Malaria Frontline Project: strategic approaches to improve malaria control program leveraging experiences from Kano and Zamfara States, Nigeria, 2016–2019

Malaria, a preventable and treatable disease, is a major cause of morbidity and mortality globally. An estimated 241 million cases of malaria occurred worldwide in 2020, of which 228 (95%) million cases were from the African region. African children under 5 years of age are the most vulnerable group accounting for 77% of all malaria deaths worldwide [1].

Nigeria has year-round malaria transmission, with 97% of its population at risk of malaria infection, transmission in the northern part of the country is however highly seasonal [2]. According to the World Health Organization’s (WHO) 2021 malaria report, Nigeria contributed 27% of the 241 million global malaria cases [1]. In the 2015 Nigeria Malaria Indicator Survey, 60% of outpatient visits to health facilities, 30% of childhood deaths, and 25% of infant mortality are attributed to malaria [3]. Under-five children experience an average of 2–4 episodes per year and account for as much as 90% of national malaria mortality with 36% attributable to malaria [4]. Nigeria’s high under-five malaria mortality is largely attributable to a health financing system that leaves many individuals uninsured, resulting in high out-of-pocket (OOP) medical expenditure that discourages care-seeking behaviour. The country accounts for the lowest rates of care-seeking for suspected cases of under-five malaria in the world accounting for less than 20% of all under-fives with fever being brought to health facilities for clinical consultation and parasitological testing [4]. Furthermore, malaria has been shown to account for over 40% of the total monthly curative healthcare costs incurred by households in Nigeria as compared to a combination of other illnesses; the cost of treating malaria and other illnesses depleted 7.03% of the monthly average household income, and treatment of malaria cases alone contributed 2.91% of these costs [5].

In Nigeria, the burden of malaria varies by geopolitical zones and states, with the northwestern states having the highest burden [6, 7]. The 2015 National Malaria Indicator Survey (MIS) showed the national average of malaria parasitemia by rapid diagnostic test (RDT) for children under five years old was 45%, but Kano and Zamfara States had parasitemia of 60.2% and 69.9% respectively [6].

The National Malaria Elimination Program (NMEP) implemented the National Malaria Strategic Plan 2014–2020 with [3] outlined targets to ensure transition from malaria control to malaria elimination.. The plan has multiple interventions based on WHO recommendations that are being scaled up for population impact. The interventions are Indoor Residual Spraying (IRS) across some geographical regions in the northern part of the country, universal coverage of Long Lasting Insecticidal Nets (LLIN), strategic use of larval source management (larvicide and environmental management), increased coverage of Intermittent Preventive Treatment (IPTp) with sulphadoxine-pyrimethamine (SP) for malaria prevention during pregnancy, strategic deployment of seasonal malaria chemoprevention in the northern part of the country (an area of high seasonal malaria transmission), and provision of prompt access to effective malaria case management with emphasis on parasitological confirmation before treatment [3]. Despite concerted efforts in implementing these interventions, malaria has continued to endanger lives, with resultant increase in morbidity and mortality amongst the population and socio-economic impact [3, 8].

In July 2012, the U.S. Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFENET) established the National Stop Transmission of Polio program (NSTOP) to strengthen the Nigeria Polio Eradication Program at the subnational (state and LGA) levels and strengthen the routine immunization program [9]. NSTOP staff provide technical support to implement the National Polio Eradication Emergency Plan in polio high-risk areas, strengthen routine immunization, and improve maternal and child health indices [9, 10]. NSTOP staff also respond to communicable diseases outbreaks like measles and rubella, across states in Nigeria.

In 2016, the CDC established the Malaria Frontline Project (MFP) in collaboration with AFENET/NSTOP and NMEP to support the elimination of malaria in Nigeria using the NSTOP structure. The project was implemented in the high malaria burden states of Kano and Zamfara. These states (Fig. 1) were selected because of their high malaria burden as documented in the 2015 MIS and their state governments’ commitment to their malaria elimination programs.

