Distribution & the Actual Use of Long Lasting Insecticide-treated Nets (LLIN)
By Dr. (Mrs) Nnenna Ezeigwe, National Coordinator, National Malaria Control Program (NMCP)
The National Malaria Control Program (NMCP) coordinates all responses in the fight against Malaria in Nigeria. NMCP is responsible for developing a time bound National framework and our current National Strategic Plan 2009-2013 objectives is summarized as follows:
- Prompt and Effective Case Management
- Intermittent Preventive Treatment of malaria in pregnancy, and
- Integrated Vector Management including the Use of Long Lasting Insecticide-treated Nets (LLIN), Indoor Residual Spraying (IRS) and Environmental Management.
Other cross-cutting interventions include Advocacy, Communication and Social Mobilization, Effective Programme Management, Monitoring and Evaluation, Partnership and Collaborations.
What we have achieved so far with LLIN
I absolutely believe that the Government’s active distribution of LLIN is one of our best solutions in tackling the malaria problem now because it is the most cost effective strategy. It is very simple to use, and its ease of distribution can be maximized to reach most of the people who need it.
The distribution system we use involves the combination of what we call the “Push & Pull” methods. The Push method is essentially the use of mass campaigns which we have been implementing since 2009 and NMCP has distributed a total of 51.7 million LLIN so far. With the rapid scale up we adopted, we have practically covered all the states in Nigeria (the outstanding four states are currently been covered now). The Pull method is still in its elementary phase and it caters for routine gradual distribution of LLIN especially among healthcare facilities using target populations such as during Ante-Natal Clinics, Immunization days and through Faith-based organizations. The guideline to ensure that routine distribution is effective has been developed and would soon be disseminated.
Challenges of giving out FREE LLIN in Nigeria
INADEQUATE AWARENESS. So far, one of our primary challenges is even getting people to know and realize the importance of using these LLIN. Many average Nigerians on the streets are still not aware that the LLIN can protect them from malaria and so do not appreciate the need to use them. During routine distribution opportunities as in MNCH week, some people may not know that there is provision for them to receive these LLINs. For instance, if more pregnant women were aware of its availability, they could demand for one when they attend their ante-natal clinics. We are actively scaling up our efforts and campaigns but there is still need for more.
INSUFFICIENT FUNDING. Sadly, the financing of this fight against malaria is not properly funded by the Government; most of the help and support we get currently is courtesy of Donor Agencies. This leads to series of other challenges like the gap that currently exists in supply because of the insufficient quantity. It invariably causes a barely avoidable problem of stampede because of the enormous crowds during wide scale distribution as well as other logistics challenge. NMCP currently focuses on sharing the available LLIN to the most malaria vulnerable populace in Nigeria (Pregnant women and children under 5 years of age).
LACK OF LOCAL CAPACITY: Currently all the LLINs used programmatically are sourced from abroad because donors fund only WHO prequalified commodities, which are not currently produced by local industries. Programmatic nets are free and not enough and so a person may not be using net either because he could not get free programme net or cannot buy from the market. This is because local manufacturers are not even encouraged to bring their plants/production to par. Their plants are resting. Building local capacity is imperative for the sustainability of the control efforts.
POOR USAGE. The next big issue is our sticky situation with actual usage of these FREE bed nets. There is an on-going national survey which should hopefully show improved results. However, going by the last survey done in 2010, our statistics have been quite interesting. People tend to use LLIN more in the Rural areas (33.5%) much more than in the Urban parts (19.2%) of Nigeria. There is also a difference across the different geopolitical zones in the country too. People residing in the North/Eastern parts of Nigeria have the highest records of compliance with the use of LLIN at a rate of 54.8% usage compared to the South/Western states where the region records barely 11%.
WHY? We’ve observed several reasons that explain these trends:
– Believe it or not, many people in urban areas think malaria is an illness of the poor so they just don’t consider it as a real threat
– But the figures may also be attributable to a possible complimentary use of the more expensive Indoor Residual Spray alternative.
– Then there are other complaints about the inconveniences of using LLINs such as it been too cumbersome, causes extra heat in addition to our already hot and humid weather.
Frankly, the best chances of improving the usage of these LLIN may be spurred by creative innovations that could make them more desirable. For instance, some companies are beginning to make some vey colourful versions of LLINs to make it more attractive to children. Another interesting example I saw during our tour at Ebonyi State was creating mobile posts which especially comes in handy for people that sleep with their mattresses on the floor. All of these innovations have been private sector driven.
A Sure Solution: INDIVIDUAL RESPONSIVENESS
I am an advocate for getting individuals to take action to prevent malaria and there are several simple measures anyone can practice:
1- Ensure a clean environment for you and your family
2- When you suspect Malaria symptoms, get tested and treated with appropriate Artemisinin Combination Therapy
3- Be more proactive about using these LLIN
4- Pregnant women should deliberately demand for their doses of Intermittent Preventive Treatment in Pregnancy (IPTp) with fansidar. Three doses of this treatment is required in the course of a pregnancy.
The hope for Mosquito Vector Control
We hope to actively engage the Federal Ministry of Environment to be more involved in malaria control efforts. For instance they can build drainage channels where necessary, and generally ensure that built environment do not constitute ‘mosquito farms’. Environmental sanitation is a very fundamental tool to sustainably achieve vector control by eradicating mosquitoes in Nigeria. One option we are seriously considering is to bring back Sanitarians (Environmental Health Officers) that existed in the immediate colonial and immediate post colonial eras. They were quite effective back then when they were operational. They conducted home to home visits and particularly looked out for breeding sites. People with dirty surroundings were sanctioned to pay fines for contravening environmental public health laws and compliance was quite good.
Our next line of approach is to scale-up the use of lavicidals and it is currently being piloted in a few states. The cost of using lavicidals on a wide scale will drastically reduce with more participation by private companies. In fact just last week Thursday, we witnessed a ground breaking ceremony for a biolavicide factory in Port-Harcourt and we are very glad about the local presence of such potential solutions in Nigeria.
I am very passionate about this area of integrated vector control and it is my prime focus as the National Coordinator of NMCP. Looking down the road in 10 years time, I believe we should have eliminated malaria. We are actively working towards vision 2020 and it is quite achievable with our current focus on integrated vector management solutions. Hopefully in the next decade, our focus should have shifted from malaria case management to surveillance from active case detection.