By Sola Ogundipe

I ALMOST died of malaria,” recounts Oluwadamilola Agbajo, Miss Nigeria 2010. “I was in school at the time, and was so ill for a long time. I missed writing a very important examination no thanks to that bout of malaria.”

This experience forever changed Oluwadamilola’s perspective about malaria. Today, she is Queen Ambassador of the Affordable Medicines Facility for malaria, AMFm, initiative in Nigeria.

She recalls that her encounter with malaria was more as a result of late diagnosis than lack of access to efficacious drugs. “My illness opened my eyes and I became really interested in treatment, prevention and management of this sickness. I have gone on the internet to find out more on available research of a lasting malaria cure. I believe in the AMFm programme because it is appropriate.”

The Queen Ambassador expresses total willingness to support the Federal Ministry of Health of Nigeria in the AMFm initiative which debuted in Nigeria in November 2010, as an effort to develop a major policy that would put in place a sustainable malaria treatment, control and prevention programme.

*File photo: Drug store

Oluwadamilola’s rendition echoes the typical Nigerian attitude to malaria infection, and even though not everyone is privileged to be appointed ambassador, it’s a safe bet every Nigerian knows malaria as much as malaria knows them. Virtually everyone has a story to tell about this “ordinary” illness with extraordinary consequences.

Extraordinary consequences

Here, the story of malaria is a mixture of misery and mystery. Every narration is a lamentation of woe, a recitation of grave repercussions and a distress call to action.  Nine in 10 persons are at risk in Nigeria which accounts for 25 percent of malaria cases in Africa. Every 30 seconds, a Nigerian child dies from malaria; 30 percent of childhood mortality and 11 percent of maternal mortality in Nigeria are attributable to malaria. Just about every other person on the street has had at least one malaria attack at some point in the last six months.

The World Health organisation, WHO, estimates that 50 percent of the adult population in Nigeria experiences at least one episode of malaria yearly, while infants and small children have up to two to four attacks annually.

Many persons actually suffer multiple attacks in the same year. Infants, young children and pregnant women are particularly vulnerable to the malaria menace. The multiple indicator cluster survey, MICS, Nigeria conducted in 2010 showed that about 52 per cent of children aged six months to five years tested positive to malaria.

Despite significant progress in increasing awareness, malaria remains one of the greatest public health burdens in Nigeria. Every year the nation loses about N132 billion to malaria in man hours, while the illness drops the nation’s annual Gross Domestic Product by one percent.

Long ago, medical experts realised that the malaria parasite will continue to debilitate its victims due to increasing resistance to older, inexpensive treatments, such as chloroquine. Currently, the WHO specifically recommends Artemisinin-based Combination Therapies, ACTs, as the best treatment for uncomplicated malaria. ACTs have remained the gold standard in malaria treatment, and, essentially, their use at the community level has been vigorously promoted over the years since the emergence of chloroquine-resistant strains of the malaria parasite.

Domestically, the Federal Government of Nigeria subscribes to globally acceptable malaria control and prevention measures, including the free distribution of insecticide-treated nets to vulnerable groups. Government also ratified global responses in the form of the Roll Back Malaria partnership by the WHO and the Global Fund to fight AIDS, Tuberculosis and Malaria, GFATM.

“The launch of AMFm will further accelerate our drive to ensure we have 50 per cent reduction in malaria by 2013,” Nigerian Minister of Health, Prof. Onyebuchi Chukwu, announced during the official kick-off in November 2010. Under the programme, all medical doctors and health officials in government hospitals utilize ACTs for treatment of uncomplicated malaria.

In Nigeria, the AMFm is being implemented by the Ministry of Health’s National Malaria Control Programme, the Society for Family Health and the Yakubu Gowon Center with support from Clinton Health Access Initiative, CHAI.

Dr Olusoji Adeyi,

Director, AMFm Nigeria explained that under Phase I implemented over 24 months, eligible first line buyers placed orders for AMFm subsidised ACTs after completing the necessary Global Fund documentation.

