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 health infrastructure. Its under-five mortality rate is 128 deaths per 1000 live births, with HIV, malaria, pneumonia and diarrheal diseases causing considerable morbidity and mortality amongst children and adults.
KanoIn 2016, PSI began projects aimed at women’s empowerment and gender equity; family planning access including long term methods; harm reduction and post-abortion care, and nutrition. PSI/Niger is a committed partner of the Nigerian Ministry of Public Health, and also collaborates with the private and public sectors.
PSI operates in Nigeria through its independent network member and implementing partner, Society for Family Health Nigeria (SFH). Founded in 1985 by several eminent Nigerians and PSI, SFH started with two employees and one office in Lagos, and has now grown to over 500 employees working in 18 territorial offices headquartered in Abuja, Nigeria. SFH began with one product and one HIV/AIDS prevention grant and now markets 18 products and manages several contracts. SFH also runs 365 franchise facilities across 21 states of Nigeria.
In 2005, SFH became the first Nigerian NGO qualified to receive funding directly from the U.S. Agency for International Development (USAID).
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 has a population of about 182 million people. According to UNAID (2016), Nigeria has a general HIV rate prevalence of 3.1% among adults and 4.4% among women attending antenatal clinics. It 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 3.5 million and AIDS related deaths average 180,000 per year.
HIV Counseling and Testing
Society for Family Health Nigeria (SFH) implemented the Global Fund Round 5 Project, which began in January 2007. The overall goal of the project was to reduce HIV/AIDS-related mortality and morbidity. SFH was responsible for Objective 2 of the program which aimed at expanding access to HIV testing and counseling services to cover all 37 states of the country. Counseling and testing 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. Counseling and testing also enables HIV-positive people to enter treatment early, access care and support, and therefore 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/AIDS in Nigeria at the end of the program. Following the Round 5 Project, SFH also implemented the Global Fund’s Round 9 Project.
Multiple partners supported SFH to implement the counseling and testing component of the project. Family Health International and Planned Parenthood Federation of Nigeria were sub-recipients managing the provision of services to public and private facilities, respectively. Nigeria Institute for Medical Research (NIMR) and Gede Foundation were the sub-recipients for training, while Crown Agents and International Dispensary Association (IDA) acted as commodity procurement agencies. Through the project, SFH ensured the availability of standard HIV counseling and treatment 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 implemented the Enhancing Nigeria’s Response (ENR) to HIV and AIDS program. A six-year integrated HIV prevention and institutional strengthening program, ENR was funded by the United Kingdom’s Department for International Development (DfID). The program commenced on January 19, 2009, with the signing of the contract between SFH and DfID. ENR was managed by a consortium, with SFH as the managing agent. Other members of the consortium were ActionAid Nigeria, PSI, BBC World Service Trust, Options Consultancy Services, Benguela Health Pty, Population Council and Crown Agents.
ENR’s goal was to reduce the spread of the HIV epidemic and mitigate the impact of AIDS on the lives of the most at risk and vulnerable groups. ENR therefore had the purpose of ensuring sustained behavior change among populations most at risk through increased and consistent use of condoms, and improved access to effective HIV and AIDS prevention, treatment, care and support information and services.
ENR was implemented in eight states: Benue, Cross River, Enugu, Kaduna, Nasarawa, Akwa Ibom, Lagos, and Ogun. The project had a Program Steering Committee that provided external advisory support and a Partner’s Management Council that saw to partnership issues and the provision of strategic oversight.
Currently, SFH is a principal recipient of the Global Fund HIV New Funding Model. Under the grant agreement, SFH is responsible for implementing five modules, which include HIV prevention programs for key populations in 11 implementing states: general population; men who have sex with men; female sex workers and their clients; people who inject drugs; and adolescent and young persons.
The adolescent and young persons programming is being implemented in four states (Oyo, FCT, Kaduna, and Akwa-Ibom), as action research to unravel factors that predispose young girls and women to HIV infections. Counselors/testers are responsible for delivery of HIV testing services to the general population in all 11 implementing states.
The Strengthening HIV Prevention Services for Most-at-Risk Populations (SHiPS for MARPs) project is a five-year project (2012-2017) funded by USAID. It implements community-based HIV prevention interventions among key populations and improves the capacity of stakeholders to offer these services. The project is currently being implemented in seven states and the Federal Capital Territory by a consortium of partners: SFH (the managing partner), PSI and the Centre for the Right to Health.
SFH has also been engaged by the National Agency for the Control of AIDS to oversee key aspects of the expansion of access to HIV treatment and support (HTS) for the prevention of mother-to-child transmission (PMTCT) under the private sector response program. This is under the World Bank’s HIV/AIDS Program Development Project II, from August 2016 to February 2017.
