Ebola outbreak in Nigeria and how it was managed

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Malaria in Nigeria:

Its impact on the population and why it remains a major health issue

TABLE OF CONTENTS

1.0 Introduction.....................................................................................................3

0. Malaria; facts & figures....................................................................................3-5

0. Nigeria; Overview and Health status of population.........................................5-6

2.0 Malaria in Nigeria...........................................................................................6-7

2.1 Impact of Malaria..............................................................................................7

2.2 How malaria has impacted Nigeria...................................................................7

3.0 Health Systems................................................................................................8

3.1 Health systems and malaria control initiatives in Nigeria................................8-10

3.2 Globalization and its impact on health in Nigeria...........................................10

3.3 Global health systems/agencies in Nigeria......................................................11

4.0 Response to increased cases of malaria in 2016..........................................11

4.1 National response.............................................................................................11-12

4.2 International response......................................................................................12

4.3 Political, Economic & Social factors that influenced response.......................13

5.0 Conclusion......................................................................................................13-14

6.0 References.......................................................................................................15-21

1.0 Introduction

The International Conference on Primary health care in Alma-Ata in 1978 expressed the need for all governments, health and development workers and the world community to act urgently to protect and promote the health of all the people of the world (WHO, 2018). In addition to various other declarations, the Conference reaffirmed that health is a fundamental human right and as such attaining the highest possible level of health is an important social goal throughout the world, that the existing inequalities in health particularly between developed and underdeveloped countries is unacceptable on all levels and being a matter of global concern. It is exactly forty years since the conference was held and declarations made but a lot remains the same with regards to health and healthcare particularly in developing countries. As Masic (2018) points out, public health has advanced in knowledge and methodology over the years, biomedical scientists have identified many of the causes of infectious diseases as well as developed methods to put them under control but many of the targets set out by the Conference declarations have not been met and in some countries, official institutions responsible for public health activities have not provided them. The direct result of this is that people continue to suffer and even die from preventable and treatable diseases such as Malaria. This piece of work explores the impact of malaria in Africa, particularly in Nigeria which according to the WHO (2018) is one of the countries with the highest cases of malaria and malaria deaths. This assignment places particular emphasis on the impact malaria has had on the health status of the population in the region. In addition, the various agencies (national and international) involved in malaria control in the region will be looked into and an evaluation of their contribution towards controlling the spread of malaria and prevention of malaria deaths in the region will be done. In an attempt to identify areas that need improvement or to establish what more could be done to control the spread of malaria and eradicate malaria deaths in Nigeria, comparisons are made with other countries in the continent that have managed to successfully control the spread of malaria and also bring down malaria deaths in their countries. Countries such as Liberia, Rwanda and Senegal are reported to have managed to control malaria for a continuous period of four years and others such as South Africa and Botswana even managed to not only halt but also reverse the incidence of malaria in their countries (Kweifio-Okai, 2016).

1.1 Malaria: Facts and figures

Malaria is described as a serious tropical disease which is spread by mosquitoes and if not diagnosed and treated in time can be fatal (NHS, 2018). The World Health Organization (2018) describes Malaria as a life-threatening disease as a result of Plasmodium parasites that are spread to the human population through bites of infected female Anopheles mosquitoes. Although there are five parasite species that are responsible for malaria transmission in humans, however there are two main species that pose the greatest threat, these are P.falciparum which is the most common parasite in Africa and is responsible for most malaria-related deaths around the world and P.vivax is more dominant in countries outside sub-Saharan Africa (WHO, 2018). According to Medicines for Malaria Venture (MMV, 2018), malaria is extremely life threatening because it can kill within 24 hours of the symptoms being experienced.

