Funding bulge fails to stem malaria scourge in Nigeria
In a fact sheet released in 2010 by the United States Embassy in Nigeria, malaria was listed one of the top causes of death in the country. The Embassy fact sheet stated that malaria accounted for over 300,000 deaths annually, more fatalities than are caused by HIV/AIDS, which kills about 215,000 Nigerians per year. In 2010, malaria contributed to an estimated 11 percent of maternal mortality nationwide.
Over 97% of the Nigerian population lives in areas where malaria is a risk. In the South West, North Central and North West regions, malaria has close to 50% prevalence in children aged from six months to five years, with the South East region having the lowest prevalence, of 27.6%. The prevention and treatment of malaria is further inhibited by a national per capita poverty rate in excess of 60 per cent (according to World Bank statistics).
As a result, a huge amount of funding has been pumped into Nigeriain recent years by various foreign donors, towards interventionsaimed at both the prevention and the treatment of malaria.For example, between 2006 and 2009 the World Bank poured a total of $180 million into a Malaria Booster Program for seven states in Nigeria – Gombe, Kano, Jigawa, Adamawa, Anambra, Rivers and Akwa Ibom. Although the funding was given primarily to the aforementioned states,the World Bank also funded some activities on the national level.
The sums of money invested in anti-malaria programs have sometimes been even higher. In 2008, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), a financial institution which gives out grants to various experts to conduct programs, pledged over US $640million to Nigeria for the treatment of malaria, particularly in women and children, to be disbursed over five years. Between 2008 and 2014, US$500 million was released.
For example, GFATM provides funding to the global Roll Back Malaria(RBM) partnership, which was launched in 1998 by WHO (the World Health Organization), UNICEF, the United Nations Development Programme (UNDP) and the World Bank. RBM presents itself as an effort to provide a coordinated response to malaria worldwide, particularly in those 100 countries where malaria is endemic, including Nigeria, Ghana, Sudan and South Africa. In Nigeria, RBM provides insecticide treated nets (ITNs), indoor residual spraying, and training for health providers.
GFATM has also provided funding tothe National Malaria Control Programme (NMCP), an agency domiciled in the Federal Ministry of Health, Abuja, which also receives direct funding from the World Bank (the latter for the Nigeria Malaria Control Booster Project and the Integrated Vector Management [IVM]). The NMCP is charged with coordinating and developing policies, strategies and guidelines to ensure the delivery of high impact malaria interventions, which means the NMCP is in charge of coordinating the activities of all non-governmental agencies involved in health programs operating in Nigeria.
NMCP is also supported by the Support to Nigeria Malaria Programme (SuNMAP), which is funded by the United Kingdom’s Department for International Development. In its own words, SuNMAP aims to “harmonize efforts of donors and funding agencies around agreed national policies and plans for malaria control”. This project is led by the Malaria Consortium.
The complex web of international funding to combat malaria in Nigeria also includes malaria intervention programs that are overseen directly by the WHO, UNDP and UNICEF.For example, WHO has offices in Nigeria where it oversees the distribution of ITNs, the training of health workers and the provision of free malaria tests.
In May 2009, Barack Obama instituted the Global Health Initiative (GHI), an effort to reduce the burden of disease and promote healthy communities and families around the world. A key component of the GHI was the President’s Malaria Initiative (PMI). By 2010, Nigeria became the seventeenth country to benefit from the PMI, because of its high mortality rate from malaria.
Through the United States Agency for International Development (USAID), PMI gave a grant to FHI 360, a United States based NGO. FHI 360 has a project in the country named the Malaria Action Program for States (MAPS), which is executed in partnership with Health Partners International, GRID Consulting Nigeria and Malaria Consortium (which also leads SuNMAP, as detailed above). MAPS is a five-year, $79.9million project that is funded by USAID. Its mandate is not so different from those of other NGOs committed to reduce the incidence of malaria in Nigeria. The organization aims to “… increase the quality, access, and uptake of malaria control interventions in Nigeria by helping implement and scale-up proven malaria control methods, while strengthening program management capacity at the national, state, and local government levels in seven states in Nigeria”. These seven states are Benue, Cross River, Ebonyi, Oyo, Akwa Ibom, Kebbi, and Kogi.
Therefore not only does Nigeria have multiple donors giving money to different malaria programs within its borders, but it seems that these multiple partnerships with their multiple organizations execute programs that often differ only in minute ways.
How many lives have these programs saved?
With such a multiplicity of organizations and funding streams involved in the fight against malaria in Nigeria, it should be easy to find statistics in the public domain that show the impact of these interventions on mortality rates.Every single NGO named above has a monitoring and evaluation departmentthat is supposed not only to keep track of how project funds are being spent, but also to measure the impact of these interventions.
However, since the release of the 2010 US Embassy Fact Sheet referenced at the beginning of this story, there seems to be very little information in the public domain that explains the impact of all these interventions. Most importantly, I could not find a recent figure detailing how these interventions have reduced the mortality rate from malaria.
To give an example of this information gap, in 2012 the Nigerian office of the Centre for Disease Control and Prevention (CDC) released a factsheet for Nigeria.Althoughthe document gave a full breakdown of the impact of its interventions against HIV/AIDS, it did not do the same for the interventions against malaria.
During the course of further research, I discovered thatmost of the international organizations involved in the fight against malaria published details of the impact that their interventions had had in various other countries. However, there was very little saidabout their impact in Nigeria, particularly regarding the reduction in the mortality rate.
Tracking down the information in person
So I decided to try to approach officials working at the NGOs behind the anti-malaria interventions, to ask them why this information was so hard to find, and how many lives their interventions had actually saved.
