Nigeria, the most populated country in Africa, is going through the longest period of civilian rule since its independence. However, in addition to rebuilding the economic and political system of the country, the Nigerian government has to rebuild its heath infrastructure. Its under-five mortality rate is 197 deaths per 1000 live births, and HIV, malaria and diarrheal disease account for about a quarter of the deaths among adults.
PSI operates in Nigeria through its implementing partner Society for Family Health (SFH), which was founded in 1985 by several eminent Nigerians and PSI. Starting with two employees and one office in Lagos, SFH has grown to over 200 employees working out of 17 offices scattered across the country. SFH began with one product and one HIV/AIDS prevention grant and now markets nine products and manages five contracts worth $120 million. SFH runs 308 franchise facilities across 21 states of Nigeria.
In 2005, past successes helped SFH become the first Nigerian NGO qualified to receive funding directly from the U.S. Agency for International Development.
PSI/Nigeria estimates that in 2015, its products and services helped avert 4,043,546 DALYs, including, by health area:
- 1,252,226 Malaria DALYs
- 1,235,950 HIV DALYs
- 1,502,329 FP DALYs
- 22,028 MNCH DALYs
- 433 WASH DALYs
- 30,490 Safe Abortion DALYs
- 89 NCD DALYs
PSI/Nigeria’s family planning programs also provided 2,775,331 couple-years of protection.
Nigeria, being the most populous African nation has a population of over 140 million people. With a general population adult HIV prevalence of 3.6 percent (FMOH 2007) and 4.4 perecnet among women attending antenatal clinics, the country has the world’s third largest burden of people living with HIV/AIDS after South Africa and India. The population of people living with HIV/AIDS is estimated to be 3.86 million, and AIDS related deaths average 310,000 per year.
HIV Counseling and Testing
The Society for Family Health implements the Global Fund Round 5 project which began in January 2007. The overall goal of the project is to reduce HIV/AIDS-related mortality and morbidity. SFH is responsible for objective 2 of the programme, which aims at expanding access to HIV testing and counselling services to cover all 37 States of the country. Counselling and testing (C&T) is an important entry point to HIV/AIDS prevention and care. People who know their HIV status are better able to take appropriate individual and collective measures to prevent transmission of HIV. C&T also enables HIV positive people to enter treatment early, access care and support and so increase their chances of better health outcomes. It is expected that there will be an increased number of people who know their HIV status, entering into treatment, care and support, leading to reduced morbidity and mortality from HIV and AIDS in Nigeria at the end of the programme. SFH currently also implements the Round 9 grant of the Global Fund in Nigeria.
Multiple partners support SFH to implement the counselling and testing component of the project. Family Health International and Planned Parenthood Federation of Nigeria are the SRs managing the provision of services to Public and Private Facilities respectively. Nigeria Institute for Medical Research (NIMR) and Gede Foundation are the SRs for training, while Crown Agents and International Dispensary Association (IDA) act as commodity procurement agencies. Through the project, SFH has ensured the availability of standard HIV C&T health infrastructures in 108 public and private health facilities, procured over 221,000 rapid test kits for various health facilities and opened 137 testing sites in the first year of the project and 108 in the second year.
SFH also implements the Enhancing Nigeria’s Response to HIV and AIDS programme. The ENR programme is a six year, integrated HIV prevention and institutional strengthening programme, funded by the United Kingdom’s Department for International Development (DFID). The programme commenced on January 19, 2009, with the signing of the contract between the Society for Health (SFH) and DFID. ENR is managed by a consortium, with the Society for Family Health as the managing agent. Other members of the consortium are ActionAid Nigeria, Population Services International (PSI), BBC World Service Trust, Options Consultancy Services, Benguela Health Pty, Population Council and Crown Agents.
With the goal of contributing to the achievement of the Millennium Development Goal (MDG) 6, ENR seeks to reduce the spread of HIV epidemic and mitigate the impact of AIDS on the lives of the most at risk and vulnerable groups. ENR therefore has the purpose of ensuring sustained behaviour change among the most at risk, through increased and consistent use of condoms, improved access to effective HIV and AIDS prevention, treatment, care and support information and services.
