Prompt and effective treatment of malaria with Artemisinin-based Combination Therapy (ACT); Use of Sulphadoxine-Pyrimethamine (SP) for Intermittent Preventive Treatment (IPT) of malaria in pregnancy and Integrated Vector Management including use of Long Lasting Insecticidal Nets (LLINs) are the bane of malaria control in Nigeria.

Other interventions include behavioural change communication and community mobilization, capacity building, partnership as well as monitoring and evaluation.

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) was set up to provide additional source of assistance to countries in their fight against these three killer diseases.

Nigeria, through an existing and functional country coordinating mechanism (CCM) made proposals to the GFATM. The acceptance of these proposals led to the signing of two grants for malaria:

Round two grant
Round four grant
The Principal recipient of the grant is Yakubu Gowon center while the Federal ministry of Health is the Sub-recipient.

Round 2 grant was signed on October 22nd, 2004. The amount is $20.9 million for the first two years. The programme started on November 1, 2004 was to end on October 31st, 2006.

It aimed at scaling up already existing RBM activities in the country. The Round 2 grant was to support 12 states namely: Yobe, Taraba, Plateau, Kwara, Zamfara, Kaduna, Ekiti, Lagos, Ebonyi, Imo, Cross River and Delta States and to strengthen programme management at Federal level.

The key objectives were:

Procuring and distributing 3 million ITNs to 2 million under five children and 1 million pregnant women within 2 years and ensuring retreatment.
Procuring and distributing 4 million doses of Artemisinin Based Combination Therapy (ACTs) to under five children for treatment of malaria within 2 years.
Providing 1 million doses of IPT to 500,000 pregnant women using SP through public and private sectors.
To achieve the above objectives, broad activities have been planned which included:

Implementation of appropriate advocacy, media and IEC/BCC activities in the selected states on ITNs usage, disease management using ACTs and IPT. These include posters, billboards, radio/ TV jingles etc.
Procurement and installation of office equipment in the RBM office of the selected states to aid appropriate communication/reporting of activities. These include purchasing and distribution of 224 motorcycles to all the LGAs of the benefiting states and computers with accessories to the States RBM offices.
Training of 2,220 health care workers (Tertiary, Secondary, Primary and Private Sector) in all the selected states on correct ITNs use and Re-treatment, Intermittent Preventive Treatment, and Case management using ACT.
Training of 444 store officers on correct drug management especially as ACT is a relatively new drug.
Community mobilization and training of role model mothers in the selected LGAs of 12 selected states in effective symptom identification and home management of malaria.
Supervision and data gathering to ensure that activity reports are received from the 12 states.
Round 4 Grant was signed on December 3, 2004. The amount was $20.47 million for the first two years. The programme started on January 1, 2005 and was to end on December 31, 2006.

Its aim was to contribute significantly to the reduction of malaria morbidity and mortality in children under five years of age through improving case management of malaria in 6 states (Bayelsa, Borno, Enugu, FCT, Oyo and Sokoto) over a period of 2 years with a three - state - per - year - incremental pattern.

The key objectives are:

To procure, distribute and increase informed demand for ACT through IEC/BCC and advocacy activities targeted at care givers.
To administer treatment of ACT to children under five years of age for malaria in the 6 selected states.
To train care givers in correct case management of malaria in order to improve compliance to ACT drug regimen in the 6 selected states.
To expand and maintain systematic monitoring of performance in malaria case management and drug efficacy.
To achieve these objectives, the following broad activities were planned for implementation:

Community advocacy visit to be conducted to the benefiting states /LGAs on ACTs.
Develop and produce IEC/BCC materials at National and State levels on ACTs targeted at care givers. This will be carried out in collaboration with RBM Partners.
Procurement, distribution and administration of 12.1 million doses of ACTs to the target group in the selected states.
National Orientation / Sensitization of 148 tertiary level health care workers (University Lecturers) on the anti-malaria drug policy change from the 36 states and FCT.
Training of 720 of tertiary/state level doctors and pharmacists in the 36 states including FCT.
Training of 770 health care workers at the LGA level from the selected states in malaria case management using ACTs.
Training of154 drug store officers in the selected states on correct drug management of ACTs.
Training of 160 RBM and M& E officers in the states and LGAs on Management Information System (MIS) for monitoring and evaluation of RBM programme.
Procurement and installation of office equipment in the RBM office of the selected states to aid appropriate communication/reporting of activities. These include purchasing and distribution of 114 motorcycles to all the LGAs of the benefiting states and computers with accessories to the States RBM offices.
Phase 1 Grant Score Card

During the first phase of implementation, about 27,743,553 USD was expended in the procurement and distribution of commodities to the supported states
10.6 million treatment courses of Artemisinin Combination treatment (ACT) for uncomplicated Malaria in children less than 5 years were distributed
1.7 Million long lasting insecticide treated nets ( LLINs) were distributed
1 million treatment courses of Sulphadoxime - Pyremethamine (SP) for intermittent preventive Treatment of Malaria during pregnancy were distributed.
Challenges in phase 1 Implementation

Several lessons were learnt during the implementation Phase 1 period including:

use of population projections and morbidity data for quantification without taking cognizance of health seeking behavior (Public - Private Mix in service provision).
Lack of data due to non-experience with ACTs resulted in the initial push of the medicines down the supply chain based on population projections and estimates (inaccurate forecasts).
Challenges in data collection and transmission especially from the health facilities to the LGAs, States and National office.
Incomplete and delayed reporting from the states
Due to delayed procurement process, emphasis was placed on the one off delivery with little emphasis placed on development of systems of delivery.
Non use of existing reordering forms
Poor outlining of inventory procedures e.g.   Lack of a clear definition of minimum stocks at the different levels, No SOPs.
Lack of a preset/predictable delivery schedule
Vaguely defined Commodity Flow Chart created bottle neck in the reporting systems.
Weak Behavioural Change Communication Strategy
Some Cases of leakage into the private sector as a result of poorly define commodity inventory processes.

Phase 2 Round 4 Malaria Grant

Phase 2 of the Round 4 Malaria grant has been approved by Global Fund with a total budget of 61,670,721 USD and roll out has commenced in earnest. The revised grant is titled: 'Scaling up malaria control in 18 states of Nigeria' and implementation will span 2007 - 2009.

The Principal Recipients of the grant are Yakubu Gowon Centre (YGC) and Society for Family Health (SFH) and these will deliver through the public and private sector mechanisms respectively. YGC is to manage 31,029,129 USD while SFH will manage 30,641,591 USD of the budget.

The public sector Sub Recipients (SRs) include:

The National Malaria Control Programme: responsible for  
Coordination of Sub SRs e.g. benefiting States
Monitoring, evaluation and supportive supervision
CHAN Medi-Pharm GTE: responsible for downstream Supply Chain Management  (supply of commodities to health facilities).
Public sector strategic partner is First Bank PLC (Fund Disbursement Solution Provider)

The objectives of the grant are: 

Improved malaria treatment for children under five years of age by providing 26,881,101 treatment courses of ACT over the 5 year life time of the project (14.5 million additional treatments in phase 2).
Distribution of LLINs (4,182,116) to children under five and pregnant women attending child welfare and antenatal clinics over the 5 year project life time (2.5 Million additional treatments in Phase 2).
Improved intermittent preventive treatment of malaria in pregnancy using SPs (4,210,907 treatment courses) over the 5 year life time of the project.
Strengthening malaria monitoring, procurement supply management and overall programming of RBM in Nigeria
Improved informed demand for malaria control health commodities through appropriate IEC/BCC, advocacy to opinion, community leaders and community mobilization and sensitization.

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