during the manufacturing process. The challenge has always been guaranteeing enough currently treated nets to cover the population and impede malaria transmission.

IMAG0170Recently Rwanda announced its intentions to establish LLIN manufacturing in-country. The Ministry of Trade and Industry has begun screening of bidders. The government’s main rationale for this move is projected the need for a large and continuous supply of LLINs in the country through 2020, “making it a prudent to set up a production plant in the country.” When this information was shared with our malaria/tropical health update mailing list a number of readers expressed interest and hope that their own governments would follow suit. This post provides some background for readers to consider.

The idea of locally made mosquito nets is not new. MacCormack and Snow documented that, “95% of people were already sleeping under locally-made DSCN5582nets,” in The Gambia in the 1980s. Likewise in Burkina Faso it was common to find nets made from imported materials or local cotton that were sewn by local tailors.

The idea of drawing on the combination of local or regional textile and chemical industries to produce an ITN kit containing both net and approved insecticide for home/community soaking was tested in several countries by the USAID sponsored NetMark project between 1999–2009. Although the project made ITNs available at reduced prices and resulted in gains in  awareness, ownership, and use of nets, “none of the countries reached the ambitious Abuja targets.”

NARCHOct03 012Even at reduced prices the ITNs made available through this commercial sector approach were still more expensive than most families could afford. In addition partway through the project the emphasis shifted from local products to imported LLiNs leaving a leaving a very bitter taste, particularly in Nigeria with its large industrial sector, in mouths of the textile and chemical partners who during malaria partners meetings at the time expressed a sense of betrayal.

A-Z Olyset Commercial BagTalk arose in Nigeria about the potential for starting LLIN production in the country, but no one stepped forward with funding or technical assistance. In the meantime, on the other side of the continent, A to Z Textiles of Tanzania entered into a partnership and by 2003 LLINs were being produced in Arusha.  Sumitomo Chemical provided a royalty-free technology license to the company for its Olyset LLINs. “By 2010, Olyset Net production capacity (at A to Z) reached 30 million LLINs per year, creating 8,000 jobs; more than half of the global Olyset Net output and an outstanding contribution to the local economy.”

Over the years A to Z Textiles were hard pressed, just like the few other LLIN manufacturers, to meet global demand. Over the period, the focus changed from protecting young children and pregnant women to universal coverage of the population. Also research and actual use found that the lifespan of an LLIN was not the 5 years as initially projected, but more like two. These factors meant that supply could rarely meet demand for regular replacement nets. No wonder Rwanda wants its own LLIN factory!

ITNs Use TanzaniaIn addition to supply issues, does local availability of LLINs make a difference in fighting malaria? Regular studies by the Demographic and Health Survey group of USAID in Tanzania found that ITN use increased over time by children below five years of age. The most recent survey still shows that the 2010 Abuja target of 80% was not met (let alone a target of universal coverage), but the findings hint at the importance of having locally available LLINs.

Let’s wish Rwanda success in establishing its LLIN manufacturing capacity. For colleagues in Nigeria and elsewhere who have expressed interest in this issue, your advocacy work is just beginning.

 

Verifying Malaria Medicines on Your Mobile

On their website Sproxil says that, “Sproxil actively supports Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) in the fight against counterfeiting by pioneering Nigeria’s first Mobile Authentication Service.” They note further that …

“On February 2, 2010, NAFDAC launched the NAFDAC MAS, putting the power of product verification right in the hands of the consumer. MAS is powered by Sproxil’s award-winning cloud-based Mobile Product Authentication™ technology, and remains the world’s largest nation-wide implementation of consumer-facing SMS anti-counterfeiting technology in the world.”

Below are two malaria medicine packets recently purchased. After scratching the small label (see it circled, we got the SMS messages as posted.  The NAFDAC registration number alone is not enough to ascertain the validity. This is a smart procedure, even without a smart phone. Of course one still needs to read the expiry dates!

