Scaling up malaria control in Nigeria: challenges and opportunities - PowerPoint PPT Presentation

Scaling up malaria control in Nigeria: challenges and opportunities Kelechi Ohiri and Ndukwe Ukoha Health Strategy and Delivery Foundation (HSDF) June 22, 2015 1

Contents ▪ Overview of Nigeria Health System ▪ Epidemiology of Malaria in Nigeria ▪ Key interventions and outcomes ▪ Opportunities, renewed approaches and initiatives 2

Nigeria is a federation with 6 zones spanning 36 state and a diverse population of over 160 Million people 3

Nigeria has a demographic profile, with a high dependency ratio (Proportion of non-working age over working age) Dependency ratio 1980 2011 2020 Indonesia 100 -41% 50 0 1980 2000 2020 Thailand 100 -45% 50 0 1980 2000 2020 Nigeria 100 -3% 50 0 1980 2000 2020 4 SOURCE: US Census Bureau: International Database

At current growth rates, Nigeria’s population is projected to double in 20 years and increase by 146% to ~400 million by 2050 making it the 4 th most populous country Estimated growth trends in the 10 most populous countries ( India, China not in chart) millions 450 USA 400 Nigeria 350 300 Indonesia Pakistan +146% 250 Brazil 200 Bangladesh 150 Mexico Russia 100 50 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 SOURCE: United Nations Population Division, Population Division of the Department of Economic and Social Affairs of the United Nations 5 Secretariat, World Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm,Sunday, August 28, 2011; 12:59:25 PM

The Federal Constitution divides responsibility for healthcare across the three tiers of government ▪ Local government authorities are responsible for The 1999 Constitution: Placed Health on concurrent list direct delivery of PHC services to the communities Then there was no explicit ▪ The State Governments are responsible for delineation of responsibilities amongst tiers of Government providing secondary care and deploying additional financial resources, skilled manpower, regulation, supportive supervision for PHC 2004 Health Policy: ▪ The Federal government promotes development Primary Health Care (PHC) became the entry point and cornerstone of and provide overarching policy guidelines, the National Health System. technical support, resource mobilization monitoring and evaluation It became the core strategy for ▪ In addition, the Federal Government is responsible ensuring access to health for all Nigerians for Tertiary Care delivery. PHC service delivery targeted mostly towards the rural population 6

Nigeria’s health system is beset with several challenges and suboptimal health outcomes ▪ Maternal mortality rate is ▪ ~23,000 health facilities 545/100,000 live births = (estimated 14,000 PHCs) 33,000 women each year but with different levels of ▪ 1 in 9 maternal deaths functionality ▪ Poor quality of care worldwide ▪ Shortage of critical human resources ▪ Infant mortality rate is ▪ Supply challenges – Inadequate power or 69/1,000 ▪ 8% of the global total, water supply ▪ An estimated 70% of these – Commodity stock-outs – Equipment inadequacy deaths are preventable – Weak standards ▪ Under 5 mortality rate is ▪ Demand for critical services 128/1,000 = ~1 million very low , largely driven by a deaths per year loss of confidence in the ▪ ~10% of the global total system e.g. – Only 38% of women have skilled births; Only 58% have ANC 7 SOURCE: Nigeria Demographic and Health Survey, 2008, 2013

Within the country, significant inequity in access to services exists Use of primary maternal and child health care services among Lowest and highest population quintiles Percentage 100 90 80 70 60 50 40 30 20 10 0 Med. Treatment of Med. Treatment of Oral Rehydration Antenatal Care Att. Delivery Full Immunization Fever Ac. Res. Inf. Thereapy Lowest 20% of Population Highest 20% of Population SOURCE: 2008 Nigerian Demographic and Health Survey 8

For instance, ITN coverage in Nigeria ranges from 18% to 82% despite a national campaign efforts LLIN coverage, 2013 % of households with at least one LLIN 82 73 73 71 70 69 67 60 59 59 58 57 57 57 56 56 54 52 52 49 49 46 45 44 43 43 42 38 37 34 34 33 26 25 25 24 18 Zamfara Benue Gombe Bauchi Katsina Kebbi Taraba Jigawa Ebonyi Plateau Sokoto Nasarawa Ondo Niger Borno Bayelsa Enugu Lagos Ogun Delta Kano Kwara Rivers FCT Kaduna Kogi Osun Adamawa Imo Abia Yobe Cross River Edo Anambra Ekiti Oyo Akwa Ibom SOURCE: Nigerian Demographic and Health Survey 2013 9

However, most of the expenditure on healthcare is spent on curative services … SOURCE: A. Soyibo et al. 2009; National health accounts: structure, trends and sustainability of health expenditure in Nigeria 10

