By the end of  2010, the world is expected to attain 80 percent coverage for treatment and distribution of bed nets; reach pregnant women with preventive treatment for malaria. It is also expected that 2015 would witness reduction in morbidity and mortality by 75 percent. These goals seem humanly possible, yet they remain far from being realised, as huge global efforts is yet to translate into total victory over the disease. In this interview with Charles Kumolu, Dr. Chioma Amajoh, Deputy Director, Roll Back Malaria, Federal Ministry of Health, called for sustainability on the gains recorded. She also noted that the Primary Health Care must be integrated in the cause, in order for the war to be all inclusive. Amajoh also spoke on possible emergence of resistance insecticides and drugs, inadequate empowerment of communities among other issues.

DO you think that some of the targets set to reduce malaria, especially diagnosis and preventive treatment for pregnant women have been attained?

Yes, up to 2008 the malaria control programme offered large attention to these major vulnerable groups, children under five and pregnant women. Despite the fact that the thrust now is universal access yet priority attention is still given to these major risk groups to ensure that they are adequately protected. If the targets must be achieved and the RBM goal attained in this last year of the initiative, It is critical that these group must receive priority attention. This is actually happening. Our modest achievements include: Development and dissemination of Policy documents, Guildelines and Training Manuals; distribution of over 28 million ITNs, in 2009 alone through the National  LLIN Campaign 14 million LLINs were distributed in  nine States; over 33.5 Million doses of ACTs, over 14 Million doses of IPT provided from 2006 to date, 37, 688 Households sprayed in seven States with Residual Insecticide in 2009, several healthworkers trained including doctors, nurses and scientists, Lab scientists, environmental health officers community extension health workers CHEWs, intensified Advocacy, communications and Social Mobilization.
To consistently monitor the efficacy of anti-malaria medicines, the Federal Government has increased the sentinel sites from six to 14. Eight sites are also established for monitoring the vector resistance to insecticides in the areas where IRS is implemented. In collaboration with NAFDAC, a Natiomal plan is developed for the implementation of Pharmaco-vigilance activities to monitor any adverse reaction to any of the anti-malaria medicines. We also carry out quality assurance tests for all commodities distributed.

Dr. Amajoh

How realistic is the 2015 target of reducing number of deaths to zero level ?
Yes, I believe that an appreciable successful impact has been recorded since the inception of Roll Back Malaria, with the goal to halve the burden of Malaria by the end of 2010.

We are now at the catch up phase because time is running out! This is a stage where we are all scaling up for impact (SUFI) and targeting Universal Access to anti-malaria commodities in malaria endemic countries like Nigeria.

The tempo is high hence we are using campaigns to ensure we rapidly scale up at this stage and achieve the goal.
As you are aware, Malaria is a disease without borders, that exerts extensive human toll particularly in Africa with 90 percent of the burden. The economic cost and loss in productivity due to cost of prevention and treatment, absenteeism from farm, market, school and workplace had been quite huge.

Strong and robust partnerships have been established at various levels to fight the disease and attain the RBM Goal. Governments at various levels have also made appreciable efforts to fight Malaria. In Nigeria, for example, the Federal Government through the MDG Debt Relief Fund has pumped in substantial financial resources into Malaria Control Programme. A number of projects are also established and are exerting great impact in the fight against Malaria. Some these major projects and institutions are Global Fund to Fight HIV/AIDS, TB and Malaria (GFATM), World Bank Malaria Booster Project, DFID Support for Nigeria Malaria Programme (SuNMaP), USAID Deliver/JSI and Presidential Malaria Initiative (PMI), WHO Global Malaria Programme, Alliance for Malaria Prevention (AMP), etc. The Private sector, the NGOs and the Civil society groups have all made appreciable contributions. Most importantly, communities are trained and empowered for ownership of the programme for sustainability. The effort is to balance equitable distribution of the commodities with sustainability for adequate health impact.

If some level of success have been recorded,  would you say it has significantly propelled efforts to achieve the Millennium Development Goals, especially on  women and children  rights and health, access to education and the reduction of extreme poverty?

The current undaunted determination and drive against malaria during this Catch up phase in the efforts to scale up for impact are critical for malaria elimination and attainment of the MDGs.

You are aware that the eight MDGs directly or remote relates to the fight against Malaria. So the universal coverage and use of malaria medicines, Long Lasting Insecticdal Nets and other commodities, particularly among children and women, is propelling efforts to achieving the RBM as well as the MDGs. However, sustainability of the gains of the programme is critical. We must therefore move from catch up phase to the keep up phase by encouraging routine access to the anti-malaria commodities through the health facility directed at Ante natal clinics for pregnant women and Child Welfare clinics for children.

Existing community structures will also serve as outlets for provision of the services. Integration at the Primary Health Care level is, therefore, quite relevant. Obviously, at this point of sustainabilty, which is beyond 2010, is when the impact to achieve MDGs will be visible and the impact on women and children rights and reduction in extreme poverty will be clearly demonstrated. You will agree that we have come a long way as developing countries, where you have the most efficient mosquito vectors of malaria.

Commitment is key including at the individual and household levels, to ensure proper use of the commodities. Individuals and households should also ensure that all water receptacles are covered or removed from their premises to reduce mosquito breeding sites. All stakeholders must play their roles for us to eliminate Malaria as well as attain the Millennium Development Goals.

