Presented at the 2016 ASTMH conference

1. Yazoume Ye
MEASURE Evaluation/ICF
November 17, 2016
ASTMH, Atlanta
Malaria Implementation Assessment in
Four States of Nigeria:
An Innovative, Comprehensive, Mixed-
Methods Evaluation

2.  Background
 Objectives of the assessment
 Methodology
 Results
 Summary
Outline of Presentation

3. Background
Source: WMR 2015
Epidemiological profile
Financing
Source: WMR 2015
 The President’s Malaria Initiative
(PMI) support to Nigeria started in
2010
 Initial focus of PMI support was in
Cross River, Zamfara, and Nasarawa,
then expanded to 11 states,
including Sokoto
 PMI works with the states to
support selected health facilities in
malaria service delivery and
information systems
 Out of a population of 192 million,
PMI targets 54 million

4. To document progress in malaria control interventions
2008 – 2016 in four PMI-supported states — Cross River,
Ebonyi, Nassarawa, and Sokoto
Objectives of Assessment
1. Describe state-level malaria interventions
2. Document trends in malaria prevention and treatment
indicators
3. Compare quality of care between PMI and non-PMI-
supported primary public health care facilities
4. Document trends in malaria morbidity and mortality
at the hospital level
5. Assess the quality of monthly malaria data at health facilities
Main objectives
Specific objectives

5. Methodology
Assessment Sites
Note: PfPR = Plasmodium falciparum parasitemia rate

6. Methods
Design
 Combination of designs
o Non-experimental (pre- and post-assessment)
o Quasi-experimental design (PMI vs. non-PMI supported
health facilities)
– Quality of care and quality of data
 Trends in key malaria outcome and impact indicators
 Period: between 2008 and 2016
 Each state treated as independent case study
o no comparison conducted across states

7. Methods
Data sources
 Secondary data collation
o Routine data from primary health
centre (PHC) facilities
o Document review: Program
documents and data, and contextual
factors
o Household surveys (Demographic
and Health Surveys [DHS] and
Malaria Indicator Surveys [MIS])
 Primary data collection at PHC
facilities
o Client exit interviews
o Key informant interviews
o Observation of malaria commodities

8. Methods
 Health facilities
o List of all PHC facilities in each state
o Stratified random sample using probability
proportional to size: Selected 140 facilities in each
state (70 PMI and 70 non-PMI-supported) = 560
o Referral hospitals of the selected PHC facilities were
included in the sample (= 20 per state) = 80
 Clients for exit interviews
o Five clients per PHC = 2,800
o Targeted pregnant women attending antenatal care
and clients with fever (all ages)
Sampling Design

9. Methods
Data collection and analysis
 Field work period: February to
June 2016
 Field team in each state:
o Data collection: 1
supervisor, 3 data collators,
1 exit interviewer
o Quality assurance: 1
oversight consultant, 2
quality control officers, 1
field manager, 1 backup
exit interviewer
 State level: Trend of household
survey data (DHS 2008, 2013, and
MIS 2015)
 PHC level (PMI vs. non-PMI-
supported facilities)
o Trend of malaria diagnostic,
treatment and morbidity
indicators
o Chi-square test: Quality of care
malaria indicators
o Data quality: accuracy,
completeness, consistency, and
availability
Data collection and collation Data collection Analysis

10. Results
Sample achievement
 Facility: 100% in all states
 Exit interview:
o Ebonyi: 82%
o Cross River: 86%
o Nassarawa: 98%
o Sokoto: 84%

11. Malaria Prevention and Treatment (State)
At least one ITN At least one ITN/2 people
Vector control coverage: Household insecticide-treated net (ITN)
ownership
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofhouseholds
DHS 2008 DHS 2013 MIS 2015
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
DHS 2008 DHS 2013 MIS 2015

12. Under five children Pregnant women
Vector control coverage: ITN use
Malaria Prevention and Treatment (State)
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofchildrenunder5yearsold
DHS 2008 DHS 2013 MIS 2015
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofpregnantwomen
DHS 2008 DHS 2013 MIS 2015

13. Women who received 2+ doses of
sulfadoxine-pyrimethamine (SP) during
antenatal care visits
Women who received 3+ doses of
sulfadoxine-pyrimethamine (SP) during
antenatal care visits
Intermittent preventive treatment in pregnancy (IPTp) coverage
Malaria Prevention and Treatment (State)
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofpregnantwomen
DHS 2008 DHS 2013 MIS 2015
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofpregnantwomen
DHS 2008 DHS 2013 MIS 2015

14. Children who received any
antimalarial treatment
Children who received artemisinin combination
therapies (ACTs), out of those that received any
antimalarial treatment
Case management coverage
Malaria Prevention and Treatment (State)
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofchildrenunder5yearsold
DHS 2008 DHS 2013 MIS 2015
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nassarawa Sokoto
%ofchildrenunder5yearsold
DHS 2008 DHS 2013 MIS 2015

15. Quality of Care in PHC Facility
Proportion of PHC facilities that experienced a stockout of ACTs (register data)
Cross River Ebonyi
Nasarawa Sokoto
0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015 2016
PMI Non-PMI
0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015 2016
PMI Non-PMI
0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015 2016
PMI Non-PMI
0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015 2016
PMI Non-PMI

