April 23, 2010 - Although malaria was once nearly eradicated in India, it returned to the country with a vengeance in the late 1970s. Today, malaria and other vector-borne diseases are the most widespread cause of death, disability and economic loss in India especially among the poor who have limited access to timely and effective treatment. Malaria also contributes to maternal deaths, stillbirths, and low birth weight in infants as young children and pregnant women have little or no immunity to the disease. Moreover, a severe and often fatal form of malaria that accounts for almost all malaria-related deaths - Plasmodium falciparum (Pf) – has been rising rapidly in India since the 1980s.
In 2009, India’s public health system reported around 1.5 million malaria cases. About half of them were caused by the deadly P. falciparum parasite. However, the actual number of those afflicted with malaria is much higher as a large proportion of fever patients do not avail of government health services, preferring to seek private health care instead; hence, their numbers are not recorded. Given this, some analysts estimate that the total number of malaria cases in India could well range between 60-75 million each year.
The most malaria-prone areas in India are also among its poorest. While malaria is now on the rise in urban India, nearly half of all malaria cases are reported from Orissa, Jharkhand, and Chhattisgarh - which have sizeable tribal populations living in the remote rural areas – as well as West Bengal. The remoteness of many malaria endemic districts poses a particular challenge in the diagnosis and treatment of the disease.
Government Policy Evolves
In 1953, the Government of India launched the National Malaria Control Programme (NMCP) with a focus on indoor residual spraying of DDT. Within five years, the program helped to dramatically reduce the annual incidence of malaria. Encouraged by this, a more ambitious National Malaria Eradication Programme (NMEP) was launched in 1958. This further reduced the number of malaria cases and eliminated deaths from the disease. After 1967, however, a sense of complacency, combined with the mosquito’s resistance to insecticides and the parasite’s growing resistance to antimalarial drugs, led to a resurgence of the disease countrywide.
In 1997, the Government of India shifted its focus from the eradication of malaria to the control of the disease and switched from the blanket spraying of insecticides to selective spraying indoors. In 2003, malaria control was integrated with other vector borne diseases under the National Vector Borne Disease Control Programme (NVBDCP) as all such diseases share common control strategies such as chemical controls (e.g. indoor residual spraying), environmental management, biological control (e.g. larvivorous fish), and personal protection strategies (e.g. insecticide treated bed-nets).
In 2005, the Government also launched the National Rural Health Mission (NRHM), one of the thrusts of which is the control of vector-borne diseases including malaria.
World Bank Support
The World Bank has been assisting the Government of India in developing effective services for the control of malaria for over a decade. Between 1997 and 2005, a Malaria Control Project, partially funded by an IDA Credit, was implemented in select states and districts. The project supported the government’s shift from trying to control the mosquito to the prevention, early detection and treatment of human cases. While indoor residual spraying was to be more targeted and employ more environmentally neutral options, the use of larvivorous fish and bio-larvicides was encouraged, and the use of insecticide-treated mosquito nets was increased. The project also supported a shift in approach from the earlier command - and - control approach for malaria control to one that emphasized community involvement and ownership.
At the project’s end, while most project districts recorded a decline in the incidence of the disease (according to the NVBDCP, the number of malaria cases in India declined from 2.66 million in 1997 to 1.86 million in 2003), it also became clear that fundamental changes were required in the operation of the program.
New Approach to Malaria Control
In 2009, under the Government of India’s (GOI) new national malaria control policy, malaria prevention was strengthened by the adoption of Long Lasting Insecticide-treated Nets (LLINs), and case management expanded through the mobilization of voluntary community workers (called ASHA, recruited under NRHM) who were trained in the use of Rapid Diagnostic Kits (RDKs), and the administration of Artemesinin-based Combination Therapy (ACT).
Although ideally, all fever patients should be tested for malaria before any treatment is administered, the distance from laboratory facilities had earlier led to a practice whereby all such patients were administered chloroquine on the presumption that they had the disease. This had however resulted in the malaria parasite’s growing resistance to chloroquine treatment, and a rise in the share of falciparum malaria cases in the country.
The Government of India has now taken a policy decision to discontinue this presumptive treatment for malaria. It states that all suspected malaria patients should have their blood tested before any medication is prescribed. Whenever results can be delivered within 24 hours, testing should be done in a quality controlled laboratory through a microscope. If not, Rapid Diagnostic Kits should be used for testing, and health care providers should be trained for this purpose.
For all confirmed uncomplicated falciparum cases, ACT should be used as the first-line of treatment. The exception is pregnant women in their first trimester, who are treated with quinine.
As many patients seek private medical care, it is important to ensure that for-profit and non-profit private sector actors are involved in the implementation of the national program. Effective oversight mechanisms, possibly combined with strategies like franchising or social marketing, are also needed to ensure that private health care providers (including pharmacies, drug vendors and non-licensed medical practitioners) who may lack the necessary training, and who do not for the most part have access to laboratory facilities, follow the national treatment guidelines. In keeping with this, last year the GOI banned mono-therapies with Artemesinin to prevent the development of resistance to the drug.
The World Bank’s National Vector Borne Disease Control and Polio Eradication Support Project (2008-2013), in partnership with other development partners, supports the Government in implementing this new policy, strengthening service delivery systems, and measuring outcomes. It is being implemented in a phased manner in 93 of the most endemic districts in 8 states, covering over 100 million people.