P-Alaxin front scratch off1. OK Genuine P-Alaxin Tablet. Your PIN:949769012921 NRN:04-9495 Problem? Call 08039012929 NAFDAC & Bliss Care Sproxil SMS

Lonart DS back PIN2. OK Original Lonart DS tabs NRN:04-9927 Use mosquito nets to help avoid malaria Problem? Call 08039012929 NAFDAC & GREENLIFE CARE Sproxil Solution

Lessons Learned from a Supervisory Visit to a Medicine Shop

DSCN2943In this posting Hajara Moses John of the Bauchi State Agency for the Control of HIV/AIDS, TBL and Malaria [BACATMA] shares lessons learned in supervising medicine sellers.

Our team had planned supervisory visit last week to patent medicine vendors (PMVs) where shop owners have been taught the correct management of childhood illnesses. Our experience one particular shop pulled together so many lessons about training and supervision, and we are sharing this here. In the first shop we visited that day we found a boy aged 12 behind the counter. I took on the role of a mystery client, and mentioned some symptoms to the boy. “My 5-year old son is at home with catarrh. His nose is really running and his breathing is fast. What do you recommend I give him?”

The boy mentioned a local brand of antihistamine. I asked if there was anything else we should do, and the boy said that should work fine.

Next I said my two-year old daughter was also unwell. She was having fever, shivers with aches and pains. Did he have any suggestions for her? His prompt answer was “Ampiclox.”

I then asked him where the owner of the shop was. He said, “Oh my father has traveled.” I asked what class the boy was in school, to which he said the first class of junior secondary school.

Word of our visit must have spread in the area, because then a woman rushed in who it turned out to be the boy’s mother and asked how she could help us.

We explained that we were from the Ministry and were going around to help medicine shop owners improve the quality of their services. The mother happily reported that she had received training “in malaria and those other small small diseases of pickin,” from the Minsirty fo health and again from a NGO.

I went back to case of the child with a respiratory infection and pointed out the breath counting beads on the table. She said it was her husband who had done the training where the beads were explained but never taught her how to use them. We then spent some time explaining to the mother and her son about the beads and demonstrated how to use them, and also explained about management of fever.

Finally I asked the mother why she was not in the shop since her husband had traveled. She said she was in the kitchen preparing lunch for the children, and as the oldest, the 12-year old was assumed capable of running the shop. We encouraged her to discuss as a family how they could share what they have learned about managing child illness and always ensure that a competent person is available in the shop.

Training of PMVs is not a simple matter. The person trained may not always be in the shop nor share what he/she learned with other salespeople. Supervision is necessary in order to reinforce what was learned during training and provides an opportunity to teach others on-the-job. PMVs provide a large portion of the services in many African communities, and we must ensure that they can focus on quality.

A role for the private sector increasing uptake of intermittent preventive treatment for malaria in pregnancy in Kenya

Jhpiego staff will again present a poster at the Tuesday noon (Nov 4) session of the American Society of Tropical Medicine and Hygiene Annual Meeting. Augustine M. Ngindu, Muthoni M. Kariuki, Sanyu Kigondu, Johnstone Akatu, Isaac M. Malonza, with support from USAID’s Maternal and Child Health Integrated Project (MCHIP) will share experiences with a poster titled, “Improving maternal and neonatal health: Complementary role of the private sector increasing uptake of intermittent preventive treatment for malaria in pregnancy in Kenya.” The abstract is provided below.

director's memoMalaria in pregnancy (MIP) is associated with poor pregnancy outcomes including maternal anaemia, intrauterine growth retardation and low birth weight. Kenya changed its policy on intermittent preventive treatment using Sulfadoxine Pyrimethamine (IPTp-SP) in 1998. However, IPTp coverage rates have remained low: 4% in 2003, 14% in 2007, 15% in 2008 and 25 % in 2010.

To increase the coverage rate, MCHIP supported malaria control and reproductive health divisions of the ministry of health, first to harmonize knowledge among service providers on provision of IPTp-SP in 2011, and second to train community health workers (CHWs) on sensitization of pregnant women to start early antenatal care (ANC) attendance in 2012.

Job AidA community survey conducted in 2013 showed a significant increase in the proportion of pregnant women receiving two or more IPTp doses from 25% to 63%, the highest increase in IPTp uptake since 1998. Following the successful scale up of IPTp, one sub-county conducted an assessment of its health facilities to determine quality of data on ANC clients accessing IPTp-SP.