The World Health assembly in conjunction other international agencies set 2015 as the target year for reducing malaria incidence and mortality (Cibulskis et al., 2016). According to Cibulskis et al (2016), there is evidence to suggest that there has been a significant reduction in the burden of the disease since the beginning of the millennium as a result of increased financing for malaria prevention, diagnostic and treatment programmes. However, the disease remains a global health issue affecting far too many people and far too many cases of malaria deaths continue to be reported around the world. For instance, the WHO (2018) reports that in 2016 alone, there were 216 million cases of malaria worldwide and out of these, 90% were in Africa. Additionally, in the same year there was an estimated 445000 deaths worldwide as a result of malaria, again, 91% of these deaths occurred in Africa. According to Binns & Low (2015), malaria control initiatives have resulted in the reduction of malaria cases in some areas of the world particularly in the Asian-Pacific region where the number has increased from eight million to three million a year. However, Binns & Low (2015) also add that 3.3 billion people still live in areas where they are at risk of acquiring a malaria infection.

Nigeria is one of the countries reported to have the highest number of malaria cases in the whole of Africa alongside The Democratic Republic of Congo and Burkina Faso (Dawaki et al., 2016; Nasr N A & Lau Y, 2016). According to reports, malaria occurs mostly in poor tropical and sub-tropical parts of the world and Africa is the most affected due to the high presence of the mosquitoes that transmit the predominant parasite species as well as local weather conditions which make it easy for transmission to occur throughout the year, in addition lack of resources and socio-economic instability have made it difficult for efficient malaria control activities to take place in the region (CDC, 2018). Despite the efforts made globally over the years to fight the scourge, Malaria still remains one of the biggest public health problems in the world and particularly in Africa which bears the brunt of the global burden of the disease. Staines & Krishna (2012) confirm that Malaria remains a massive global problem and that nearly half the world’s population lives at risk of the disease and those who suffer from the disease also carry an increased burden of other illnesses such as HIV/AIDS, measles, respiratory tract infections, diarrhoea and anaemia.

Although it is preventable and treatable, malaria still claims more than half a million lives a year and threatens global prosperity, it is a leading cause of death for children under five years of age in sub-Saharan Africa, reportedly killing a child every sixty seconds and also poses a deadly threat to pregnant women (Malaria-free future, 2018). Bearing in mind these facts and figures, it is clear that the disease continues to be an issue of public health globally. In the next chapters, the impact of malaria on the population of Nigeria is explored as well as the health systems in the region and the efforts made by national and global agencies to eradicate or reduce the spreading of malaria in the region.

1.2 Nigeria: Overview and Health status of the population

In understanding the health status of the population in Nigeria, it is important to look into the factors that might impact their health such as socio-economic factors, demographics and health indicators impacting on the country’s disease profile (Olaniyan, 2015; UNICEF, 2018). Nigeria is located on the western part of the African continent and is said to be the most populous country in Africa (Newcomb, 2014). The population of Nigeria as at 2017 stood at 192 million and is currently the most populous country on the continent of Africa and the seventh most populous country in the world (Nations Online, 2018). Nigeria is considered as having the biggest economy in Africa due to oil revenues, with a GDP estimated at 508 billion dollars in 2017 (Nations Online, 2018). This is consistent with the report by Beaumont & Abrak (2018), describing Nigeria as the wealthiest country in Africa, with a higher GDP than South Africa, thereby confirming it to be the largest economy in Africa.

Despite all the interesting report on the wealth status of Nigeria, many people in Nigeria are unable to partake on the dividends of the thriving economy, causing millions of people to continue to live in poverty (Olaniyan, 2015). Retrospectively, in 2001 Nigeria was not as wealthy as observed today and the population of the country was about 124 million, though a large percentage of the population still lived in extreme poverty, while those in rural areas had no access to potable water and adequate healthcare (Akinwotu and Olukoya ,2017). More than a decade later, Nigeria’s population has greatly increased and despite the country’s wealth, majority of the Nigerian population are poor with more than 70% of the population living on less than a dollar a day (UNICEF, 2018). According to Beaumont & Abrak (2018), the country has recently overtaken India to become the country with the world’s greatest concentration of extreme poverty with 87 million people reported to be living in extreme poverty. Newcomb (2014) also highlights this issue stating that even though Nigeria is acclaimed as having the largest economy in Africa, wealth disparity in the country is still quite significant. The increase in the number of people living in poverty has been attributed to many factors such as unequal distribution of resources and poor governance which has failed to create an enabling environment for poverty alleviation among the masses (Muhammad, 2018). This high level of poverty in Nigeria as well as the continued growth of the population is likely to have an impact on the health status of the population.

