Data needed to ‘count malaria out’ – the Nigerian situation

With the theme of the second World Malaria Day being counting progress, RBM Partners are highly challenged. “The international malaria community has merely two years to meet the 2010 Abuja targets and achieve universal coverage with all malaria interventions.” Partners will never know if they are meeting targets unless accurate and timely local data are generated in endemic countries.

Data in UNICEF’s 2009 State of the World’s Children Report has provoked the ire of Nigeria’s new Minister for Information and Communications.  The Punch explains that, “Prof Dora Akunyili, was reported to have expressed strong reservations over the damning statistics released by the United Nations Children‘s Emergency Fund (UNICEF) on three critical health indicators in the country.”  The ‘dismal’ national performance led to the following response seen in the Punch:

However, no sooner was the report made public than the Minister picked holes in the figures, describing it as unacceptable and unfair ”especially at this time when the country is trying to rebrand and project a new image”. And, without an alternative locally-generated data at her disposal to counter the supposed ‘unfair” figures, a visibly peeved Prof Akunyili … stressed that ”The figures for maternal mortality, infant and Exclusive Breast Feeding cannot be correct when put side by side with the great feat achieved by Nigerians in the area of salt iodization and vitamin A fortification, both of which enhance child and maternal survival and well being.”

The lack of up-to-date national statistics is especially important for judging progress toward RBM targets.  The most recent national figures come from the 2003 Nigeria Demographic and Health Survey (co-sponsored by the National Population Commission and USAID).  Most countries do perform a DHS only about every 5 years, and the 2008 Nigeria DHS is still being completed.  In the 2003 version –

  • 6% if Nigerian children under 5 years of age had slept under a bednet the previous night
  • 1% of these children had used an ITN
  • 34% of suspected malaria cases had been treated with an appropriate antimalarial drug

Since that time Malaria control has been intensified in 18 of 36 states with support from the Global Fund and in a few other states with help from USAID and DfID.  Additional support from DfID, World Bank, Global Fund and USAID to cover the remaining states is slowly forthcoming.

In the absence of more recent national survey data some studies have reported increases in net use, but these data are still far below targets.  A 2008 article in Malaria Journal found in 12 states that ownership of any net was 23.9% and utilization of any net by children under-five was 11.5%. A follow-up article in 2009 found that even after a major net distribution campaign, the number of  under 5 years aged children sleeping under nets was only 40%.  Importantly, the proportion was three times higher in southern than in northern states even though all areas had been equally targeted with nets.

The availability of these local data should make the Minister happy, but traditionally there has been poor communications between researchers and government officials. Government needs to reach out more effectively to the research community and be willing to learn.

Nigeria has been a place where much innovative malaria implementation research has taken place.  The question is whether the health system enables such research to be taken to scale.  The Punch is doubtful and scolds the government for allocating less that 5% of its annual budget when WHO recommends 15% and is skeptical that the existing system can deliver the goods:

Obviously, the country‘s neglect of primary health care service delivery as well as government‘s tardy response to health matters in the country seem to have, among other things, accounted for such evidently unpleasant reality. As a matter of fact, Nigeria ‘s primary health care system, responsible to anchor, as it were, maternal and infant health services, is currently in complete and total disarray, as a visit to the various health centres across the country will show. This explains why routine immunization programme that could have helped mitigate the spread of such child-killer diseases like polio, meningitis and others are difficult to be effectively implemented.

It is likely that the lack of national budgetary resources for health makes it difficult for the health system to conduct the monitoring and evaluation needed show Nigeria’s progress toward RBM indicators in a better light. Also some light needs to shine on current health systems challenges leading to soul searching and honest commitments to saving lives.

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