The recent withdrawal of United States aid for malaria control in Nigeria has raised concerns among health experts, who warn that unless the Federal Government intervenes urgently, the country risks losing the progress made in combating the disease.

Since 2011, the U.S. President?s Malaria Initiative (PMI), implemented by the United States Agency for International Development (USAID), has been instrumental in Nigeria?s fight against malaria, contributing $914 million, including $73 million in 2023 alone.

Over the past year, PMI-funded programmes delivered 13.4 million bed nets, six million doses of fast-acting malaria medicines, and 11.8 million rapid diagnostic tests across clinics and communities. Also, over 7,200 health workers were trained in 2023 to enhance malaria detection, treatment, and community care.

Findings by The Guardian revealed that PMI-supported interventions cover public health facilities in 11 states: Nasarawa, Plateau, Benue, Zamfara, Kebbi, Sokoto, Bauchi, Akwa Ibom, Cross River, Oyo, and Ebonyi. These include the distribution of bed nets, seasonal malaria prevention measures, diagnosis, and treatment.

Nigeria bears the highest global burden of malaria, accounting for nearly 27 per cent of cases and 30.9 per cent of deaths in 2023, according to the World Health Organisation (WHO). The country also accounts for nearly 40 per cent of global malaria deaths among children under five, recording around 55 million cases and 90,000 deaths yearly.

Nigeria has been at the forefront of implementing data-driven strategies under the High Burden to High Impact (HBHI) approach, prioritising high-burden states for support from both PMI and the Global Fund. However, with the recent funding challenges, malaria rates in 12 states and the Federal Capital Territory have reportedly begun to rise.

While PMI interventions support 11 states, an additional 13 states receive support from the Global Fund. Moreover, 12 states and the FCT have recently accessed support from the World Bank and Islamic Development Bank.

AID cuts will severely undermine malaria control efforts in Nigeria, the Executive Director of the Civil Society Legislative Advocacy Centre (CISLAC), Mr. Auwal Rafsanjani, warned.

Speaking with The Guardian, Rafsanjani noted that the reduction in funding will affect key malaria interventions, including the distribution of insecticide-treated nets, indoor residual spraying, and access to effective treatment, especially in vulnerable communities. He stated that the funding gap would worsen Nigeria?s already dire malaria situation, where the disease remains a leading cause of morbidity and mortality.

Rafsanjani lamented that the high cost of malaria drugs continues to pose a significant challenge for many Nigerians, pushing families deeper into poverty and hindering efforts to curb the disease. He warned that without urgent intervention, the high cost of treatment would delay care, increase severe illness, and perpetuate malaria transmission across communities.

?In Nigeria, where many people live below the poverty line, the cost of effective treatment can be prohibitively expensive, leading to delayed or inadequate treatment. This not only puts individuals at risk of severe illness and death but also contributes to ongoing malaria transmission in the communities.

?The 2030 malaria elimination target is ambitious, and Nigeria faces significant challenges in achieving it. The aid cuts, inadequate funding, and high cost of malaria drugs all pose threats to progress,? he said.

He stressed the need for increased access to affordable and effective malaria treatment through subsidies, price controls, and public-private partnerships, especially for the most vulnerable.

While acknowledging efforts by the government and donor agencies to fund malaria elimination initiatives, Rafsanjani expressed concern over the mismanagement and inefficiencies that have plagued malaria control programmes. He noted that weak institutional capacity, lack of coordination, and corruption, including the misuse and embezzlement of funds, continue to hinder progress.

?Effective utilisation of funds requires strong coordination, transparency, and accountability. Unfortunately, there have been instances of mismanagement and inefficiencies in the use of funds, which have hindered the progress of malaria control efforts. Weak institutional capacity within government agencies and implementing partners can lead to inefficient use of resources,? he noted.

Rafsanjani called for urgent reforms to strengthen institutional capacity, enhance transparency, and promote good governance in order to ensure that available funds are used efficiently. He maintained that by improving accountability and building the capacity of implementing partners, Nigeria can make meaningful progress towards malaria elimination and reduce the burden of the disease on its citizens.

The Director General of the Nigerian Natural Medicine Development Agency (NNMDA), Prof. Martins Emeje, called on the Federal Government and stakeholders to prioritise the complete eradication of malaria in Nigeria rather than focusing on statistical targets.

Speaking in an interview with The Guardian, Emeje urged increased investment in indigenous solutions and natural medicine, stressing that malaria eradication should not be left solely to the government. He appealed to private sector players, including banks, pharmaceutical firms, and philanthropists, to contribute actively towards achieving this goal.

The NNMDA chief emphasised the need for national unity and pride in developing homegrown health solutions, noting that Nigeria possesses the capacity to overcome malaria using its resources.

According to him, ?We already have over 23 plants in Nigeria that are better in treating malaria than the one the whole world is using from China. But the Chinese took their research seriously. They developed their medicine and made the world use it. We must do the same.?

Emeje criticised the disconnect between malaria prevention strategies and the economic hardship faced by ordinary Nigerians, particularly in rural areas. He highlighted that many people cannot afford the high cost of artemisinin-based combination therapies.

?Somebody should carry N5,000 or N6,000 to buy malaria drugs when the person is still looking for N500 to eat. Who will do that?? he asked. IN the same vein, the Managing Director of Engraced Pharmacy, Jonah Okotie, drew attention to the economic barriers preventing many from seeking proper care.

According to him, the average cost of malaria testing and treatment ranges between N3,000 and N4,000 per person, an amount that many cannot afford. He noted that despite government policy requiring diagnostic tests before treatment, patients frequently resist, citing lack of funds.