According to UNICEF (2018), health care, the state of health and the living conditions in Nigeria are seen to be in a deplorable condition particularly for children and women, accounting for high mortality rates for children under the age of five and a weakened Public Health Care (PHC). This obviously means that the country is susceptible to high disease burden. In 2017, Nigeria was reported to be in critical point of medical crisis, having suffered from the Ebola outbreak in 2016 while at the same time trying to tackle Malaria (Elkins, 2017). HIV/AIDS also remains prevalent particularly among children, young people and women in Nigeria with an estimated 2.9 million Nigerians living with the virus (UNICEF, 2018). There are health inequalities amongst different population groups in the country particularly between those in rural areas and those in urban areas and although this can be due to individual choices such as traditional beliefs where some refuse to take ‘modern’ treatments. Nevertheless, a lot of it can be attributed to factors such as lack of proper transportation which makes it difficult for people to access health care (Olaniyan, 2015). Nigeria’s health system has not been able to attain effective coverage for all, especially the vulnerable population due to factors such poor management of the public finance which allows continuous corruption (Adeyi, 2016). Furthermore, health outcomes in Nigeria are impeded by lack of adequate education and knowledge and poor infrastructure e.g. poor water supply, poor sanitation and unstable power supply for households and health care facilities (Adeyi, 2016).

2.0 Malaria in Nigeria

Malaria is considered one of the biggest causes of death in Nigeria(WHO,2018). In 2016 alone, the disease claimed at least 100000 lives in Nigeria (Gulland, 2018). As reported by (Mokuolu, 2016), significant number of malaria cases was recorded in various states across the country in the year 2016. Furthermore, as reported by WHO (2016), a team from WHO in October 2016 in collaboration with the Nigerian Centre for Disease Control found a malaria outbreak in Sokoto State in the north western region of Nigeria, where more than 300 confirmed cases of malaria were being reported, as was confirmed by the primary health centre showing 50 deaths due to the malaria outbreak in the state (Mokuolu, 2016). In the period between October-December 2016, there were massive numbers of people visiting health facilities because of malaria (Orimadegun, 2015). Overall, the situation in the year 2016 was one of the most challenging situations ever faced by the government of Nigeria as the outbreak was severe in most of the states and there were little interventions being employed (WHO, 2016).

The increased cases of malaria in Nigeria can be attributed to various factors such as lack of awareness where people resorted to traditional forms of treatment like the use of herbal and home remedies which meant the patients continued to suffer and, in many cases, died as a result (Tatem et al., 2017). According to WHO (2017), the increased cases of malaria in Nigeria in 2016 resulted in at least 150000 deaths. Lisewski et al (2018) however maintained that this number might be higher than was reported. According to Saleh et al (2016), the suspected outbreak of malaria in Sokoto state as well as the increased cases of malaria in various rural areas around Nigeria shows that the malaria control initiatives in Nigeria need reviewing.

2.1 Impact of malaria

As at November 2016, there were 216 million cases of Malaria, as compared to five million cases in 2015 and the estimated number of deaths due to malaria in the same year, estimated at 445000 (WHO, 2018). This shows no significant change as compared to the previous year where the estimated number of malaria deaths was 446000 (WHO, 2018). The biggest and worst effect of malaria on a population is the lives lost. Lisewski et al (2018) indicated that the period of being ill due to malaria fever, money spent preventing and treating the disease, the indirect cost of lost wages and time spent caring for sick children all affect the population at a individual level. In addition, the disease also has an impact on the economic status of a population because a heavy national burden of malaria affects economic development (Akinwotu and Olukoya ,2017). As stated by Staines and Krishna (2012), malaria has an indirect burden in that it affects education, worker productivity and investment. It is fair to say that malaria directly impacts individuals and their families and by extension the societies in which they live.