ENR is currently operational in eight selected states, namely Benue, Cross River, Enugu, Kaduna, Nasarawa, Akwa Ibom, Lagos and Ogun. The project has a Programme Steering Committee that provides external advisory support; and a Partner’s Management Council (PMC) that sees to partnership issues and the provision of strategic oversight.
Malaria has the highest burden of disease in Nigeria – with an estimated 300,000 children dying of malaria each year. It accounts for over 25 percent of infant mortality, 30 percent of childhood mortality (children under five), and 11 percent of maternal mortality. At least 50 percent of the population has at least one episode of malaria annually, while children aged less than 5 years have 2 to 4 attacks annually (NDHS 2008). Malaria is particularly severe among pregnant women and children under 5 years old. SFH implements ACT Watch and Global Fund Malaria Rounds 4 and 8 projects.
Long-Lasting Insecticide-Treated Nets
SFH malaria programming includes both prevention and treatment activities. Malaria prevention is a top priority – it is estimated that prevention alone could save Nigeria billions of Naira in treatment expenses as well as illness-related loss of productivity. Prevention programmes focus on the promotion and use of mosquito bed nets, called Long Lasting Insecticide Treated Nets (LLINS), along with education for families and health care providers on the importance of using bed nets to prevent mosquito bites, the mode of transmission for malaria. LLINs are factory-treated mosquito nets that are safe, easy to use, and come in a variety of sizes and colours to address individual needs. Some LLINs are effective for up to 4 years and will last a minimum of 20 washes – they require no re-treatment during this time, making them 5-10 times more effective than conventional re-treatable mosquito nets. LLINs are an inexpensive and easy way of preventing malaria and thus reduce its burden on the health and economic well-being of Nigerians. SFH uses its extensive marketing and distribution channels to move LLINs all across Nigeria, so that they are available to everyone, but particularly women and children.
Pre-Packaged Therapy: Artemisinin-based Combination Therapy (ACT)
When prevention fails, treatment of malaria is critical. In seeking treatment for malaria, some mothers are given incorrect drug treatment doses or ineffective drugs to give their children, or find treatment options confusing and difficult to complete. So, in 2003, SFH developed an innovative approach to “pre-package” malaria treatment for easy use among mothers and families to rapidly and correctly treat malaria. SFH treatment programmes to combat malaria focus on the promotion and distribution of a new and effective drug for malaria, called Artemisinin-based Combination Therapy (ACT). This is an easy to use pre-packaged formula that facilitates fast and effective treatment of malaria for children and families. Now, SFH is promoting this ACT treatment, using the pre-packaged method, and distributing this product throughout all of Nigeria, even to remote and rural communities.
SFH conducted the first pan- Nigerian radio campaign to promote the new policy of Artemisinin-based Combination Therapy (ACT) as the drug of choice for the treatment of uncomplicated malaria. This new brand, Coartem will be heavily subsidised to increase affordability for the poor and vulnerable who shoulder the largest burden of malaria in our society. These medicines will be distributed through private health care providers including Proprietary Patent Medicine Vendors (PPMVs) (local drug shopkeepers) and community-based pharmacies. SFH works closely with the Federal Ministry of Health, with technical matters, education, training, and coordinating on policy and research — to move the nation forward on both prevention and treatment issues in its battle against malaria.
Spacing of births of three to five years allows each child to develop and grow best, and gives mothers the chance to recover their health and strength between pregnancies, for the benefit and well-being of the whole family. SFH does this through education and empowerment of couples through the provision of information, services, and products for both modern and natural birth spacing methods. The Family Planning Division of SFH works to achieve the following goals: 1) increase knowledge of modern child spacing methods among couples of reproductive age, 2) increase positive attitudes and understanding of the importance of child spacing products, 3) to achieve a national reduction in maternal mortality, 4) to improve inter-spousal communication among couples, 5) to increase the number of women using modern methods, and 6) to improve the capacity of health care providers to offer correct child spacing information and services.
SFH just concluded implementation of the Improved Reproductive Health in Nigeria Project (IRHIN), funded by USAID, a six-year project, from 2005 – 2011. This project contributes to the Millennium Development Goal (MDG Goal #5) of reducing maternal mortality rates in Nigeria and to contribute to national awareness of population management issues and child spacing, while the overall purpose is to improve the understanding of, access to, and correct use of contraceptives to reduce unintended or mis-timed pregnancies.