The objectives of the project were to strengthen the technical capacity of healthcare workers (HCWs) to implement malaria interventions (diagnosis, treatment, and prevention services), strengthen malaria surveillance and facilitate evidence-based decision making, and improve malaria commodities distribution to health facilities using routine health facility data. This paper describes MFP implementation and its contributions to malaria control programs in health facilities in Kano and Zamfara States, Nigeria.

The MFP leveraged the success of the NSTOP program strategy to build capacity of HCWs in malaria case management, surveillance, and data management using the three-prong training strategy approach of didactic training, post-training assignments, and health facility supportive supervisory visits with on-the-job training and mentorship [9]. The content of the training materials was very much oriented to the expected services that is to be delivered at the facility level. There were improvements in some of the malaria control interventions. Improved case management practices reduced clinically diagnosed malaria cases, increased testing of all febrile cases before treatment, and improved use of data for decision making at all levels. Gaps from the baseline assessment were addressed through targeted interventions of conduct of thematic modular trainings and health facility supportive supervisory visits during project implementation and measured through the end-line.

One of the objectives of MFP is capacity building of HCWs at LGA, ward and health facility levels. The National Malaria Strategic Plan 2014–2020 recommends that, by 2020, all febrile persons seeking care should be tested for malaria to confirm or rule out a parasitological diagnosis. The national malaria guideline states that all fever cases should be tested by rapid diagnostic test (RDT) or microscopy [15, 16]. Prior to the implementation of MFP many health workers practiced presumptive diagnosis of malaria, which was contrary to the national recommendations for management of uncomplicated malaria aimed at mitigating the problem of misdiagnosis leading to mismanagement of suspected malaria cases [17‐19]. Parasitological diagnosis is a component of malaria case management. Improper use of ACTs without confirmatory diagnosis will result in negative clinical and economic impact [20].

The thematic modular trainings, post-training assignments on malaria case management practices, provision of hard copies of a simplified diagnosis and treatment algorithm in the consulting room, and regular (as permitted by other activities) LGA health team supportive supervisory visits mostly driven by NSLOs and on-the-job mentoring are all contributing factors to improvements in health workers knowledge and adherence to national guidelines on malaria diagnosis and treatment.

The capacity building of HCWs in filling out the malaria monitoring wall chart improved data capturing using the monthly summary form and increased health facilities using analyzed data for decision making. All health facilities implemented the use of monitoring wall chart successfully. This provided an opportunity to use data for decision making at the health facility level. But it also improved data validation at that level before the data were transferred into monthly summary form. Data validation meetings provided another layer of data quality assurance such as correction of identified errors for the data aggregated using the MSF. The gaps such as transcriptional, summarizing, and trans-positional errors were identified and resolved before data entry into DHIS. Impact of the project as reflected in key malaria indicators, include declines in clinically diagnosed malaria cases and health facilities administering ACT to negative malaria patients.

The improved adherence by HCWs to national guidelines on diagnosis and treatment of malaria is similar to studies conducted in other states in the north west region of the country, which found the expectation of the patient to be given antimalarial treatment and HCWs’ prior receipt of training on malaria case management (both by governmental and non-governmental organizations) were predictors of using rapid diagnostic test results to guide treatment [21, 22]. Studies have shown that when HCWs practice evidence-based medicine most especially, testing fever cases before treatment, resources are conserved, selective pressure on ACT is reduced, and ultimately potential early resistance to anti-malarial medicines can be averted [23]. The majority of HCWs at PHCs in the MFP states were community health extension workers (CHEWs). Within the context of PHC settings in Nigeria, CHEWs play a major role in the provision of basic health care services and have a higher likelihood of adherence to defined guidelines through periodic trainings and re-trainings, as conducted by MFP with support from project states malaria programs and regular health facility supportive supervision and on-the-job mentoring. The study findings of improved adherence to national guidelines on diagnosis and treatment is similar to other studies that reported the relationship between adherence to test results and training [24, 25]. There was improvement in HCW’s knowledge about drugs for intermittent preventive treatment during pregnancy (IPTp) using SP and, in Zamfara, about the time of commencement of IPTp. This was likely attributable to the development and distribution of a malaria-in-pregnancy algorithm as a job aid for frontline line workers providing ANC services in health facilities across the two project states. This finding is similar to a study conducted in south-west Nigeria [26] and in contrast to other studies [27, 28]. However, the coverage of IPTp was very low, not meeting the 2016 national target of 80%. This low coverage of IPTp is similar to the study conducted in south-west Nigeria in which late ANC bookings and stock out of sulphadoxine-pyrimethamine were associated with the low IPTp uptake [29]. Another study in Malawi found low IPTp uptake was associated with number of ANC visits [30] It is important to conduct a detailed study of factors contributing to the low uptake of IPTp in the second and third trimesters to improve the protection of the pregnant woman and her unborn child. The stockout of SP for IPTp during the MFP implementation contributed to the low uptake, hence partners and state health authorities need to procure adequate amount of SP and have equitable distribution to health facilities.