2.2 How malaria has impacted Nigeria, its population and their health status

In Nigeria, like in many other parts of the world, malaria places a significant economic burden on the country and its population. According to Onwujekwe et al (2017), households in Africa spend between $2 and $ 25 on malaria treatment and $15 on prevention every month which consequently results in loss of resources. As mentioned in the previous paragraph, a large part of the population in Nigeria are living in poverty which means they are unlikely to afford treatment when they become infected and as such are more likely to remain ill for long period of time and in some cases die thereby creating a vicious cycle. Ricci (2012) also indicated the link between malaria and poverty stating that poor households and individuals are prevented from consuming goods and services that would otherwise protect them against the risks of malaria. Another way malaria is likely to impact the economy of Nigeria is by causing people to be unable to work and contribute to the local economy (Akinwotu and Olukoya ,2017).

On a social level, malaria is likely to put a strain on social relations where the burden of caring for a person with malaria disease becomes that of the family members who struggle to cope with some other pressures existing in a in family. Furthermore, malaria is likely to cause social exclusion among a population in Nigeria because the disease is reported to mostly affect people who are economically challenged (Dawaki et al., 2016), this means that it will further increase the gap between the rich and the poor, thereby causing those on low incomes to live in isolation.

3.0 Health Systems

Health systems or healthcare delivery systems as it is referred to in some cases, is the completion of actions instituted by a social system for preventive, curative, rehabilitative and the promotion of health services in a location (Nwankwo, 2015). According to the WHO (2018), a good health system delivers quality services to all people, when and where they need them and usually requires adequate financing, a well-trained and adequately paid workforce, reliable information on which to base decisions and policies, well maintained facilities and logistics to deliver quality medicines and technologies.

3.1: Health systems and Malaria control initiatives in Nigeria

Nigerian healthcare system consists of the traditional medicine and modern forms of medicine established by the western merchants, missionaries and colonialists (Nwankwo, 2015). The Nigerian healthcare system is reported to have suffered a series of downfalls in last few years and despite the country’s strategic position in Africa, its healthcare system is not up to standard, being unable to effectively meet the health needs of the population (Welcome, 2011). Nwankwo (2015) opined that an effective and efficient health service is one that attains its set targets, easily accessible and affordable to the masses especially the poor. This however does not seem to be the case for the health system in Nigeria. As indicated by Onwujekwe et al (2010), the healthcare centers, facilities, equipment, and the work force particularly in the rural areas of the country are found to be inadequate and lacking the standard or quality and expertise as required.

There is no doubt that the government has taken steps to try and improve the state of healthcare in the country, but the major concern remains in the form of lack of proper implementation processes at the local and national level (Ajuwon, 2006). According to Ojewumi (2012), this lack of a proper process for implementing healthcare initiatives at local and national level has affected the healthcare system in a negative manner. Fillinger and Lindsay (2011) believed that the healthcare system in Nigeria remains weak as there was significant evidence of lack of cooperation and coordination, fragmentation of services, shortage of drug and related supplies, inadequate infrastructure, inequality in the distribution of sources and resources, difficulties in accessing the healthcare system, and lack of quality in the healthcare model and system. Good and Doolan (2010) highlighted another concern in the form of lack of clarity on the roles and responsibilities of the individuals concerned, in addition lack of a clear government vision on the healthcare situation and system.

There are many other factors that are likely to have an impact on the health care system in Nigeria and by extension its ability to successfully tackle the burden of malaria across the country. For instance, some have asserted that the political situation in the country is in many ways responsible for the state of the health system and the issues prevailing in the healthcare system (Zurovac et al., 2012). Additionally, Huxley (2015) found that the Nigerian government took good amount of time to react to different kinds of outbreaks of diseases which greatly affected the overall social environment. This is however not to say that there have been no attempts to tackle outbreaks of diseases, there is evidence to suggest that efforts have been made. For instance, with regards to malaria, it was found that since 2008, the Nigerian malaria control programmme has aimed to introduce a robust system for malaria control through the introduction of three core interventions in the form of prevention of malaria transmission, prompt diagnosis and real time response, in addition the treatment and prevention of malaria among pregnant women (Wright, 2016). In the year 2014, the malaria control program began implementing the National Malaria Strategic Plan to achieve the pre-elimination status revolving around less than 5000 cases and reducing the numbers of deaths causes by malaria to zero by the end of 2020 (WHO, 2016).

