Akwa Ibom State is pivotal in the fight against malaria in Nigeria. The environment supports year round transmission of the disease. While it has a strong basic health infrastructure, it has been unable to live up to its potential consistently to deliver high quality malaria control services.
cdd-service-community-iptp1a.jpgIn 2006 Jhpiego and ExxonMobilconducted a situation analysis of malaria programming in the state. At that time Akwa Ibom was considered an ‘orphan’ state in the context of malaria control since other states benefited from the Global Fund and other donor agencies. Findings from both desk review and field work pointed to low use of and access to malaria commodities such as insecticide treated bednets (ITNs), appropriate treatment with artemisinin-based combination therapy (ACT) and intermittent preventive treatment (IPT) of pregnant women with sulphadoxine-pyrimethamine (SP). In short, the health system was failing to make these lifesaving technologies available to the public.
The state was not implementing national malaria program guidelines, and in fact front line health staff were unaware of these.  In addition basic primary health care services like antenatal care (ANC), which could serve as a platform for delivering malaria services, did not function well and were seriously underutilized.  Little effort to reach out and involve the community in malaria or health matters generally was found.
By 2007 Akwa Ibom was transitioning away from its ‘orphan’ status. ExxonMobil agreed to fund a proposal by Jhpiego, arising from the previous year’s situation analysis. The World Bank Malaria Booster program in Nigeria chose Akwa Ibom to be one of its seven states for enhanced malaria commodity supplies. While not using a formal agreement, the World Bank and Jhpiego tried to work in concert such that the Bank loan could help increase the supply of ITNs and ACTs while Jhpiego would work on health systems strengthening so that the commodities would reach intended audiences.
Over the ensuing six years at the State level, Jhpiego built an interdisciplinary malaria training team that could update local government area (LGA) health department staff on national malaria policies and guidance. This team in turn facilitated LGA staff to organize updating for the staff of their PHC facilities.  Jhpiego rallied all malaria-related organizations working in Akwa Ibom, ranging from government agencies and departments, donors and local non-governmental organizations, to form a malaria program coordination partnership. This partnership committee met regularly to share information and updates and plan advocacy efforts that would encourage increased State and LGA support for the malaria program.  Jhpiego assisted the World Bank supported effort to inventory all public, private and informal health (and thus malaria service) providers in the state.  Finally, Jhpiego was constantly on call to advise the State’s Malaria Control Unit.
community_training_of_cdds-sm.jpgJhpiego was able to work directly in seven LGAs to develop and implement an innovative community directed intervention that was based on a community-clinic partnership.  The trained health facility staff reached out to villages and kin groups (clans) in their catchment area who in turn selected volunteer community directed distributors (CDDs), also known as community health workers (CHWs). The CDDs were trained and stocked from their nearest PHC facility, and those health staff provided supervision and encouragement.  CDDs kept records which were incorporated into the PHC monthly summaries, thus demonstrating a significantly increased coverage of malaria services by the health team in that catchment area because of the community-clinic partnership.
Challenges existed in terms of the actual availability of malaria commodities. Jhpiego had to buy starter supplies of SP and involve other NGOs in giving the first stack of ITNs.  Later Jhpiego also had to buy demonstration stocks of malaria rapid diagnostic tests (RDTs) for community case management, all because the start up of the World Bank Booster effort in Akwa Ibom was extremely slow and cumbersome. Here again is why Jhpiego’s constant consultation with the State malaria Unit and work with the State Malaria Partners Committee was of great value.
Most NGO contributions to the fight against malaria consist of short term, one-off contributions of ITNs or media based communication campaigns that leave little behind in terms of a functioning health system.  Jhpiego’s commitment to health systems development over the long haul is what is needed to turn dysfunctional systems around.  Not only did Jhpiego focus on the formal health system, but strengthened community systems so the two could work hand-in-hand.
Even after six years the work is not complete. Since Jhpiego’s funding stopped the State Malaria Unit has suffered from staff changes and the World Bank project has been put on hold. If donors want to see progress in the fight against malaria at State and LGA level in Nigeria, they must be willing to commit to the longer term strengthening of health and community systems.  Without such a commitment mosquitoes and malaria parasites will once again get the upper hand and malaria deaths will rob the communities of a promising future.