A total of 15 (58%) out all 26 health facilities in the sub-county (public – 6 out of 8, faith-based – 2 out 3 and private – 7 out of 15) were selected. Data on new ANC clients, revisits and IPTp doses given was collected from the ANC registers.

Among thservices providede assessed health facilities 13 (87%) out of the 15 were registering new ANC cases, revisits and provided IPTp-SP (public 6, faith based 2, private 5. One private clinic provided ANC services to revisits and IPTp2 doses only after the clients had been registered in public facilities, the second did not offer ANC services.

In 2013 the government declared provision of free maternity services in public facilities but ANC clients have continued to utilize services from the private sector. This is an indication of the untapped potential in the private sector in increasing access to high impact interventions and importance of supporting the sector by all partners to provide these interventions.

Such complementary efforts if implemented will not only result in enabling the country to move towards achievement of set targets but also improve pregnancy outcomes through reduction in effects of
malaria in pregnancy.

Ghana at ASTMH: Mapping out of antimalarial drugs on stock at the market in a rural districts of Ghana

The first Poster Session of theDodowa American Society of Tropical Medicine and Hygiene (Monday noon) will feature a study on availability of malaria medicines in rural Ghana. “Mapping out of antimalarial drugs on stock at the market in a rural districts of Ghana” was developed by Alexander A. Nartey, Evelyn K. Ansah, Patricia Akweongo, Gloria A. Nartey, Mary A. Pomaa, Doris  Sarpong, Clement Narh, and Margaret Gyapong of the Dodowa Health Research Centre.

AA Picture1Antimalarial drugs are a very important component of any policy for effective reduction of morbidity and mortality related to the malaria disease. The availability of efficacious and high quality antimalarials and their correct use can mitigate the risk of morbidity and mortality among the people of sub-Saharan Africa who have the highest risk of contracting and dying
from malaria.

Chemical (medicine) shops are major source of care for most developing countries where anti-malarial drugs can be purchase at the counter. The paper seeks to identify the different kinds of anti-malarial drugs on the market for malaria treatment in a rural district in Ghana.

Chart Picture1A structured questionnaire was used during two seasons (peak and low malaria transmission seasons) to collect information on anti-malarial drugs from all 58 chemical shops within the Dangme West district now (Shai Osudoku and Ningo Prampram districts). Pictures of the anti-malarial drugs were taken,

The active ingredients, and also the source of the drugs documented. GIS locations of the shops were also recorded to ascertain the proximity of the shops to households in the communities. Majority (72.0%) of the chemical and pharmacy shop owners are males. Only 7.0% of the shops are pharmacy while the remainder is licensed chemical shops.

GHSThe total numbers of antimalarial drugs counted were forty nine (49). Among the stock, 4.2% were quinine, 31.9% of them were monotherapies such as artemether, Amodiaquine, Artesunate etc. Altogether, 59.4% of the artemisinin combination therapies (ACTs) were artemether + Lumefantrine, 25.0% were Artesunate + Amodiaquine.

Other antimalarials observed were 9.4% Sulfadoxine + Pyrimethamine and 3.1% of of Artesunate + Sulfamethoxypyrazine + Pyrimethamine. About 47% of the anti-malarial drugs were pediatric formulations.

Map Picture1GIS mapping shows that majority of the households are within a periphery of 5km to a chemical shop.

The national antimalarial drug policy recommends the use of ACTs for malaria treatment however; all sorts of anti-malarial drugs which are not ACTs are in stock at the chemical shops in Ghana. Chemical shops are closer to households and play a very important role in the treatment of malaria hence there is the need to train chemical sellers to stock and administer the recommended antimalarials.

Registered drug shops are preferred for treating acute febrile illness in rural Uganda

The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.

globalsymposium_logosBelow is an abstract by Freddy Kitutu, Chrispus Mayora, Phyllis Awor, Forsberg  Birger, Stefan  Peterson, and Henry Wamani of Makerere University and the Karolinska Institute on use of medicine shops in Uganda.