In June 2011, Nigeria became a signatory to the United Nations Global Plan towards elimination of new HIV infections among children. One of the priority areas in realizing this plan is the engagement of the private health sector in order to expand access to PMTCT services. It was a recommended strategy in the 2010 to 2015 PMTCT scale-up plan, and the mid-term review of the National Strategic Plan. In line with the above, one of the priority areas in the National Operational Plan 2015 to 2016 for the Elimination of Mother-to-Child Transmission (eMTCT) is increased involvement of formal and non-formal private health service providers in PMTCT. This is in recognition of the fact that the private health sector accounts for about 34% of all health facilities in Nigeria and 43% of facility-based deliveries. Engagement of the private sector has therefore become imperative in order to realize the national eMTCT goal. This effort therefore focuses on increasing PMTCT coverage towards averting 240,000 vertical infections between 2015 and 2020.
This project is being implemented in seven states: Akwa-Ibom, Cross-River, Kano, Kaduna, Rivers, Sokoto, and Taraba. This is based on the findings of the 2014 Nigerian HIV/AIDS Epidemic and Impact Analysis, which established that two-thirds of the national HIV burden and almost 70% of new HIV infections occur in 12 states (Kaduna, Akwa Ibom, Benue, Lagos, Oyo, Kano, Rivers, Sokoto, Taraba, Nasarawa, Cross River, and Imo), of the federation and the Federal Capital Territory.
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% of infant mortality, 30% of childhood mortality (for children under five), and 11% of maternal mortality. According to 2008 Nigeria Demographic and Health Survey (NDHS), at least 42% of the population has at least one episode of malaria annually, while children under five years old have two to four attacks annually. Malaria is particularly severe among pregnant women and children under five years old. SFH implements ACTwatch 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 a large amount of money in treatment expenses, as well as in illness-related loss of productivity. Prevention programs 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 colors to address individual needs. Some LLINs are effective for up to four years and will last a minimum of 20 washes – they require no re-treatment during this time, making them five to ten times more effective than conventional re-treatable mosquito nets. LLINs are an inexpensive and easy way of preventing malaria, thus reducing its burden on the health and economic well-being of Nigerians. SFH uses its extensive marketing and distribution channels to move LLINs across Nigeria so that they are available to everyone, especially 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. 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 programs to combat malaria focus on the promotion and distribution of a new and effective drug, 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. SFH is now promoting this ACT treatment, using the pre-packaged method, and distributing this product throughout Nigeria, to remote and rural communities.
SFH conducted the first pan-Nigerian radio campaign to promote the new policy of ACT as the drug of choice for the treatment of uncomplicated malaria. The brand, Coartem, was heavily subsidized to increase affordability for the poor and vulnerable who shoulder the largest burden of malaria in Nigeria. These medicines were distributed through private health care providers including proprietary patent medicine vendors (local drug shopkeepers) and community-based pharmacies. SFH works closely with the Federal Ministry of Health on 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.
Malaria Diagnosis Component (RDT)
In line with the National Policy on Malaria Treatment, which states that all suspected malaria cases should be confirmed before treatment, SFH currently promotes parasitological diagnosis of malaria through microscopy or rapid diagnostic tests (RDTs). A multi-pronged approach, which includes training of service providers on diagnosis, distribution of RDTs to private health facilities, and targeted behavior change communication messages, is used to boost the uptake of RDTs and ensure adherence to test results. SFH collaborates with the Federal Ministry of Health and other partners to uphold this policy.
Integrated Community Case Management
In 2012, the World Health Organization (WHO), through the Global Malaria Program, launched the Rapid Access Expansion (RAcE) Program in five countries: the Democratic Republic of the Congo (DRC), Malawi, Mozambique, Niger, and Nigeria. The aim is to increase access to treatment for malaria, pneumonia and diarrheal disease among children under five, through scaled-up integrated community case management (iCCM) programs. Since project inception, RAcE has been increasing coverage of diagnosis, treatment and referral services for these three major causes of childhood mortality in hard-to-reach areas in Nigeria.
SFH is leading the implementation of the RAcE Program in Abia State in partnership with the Abia State Ministry of Health through the Primary Health Care Development Agency. The partnership catalyzed the scale-up of integrated community case management (iCCM) of malaria, pneumonia and diarrhea as an integral part of government health services in Nigeria. The RAcE project started in November 2012 and ends in December 2017. Through this project, SFH is currently serving an estimated population of 202,998 children aged two to 59 months, living in iCCM eligible areas of Abia State. To date, 1351 community resource persons and 150 community health extension workers have received the six-day iCCM training.
Spacing births for three to five years between each pregnancy allows each child to develop and grow best. It also gives mothers the chance to recover their health and strength between pregnancies for the benefit and well-being of the whole family. SFH encourages birth spacing by providing couple with the 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) Achieve a national reduction in maternal mortality.
4) Improve inter-spousal communication among couples.
5) Increase the number of women using modern methods.