Africa is hugely affected by malaria unlike other parts of the globe, do you think that African governments, especially the African Union,AU, has done much at combating malaria in the continent?
You will recall that in the last decade, three main Summits on Malaria had been convened in Abuja. The RBM Summit held in 2000 came up with Abuja RBM Declaration with the Abuja Targets and the Plan and Framework for implementation. Forty five African countries were in attendance. The ATM Summit, which gave birth to GFATM Project was convened in 2001.  Another ATM Summit, which emphasise the necessity for Universal Access to commodities for combating these three major diseases held in 2006. Each of the Summits was well represented by the various Afriacn countries. That is great commitment and interest. A number of these countries have actually made appreciable impact in reducing the malaria scourge. Political will on the part of the leadership in the region is also on the increase.

Some have argued that treated mosquito nets, have not proved to be the best preventive measure in Africa given some inherent dangers associated to its usage?
The African countries are applying various arsenals  against the scourge. Remember, we are still faced with the issue of resistance. We are grappling with vector resistance to chemicals, parasite resistance to drugs and the resistance of humans to the proper use of anti malaria medicines, sleeping under nets, having their houses sprayed with insecticides with residual effect to last for months and even resistant to discouraging mosquito breeding sites.
However, with the current weapons available to us in Africa, it is total war against Malaria. These include advocacy, behaviour change communication and Social mobilisation, effective supervision, monitoring and evaluation and operational research to fill gaps. The local technology transfer into the region for the production of large quantities of the current strategic materials including LLINs and Insecticides is also encouraged.

How best do you think  government can be involved in this fight?
The appropriate use of Long Lasting Insecticidal Nets have been proven effective and efficacious. Trials in four African countries show that the proper use of Insecticide Treated Nets (ITNs) was able to reduce Malaria Mortality among children under five year by 25 percent.  A comparative trial in Nsukka, Enugu State showed that the use of ITN offered better protection than insecticide treated curtains and ITN use was well accepted by the communities. Where you have 80 percent of people in the Household or Community using LLINs, you have mass effect, where every other person around receives some measure of protection from infectious mosquito bite. It is a very cost effective measure for malaria prevention. So the use of Insecticide treated Nets is evidence based. The use of LLIN is very effective. We encourage it.

The complementary roles of IRS and larviciding can never be over emphasised.

Government at the State and LGA level should intensify Indoor Residual Spraying especially in the hot season when sleeping under the net is quite uncomfortable. Larviciding is of essence in the urban and peri urban drains.
Malaria control in Nigeria commenced before independence just before the Second World War. A number of approaches have been tried with various groups working independent of each other on relevant malaria control issues. The efforts were fragmented and uncoordinated.

Well, Roll Back Malaria, which is Multi Actor, multi Strategy and Multi Sectoral, is the current initiative.

By initiating and successfully hostimg the RBM Summit in 2000, Nigeria has since shown high level of political commitment to RBM activities. This initiative which was spearheaded by the World Health Organization in 1998 emphasised multiple strategies. And partnership.

Strategies adopted in Nigeria include promotion and use of Long Lasting Insecticidal Nets (LLINs) to prevent infectious mosquito bites,House-to- House spraying of residual insecticides, approved by WHO and with effect lasting for some months. Other Mosquito Control measures include environmental management. We have Intermittent Preventive Treatment (IPT) in pregnancy, where pregnant women, who are at increased risk for malaria death, receive preventive treatment during pregnancy. We also promote prompt diagnosis and provision of effective Anti malaria medicines.

Between 2000 and 2006 most of the interventions were small pilot projects due to the very limited resources avilable. We were able to mobilise significant resources within and outside the country from about 2006.

In November, 2008, all partners working in Malaria Programme agreed to pool all resources so as to provide more support to all States and FCT. This decision was taken to strive to achieve high level of coverage for all interventions. With the properly articulated current five – year Strategic Plan for 2009 to 2013. This doggedness with the effective coordination  led Nigeria and its RBM Partnership to pool resources for the distribution of 63 million Nets in 2009 and 2010. This earn RBM Nigeria an award from Alliance for Malaria Prevention (AMP), as the country that had the highest level of LLIN coverage I 2009 – 14 million LLINs, with a very effective coordinaton mechanism, using State Support Teams (SSTs).

Do you mean all these are being done, yet, the measures seems to be achieving the opposite result (increasing spread of the disease)?
Free ACTs are provided to Trained Community based providers such as Roll Model Care Givers. Subsidised ACTs are made available in the Private Sector outlets as well as improve the knowledge and behaviour of Care Givers especially Roll Model Mothers. Increased availability and quality of microscopy in Health Facilities and scaling up Rapid Diagnostic Tests. Functional coordination platform (ATM TWG Malaria and Sub committees, Partners Forum, State Review Meetingas etc). Strengthen RBM Partnership exists. Key RBM Partners such as WHO, UNICEF, DFID, SNMP, USAID, JSI/DELIVER, SFH, Yakubu Gowon Centre, as well as the Private Sector, the Global Fund to fight AIDSN TB and MalAria (GF), and the World Bank, are all contributing in their various areas of comparative advantage. Each partner accepts its vital role and initiates actions individually or collectively to play its vital role for effective Malaria Control. At the Federal Ministry of Health, we are involved in policy formulation and strategic planning including resource mobilisation to support the states and Local Government Areas. It is at the State and LGA levels that implemenation takes place.

Having said all this, remember the huge size of our beloved country. I always envisage this as a strength and advantage though. Nigeria habours about 25 percent of the burden of Malaria in Africa.

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