“Under-five child mortality in Uganda is still high and majority is caused by easily treatable pneumonia, malaria and diarrhoeal diseases among the poorest people. One of the reasons for these deaths is the lack of timely access to proven life saving medicines. This hinders progress towards attainment of MDG 4 target by 2015.

“To increase access to quality medicines and diagnostics for child febrile illnesses, Makerere University School of Public Health (MakSPH) in collaboration with WHO Alliance for Health Policy and Systems Research, is doing a project to assess the potential to deliver quality integrated care for malaria, pneumonia and diarrhoea using integrated community case management (iCCM) strategies and tools. Hence, an assessment was conducted to determine baseline care seeking preferences.

“A baseline household survey interviewed caregivers of children under-five years. The study protocol and data collection tools had been reviewed and approved by Research and Ethics Committees at WHO, MakSPH and Uganda National Council of Science and Technology.

“A total of 2606 households were surveyed. The main childhood diseases reported included fever (70%), cough (77%), and diarrhoea (40%) convulsions (16%) Most households use private drug shops to purchase medicines to manage these illnesses. Use of drug shops was attributed to long distances to public health facilities, availability and reliability of drug stocks at drug shops, perceived high quality of services, and options for credit.

“Interventions that target public health facilities are likely to miss many healthcare seekers especially the poor in rural distant areas. Conclusion: Drug shops are the convenient and preferred outlets for rural poor communities, and therefore need to be included in interventions such as iCCM strategy.

“Significance for the selected field-building dimension: This abstract presents findings from the baseline assessment prior to introducing a health system intervention in drug shops to improve access to and quality of care for under-five children.”

Licensed chemical sellers and antimalarial prices in northern Ghana under the affordable medicines facility

The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makerglobalsymposium_logoss.

Below is an abstract by Heather Lanthorn of the Harvard School of Public Health on the AMFm program testing in Ghana. Other abstracts will appear subsequently.

“The Affordable Medicines Facility – malaria (AMFm) represents an important experiment in using private retail chains to improve access to medicines in low- and middle-income countries. AMFm aimed to make quality-assured artemisinin-based combination therapies (QA.ACTs) accessible at the variety of outlets where citizens treat fevers. In Ghana, where ACTs are legally sold over the counter, Licensed Chemical Sellers (LCS) are a key antimalarial provider.

“I use a framework adapted from industrial organization to study a unique, geo-coded data set of 250 LCSs in and around Tamale, Ghana collected explicitly for this study. Through well-integrated quantitative (multiple logistic regression) and qualitative (open thematic analysis) approaches, I analyze: the experiences of LCSs with AMFm; LCS reported compliance with recommended retail prices (RRPs); LCS economic and social explanations for compliance; and associations between LCS objective characteristics – including geo-location – and RRP compliance.

“We find high stocking of subsidized QA.ACTs and high RRP compliance. 18% of LCSs report selling above the RRP. The majority of non-compliers cite rising prices from their supplier as the major determinant of their own pricing. The majority of non-compliers sold at USD 1.5 rather than the RRP, USD 1.0. Indeed, in the quantitative analysis, RRP compliance is most clearly associated with the distributor prices and with LCS reputation (years in business).

CAM04418 a“A driving motivation for experimentally piloting AMFm was to learn whether the QA.ACT subsidy would be passed on to end-line private retailers and, in turn, to consumers. We find that, largely, it is. By considering LCSs both as economic agents and community members, the present analyses accord with, complement and innovate on the large, independent evaluation of AMFm, which focused on prices but neither objective nor perceptual explanations for price-compliance.”

UN General Assembly Resolves to Fight Malaria

unlogo_blue_sml_enGhanaWeb reported this morning that, “The United Nations General Assembly at its 68th Session, adopted Resolution A/68/L.60, “Consolidating Gains and Accelerating Efforts to Control and Eliminate Malaria in Developing Countries, Particularly in Africa, by 2015” by consensus.”

