Beyond Scaling Up: Working with patent medicine vendors in Nigeria

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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.

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Beyond Scaling Up: Working with patent medicine vendors in Nigeria

  1. 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. 2. Oladepo _ Involvement of PMVs in Malaria control 2
  3. 3. The Central Question Why involve PMVs in malaria control services ? Oladepo _Involvement of PMVs in Malaria control 3
  4. 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. 5. Fig 1: Major Communicable Diseases in Nigeria , 2005 (Source Erinoso, 2010) Oladepo _Involvement of PMVs in Malaria 5 control
  6. 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. 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. 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. 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. 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. 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. 12. FHS Nigeria :Project Phases How can the poor get access to effective malaria treatment? Inception Phase FHS Phase II Phase I 12
  13. 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. 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. 15. Oladepo_ Strengthening Malaria Control Interventions through PMVs- Nigeria 15
  16. 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. 17. 54 Different Types of Anti-malarial Drugs Found in Oyo, Enugu & Kaduna 17
  18. 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. 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. 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. 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. 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. 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. 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. 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. 26
  27. 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. 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. 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. 30
  31. 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. 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. 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. 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

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