On the other hand, the response and prevention of malaria for pregnant women has been quite unsatisfactory because of the barriers in regard to implementing the interventions (Federal Ministry of Health, 2015). Despite the efforts by the Nigerian government and other international agencies to tackle malaria in the country, the disease has continued to spread, even though there has been evidence of some reduction in cases of death, the number of cases and deaths still recorded are still a major concern and a major issue of public health. As pointed out by Ardal et al (2016), even though WHO has been working in partnership with local NGO’s to tackle the issue of malaria in Nigeria along with gaining support from the local NGOs, the issue remains the same because of barriers like poor healthcare reforms, lack of quality treatment, and support and coordination between the human resources. Furthermore, there is also a lack of proper treatment facilities and equipment in the rural areas and this has further aggravated the issue in the rural areas (Uguru et al., 2009).

In tackling this issue, it might be prudent to look into other countries that have successfully managed to significantly reduce cases of malaria and malaria deaths. For instance, in the same year that Nigeria experienced a significant increase in the number of malaria cases and deaths, South Africa was recognized for its fight against malaria having seen a massive decrease of 82% in malaria cases (Brand South Africa, 2016). The decrease in malaria cases in South Africa was due to sound malaria vector control programmme whereby the country used dichlorodiphenyltrichloroethane (DDT) odourless insecticide for inside spraying as well as various other WHO recommended interventions. It is reported that South Africa has been using DDT for a while even though at some point it had been banned by the WHO (Brand South Africa, 2016). In 1996 South Africa stopped using DDT and a 600% increase in malaria rate was recorded within five years, following that, South Africa applied to be exempted from the DDT ban and they reverted to DDT (Brand South Africa, 2016). It is not clear why exactly South Africa is close to eradicating malaria and Nigeria continues to struggle with it, it is possible that the reduced use of DDT following the ban by WHO might have impacted their malaria reduction efforts. It is possible that some of the issues in Nigeria are not experienced by South Africa, for example South Africa just as Nigeria has suffered the impact of health worker emigration, however at the same time as a country they have also had health workers coming into the country to work which means the country does not suffer health worker shortage (WHO, 2015).

3.2 Globalization and its impact on health in Nigeria

Globalization is defined as the process where societies get connected in a way that events or incidents happening in one country can affect the social and economic environment of other countries (Wright 2016). Nwankwo (2015) defines globalization as the flow of information, goods, capital and people across political and economic boundaries. Globalization also impacts health status, healthcare initiatives and healthcare models (Naicker et al., 2009). According to Huxley (2015), globalization is helpful in dealing with epidemic outbreaks by making it easier for agencies to deploy quick responses. Globalization can have both positive and negative impact on a country and Nigeria as a country has been exposed to both the negative and positive effects of globalization (Adesina, 2012). Globalization has enormous implications on health and welfare in Nigeria and its population and these have both positive and negative dimensions (Nwankwo, 2015). One of the most positive impacts of globalization in Nigeria is that it has made it possible for international agencies such as WHO to have a presence in Nigeria and implement health initiatives to benefit the country. Nwankwo (2015) explained that globalization has facilitated the spread of health sector reforms through the transferring of policies on health provision and financing across the world causing national health systems to try and incorporate these health policies into their local systems. This has seen the introduction of strategies such as the Millennium Development Goal (MDGs) and Health for All.

