This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Oladepo presented on work with patent medicine vendors of malaria drugs in Nigeria.

1. Strengthening the Delivery of Key Malaria
Control Interventions through Patent
Medicine Vendors in Nigeria
Oladimeji Oladepo
Country Coordinator
Future Health Systems (Nigeria)
University of Ibadan
Beyond Scaling Up-May 24-26, 2010
Oladepo_ Strengthening Malaria Control Interventions
through PMVs- Nigeria 1

2. Oladepo _ Involvement of PMVs in Malaria
control
2

3. The Central Question
Why
involve
PMVs in
malaria
control
services
?
Oladepo _Involvement of PMVs in Malaria
control 3

4.  Very high Malaria burden
 Nigeria contributes ~25% of the total African
malaria morbidity and mortality burden
Estimated 57.5 million cases and 225,000
deaths (25% of global malaria burden; WHO
2008)
11% of maternal and 29% of under five
death is due to malaria
Malaria is intricately linked with
poverty (significant drain on the economy
and wellbeing)
Oladepo _ Involvement of PMVs in Malaria control
4

5. Fig 1: Major Communicable Diseases in Nigeria , 2005
(Source Erinoso, 2010)
Oladepo _Involvement of PMVs in Malaria
5 control

6.  Low coverage of ACTs, first-line
drug
 ACTs most effective form of Medicine
for treating malaria, yet ……
access through Public Sector is highly limited
Quantity stocked or sold by PMVs is very low
 8.5% of PMVs stocked ACTs compared to
32.1 for monotherapy and 71.7 for
Chloroquine (Oladepo et al,2007)
 Overall ACT access in Nigeria remains critically
low with a projected gap of 80 % stretching
through 2011(AMFM,2010)
Oladepo _ Involvement of PMVs in Malaria
control
6

7. Projected gap in ACTs till 2011(Source AMFM, 2010)
Children <5 Receiving 2008 ACT Need and Gap
an ACT Within 24hrs MN
%
90% 100
89.5 6
80% 11.5
70% 71.9
60%
50%
50
40% ~80% of
need not
30%
covered
20%
10%
0% 0
2007 2008 2011 Total ACT Dist. in Gap
MICS 18 GF Target Dist. in
Need to public
States private
Cover Pop. sector
Oladepo_ Involvement of PMVs in Malaria
sector
control
7O

8.  Untapped capacity of PMVs in Anti-
malarial Medicine provision
 PMVs remain the first point of call seeking
treatment for fevers in Nigeria (Salako, Brieger,
Afolabi, Umeh, & Agomo, 2001)
 High level of patronage (up to 70%)
 Used even when supposedly more
convenient and cheaper alternatives exist
(e.g PHC centres,Village health workers)(Brieger, Salako, Umeh,
Agomo, Afolabi & Adeneye, 2002-3; Kaseje, Spencer& Sempebwa, 1987)
 The most common item stocked by PMVs is
anti- malarias (ACTWATCH,2010)
Oladepo _ Involvement of PMVs in Malaria
control
8

9. Proportion of the total volume of all anti-malarials sold or
distributed in the 1 week preceding the ACTwatch survey
(Source ACTWATCH, 2010)
Oladepo _Involvement of PMVs in
9 Malaria control

10.  Despite existence of supportive
policy documents, access of
poor people to quality anti-
malarial services remains low
 government approved policies
 Investment in pro-poor programs targeting
malaria(NEEDS)
 ACTs as first line treatment for malaria
 Public- Private partnership (to address demand and
supply side of anti-malarial drugs
 use of research evidence to address diseases of
poverty
 Difficult to achieve MDGs without addressing
poor peoples’ access to quality anti-malarial
services through evidence-based innovations.
10

11. FHS Nigeria:-Purpose and Objectives
Goal
 To improve PMVs’ provision of quality malaria
services to poor people through innovative
public and private sector engagement, citizen
empowerment, surveillance and sustainable
malaria drug regulation policies.
Specific objectives
 Generate knowledge that would aid the
understanding of issues and perceptions
related to poverty and malaria vulnerability.
 Develop intervention proposals that will test or
guide changes in the health systems that could
have a major impact on the poor
Oladepo_ Strengthening Malaria Control
Interventions through PMVs- Nigeria 11

12. FHS Nigeria :Project Phases
How can the poor get access to effective malaria treatment?
Inception Phase
FHS Phase II
Phase I
12

13. FHS Nigeria :Inception Phase
How can the poor get access to effective malaria treatment?
Inception Phase
Oct 2005-Mar2006.
Engaged stakeholders
to define research
agenda through
bilateral consultation
(NAP, PMV associations,
MOH, DFID)
13

14. FHS Nigeria :Project Phase I
How can the poor get access to effective malaria treatment?
Phase I
Apr 06-Dec 07
Formative research
Intervention design
Research to policy
14

15. Oladepo_ Strengthening Malaria Control
Interventions through PMVs- Nigeria 15

16. Formative Research-Results
First Source of Treatment for Most Recent Episode of Malaria
100%
80%
Government health facility
Percent of Cases
60% Private health facility
Self-treatment traditional
medicine
Self-treatment with modern
40% medicine
Patent Medicine Vendor
20%
0%
Oyo Kaduna Enugu
16

17. 54 Different Types of Anti-malarial Drugs
Found in Oyo, Enugu & Kaduna
17

18. Percent of Patent Medical Vendor
Shops with Anti-Malarial Drugs
100
90
80
70
Percent of Shops
60
50
40
30
20
10
0
ACTs Monotherapy Chloroquine Sulfadoxine- Other
artusenates pyrimethamine
Oladepo_ Strengthening Malaria Control
Interventions through PMVs- Nigeria 18

