End Malaria for Good: Improving access to mRDTs to reduce malaria-related mortality in Nigeria

World Malaria Day 2016 reminds us that robust financial investment, political will, and innovation are essential to ensure continued success in ending malaria for good. Prevention and treatment are equally important in the fight against malaria, and both depend on accurate and timely diagnosis. Nowhere is the need greater than in Nigeria, which has the highest mortality and morbidity due to malaria infections in the world. Malaria accounts for about 30% of all under-5 pediatric deaths each year and is the single biggest driver of demand for health services, accounting for 60% of all outpatient visits annually.

Early and accurate diagnosis of malaria is essential to reducing morbidity and mortality through prompt treatment, which also helps reduce transmission. One of the greatest challenges in reducing malaria-related illness and death in Nigeria is chronically weak supply systems. These are exacerbated by poor information systems that do not provide the data needed to forecast demand and ensure availability of high quality and affordable malaria rapid diagnostic tests (mRDT). The poor data flow results in poor product flows leading to frequent stock outs of mRDTs. In addition, provider bias has an effect on demand; health workers are reluctant to trust the validity of test results. Findings from the quarterly End Use Verification Report show that half of all under-5 pediatric fever cases were symptomatically diagnosed as malaria, while 43% were diagnosed using mRDTs.

To address the supply chain and data challenge, John Snow, Inc. (JSI), with funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, has been working with the National Malaria Elimination Programme (NMEP) in Nigeria to strengthen the malaria commodity supply chain. One of the central interventions was a collaborative effort to develop the Excel®-based National Data Aggregation (NDA) tool. The tool is used to collate mRDT and antimalarial medicines consumption data as well as stock balance to calculate the remaining months of stock on hand from facilities up through local government authorities (LGAs) to states, and then to the federal level. A first of its kind in malaria commodity logistics in Nigeria, the NDA tool was designed to generate a bimonthly national consumption outlook, stock balance by level, and stock out profile at the LGA, state, and national levels. The outcome? Data that previously existed only at facilities and the LGA level is now visible at state and federal level.

National officers were trained on the use of the NDA tool, and they in turn trained key officers in the states. The second phase of the intervention involved mentoring state logistics management coordinating unit (LMCU) members on the use of the NDA tool to produce state reports, make resupply decisions, and use as a basis for data-driven Procurement and Supply Management (PSM) sub-committee meetings at the state and national levels.

Outputs/Outcome

• Prior to the development of the NDA tool, few states submitted logistics reports to the federal level, so national-level visibility was very limited. With the deployment of the NDA, combined with deployment of newly recruited logistic officers to states for system strengthening, the reporting rate from the states rose from less than 12% in Nov-Dec 2013 to over 65% in Jan-Feb 2016, as shown below.

• The use of findings and recommendations from NDA reports, coupled with other interventions, were instrumental in increasing the rational use of antimalarial artemisinin-based combination therapies (ACTs) that are distributed in the same supply channel as the test kits.
• State reports have been used to present mDRT stock and consumption profiles at the state LMCUs, and have helped improve stock accountability at health facilities.
• Oyo State has used its NDA report to advocate for additional funding commitments to procure mRDTs.
• The reports have helped states better calculate resupply quantities when requisitioning from NMEP.

While a great deal of progress has been made, very real challenges remain. Data from some states are incomplete’ although all facilities are supposed to report, in practice reporting is higher from facilities receiving Global Fund-financed products. There have also been stockouts throughout the pipeline due to funding and procurement delays at the federal level, and delays in last-mile distribution. Furthermore, not all states are covered under the Global Fund’s new funding model; the excluded states have few to none mRDTs in their pipelines, and therefore seldom submit NDA reports. Without greater attention to clinical supervision, provider bias will continue to affect demand and use of mRDTs. JSI continues to support the NMEP to improve data reporting and use for national demand and supply planning, with a special focus on the state-level obstacles mentioned above.

While it might seem overly technical to celebrate improved reporting rates, we know that the greater the visibility and timeliness of data, the better the decisionmaking is for operating a supply chain and understanding demand patterns. And that leads to better performing supply chains, which lead to better access to medicines and diagnostics, which leads to effective prevention and treatment and improved health outcomes. As the saying goes, “No Product? No Program!”

Written by Chris Wright and Grace Omole