What is the available data on malaria telling us? According to the Primary Healthcare Performance Initiative funded by the Bill and Melinda Gates Foundation, diagnostic accuracy in Nigeria is as low as 36.4%. This means that less than 4 out of 10 patients who seek healthcare are accurately diagnosed. Since 70% of diagnostic decisions depend on laboratory tests, the statistics also suggest that most patients are treated without objective evidence from medical tests, also referred to as in-vitro diagnostics.
Of all the diseases wrongly diagnosed in Nigeria, malaria remains the most frequently treated disease in community-based healthcare settings like pharmacies, clinics, and primary health centres. However, it is largely treated without evidence from testing, resulting in poor outcomes like preventable deaths and complications.
Consequently, it is imperative to build capacity for accurate and consistent testing of malaria at the point of care where health workers like community health practitioners, community pharmacists, nurses, and primary care physicians directly provide treatments for patients.
For context, Point of Care Testing for malaria refers to the use of Malaria Rapid Diagnostic Test for screening or diagnosis of malaria. Malaria RDT is the most accessible, affordable, and easiest-to-perform method of diagnosis. However, it is still not accessible or utilised efficiently and widely by health workers due to several addressable factors. This includes concerns over the validity and accuracy of the results, logistic challenges, food poverty, etc.
Crucially, there is a need to rethink the malaria strategy. The fact that Nigeria alone still accounts for approximately 30% of global malaria cases, which amount to 68 million cases, and 23% of malaria mortality, valued at 194,000 deaths, despite 70 years of implementing various outlandish strategies, highlights the critical need for us to rethink our strategy and execute homegrown solutions for malaria control and elimination rather than over-relying on international funding bodies.
Applying homegrown solutions that address the nuances and peculiarities of Nigerian communities and economy is what will put us on track to achieve malaria control and elimination targets. The World Health Organisation’s goals for malaria control and elimination by 2030 include reducing malaria incidence and mortality rates by at least 90% compared to 2015 levels, achieving malaria elimination in at least 35 countries, and preventing the re-establishment of malaria in countries that are currently malaria-free.
Thankfully, the Honourable Coordinating Minister of Health and Social Welfare Professor Ali Pate has called for a rethink of malaria elimination strategies in Nigeria in his address to stakeholders in Abuja at an event organised by the National Malaria Elimination Programme in May 2024. The minister noted that 60% of all hospital attendance in Nigeria, including at tertiary hospitals, is due to malaria. This means that there are serious loopholes and issues at the community and primary care level where uncomplicated malaria ought to have been fully managed.
I conducted a survey-based research among community-based healthcare professionals in Nigeria across cadres and found out many of them had abandoned the MRDT altogether for various reasons despite policy support from the government.
These are community pharmacists, community health and extension workers, nurses, and community physicians who are the first port of call for malaria case management. Now, when we have a situation where those who treat over 70% of malaria cases are not running diagnostic tests, then we should not be surprised that malaria-related deaths and complications continue to remain high and our teaching hospitals are inundated by malaria cases.
As sub-Saharan Africa grapples with a disproportionate burden of malaria, accounting for 95% of the cases and 96% of global malaria deaths, the African Leadership and Management Training for Impact in Malaria-Eradication, an NGO, is striving to provide a homegrown solution to situation. ALAMIME, funded by the Bill and Melinda Gates Foundation, is coordinated by the Ugandan Makerere University’s School of Public Health, and runs in 9 African countries; Nigeria, Uganda, The Democratic Republic of Congo, Tanzania, Zambia, Sierra Leone, Burkina Faso, Togo, and Benin. The programme has produced over 500 alumni in the last 3 years. According to the Programme Lead in Nigeria, Prof. Olufunmilayo Fawole, it was designed to build leadership and management competencies among people working in malaria programs in Africa.
Amidst concerns about fake drugs in Nigeria, we need to put the issue of the efficacy of malaria drugs into context because even authentic anti-malaria medications may still fail to work for various reasons not previously given deserving attention.
Food poverty is a critical issue that must be addressed by the government, as it significantly affects malaria treatment and overall health outcomes. Malnutrition increases vulnerability to malaria, particularly among immunocompromised infants and adults, leading to severe cases or even death. Additionally, food poverty is linked to malaria treatment failure. For example, when a mother can only afford to feed her baby a low-nutrition diet, such as pap, while administering an artemether/lumefantrine anti-malarial drug, the treatment is likely to fail due to the lack of a fatty meal, which is essential for proper drug absorption. Many mistakenly believe the treatment failed due to fake drugs or misdiagnosed typhoid, when in fact, poor nutrition is the culprit.
Another significant issue is the suboptimal dosage of anti-malarial drugs. In many cases, children, especially, are prescribed inadequate doses, either due to insufficient knowledge of proper dosing by health workers or because of financial constraints. Proper dosage is critical, as inadequate treatment can lead to severe complications or death, especially among children and pregnant women. The National Malaria Elimination Programme should increase the standard tablet pack size from six to twelve to ensure better treatment outcomes, as the cost difference is minimal.
Moreover, there is widespread scepticism among health workers regarding Malaria Rapid Diagnostic Tests, leading to inaccurate diagnoses and poor access to testing. One cause is the misuse of antibiotics, which can mask the presence of malaria parasites, leading to false-negative test results. This issue calls for stricter control over public access to antibiotics. Furthermore, many MRDT kits in the market lack the sensitivity to detect low levels of parasitaemia, contributing to the mistrust of these tests. Health workers often cite this as a reason to bypass testing altogether.
To address these issues, a multi-pronged approach is needed, including improved education on proper dosing and nutrition, stricter antibiotic control, and enhanced MRDT sensitivity. The newly inaugurated Committee on Antimicrobial Resistance should prioritize these challenges to improve malaria diagnosis and treatment across Nigeria.
By Akindele Opeyemi, Punch
