By Ayodele Olofintuade
In a fact sheet released in 2010 by the US Department of State, malaria was listed as one of the top causes of death in Nigeria. The fact sheet stated that it accounted for over 300,000 deaths annually, more fatalities than are caused by HIV/AIDS, which kills about 215,000 Nigerians annually. In 2010, an estimated 11 per cent of maternal mortality nationwide occurred as a result of malaria.
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 having the least prevalence of 27.6%. The prevention and treatment of malaria is further inhibited by a national per capita poverty rate in excess 60 per cent (according to the World Bank).
As a result, a huge amount of funding has been pumped into the country in recent years by various foreign donors, for interventions aimed at both the prevention and the treatment of malaria. For example, between 2006 and 2009 the World Bank committed a total of $180 million into a Malaria Booster Programme for seven states in Nigeria – Gombe, Kano, Jigawa, Adamawa, Anambra, Rivers and Akwa Ibom.
Although the money was given primarily to the states, part it was to go into some activities on the national level.
The sums of money invested can be 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 programmes, pledged over US $640 million to Nigeria to be disbursed over five years for the treatment of malaria, particularly in women and children. Between 2008 and 2014, US$500 million was released.
The National Malaria Control Programme, NMCP, is an agency domiciled in the Federal Ministry of Health, Abuja, which receives direct funding from both GFATM and the World Bank (the latter for the Nigeria Malaria Control Booster Project and the Integrated Vector Management, IVM,). It is charged with coordinating and developing policies, strategies and guidelines that would 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.
SuNMAP, Support to Nigeria Malaria Programme is a project being executed in support of NMCP, funded by the United Kingdom’s Department for International Development, DFID. SuNMAP aims to “harmonize efforts of donors and funding agencies around agreed national policies and plans for malaria control”.
The partners for this project include GRID Consulting, Health Partners International and Malaria Consortium and all these bodies are providing malaria intervention in Nigeria.
There are yet more international organizations active in combating malaria in Nigeria. The global Roll Back Malaria, RBM, partnership was launched in 1998 by the World Health Organisation, WHO, UNICEF, the United Nations Development Programme, UNDP, and the World Bank.
There are 100 countries where malaria is endemic, including Nigeria, Ghana, Sudan and South Africa. RBM presents itself as an effort to provide a coordinated response to malaria worldwide. In Nigeria, RBM provides insecticide treated nets, ITNs, indoor residual spraying, IRS, and training for health providers, and it has been funded by GFATM
Also, WHO, UNDP and UNICEF also have malaria intervention programs they are directly overseeing in Nigeria. For example, WHO has offices in Nigeria where it oversees the distribution of ITNs, training of health workers and provision of free malaria tests.
Then, in May 2009, the Global Health Initiative, GHI, an effort to reduce the burden of disease and promote healthy communities and families around the world was instituted by the president of the United States, Barack Obama.
The core of this initiative is 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 non-governmental organization, NGO. FHI 360 has a project in the country named the Malaria Action Program for States, MAPS, being executed in partnership with Health Partners International, GRID Consulting Nigeria and Malaria Consortium. 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 these multiple partnerships with their multiple organizations execute programs that often differ only in minute ways.
Where are the statistics?
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 department that is supposed not only to keep track of how the funds are being spent, but also to measure the impact of the interventions.
However, since the 2010 Department of State Fact Sheet that was referenced at the beginning of this story, there seems to have been no comprehensive measurement of how all these interventions have affected the number of Nigerians who die from malaria each year.
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 their interventions regarding HIV/ AIDS, it did not do the same for the interventions against malaria.
During the course of this investigation, this reporter noted that RBM, GTFAM and most other international organizations involved in the fight against malaria worldwide, had details of almost every country they worked with, their interventions, the impact of these interventions and other relevant information, on their website. But one thing these organizations had in common was a paucity of statistics on the status of their interventions in Nigeria.
Funding impact and conspiracy of silence
In order to find out why there has been such a lack of information about how the foreign-backed interventions have impacted the mortality rate by malaria in Nigeria, the reporter tried to get in touch with officials working in Nigeria at the NGOs behind the anti-malaria interventions.
She first attempted to contact Halima Mwenesi, the Senior Project Director of MAPS. She tried to call her many times over the course of two days to ask for statistics regarding the effectiveness of the MAPS program in reducing the incidence of malaria in the states, but could not get through. I sent an email to her address domiciled at the US NGO FHI 360, but still did not receive a reply.
Our reporter then sent a mail to Abba Umar, listed as Chief of Party for MAPS on the FHI 360 website. He sent me a reply saying that he was no longer with the organization, but gave me the email address for Oluwole Adeusi, the man who replaced him in that position.
Understandably, Umar claimed that Adeusi was in a better position to answer my questions. But an email to Adeusi, again went unanswered.
