A view from the frontlines

Q&A with Dr Lynda Ozor, WHO malaria focal point, Nigeria

24 April 2018

This interview has been edited and condensed from the audio version (Duration 12:11 [mp3 21 Mb])

Globally, 91 countries had ongoing malaria transmission in 2016. Nigeria bore the heaviest burden, with an estimated 9.4 million malaria cases in 2016 alone. Worryingly, cases are on the rise: WHO’s latest World malaria report showed an increase of more than 800 000 malaria cases nationwide between 2015 and 2016. In this interview, Dr Lynda Ozor, WHO’s malaria focal point in the country, shares what the Organization is doing to fight the disease. She is based in Abuja.

Frontline health workers are the backbone of community-based responses to malaria (animated illustration)

Dr Ozor, you’re at the frontlines of Nigeria’s malaria response. What are some of the main challenges in fighting this disease?

There are quite a number of challenges in fighting malaria in a big country like Nigeria. First, Nigeria's surveillance system: though progress has been made, it remains difficult to track and quantify the burden of the disease. This is especially the case with the private healthcare sector and at the community level where national and state programmes do not have direct oversight, making it difficult to capture malaria data. So as we grapple with controlling the disease, we are doing our best to make sure that we improve the surveillance system.

Also, with malaria being endemic in Nigeria, the disease has become regarded as a ‘traditional disease’, which people assume to be part and parcel of their daily lives. This means that the individual sometimes does not give malaria the attention it deserves. For example, fever is automatically considered as malaria, leading to self-medication and resulting sometimes in late presentation for adequate assessment and treatment.

What are some of the challenges in tackling malaria in an area like Borno State where there's the challenge of conflict?

Conflict compounds the already-existing challenges and the inability to reach children or people when they need healthcare. The destruction of health services and facilities has really hampered the ability of people to seek and receive quality care. So, if Nigeria in itself had a big challenge in handling the disease, the complexity of the humanitarian situation certainly triples the challenge.

Children are particularly vulnerable to malaria because they don't have immunity built up to the disease. What is WHO doing in particular to address the risk for children?

In 2017 WHO teamed up with the Borno State Ministry of Health to launch a special initiative aimed at swiftly reducing the toll of malaria on children. Through the campaign, 4 monthly cycles of antimalarial medicines reached 1.2 million children under the age of 5. Community health workers administered the medicines to children in targeted areas, regardless of whether or not they showed symptoms of malaria, to mitigate the disease.

What are the complexities of a campaign like that?

Nigeria is quite complex. One thing we have learned over the years is that you cannot use a one-size-fits-all approach. While we have a blueprint for deploying interventions, they must be contextualized for every particular location. Using strategies that work in a particular location helps ensure acceptability by communities and the uptake of interventions.

Luckily, we had an existing structure through the polio programme, which has been on the ground trying to reach the last mile with the polio vaccine. There are definitely issues of security and accessibility, but by using the polio structure it meant we had personnel at the national, state, local government, and ward level so there was a lot of decentralization in getting the intervention actually to children.

Another approach that WHO has used in Nigeria is Integrated Community Case Management (iCCM). Can you tell us a little bit about the experience of that programme?

WHO received funding from Global Affairs Canada to introduce and rollout iCCM in Abia and Niger States with the aim of bridging the access gap in health services for children living in underserved communities. Community members were trained to correctly assess and manage malaria, pneumonia and diarrhoea for children living in hard-to-reach communities.

The community health workers were selected and identified by the communities themselves. They were people the community could relate with, they were people the community respected and they were willing to take their children to seek care. In some communities in Niger State, the community contributed money to build houses for these health workers as a way of appreciation for the work they have done.

There have been a lot of testimonials on the work of iCCM, and the government of Nigeria and the state governments have said that iCCM is one of those interventions that has worked in bridging the health access gap that exists, especially for children living in underserved communities.

What impact are you seeing from the iCCM programme?

In the 2 states that we supported, we found that there was increased care-seeking from community health workers. We also found an improved quality of diagnosis and treatment. For both Abia and Niger States, there was remarkable increase among those who were properly assessed and received adequate care. Thousands of lives were saved, and communities have accepted and supported iCCM. The government plans to scale up the effort to other states, with widespread interest among all 36 states in the country to deploy iCCM.

What gives you hope that the response to malaria in Nigeria is going in a good direction?

Being a front-line worker in Nigeria, I'm very optimistic that the country will eventually win the war against malaria. This is because, first, there's a renewed political commitment to malaria, which we have seen through the willingness of the government at all levels to provide domestic resources for malaria.

Second, the country has an ambitious strategic vision. The malaria programme in Nigeria has been renamed the National Malaria Elimination Programme. This is quite ambitious. But this vision is being pursued with intent.

If we continue, if we have adequate resources and political commitment to fight the disease, and we align ourselves with the intent to achieve universal coverage of anti-malaria interventions, we will be heading towards the strategic goal of reducing malaria to pre-elimination levels by 2020.

Dr Lynda Ozor was interviewed by WHO Communications Officer, Nyka Alexander, from the Organization’s headquarters in Geneva.