The client exit interview confirmed the increase in HCWs’ requests for parasitological confirmation of diagnosis and the increased prescription of ACT to treat malaria cases. This finding was similar to a study conducted in North-Central Nigeria in which healthcare providers prescribe ACTs based on test results, and good knowledge of malaria diagnosis and treatment as a result of prior trainings on malaria case management [31]. This finding was in contrast with a study conducted in Ebonyi State, Nigeria [32] in which health workers had poor perceptions of RDTs as reflected in the level of reported wrong prescription practices, and in contrast with other studies [33, 34].

Furthermore, the improvement in clinician’s adherence to national guidelines on diagnosis and treatment can be likely attributed to the collaborative efforts of the national and state malaria programs, MFP, and other malaria implementing partners. With continued trainings and re-trainings, clinicians now appreciate giving feedback to their clients on test results and diagnosis. However, the occasional shortages of diagnostic kits and antimalarial drugs during the project implementation affected HCWs adherence to national guidelines when faced with stockouts. It will be good for the state to assure adequate supply of antimalarial commodities to all health facilities because currently some facilities are not supported by any partner, and the state government is unable to provide adequate commodities. Despite facility records showing high percentages of antimalarial drugs given to confirmed malaria patients, the findings from client exit interview show a moderate result. This could be due to antimalarial commodities stock at the time of the assessment or the need to check on data quality at the facility level. Regular supportive supervision by LGA team to facilities is an important contributing factor for health workers adherence to the national guidelines.

The MFP implementation experienced some limitations which however were addressed. There was high transfer or movement of HCWs between states, within state, and rotation to different departments after training by MFP. This was however addressed by regular advocacy and follow up visits to the State Primary Health Care Board/Agency for retention of service providers across supported health facilities in both project states. Also, MFP did not provide any malaria commodities in the project area, however worked with other malaria implementing partners in ensuring continuous and uninterrupted supply of malaria related commodities to supported health facilities. Sustainability of innovative approaches implemented during the project implementation have been institutionalized with the state and LGA health teams’ involvement and ownership. The conduct of ward level data validation as a peer-to-peer capacity building platform for service providers with the routine health facility supportive supervision and mentorship, and use of data at the health facility for decision making have greatly helped resulted in data quality improvement during and after the project’s implementation in Kano and Zamfara states. The approach provided the opportunity to validate data efficiently in much smaller groups compared to the previous LGA level data validation and it facilitated earlier submission of the data into DHIS2. The ward level data validation meeting was adopted by NSTOP for routine immunization program. NMEP planned to expand the project to other states but there have been lot of changes in the program hierarchy. Our findings are not generalizable to other settings because of the non-probability approach to sampling the study population and the absence of control health facilities.

MFP was successfully implemented in both Zamfara and Kano States using tailored training materials, job aids, and supportive supervision, contributing to improved HCWs knowledge and adherence to guidelines on malaria case management. The strategy used to implement this project can be adapted to improve the efficiency and effectiveness of malaria program implementation in other states in Nigeria as well as other malaria endemic countries, especially on the African continent. Building the capacity of health facility leads in basic data analyses and use of the data for management will improve the health delivery system at the lower levels of the health system.

State malaria programs should continue with political commitment for implementation of malaria interventions, continuous capacity building of HCWs on adherence to national guidelines, sustaining and improving health facility supportive supervisory visits, sustaining LGA monthly data analysis of key malaria indicators, and the production of malaria monitoring wall charts.