The main target groups the RH/FP division works with, providing education and training, are:
- Women: 18 – 40 years, married or unmarried, intending to use a child spacing method in the next 12 months
- Men: 18 – 50 years
- Providers: Nurses, Doctors, Pharmacists, PPMVs (medicine vendors) and CHEW`S (community health workers)
The Expanded Social Marketing Project in Nigeria (ESMPIN), SFH’s newest project which began in 2011, aims to improve the health of women and children in Nigeria primarily by increasing the use of modern family planning methods and secondarily by increasing the use of child health products. To achieve this, the project will increase access to family planning, reproductive health, and child health products; increase use of health products and practice of healthy behaviors; generate support from all sectors for social marketing as an important part of a total market approach; and assess the viability of local manufacture of key health products. It is a 5-year $56.3 Million USAID funded project implemented in partnership with the Society for Family Health, Nigeria, Association for Family and Reproductive Health, BBC World Service Trust and Population Services International.
Water, Sanitation and Hygiene
Safe Water Systems: Water Guard® and PUR®
In Nigeria only 56 percent of households have access to improved sources of water. One in five rural households have a clean water at the home, and most families must collect water from unsafe sources, such as rivers or streams. Only 10 percent of Nigerian households use an appropriate method of water treatment.
SFH promotes safe water through:
- Sale and distribution of water disinfection products.
- Promotion of safe water storage in plastic containers with a narrow mouth, lid, and spigot to prevent recontamination,
- Behaviour change and communication, along with community mobilization, education, and awareness on the importance and benefits of safe water, safe storage, and community hygiene.
In 2004, PSI/SFH began development and local production of Water Guard, a 1% sodium hypochlorite, point-of-use water disinfectant targeted at caregivers of children under five years of age. A bottle of Water Guard will provide safe water for a household for a month and it sells for between N50 and N100 in chemists and pharmacists all over Nigeria. It is safe to use by both adults and children, and provides protection against water borne diseases, including cholera (which causes severe diarrhoea and vomiting in epidemics) as well as dysentery and other forms of water borne disease causing agents.
In 2008, PUR (manufactured by Proctor & Gamble) was introduced to complement Water Guard. Both products are distributed and sold nationwide.
- Dutch Ministry of Foreign Affairs
- Exxon Mobil
- Global Fund to fight AIDS, Tuberculosis and Malaria
- Oxfam Novib
- Procter & Gamble
- Nigerian Bottling Company
- Nigerian Liquefied Natural Gas
- Nigerian Government
- ShellPetroleum Development Corporation
- United Kingdom Department for International Development
- United Nations Population Fund
- U.S. Agency for International Development
- World Health Organization
- World Population Foundation
- Action Aid International
- Association of Civil Organizations in Malaria Control Immunisation &. Nutrition
- BBC Media Action
- Benguela Pty
- Centre for the Right to Health
- Coca Cola Foundation
- Comic Relief
- Community based organisations
- Crown Agents
- Family Health International
- Federation of Muslim Women Associations of Nigeria
- Grameen Foundation
- Institute of Tropical Disease Research University of Calabar
- International Finance Corporation
- Marie Stopes International
- Medical Credit Fund
- National Primary Health Care Development Agency
- National Union of Road Transport Workers
- Nigeria Ministry of Education
- Nigeria Ministry of Health
- Nigeria Ministry of Information
- Options Consulting
- Planned Parenthood Federation of Nigeria
- Population Council
- Safe Care
- Save the Children
- London School of Hygiene & Tropical Medicine
- State Ministries of Health
- University of California San Francisco Global Health Group
- University of Ibadan
- Vital Waves
- Adolescents 360: Nigeria Emerging Insights Slide Deck
This document is intended to capture what A360 programmers and implementers learned during the inspiration phase in Nigeria. It reflects the voices of the people the team spoke with and provides the A360 Consortium with a springboard for design opportunities.
- Towards Subsidized Malaria Rapid Diagnostic Tests. Lessons Learned from Programmes to Subsidise Artemisinin-Based Combination Therapies in the Private Sector: a Review
Private sector subsidy programmes of ACTs have been effective in increasing availability of ACTs in the private sector and driving down average prices but struggled to crowd out antimalarial monotherapies. A subsidy of rapid diagnostic tests (RDTs) in the private sector has been recommended by governments and international donors to cope with over-treatment with ACTs and to delay the emergence of resistance to artemisinin. In order to improve the cost-effectiveness of co-paid RDTs, we should build on the lessons we learned from almost 10 years of private sector subsidy programmes of ACTs in malaria-endemic countries.