6) Improve the capacity of health care providers to offer correct child spacing information and services.
SFH implemented the Improved Reproductive Health in Nigeria Project (IRHIN), funded by USAID, from 2005 to 2011. This project contributed to the Millennium Development Goal (MDG) #5 of reducing maternal mortality rates in Nigeria. It also contributed to national awareness of population management issues and child spacing. It achieved its overall purpose: to improve the understanding of, access to, and correct use of contraceptives to reduce unintended or miss-timed pregnancies.
The main target groups who are provided with education and training are:
- Women 18 to 40 years, married or unmarried, intending to use a child spacing method in the next 12 months.
- Men 18 to 50 years.
- Providers including nurses, doctors, pharmacists, medicine vendors and community health workers.
The Expanded Social Marketing Project in Nigeria (ESMPIN), 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 expand access to family planning, reproductive health and child health products; increase the 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 manufactures of key health products. It is a five-year, $56.3 Million USAID-funded project, implemented in partnership with SFH, Association for Family and Reproductive Health, BBC World Service Trust, and PSI.
ESMPIN, in partnership with the Federal Ministry of Health and MalariaCare, also implemented an integrated community case management (iCCM) pilot to improve case management of childhood illnesses in Ebonyi Sate, in south eastern Nigeria. The project employed an integrated approach in the appropriate management of malaria, pneumonia and diarrheal diseases among children under the age of five, particularly those aged two to 59 months using patent and proprietary medicine vendors in the state.
The goal of the pilot was to improve and increase coverage of diagnostic, treatment and referral services for the major causes of childhood mortality (pneumonia, diarrhea and malaria) in four local government areas of Ebonyi State, with the overall aim of scaling-up and accelerating the achievement of the health-related Millennium Development Goals. The intervention took place in two areas while two others served as control.
Water, Sanitation and Hygiene
Safe Water Systems: Water Guard Plus® and P&G Purifier of Water®
In Nigeria only 60.6% of households have access to improved sources of water. One in five rural households have clean water at the home and most families must collect water from unsafe sources, such as rivers or streams. Only 4.7% 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.
- Behavior 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 the 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 chemists and pharmacists sell it for between 50 and 100 naira (the Nigerian currency) 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 diarrhea and vomiting in epidemics) as well as dysentery and other forms of waterborne disease causing agents.
In 2015, SFH reformulated and repackaged Water Guard (now Water Guard Plus®) to improve the product’s shelf life.
Every year about 854,000 children under five in Nigeria die, with 53% of these deaths attributed to malnutrition, according to NDHS, 2013. In the northeast, the prevalence of stunting, wasting and extremely low weight among children below two years is 42.3, 19.5% and 30.8% respectively, showing the poor nutritional status among children under five. The WHO promotes breastfeeding as an unrivalled way of providing ideal food for the healthy growth and development of infants and recommends that babies should be exclusively breastfed during the first six months of life. However, according to the 2013 NDHS, only 17% of Nigerian children less than six months are exclusively breastfed .
Under the ESMPIN project, SFH promotes better maternal and child health. It utilizes multiple, integrated approaches to increase demand and uptake of modern family planning methods, uptake of child survival products, and increase the practice of exclusive breastfeeding for children up to six months. These are done to reach target audiences with appropriate messages on family planning, malaria and diarrhea management, and exclusive breast feeding. These interventions address myths and misconceptions, promote benefits, and increase support and uptake of maternal and child survival commodities in 22 priority states. The project adopts an integrated interpersonal communication strategy to reach mothers, pregnant women and influencers of women on family planning, nutrition (exclusive breastfeeding) and child survival. Special sessions are held at antenatal clinics and child welfare clinics to reach mothers. Similarly, male involvement sessions target male groups to promote spousal support. Specially designed and culturally sensitive media jingles (a short song used for advertising) on child survival, malaria and diarrhea management, and exclusive breast feeding have been developed. These air in the northeast states to address misconceptions and the benefits of the health behaviors promoted.
- Bill & Melinda Gates Foundation
- Ministry of Foreign Affairs of the Netherlands
- Exxon Mobil
- Global Fund to fight AIDS, Tuberculosis and Malaria
- Oxfam Novib
- Procter & Gamble
- Nigerian Bottling Company
- Nigerian Liquefied Natural Gas
- Government of Nigeria
- Shell Petroleum Development Corporation
- UK Department for International Development (DfID)
- United Nations Population Fund (UNFPA)
- U.S. Agency for International Development (USAID)
- World Bank
- World Health Organization
- World Population Foundation
- Action Aid International
- Association of Civil Organizations in Malaria Control Immunisation and Nutrition
- Association of Reproductive and family health
- BBC Media Action
- Benguela Pty
- Centre for the Right to Health
- Coca Cola Foundation
- Comic Relief
- Community-based organizations
- 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
- National Agency for Food and Drugs Administration and Control
- 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
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