… although the burden of disease is largely driven by preventable infectious and parasitic diseases Estimated total DALYs (000s) by cause 5,249 77,690 1,231 2,587 Injuries 5,249 1,431 Other unintentional Intentional injuries RTAs Total NCDs 16,648 16,178 injuries 764 1,124 1,233 1,274 1,457 1,578 1,670 4,124 2,954 Neuro- CVD Sense Resp Cong Cancers Digestive Diabetes Others Total Psychiatric organ anomalies /Endo disorders CMPN* 55,793 55,792 1,601 3,218 8,146 33,887 8,940 Infections/ Respiratory Perinatal Maternal Nutrition Total 2004 Parasitic infections CMPN: Communicable, Maternal, Perinatal and Neonatal conditions SOURCE: WHO Department of Measurement and Health information 2009. Based on 2004 DALYs 11

In summary, the health system, despite recent improvements, still faces the following four challenges • High maternal, newborn and child mortality rates Suboptimal health • Inequalities in health outcomes and utilization by socioeconomic status, urban/ outcomes rural and by regions across the country • Persisting vaccine-preventable diseases, such as Polio, Measles and Meningitis Triple burden • Rising burden of non-communicable diseases of disease • Significant burden of injuries and trauma-related deaths • Poor quality of health care services in public and private facilities that is Poor quality of unresponsive to the needs of the population health services • High rates of outward migration for health care services for those who can afford it • Health insurance coverage is minimal. Most payment remains out of pocket Lack of • National health insurance scheme currently covers only the formal sector protection from financial risk 12

Contents ▪ Overview of Nigeria Health System ▪ Epidemiology of Malaria in Nigeria ▪ Key interventions and outcomes ▪ Opportunities, renewed approaches and initiatives 13

Nigeria is strategically important to global malaria control efforts 1 ▪ An estimated 3.3 billion people are at risk of malaria Global ¡ ¡ ▪ 25-30% of global malaria-related mortality is attributable to Africa 2 ▪ Africa still bears over 80% of the global burden, despite recent declines in ¡ morbidity ¡ Africa ¡ ¡ ▪ Nigeria and the DRC account for 40% of the continental burden 3 ▪ An estimated 97% of the country’s 176 million people is at risk of malaria. ▪ About 11% of all child deaths worldwide are estimated to occur in Nigeria. ¡ ▪ Annual financial loss due to malaria in Nigeria is estimated at132 billion Naira ( ≈ USD Nigeria 800,000)-cost of treatment, prevention, loss of man-hrs. etc. SOURCES: World Malaria Report 2008,2009,2010, 2011,2013, 2014; Nigeria National Indicator survey 2010, Nigerian Demographic and Health Survey 14 ¡ ¡ 2008 and 2013

The drivers of malaria prevalence in Nigeria are environmental, socio-economic and health systems-related factors Key ¡factors ¡ Issue ¡ Implica5ons ¡in ¡Nigeria ¡ ▪ Climac-c ¡and ¡ ▪ Vector ¡Distribu-on ¡ ▪ Nigeria ¡has ¡different ¡dis-nct ¡clima-c ¡zones ¡ – Rainfall ¡ environmental ¡ ¡ (arid ¡deserts ¡in ¡the ¡north, ¡to ¡rainforest ¡and ¡ – Temperature ¡ mangrove ¡swamps ¡in ¡the ¡south) ¡ ▪ Variability ¡in ¡vector ¡distribu-on ¡across ¡states ¡ – Land ¡Use ¡ – Land ¡cover ¡ in ¡Nigeria ¡ ▪ Health ¡educa-on ¡and ¡knowledge ¡ ¡ ▪ Socio-­‑ ▪ Human ¡Vector ¡Contact ¡ ¡ ▪ The ¡use ¡of ¡personal ¡protec-on ¡measures ¡ – behavioral ¡factors ¡ ¡ economic ¡ Malaria ¡ – occupa-onal ¡factors ¡ ¡ against ¡mosquito ¡bi-ng ¡ Prevalence ¡ ¡ ▪ Distance ¡to ¡known ¡breeding ¡sites, ¡type ¡of ¡ ▪ Human-­‑host ¡related ¡factors ¡ – Popula-on ¡movement ¡ household ¡construc-on, ¡household ¡occupancy ¡ ▪ Migra-on ¡and ¡internal ¡displacement ¡of ¡ – Educa-on/Income ¡ – Sanita-on ¡ popula-ons ¡ ▪ Health ¡ ▪ Poor ¡quality ¡of ¡care ¡ ¡ ▪ In ¡Nigeria, ¡issues ¡related ¡to ¡quality ¡of ¡care ¡ Systems ¡ ▪ Complex ¡opera-onal ¡structure ¡ exist, ¡including ¡but ¡not ¡limited ¡to ¡misdiagnosis ¡ ▪ Weak ¡program ¡coordina-on ¡ of ¡malaria ¡ ▪ Poor ¡health-­‑seeking/care ¡ ▪ Poor ¡access ¡to/uptake ¡of ¡preven-ve ¡ prac-ces ¡ ¡ interven-ons ¡ SOURCES: NDHS, 2013, J.S Ogboi et al. 2014. Misdiagnosis of malaria using wrong buffer substitutes for RDT in poor resource settings in 15 ¡ ¡ Enugu, Nigeria.; Multi-indicator cluster survey 2011, NBS Nigeria