16. 0%
20%
40%
60%
80%
100%
120%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Nasarawa
PMI Non-PMI
Proportion of children under five (U5) that presented at PHC facility with fever
and were tested by RDT (register data)
0%
20%
40%
60%
80%
100%
120%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Ebonyi
PMI Non-PMI
Data completeness was too
low (<50%) for Sokoto to
compute indicators.
0%
20%
40%
60%
80%
100%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Cross River
PMI Non-PMI
Quality of Care in PHC Facility

17. Proportion of U5s with confirmed malaria receiving ACT (register data)
Data completeness was too
low (<50%) for Sokoto to
compute indicators.
0%
20%
40%
60%
80%
100%
120%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Cross River
PMI Non-PMI
0%
20%
40%
60%
80%
100%
120%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Ebonyi
PMI Non-PMI
0%
20%
40%
60%
80%
100%
120%
2008 2009 2010 2011 2012 2013 2014 2015 2016
Nasarawa
PMI Non-PMI
Quality of Care in PHC Facility

18. Malaria case management (exit interviews)
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nasarawa Sokoto
%ofclientswithfever
% of clients with fever who had a
test done
PMI Non-PMI
* Significant differences between PMI
and non-PMI facilities in Cross River
0
10
20
30
40
50
60
70
80
90
100
Cross River Ebonyi Nasarawa Sokoto
%ofclientswithfever
% of clients with fever that tested
positive for malaria, who were given
ACTs
PMI Non-PMI
Quality of Care in PHC Facility
* Significant differences between PMI
and non-PMI facilities in Ebonyi

19. 0
20
40
60
80
100
Cross River Ebonyi Nasarawa Sokoto
%ofpregnantwomen
% of pregnant women who were given
SP during visit
PMI Non-PMI
0
20
40
60
80
100
Cross River Ebonyi Nasarawa Sokoto
Among pregnant women who were
given SP, % asked to swallow tablets in
presence of health worker
PMI Non-PMI
* No significant differences between PMI and non-PMI facilities
were observed in any of the states for either indicator
Malaria in pregnancy (exit interviews)
Quality of Care in PHC Facility
%ofpregnantwomen

20. Quality of Data in PHC Facility
0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
Cross River
PMI Non-PMI
0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
Ebonyi
PMI Non-PMI
0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
Nasarawa
PMI Non-PMI
0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
Sokoto
PMI Non-PMI
Availability: Proportion of monthly summary forms (MSFs) available for review
at PHC out of the total number of MSFs that should be available
to review.

21. 0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
Cross River
PMI Non-PMI
0
20
40
60
80
100
2008 2010 2012 2014 2016
Ebonyi
PMI Non-PMI
0
20
40
60
80
100
2008 2009 2010 2011 2012 2013 2014 2015 2016
Nasarawa
PMI Non-PMI
0
20
40
60
80
100
2008 2010 2012 2014 2016
Sokoto
PMI Non-PMI
Completeness: Proportion of MSF data fields completed (filled in) out of the
total number of MSF data fields reviewed.
Quality of Data in PHC Facility

22. 0.00
0.50
1.00
1.50
Ebonyi Cross River Nasawara Sokoto
# of children under five presenting with
fever and tested by rapid diagnostic
test (RDT)
PMI Non-PMI
0.00
0.50
1.00
1.50
Ebonyi Cross River Nasawara Sokoto
# of children under five tested positive
for malaria by RDT
PMI Non-PMI
0.00
0.50
1.00
1.50
2.00
Ebonyi Cross River Nasawara Sokoto
# of children under five with confirmed
malaria
PMI Non-PMI
0.00
0.50
1.00
1.50
2.00
Ebonyi Cross River Nasawara Sokoto
# children under five with confirmed
malaria receiving ACT
PMI Non-PMI
Consistency: Verification ratio — Count in PHC register vs. value reported in the
MSF.
Quality of Data in PHC Facility

23. Summary
 Coverage of malaria interventions at the state level improved
since 2008, but overall remains below set national targets
 Availability of malaria commodities at PHCs improved in latter
years of the assessment period in both PMI and non-PMI-
supported facilities, with greater increases in PMI-supported
facilities
 Quality of malaria case management was good across all states
and slightly higher in PMI-supported PHCs; quality of malaria in
pregnancy care varied across all states, however, was generally
higher in PMI-supported PHCs
 Availability and completeness of routine data at PHC improved in
both PMI and non-PMI-supported facilities; consistency results
show discrepancies in data transfer

24. Acknowledgments
National Malaria Elimination Programme: Festus Okoh,
Taiwo Orimogunje, Nnenna Ezeigwe, Perpetua Uhomoibhi,
Timothy Obot, Olufemi Ajumobi
PMI/Nigeria: Uwem Inyang, Jessica Kafuko, Richard Niska, Abidemi
Okechukwu
Nielson Nigeria: Greg Nzuk, Uwem Ndah, Ochiedike Chijioke,
Joshua Bamigbode, Pradipta Mitra, Seun Olonade
MEASURE Evaluation: Ana Claudia Franca-Koh, Tajrina Hai,
Samantha Herrera, Lanre Adesoye, Balarabe Ibrahim, Abimbola
Olayemi, Mariam Adio Wahad

25. This presentation has been supported by the President’s Malaria
Initiative (PMI) through the United States Agency for
International Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement AIDOAA-L-14-00004.
MEASURE Evaluation is implemented by the Carolina Population
Center at the University of North Carolina at Chapel Hill, in
partnership with ICF International; John Snow, Inc.; Management
Sciences for Health; Palladium; and Tulane University. Views
expressed are not necessarily those of PMI, USAID, or the United
States government.
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