Undeterred, the reporter contacted the media director at FHI 360, Natasha Abel. However, Abel was unable to answer any questions regarding the success of the MAPS intervention and suggested contacting MAPS directly.
Feeling like she had reached a dead end, the reporter decided to approach Malaria Consortium, one of the working partners MAPS listed on its website. She was passed through to Kolawole Maxwell, the director for the Malaria Consortium in Nigeria.
An email was immediately dispatched to him but again he was unable to answer relevant questions and redirected the reporter to Adeusi, who in turn still did not reply to any of the emails sent to him.
After requesting help from contacts who work in various NGOs, our reporter located Maxwell’s direct telephone number but was unable to set up a meeting with him in Abuja. Eventually, she managed to speak to him on the phone.
He was asked whether any data was available regarding the effect that MAPS had had upon mortality rates in Nigeria the data and what tools were being used to measure the impact of the interventions.
In a conversation that lasted for close to 45 minutes, Maxwell was not able to provide any concrete answers to questions about where the reporter could access data on the impact of the interventions in Nigeria.
Even after pointed out that the Malaria Consortium seems to be involved in a large number of malaria partnerships, Maxwell was unable to provide answers to any of the reporter’s questions.
At the end of the conversation he simply directed the reporter back to the National Malaria Control Programme. None of the emails sent to various NMCP employees elicited a response and the phone numbers listed on the NMCP website were not working – the network provider either said that the numbers were incorrect or that they were not available.
It was time for a change of strategy. Our reporter thus moved on in the search for some statistics that would justify the hugely expensive interventions against malaria in Nigeria, and succeeded in getting through to Uwem Inyang, the Program Manager Malaria at USAID Nigeria.
He said that USAID has monitoring tools and data about how the funds are being disbursed but that he was unable to answer questions about the impact that their interventions have had.
The reporter was then able to set up an interview with the group within USAID in charge of overseeing malaria funding in Nigeria. At the 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 talked about 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.
However, they too were unable to give me any links to available data on the impact on mortality rates of their interventions in Nigeria.So, at the end of that meeting, in what was becoming a predictable pattern, she was redirected to the Nigerian Malaria Control Programme.
How the malaria interventions are failing ordinary Nigerians
Although it was impossible to find anyone who was willing and able to provide any statistics regarding the effect of many interventions against malaria on mortality rates in Nigeria, from the information that is available on the standards of preventative care against malaria, it is clear that not all is well.
In February 2013, the monitoring and evaluation branch of the NMCP released its third quarter report on its supervisory/data verification visits to primary health care units across 29 states and the FCT.
The NMCP visited a sample 116 primary health care units (out of a total of 13,000 facilities) across the nation. A total of 71 of these units (61%) reported stock outs (they had no anti-malarial drugs), while 20 more (17%) more 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 centres visited, less than 45% had received training on malaria control interventions. As if that was not bad enough, 89% of the facilities visited had no data records. And of the 11% that had records, 50% of the data was not valid (Report of Third Quarter supervisory/data verification visits to twenty nine states and FCT).
The reporter decided to visit south western Nigeria to see the situation on the ground. In the quest for statistics online about the impact of malaria interventions in Nigeria, she came across a lot of statistics in particular about the distribution of insecticide-treated bed nets (ITNs) and how they are supposed to reduce the incidence of malaria amongst the populace.
Instead of answering questions about how the ITNs has bettered their fight against malaria, she found out, from the straw poll she conducted among people attending health centres in three different states in the south-west, that although about 80% of the respondents had heard about ITNs being given out in different parts of their states, less than 10% of them had received the nets.
Busari is a 63years old printer, who runs Molak Printers and a community leader at Oke-Itunu, Ibadan, Oyo State, who was directly involved in the distribution of the impregnated nets in the state. When asked how he came about distributing the nets, he claimed that the nets were given out to him by Ibadan North local government.
He accused people of selling the nets, after they had collected them. He also said that the people that helped him in the distribution of the nets were eventually trained by one NGO that approached him after they had completed the distribution. He was unable to give the name of the NGO or the nature of the training.
Our reporter also discovered that treatment for malaria is not free here. Mulikat Akinlolu, a 35-year old street trader, brought her 10-month old daughter to the primary health care unit at Ibadan North local government of Oyo State because she had malaria. Asked about the treatment and drugs given to the child, she said a test was carried out and she was given prescriptions that she would have to take to a pharmacy. She expressed surprise that the treatment was not free.
When the nurse on duty at the local government authority was questioned about this, she refused to give me any answers, stating that she is a government worker and is therefore not allowed to speak with journalists.
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, perhaps one should not be so surprised that statistics regarding these interventions have proved so hard to come by But, as the reporter found out in the course of this investigation, the more questions you ask, the more questions you come away with.
This report was produced with support from Partners for Democratic Change and the Institute for War & Peace Reporting. It is part of the Access Nigeria/Sierra Leone program funded by the United States Department’s Bureau of International Narcotics and Law Enforcement.