- What Happened to the Malaria Market in Nigeria after the AMFm?
AMFm continuation under the private sector co-payment mechanism (CPM) has been successful in further improving access to quality assured ACTs in the private sector, where the majority of antimalarials are distributed in Nigeria. High QA ACT price relative to nonartemisinin therapies including SP and chloroquine is likely still a barrier to uptake. Furthermore, the very low availability of confirmatory testing in the private sector suggests that presumptive treatment remains common.
- Expanding Access to HIV Self-Testing: A Market Development Approach
PSI envisions a healthy market for HIVST to be one that is supported by multiple buyers and suppliers and that delivers on the 5As (Availability, Assured Quality, Appropriate Design, Awareness, and Affordability) to achieve public health goals. Realizing this vision for the HIVST market will require consideration of two key markets- public and private sectors. While HIV testing has traditionally been driven by the public sector, HIVST opens up the possibility of utilizing private sector pharmacies to expand and extend the reach of testing.
- Task Sharing Policy Change and Implementation in Nigeria
Human resources shortages, higher number of CHEWs compared to nurse/midwives, a freeze on employment due to funding constraints, and a preference for CHEWs employment due to availability and lower remuneration packages are all enabling factors for task-sharing. Thus, a task-shifting policy was developed in 2014 at the 55th NCH meeting in Uyo, Akwa Ibom State. This presentation reviews the policy, how it was operationalized, how quality is assured, and gives recommendations for moving forward.
- Simplified Asset Indices to Measure Wealth and Equity in Health Programs: a Reliability and Validity Analysis Using Survey Data from 16 Countries
Many program implementers have difficulty collecting and analyzing data on program beneficiaries' wealth because a large number of survey questions are required to construct the standard wealth index. We created country-specific measures of household wealth with as few as 6 questions that are highly reliable and valid in both urban and rural contexts.
- Market Trends for Malaria Blood Testing in Sub-Saharan Africa, 2009-2014
In 2012, the World Health Organization (WHO) launched the Test, Treat, Track initiative recommending confirmatory testing prior to antimalarial treatment. National malaria control programs (NMCP) across subSaharan Africa (SSA) subsequently aligned national guidelines with this recommendation. Strategies to scale up testing using malaria rapid diagnostic tests (mRDT) were introduced by NMCPs. We examine malaria testing availability, price and market share using national market survey data collected by the ACTwatch project.
- SP Availability and (Mis)Use in Sub-Saharan Africa: Antimalarial Market Data From 8 Countries
As evidence of reduced chloroquine efficacy against plasmodium falciparum mounted in the 1990’s, sulfadoxine-pyrimethamine (SP) became first-line malaria treatment in many endemic countries in sub-Saharan Africa (SSA). Between 2002-2005, countries in SSA adopted artemesinin combination therapies (ACT) as first-line treatment. SP is still recommended by the WHO and used across SSA for intermittent preventive treatment of malaria during pregnancy (IPTp). We examine availability and distribution of SP using national antimalarial market survey trend data collected by the ACTwatch project.
- Greater Impact at Lower Cost: Prioritizing Support to Private Patent Medicine Vendors for Increased Quality Fever Case Management in Ebonyi State, Nigeria
In Nigeria, the majority of households seek basic health care through private sector health providers, known as Private Patent Medicine Vendors (PPMVs). Recent data from ACTwatch outlet surveys have found that PPMVs play a significant role in providing antimalarials, antibiotics and other medicines to the general population. This has raised concerns about the overall quality of care offered by PPMVs, as well as in the ability of PPMVs to correctly diagnose and prescribe drugs, given that large-scale support systems for PPMVs are incomplete and do not always emphasize quality of care.
- Improving Provider Behavior Change Communication and IPC: Best Practices from the Women’s Health Project
This brief describes the challenges faced, strategies developed, and lessons learned by the Women's Health Project. It also proposes a set of best practices for improving productivity of interpersonal communications (IPC) agents and increasing providers' skills and motivation.