?There is pervading poverty in the land. Some will just tell you to mix something for N200 or N500 because that is all they have,? he explained. The pharmacist also raised concerns over persistent misconceptions, widespread poverty, and the activities of unqualified health practitioners contributing to the deadly toll of the disease. He lamented the continued use of outdated and ineffective malaria treatments and revealed that some patients arrive with prescriptions requesting Artesunate as monotherapy, a practice that has been outlawed due to resistance issues.

?You even get phone calls from so-called nurses or doctors recommending such treatments, and you begin to wonder what kind of training they received. Malaria is still claiming lives first and foremost because of ignorance, myths, culture, poverty, and quackery,? he added.

Okotie acknowledged the role of healthcare providers and government officials, stressing that their actions can either encourage or discourage citizens from seeking proper healthcare.

Calling for a collective response, he emphasised the need for collaboration across sectors. ?Every hand needs to be on deck, including schools, professional groups, governments, partners, research institutions,? he said.

However, Head of Case Management at the National Malaria Elimination Programme (NMEP), Dr Shekarau Emmanuel, told The Guardian that although the aid cuts and dwindling donor funds will have a huge impact on malaria control over the years, especially in the eleven PMI-supported states, the current administration is putting measures in place to provide some level of subsidy for anti-malaria drugs through an initiative known as the Affordable Medicines Facility for Malaria (AMFM) concept, which is currently in the pipeline.

He stated that the Federal Government is taking proactive steps to make funds available to ensure malaria interventions are sustained, adding that certain high-impact, capital-intensive interventions like larviciding are currently being rolled out to reduce malaria transmission.

Shekarau noted that the mass net distribution campaign is carried out every three years in 24 states, consisting of 13 states supported by the Global Fund and the 11 states supported by PMI.

He observed that high-burden states were prioritised for Global Fund and PMI interventions, taking into consideration factors such as epidemiology and funding. However, having been left without support for a while, the malaria burden in the 12 states and the FCT has been rising.

Shekarau stated that 12 states: Lagos, Ekiti, Ondo, Rivers, Abia, Bayelsa, Kogi, Enugu, Edo, Anambra, Imo, and the Federal Capital Territory (FCT), which are not supported by either the Global Fund or PMI, have not had mass net distribution campaigns for the past 10 years. Instead, they have relied on routine net distribution, which takes place in health facilities through antenatal care (ANC), specifically for pregnant women and children when they receive their measles immunisation.

He revealed that, just recently, six of the states: Lagos, Ekiti, Ondo, Rivers, Abia, and Borno secured support from the World Bank, while another five states: Bayelsa, Ekiti, Kogi, Enugu, and Edo secured support from the Islamic Development Bank and will soon commence mass net distribution campaigns.

On allegations that treated mosquito nets meant for free distribution are being sold in the markets, Shekarau said, ?Lagos State, I don?t know where those nets may be coming from, but the truth is that in terms of mass distribution, it doesn?t happen in Lagos State anymore. What you should understand is that the fact that those nets have not been distributed by the government or partners does not mean that people cannot buy them.

?They are still sold in the markets, and we encourage people to buy from authorised outlets. It?s not as though they are only produced and distributed for free. There are companies that still manufacture these nets, and they are also sold in the markets. As a matter of fact, we encourage that because it is part of private sector investment.

?I am not saying that such things don?t happen. Of course, we have had instances of people trying to go around communities to buy from those to whom these nets have been distributed, but I can assure you that this has largely been controlled. When those nets are being moved towards areas where they are not supposed to go, they are noticed, especially at the point of distribution. However, what happens after the distribution is something we may not have total control over, but during the actual distribution, I can assure 100 per cent control.?

Similarly, the Executive Secretary of the Country Coordinating Mechanism (CCM) of the Global Fund, Tajudeen Ibrahim, noted that the Federal Government has initiated efforts to unlock the healthcare value chain by promoting local production as a mechanism to shift from donor-dependence to strategic investment.

Nevertheless, he admitted that the high cost of drugs, recent aid cuts, and dwindling donor funds pose a great threat to the 2030 malaria elimination target.

Ibrahim said, ?For the 2030 malaria elimination target, the launching of Rethinking Malaria on May 3, 2024 signifies a complete movement from idealism to practicality, a shift from fragmentation and an emphasis on adaptation to local content, moving from inputs and processes to outputs and outcomes, implementing interventions with the help of stratification, and moving from dependency to efficiency.?

He disclosed that the Global Fund has invested about $700 million in malaria response in Nigeria over the last five years to support different interventions in 13 supported states.

According to him, the interventions span different areas, including health system strengthening, LLIN/SMC campaigns and routine distribution, case management and procurement of ACTs, diagnostics with procurement of mRDTs, capacity building, research, and innovation, among others.

He revealed that some states, like Kwara and Lagos, are approaching malaria pre-elimination, which is one of the signs that Nigeria will strive to attain the 2030 malaria elimination target.

On whether the huge funding investments in malaria response in the country are judiciously utilised, Ibrahim said, ?Yes, and the 2024 NDHS confirmed the level of investment with the status of health reports in most supported states.?

Ibrahim explained further that the funding support on a yearly basis for the 11 PMI-supported states is about $70.2 million to implement malaria interventions in 5,387 health facilities across the states, adding that these interventions will be missed because of President Trump?s Executive Order.

He noted that Nigeria has adopted the use of insecticide-treated nets (ITNs) as a strategy recommended by the World Health Organisation (WHO) for malaria prevention since 2007, adding that ITN distribution has been periodically done through mass campaign activities in the supported states. He explained that the national campaign aims to provide enough nets so that every Nigerian may be protected from the deadly disease every night.

?For the ITNs in the open market, the end users are also culprits. In 2018, I witnessed a situation where one of the households that received four ITNs decided to sell three out of the four nets because they did not have food for the day,? he added. (The Guardian)

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