I first attempted to contact Dr Halima Mwenesi, the Senior Project Director of MAPS. I tried to call her many times over the course of two days, to ask for statistics regarding the effectiveness of the MAPS program, but I could not get through to her. I then sent anemail to her address domiciled at the US NGO FHI 360, but still did not receive a reply.
My next target was Abba Umar, listed as Chief of Party for MAPS on the FHI 360 website. He sent me a reply telling me that he was no longer working forMAPS,and gave me the email addressfor Oluwole Adeusi, the man who replaced him in that position. Understandably, Umar reasoned that Adeusi was in a better position than he was to answer my questions. I immediately sent anemail to Adeusi, but this again went unanswered.
Undeterred, I contacted the Media Director at FHI 360, Natasha Abel. However, Ms Abel was unableto answer any of my questions regarding the success of the MAPS intervention, and suggested that I get in touch with MAPS directly.
Feeling that I had reached a dead end here, I decided to approach Malaria Consortium, one of the working partners MAPS listed on their website. I was passed through to Dr Kolawole Maxwell, the director for the Malaria Consortium in Nigeria. Again he sent me an email saying that he was unableto answer my questions, and redirected me to Oluwole Adeusi(who had still not repliedto any of the mails sent to him).
After requesting help from contacts who work in various NGOs, I locatedDr Maxwell’s direct telephone number. I was unable to set up a meeting with him in person in Abuja, but eventually managed to speak to him on the phone. I asked him whether any data was available regarding the effect that MAPS had had upon mortality rates in Nigeria, and what tools were being used to measure the impact of the interventions.
During the course of a conversation that lasted for close to 45minutes, Dr Maxwell was not able to provide any concrete answers to my questions about where I could access data on the impact of the interventions in Nigeria. Even after I pointed out that the Malaria Consortium seems to be involved in a large number of interventions against malaria, he was unable to provide answers to any of my questions. At the end of the conversation he simply directed me back to the National Malaria Control Programme. None of the emails I sent to various NMCP employeeswere responded to, and the phone numbers listed on the NMCP website were not working– on different occasions, the network provider either said that the numbers were incorrect or that they were not available.
It was time to try someone else in my search for some statistics that would justify the hugely expensive interventions against malaria in Nigeria. Isucceeded in getting through to Uwem Inyang, the Program Manager Malaria at USAID Nigeria. He informed me that USAID has monitoring tools and data about how funds are being disbursed,but that he was unable to answer questions about the impact that USAID’s interventions have had.
What he did do for me was to set up an interview with the group within USAID in charge of overseeing malaria funding in Nigeria. Present at this meeting were the USAID Nigeria Health Office Director, the CDC Resident Malaria Adviser and the Malaria Program Manager.The meeting lasted for 15 minutes, during which time the team told me why they were in Nigeria (poverty alleviation), where they received the funding to carry out their work (the President’s Malaria Initiative [PMI]) and how their interventions worked in the Sudan. What theydidn’t give me wereany links to available data on the impact of their interventions in Nigeria.
At the end of that meeting, in what was becoming a predictable pattern, I was redirected to the Nigerian Malaria Control Programme.
How the malaria interventions are failing ordinary Nigerians
Despite my efforts, nobody could give me data on the impact of the many anti-malaria interventions in Nigeria.Yet, from the information that is published regarding standards of preventative malaria care in Nigeria, it is clear that not all is well on the ground.
In February 2013, the monitoring and evaluation branch of the National Malaria Control Programme released its third quarter report on supervisory/data verification visitsto primary health care units, across 29 states and the Federal Capital Territory. NMCP had visited a sample of 116 primary health care unitsacross the nation, of a total of 13,000 such facilities in Nigeria.71 of these units (61%) reported stock outs (they had no anti-malarial drugs), while 20 more (17%) reported that their stocks were actually missing!
The most shocking part of the report was that,of the total staff at the 116 health care centers visited, less than 45% had received training on malaria control interventions. As if this were not bad enough, 89% of the facilities visited had no data records.
I decided to visit southwestern Nigeria myself to see the situation on the ground. In my quest for statistics online about the impact of malaria interventions in Nigeria, I had come across a lot of statistics in particular about the distribution of insecticide-treated bed nets(ITNs), and how these are supposed to reduce the incidence of malaria.According to the straw poll I conducted among peopleattending health care centers in three different southwestern states, althoughabout 80% of the respondents had heard about ITNsbeing given out in different parts of their states, less than 10% had actually received the nets.
I tracked down Alhaji Busari, a 63-year old printer and community leader in Ibadan, Oyo State, who was directly involved in the distribution of the impregnated nets in Oyo. When asked how he came to distribute the nets, Busari claimed that they had been given to him by the local government. He accused other distributors of selling the nets after they had collected them from the government, suggesting major problems in the way such distribution programs are run.
Neither, despite the huge amounts of money poured into anti-malaria programs, is treatment for malaria free in Oyo State. Mulikat Akinlolu, a 35-year old street trader, brought her 10-month old daughter for malaria treatment to the primary health care unit at Ibadan North Local Government. She said that a test had been carried out and that she had been given prescriptions for her daughter that she would have to take to a pharmacy. When she got to the pharmacy, she was surprised to find that she had to pay a total of N100.When I tried to ask questions to the nurse on duty at the Local Government Authority, she refused to give me any answers, stating that she is a government worker and istherefore not supposed to grant interviews.
Given the state of primary health care units in the country, and the lack of impact felt by Nigerian citizens from the foreign interventions on malaria, then perhaps one should not be so surprised that statistics regarding these interventions have proved so hard to come by. But, as I’ve found out in the course of this investigation, the more questions you ask, the more questions you come away with.