19. Mean Price of Malaria Brands
600
504
500
393
400
Naira
300 272
200
83 91
100
0
ACT AS-Mono CQ SP Other
Oladepo_ Strengthening Malaria Control
Interventions through PMVs- Nigeria 19

20. Other Study Findings
 PMVs know little about malaria policy
change
 Low quality drugs cited as major problem
HH leaders, PMVs associations & Policy makers &
Public facility health workers)
 Most express low confidence in
government to regulate (wide regional variation)
 Gov’t officials know very little about PMV
Associations
 DISSEMINATED FINDINGS TO POLICY MAKERS &
OTHER STAKEHOLDERS
Oladepo_ Strengthening Malaria Control
Interventions through PMVs- Nigeria 20

21. What are the Options?
 Business as usual
 Educate parents, PMVs
 Subsidize all ACTs
 Support low-cost diagnostics
 Support local institutions that work:
civil society, PMV associations, gov’t
regulators, industry, to monitor
treatment/quality of drugs
Oladepo_ Strengthening Malaria
Control Interventions through PMVs-
Nigeria 21

22. FHS Nigeria :Project Phase II
How can the poor get access to effective malaria treatment?
Phase II
Jan08- June 2009
Intervention design
 Evidence to policy
22

23. Proposed Interventions
 Quality Drug Testing with Mini-Lab Equipment by
PMVs ( )
 Performance improvement
 Training-Increasing PMV knowledge through competency
based Training (
)
 Use of Cell phones-Messaging and information sharing on
drugs, policy, regulations, guidelines between government
health workers and PMVs ( )
 Co-regulation with PMV Associations, citizens groups,
government
 Increasing consumer knowledge and engagement
for monitoring drug quality
Oladepo_ Strengthening Malaria Control
Interventions through PMVs- Nigeria 23

24. Stakeholders meetings
 Series of stakeholders’ meetings organized
by FHS with Stakeholders led to sharing
and refining scope of proposed
interventions
Oladepo_ Strengthening Malaria
Control Interventions through PMVs-
Nigeria 24

25.  FHS :The Abuja Meeting-Jan.2009
Theme:“Making health markets work for the
Poor”
 Policy makers, potential collaborators, civil society,
representatives of private sector partners, the media
and innovators from organized private sector and
Consortium research partners from over the world
came together to learn, gather resources and plan for
implementation
25

26. 26

27.  The Speaker of the House of Representatives, the Right
Honourable Dimeji S Bankole, stated thus about the
Abuja workshop:
“Current indicators point to the fact that we are seriously lagging behind,
particularly on the MDGs health components of maternal and child
health… I truly appreciate the overall goal of this workshop which is
meant to share experiences on innovative health interventions that
benefit the poor and under-privileged segments of our population...I
consider this discourse of utmost relevance in the overall strive to
deliver affordable, accessible, qualitative and all-encompassing
healthcare through a complementary multi-stakeholder
partnership...Initiatives such as conceptualised by this workshop are
important to us in the House of Representatives...”
 Abuja workshop Outcome- High-level policy makers indicated strong
support for formal integrating of PMVs into National malaria control
interventions
27

28. FHS Nigeria :Project Phase III
How can the poor get access to effective malaria treatment?
Phase III
July 09- September 2010
 Evidence to policy
28

29.  Follow –up stakeholders consensus meetings
 National stakeholders meeting for integrated and
unified approach to PMV work through NMCP
facilitated by FHS
Outcome
 Two interventions approved (PMV Institutionalized
Training and PMV Regulatory framework)
 PMV curriculum and regulatory framework documents
developed and approved by National Malaria Control
Program (NMCP) for implementation at the state level
 National Malaria Control Program adopted the use
of PMV for treatment of uncomplicated malaria in
Nigeria
Oladepo_ Strengthening Malaria
Control Interventions through PMVs-
Nigeria 29

30. 30

31. World Bank (WB) Additional Financing
support for PMV Work-Nigeria
 Stimulated by the FHS generated evidence
which informed FMOH NMCP decision making
on PMV involvement in malaria control, NMCP
is targeting World Bank additional financing to
strengthen private sector delivery of key
malaria control interventions through PMVs
 Goal is to effective scale up, increased and
sustained malaria coverage with existing
control tools
 A hybrid PMV Malaria Intervention model to drive
implementation has been developed
Oladepo_ Strengthening Malaria
Control Interventions through PMVs-
Nigeria 31

32.  Tools have been developed for implementation
of components of the model in Booster States (7
states {Green Colour in theMap below)
 State level start-up activities with PMVs have
commenced
Oladepo _Involvement of PMVs in
32 Malaria control

33. Conclusion from FHS Nigeria PMV
Study
 New policy knowledge created,which enables a
more systematic process of learning
 Generated evidence better informs decision-
making about private sector involvement in
malaria interventions through PMVs
 Creation of national and international interest
and support for PMV work in Nigeria (e.g. World
Bank’s Additional Financial support for PMV
work)
 Capability to do and use research strengthened

34.  PMV associations being strengthened
PMV capacity to deliver quality services (ACTs,
Counseling and Referrals) consistent with
government guidelines and best malaria
treatment practices.
 Finally, research funded by DFiD has helped
shaped national health policy/program in
favour of PMV integration into Malaria Control
program in Nigeria
Oladepo _ Involvement of PMVs in Malaria control
34