Globalization has however also had a negative impact on the health status of Nigeria’s population. For instance, it has led to easier and increased migration between countries as well as movement from rural to urban areas within the country and this has posed a threat in the form of migration of quality and professional resources and services (Adeyemo, 2005). Nwanwko (2015) supports this point by stating that Nigeria as a country has seen increased migration, for instance among Nigerian medical professionals which has resulted to inability of the national health system to optimally respond to the health needs of the population in Nigeria. The Premium Times (2015) reported that there are about 35000 doctors in Nigeria and to meet the health needs of the country, at least 237000 doctors are needed. Migration of skilled doctors to developed countries may not be the only reason for this shortage but remains a contributing factor. As Wright (2016) aptly pointed out; it has left a serious vacuum in the healthcare industry of Nigeria where lack of doctors has been affecting the treatment of diseases such as malaria. Increased migration within the country, from one state to another has also contributed to the spread of malaria across the country because it is possible for the people who are infected to spread malaria to malaria free zones by moving from their place of residence to other areas perhaps for economic benefits (Ricci, 2012).

3.3 Global health systems/agencies in Nigeria

There are considerable number of global agencies that contribute to the health system in Nigeria. For instance, agencies such as USAID in partnership with Centers for disease Control and the U.S Department of Defense Walter Reed Program together with the Nigerian government has been supportive in helping Nigeria to build its capacity to manage diseases such as HIV/AIDS and Tuberculosis (USAID, 2018). Other developed countries such as the UK, US and France have over the years contributed to tackling malaria in Nigeria and other countries. Over the years, there have also been a number of initiatives aimed at reducing the effects of malaria such as the Roll Back partnership by the World Health Organization and the Global Fund to fight AIDS, TB and Malaria (GFATM) (Jimoh et al., 2007). In addition, the Nigerian government also introduced initiatives such as distribution of insecticide treated nets (Aderibigbe, 2014). More recently, the UK government announced further support for the fight against malaria particularly in commonwealth countries like Nigeria (DFID, 2018). Over the years, the WHO has also made and continues to make a considerable contribution to the fight against malaria in Nigeria. In the year 2016 for instance, WHO invested 2.7 billion dollars into malaria control and elimination programs in Africa and also delivered millions of ITN’s in Nigeria (WHO, 2017).

4.0: Response to increased cases of malaria in 2016

In response to the malaria outbreak in Sokoto, the WHO had to introduce the Early Warning Alert Response System (EWARS) in many cities in Nigeria to get a clearer picture of its prevalence and to facilitate the data collection process using the modern technology to identify and track the major health concerns (Okorie et al., 2016). The EWARS system confirmed malaria as extremely rampant in Nigeria and the most common killer disease (O’Brien et al., 2016). Ramsay et al (2016) added that the response towards the outbreak in Sokoto also involved supplying medicines wherever needed along with implementing preventive care measures by distributing mosquito bed nets. The Nigerian government also responded positively by making sure that large numbers of people are covered under the preventive plan and are offered preventive check-ups, free medicines, and urgent treatment (Kaur et al., 2016). The quick and timely response was helpful in managing the malaria cases as well as preventing new cases from arising (Chanda et al., 2016).

4.1. National Response

The goal of the President’a Malaria initiative was to reduce the numbers of malaria related mortality by more than 50% in Africa and especially in Nigeria (Garley et al., 2016). The introduction of this initiative has been beneficial in terms of effective prevention of malaria and appropriate treatment measures in the form of the indoor residual spraying (IRS), insecticide treated nets (ITN), accurate and on-time diagnosis, artemisinin-based combination therapies (ACTs), and preventive treatments in pregnancy (Ardal et al., 2016). In the year 2015, the government further launched the six-year strategy that was based on eradicating malaria at the national level (Iwuafor et al., 2016). The National Malaria Elimination Program (NMEP) was further developed to deal with the rising cases of malaria in the country (Young et al., 2018). The strategy included capacity building, strengthening of the supply chain, monitoring and evaluation of the cases, and identifying key stakeholders who can help in dealing with the issue of malaria (Ramsay et al., 2016).