The goal of the AMFm initiative is simple. Enable increase in provision of affordable ACTs through the public, private not-for-profit and private for-profit sectors, through provision of a subsidy of up to 95 percent of the manufacturers cost of ACTs. The goal is to facilitate the increased use of ACTs by drastically reducing the cost of these drugs (potentially to N75.00 for end users for an adult dose).

The first objective is to increase availability of ACTs in public and private outlets; second, to reduce the cost of ACTs to a level that is comparable with other anti-malarials (such as chloroquine, sulphamethamine, and artemisinin monotherapy); third is increasing the market share of ACTs among antimalarials. And lastly, to increase use of ACT among vulnerable groups such as poor people, rural communities, and children.

While the AMFm remains an interesting model, so far, it appears effective only on paper. How much its objectives have been achieved is debatable. Nigerians still do not have penchant to seek a clinician’s assistance at the onset of symptoms. Rather, preference is for self-medication, fueling sub-clinical therapy.

People complain of the side effects of orthodox drugs and would rather settle for herbal remedy in malaria treatment. Then there is the problem of misdiagnosis and several cases of malaria are still treated as typhoid.

Argument has been that low cost ACTs would only be a reality if the public is fully aware of the programme, the effectiveness of ACTs and the fact that they are to be made affordable by retailers. The current picture is that Artesunate/Amodiaquine (AS/AQ) combinations and Artemether Lumefantrine (AL) though widely available, are expensive. Patients of uncomplicated malaria still do not have adequate access to ACTs comparable to prices of other less effective medications such as mono-therapies. From this perspective, the goal of AMFm to eventually crowd out the ineffective medicines cannot be said to have come to light.

The National Malaria Control Programme, argues that for eligibility to supply ACTs under the AMFm, a manufacturer must meet criteria set out in the Global Fund’s Quality Assurance Policy. Under the signed agreement, the Global Fund mandates local manufacturers to mandatorily brand all AMFm ACT packages with a special logo of a green leaf with the words “ACTm” underneath. The logo is meant to be a symbol of high quality and affordability.

Obtaining subsidized drugs, a challenge

However, in practice, it is a challenge obtaining the highly subsidized medicines at health facilities, pharmacies and chemist stores at the advertised shelf price of about N30.00 per dose for children and N75.00 for an adult dose.

A spirited search of drug stores in Lagos neighbourhoods for ACT packs with the green leaf logo yielded little success. None of the drug stores visited stocked the specially branded drugs. Random sampling among buyers of malaria medicines showed there is limited public awareness about this requirement.

This is regardless of a nationwide awareness campaign for the AMFm brand by the three Principal Recipients viz: the National Malaria Control Programme, the Society for Family Health, SFH and Yakubu Gowon Centre.

At inception in 2011, 43 importers were signed up to participate in the commitment to making ACTs affordable and available across Nigeria. More than 20 million doses of ACTs were brought in for distribution through first line buyers in the public, private and not-for-profit institutions.

Anti malarial treatment

Although ACTs account for significant numbers of anti-malarial treatments, cost is still a major hindrance. Use of local herbs, consultation of spiritualists/traditional priests is not uncommon in preference to use of the clinic/hospital services or routine prevention measures such as use of medicine (prophylaxis), insecticides (coils and sprays), ordinary mosquito nets, insecticide-treated nets (ITNs) and window/door nets.

That the degree of suspicion for malaria is high does not help because required confirmatory laboratory tests are often ignored. Once an adult or child complains of headache, weakness, fever, aches and pains, high body temperature (chills and rigors) and bitterness in the mouth (and loss of appetite), or  shows manifestation of more than normal sleeping, nausea and vomiting, he or she is automatically “diagnosed” with malaria and “treatment” commences, usually at home.

The truth is that in these parts, malaria treatment is still expensive, quite expensive. For most Nigerians, this is a bitter pill to swallow. Self-medication and other problems prevail. More than two years on, the bulk of Nigerians which comprises the poor and down-trodden, still do not have access to cheap, effective ACTs. Access to lowered cost of malaria drugs and treatment is still not within reach.

But all this is expected to change as the AMFM exits the pilot stage into the transition stage. However, expectations are high that things will generally pick up after the transition stage, when the new AMFm takes off with country specific grants to address their malaria problems using stakeholders of their choice.