Capital City: Abuja
With a population in excess of 170 M, the majority (70%) living in poverty, the burden of all 17 reported NTDs in Nigeria is vast.
There are 36 autonomous states and a Federal Capital Territory (Abuja) within the country, assigned to 6 geo-political zones (see Figure 1).
Across the country, the smallest administrative unit is the Local Government Area (LGA), of which there are 774, and has an elected Chairperson and Legislative Council. Each state and LGA is autonomous generating their own internal revenue and each tier of government prepares its own annual plan and budget. Although English is the national language there are 350 ethnic groups, the predominant ones being Hausa in the north, Yoruba in the South-West and the Ibo in the South East. In many areas in the north literacy, even in local languages, is low and English frequently not understood. Owing to civil insecurities, many of the North-East Zone states are considered fragile and are unable to maintain public health campaigns based on preventive chemotherapy.
In the North-West and North-Central zones, with substantial support from USAID (RTI/ENVISION programme), DFID (i.e. Sightsavers/Helen Keller International/UNITED programme) and UNICEF, the Federal and State Ministries of Health are presently engaged in increasing the availability of NTD treatments through training health staff and improving data systems using mobile phones and cloud technology for delivery of better primary health care. Achieving this will require internal technical support and application of targeted implementation research to develop expertise for mapping, monitoring and evaluating at different levels of the health system, as well as, introduction of appropriate process indicators within the health system to document success or failure. An extensive baseline mapping exercise has recently been completed and help to set intervention areas according to the endemicity of NTDs within each LGA.
In Nigeria, there are NTD elimination programmes in place within the endemic States for the PCT NTDs. The health system and policies in place need strengthening to maintain the effectiveness, scale-up and sustainability of the programmes at all levels of the health system. As a first step in identification of critical implementation research questions, we will conduct a situational analysis of NTD elimination implementation in Kaduna and Ogun States in Nigeria. This research will bring together the Federal and State Ministries of health as well as researchers focusing on health economics, social science, public health and epidemiology. It hopes to draw a comprehensive picture of how health systems across each of the WHO health system building blocks (Governance/Leadership, Health Financing, Health Workforce, Health Information Systems, Service Delivery and Access to Essential Medicines (WHO, 2007)) respond and adapt to health policies and how these policies have impacted NTD implementation in endemic States in Nigeria.
We will engage relevant stakeholders who are implementing the NTD programmes at all levels in order to identify the key successes and challenges of NTD elimination implementation in the two States.
Kaduna and Ogun States receive support from the government to implement the NTD programmes. Kaduna State also receives high levels of NGDO support in the delivery of its NTD control programme. These States are also at differing phases of NTD control with Kaduna being further advanced than Ogun State. These two States have therefore been chosen as the case study States for the COUNTDOWN project to allow for maximum contextual variation.
Our strategy in Nigeria replicates the overall COUNTDOWN logic and approach to encourage use of evidence in policy and practice for scale-up of NTD control. With just over 170 M people, Nigeria has the highest prevalence of NTDs in sub-Saharan Africa and presents with 25% of Africa’s NTD burden. Across the 63 autonomous states preventive chemotherapy campaigns, as co-ordinated by the Federal Ministry of Health (FMoH) in Abuja, range from those accomplishing satisfactory treatment coverage to those yet to commence. With substantial domestic funding and external support from bilateral donors USAID (i.e. ENVISION programme) and DFID (i.e. UNITED programme), Nigeria is moving towards co-ordinated national scale-up.
Our research will be built upon existing Mass-drug Scale-up Themes (MST), with MST 3 expanded to include scale-up modelling and financial forecasting, with sensitivity analyses. Since loaiasis is not a country-wide impediment and vector control for lymphatic filariasis is already integrated in Nigeria, our Integrated Complementary Strategies Themes (ICST) will concentrate on a revised ICST 2. This will specifically address praziquantel/albendazole treatment for out-of-school children, preschool-aged children, men and (pregnant) women and of reproductive age by strengthening existing and exploring alternative drug delivery channels. Urogenital schistosomiasis is alarmingly high in these states, especially in Ogun, thus reprioritisation of the importance of male and female genital schistosomiasis is needed to indict concerted effort across the health system addressing this gender-based NTD inequity as well as with inter-sectoral actions, e.g. agriculture.
In Nigeria, the Federal Ministry of Health (FMoH) also employs the PC strategy. Preventive Chemotherapy (PC) is the core control and elimination strategy for 5 of the 17 NTDs; Lymphatic Filariasis (LF), Onchocerciasis, Soil Transmitted Helminths (STH) (using ivermectin and albendazole), Schistosomiasis (using praziquantel) and Trachoma (using azithromycin). Previously, PC for these diseases has been implemented through vertical programmes for each of the NTDs. However, there is currently a global shift under the umbrella of Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) for a more integrated approach to PC delivery across these 5 diseases.
Nigeria has the largest burden of NTDs in sub-Saharan Africa accounting for 25% of the total burden of the diseases in Africa (NTD Master Plan, 2012). In Nigeria the FMoH provides oversight and policies for endemic States who implement the NTD programme. The intervention unit is considered to be the LGAs embedded within each State. At the Federal level, there exists an NTD Multi-Year Master Plan, which was designed to achieve the WHO target of eliminating /controlling the NTDs by 2020.
The strategic goal of the NTD programme is to progressively reduce morbidity, disability and mortality of these diseases using integrated and cost-effective approaches with the view to eliminate NTDs in Nigeria by the year 2020 (NTD Master Plan, 2012; FMoH, 2010). While progress has been made, a number of barriers/challenges to sustaining progress and achieving the goal have become apparent.
Sightsavers Nigeria is collaborating with COUNTDOWN in operational research across the Mass Drug Administration scale-up themes (MST) to identify operational issues, to be addressed for the improvement of programme delivery. The outcome of the research will provide the evidence needed for policy change and enhancing coordination and programme delivery. The collaboration between Sightsavers and the other partners seeks to:
1) Create the COUNTDOWN Project presence in Nigeria, ensuring visibility, communication and coordination of Project activities in Kaduna and Ogun
2) Develop administrative and technical capacity to manage and implement the Project
3) Generate research evidence to respond to priority information needs of NTD policy makers and program managers at local, national and international levels
4) Support the incorporation of evidence to improve operational plans and practices for scale-up of NTD control in Nigeria
5) Develop capacity for evidence decision-making and planning expanded programmes through multi-sectoral linkages and partnerships to enhance evidence-based NTD policy-making and programming at local, national and international level