The Nigerian government came together with NGO’s in Nigerian to tackle malaria in the country (Iwuafor et al., 2016). NGOs work directly in the field and had better ideas and understanding on the issue. They were further helpful in highlighting the gaps and challenges found in different areas regarding the treatment and prevention of malaria (Yakob et al., 2014). The usefulness of NGOs was further in the form of enhancing the operational presence in the crisis affected areas along with providing the staff with adequate knowledge and awareness (Onyeneho et al., 2016). Overall, it can be said that the role of NGOs was of supporting the actions and planning of the government along with offering private inputs to enhance the degree of malaria awareness and prevention strategies (Okorie et al., 2016). It needs to be stated that the NGOs have the right to work independently or as a support system to the government and during the outbreak of 2016, NGOs acted privately and also under the guidance and support of the government (WHO, 2017).

4.2 International Response

In the year 2016 2.7 billion was invested in malaria control and elimination programs at by the global governments and international partners like WHO (WHO, 2017). The majority of the investment was made in the African region and governments of the endemic countries contributed around 31% of the total funding that was around $800 million (WHO, 2017). The WHO further delivered millions of ITNs in Nigeria in the year 2016 and around 30% of the global distribution of the ITNs were distributed in Nigeria (WHO, 2017). The WHO further delivered millions of ITNs in Nigeria in the year 2016 and around 30% of the global distribution of the ITNs were distributed in Nigeria (WHO, 2017). Overall, it can be said that the contribution of WHO was crucial in identifying the cases of malaria along with using preventive measures in a planned manner (WHO, 2017).

4.3. Political, Economic and Social factors that influenced the response

The political system of Nigeria appears to be unstable and is threatened by a number of factors in the form of increasing numbers of refugees, internally displaced population, and many other forms of conflict(WHO, 2012). Even though the government has introduced a number of programs,even with the support of many national and international organisations to fight against malaria,but there remains political issues which impact successful delivery of malaria programs. Nigeria is plagued by a number of terrorism activities, migration, ethnic and religious conflicts, and issues of displaced person (Ezenduka et al., 2014). In terms of the social factors, it was found that the perceptions regarding malaria and beliefs regarding the seriousness of the issue greatly influenced the preventive and curative actions (Berkman et al., 2014). furthermore, the understanding on the mode of transmission, adoption of the preventive measures, and decision-making differ from community to community,as there are misconceptions regarding malaria (Erhabor et al., 2010). The attitude and practices regarding malaria have been unsatisfactory in Nigeria, a majority of the people still believe in treating the disease at home through some rituals shaped by the culture and traditions of the past (Ezenduka et al., 2014). Based on an economic perspective, the fact that so many people live in poverty may indicate their inability to afford for treatment or spend money on preventative measures ,meaning that any measure introduced as an intervention would need to take this into account and provide free or affordable forms of prevention and cure.

5.0. Conclusion

It is challenging to ascertain one major reason why Nigeria continues to experience significant cases of malaria and malaria deaths despite all the efforts being made by the local and foreign bodies in combating this infectious disease in the country. Though poor socioeconomic status, poor-quality housing, unpaved roads, and limited access to healthcare has contributed significantly to weak health system in Nigeria, however, Political instability and corruption are key factors that have impeded efforts to improve the Nigerian health system. Importantly, poverty and unequal distribution of resources despite the country’s wealth status in addition has made it difficult for people to access the healthcare. An ever-growing population, poor planning and lack of education have all contributed to poor healthcare system in Nigeria.

It is clear that the country’s health system has the ability to deal with outbreak of disease-like the Ebola outbreak in 2014 which the country was able to contain and successfully bring to a halt. The suspected outbreak in Sokoto state in 2016 also elicited a huge response from the government and NGO’s. It appears that the government and local agencies tend to invest more when there is a suspected outbreak of disease and less on preventive measures. This might be the biggest lesson learnt in this case,such that the country needs to move from a reactive approach to practive approach,thereby investing more on preventive measures. Okorie et al (2016) sums it up thus; The support and cooperation of international organisations have been helpful but the major concern remains in the form of taking a proactive approach and implementing interventions before the outbreak of malaria rather than taking corrective actions after the outbreak of the disease.

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