Likewise the UN itself issued a press release confirming that in a final act the Assembly adopted this resolution in order to call for increased support for the implementation of international commitments and goals pertaining to the fight to eliminate malaria. GhanaWeb reiterated the UN’s message that, “with just less than 500 days until the 2015 deadline of the MDGs, the adoption of this resolution by the General Assembly reiterates the commitment of UN Member States to keep malaria high on the international development agenda.”

The UN Press Release explained that, “The resolution urged malaria-endemic countries to work towards financial sustainability to increase national resources allocated to controlling that disease, while also working with the private sector to improve access to quality medical services.  Further, the resolution called upon Member States to establish or strengthen national policies, operational plans and research, with a view to achieving internationally agreed malaria targets for 2015.”

DSCN0730This effort is consistent with moves two years ago in the 66th General Assembly when it called for “accelerated efforts to eliminate malaria in developing countries, particularly Africa, by 2015, in consensus resolution” (document A/66/L.58) where the “Consolidating Gains …” document was first shared. The draft of the 2012  resolution, according to the UN Press release was sponsored by Liberia on behalf of the African Group, and called on Member States, particularly malaria-endemic countries, to strengthen national policies and operational plans, with a view to scaling up efforts to achieve internationally agreed malaria targets for 2015.

The sad irony of Liberia’s current predicament wherein the Ebola epidemic is rendering it nearly impossible to provide malaria services should give us pause. According to Reuters, “Treatable diseases such as malaria and diarrhea are left untended because frightened Liberians are shunning medical centers, and these deaths could outstrip those from the Ebola virus by three or four fold.”

The new resolution (A/68/L.60) in calling for increases national resources allocated to controlling that disease from public and private sources demonstrates the importance of national commitment to sustain and advance malaria control into the era of malaria elimination. It is now up to local malaria advocates to ensure that their governments, as well as private sector and local NGO partners, follow through to guarantee the needed quantity and quality of malaria services.

Malaria and febrile illness care seeking in Bauchi State, Nigeria

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health. Admiral Tim Ziemer, the Coordinator of the US President’s Malaria Initiative was keynote speaker. Other speakers from the NGO and faith based organization community also talked about the importance of partnership in fighting a disease that still claims 600,000 lives annually.  In addition 21 posters were presented.

Below is the abstract of one poster representing our work with USAID’s Targeted States High Impact Project in Nigeria.

Malaria and febrile illness care seeking in Bauchi State, Nigeria: context for improving case management at the primary level

Seeking of appropriate and qDSCN2939uality care for childhood illnesses is a major challenge in much of Africa including Bauchi State, Nigeria. In advance of an intervention to improve available care in the most common points of service (POS), government primary health care centers (PHCs) and patent medicine vendors (PMV), a survey was done of child caregivers in four districts concerning responses to febrile illness, suspected malaria, acute respiratory disease and diarrhea. The ethical review committee in the Bauchi State Ministry of Health approved of the study.

A total of 3077 children below the age of five were identified in the households sampled. Their mothers, fathers or other caregivers consented and were interviewed. Among the children 74% had any Illness, 57% had fever, 26% had cough, and 15% had diarrhoea. Only 8.7% of 1186 febrile children had their blood tested.

Care seeking from PMVs varied from 45% with fever, 40% with cough to 36% with diarrhoea. Care from public sector POS varied from 26-33%. Treatment that might be considered ‘appropriate’ for each also varied with 30% receiving antimalarial drugs for suspected malaria, 20% getting oral rehydration solution for diarrhoea and 50% being given an antibiotic for a suspected acute respiratory illness.

The results show that providing quality integrated case management with appropriate commodities through PHCs and PMVs can improve the illness care of a majority of children in Bauchi State, and interventions are currently being planned to do this.

Poster by … William R. Brieger, MPH, CHES, DrPH 1, Bright Orji, MPH 2, Masduk Abdulkarim 3, (1) International Health, Bloomberg School of Public Health, The John Hopkins University, 615 N Wolfe St, Baltimore, MD 21205 (and Jhpiego). (2) Jhpiego, Thames St, Baltimore, MD 21231`. (3) Targeted States High Impact Project USAID Nigeria, Bauchi, Nigeria.