The hilly, wooded landscapes of India’s north and north-eastern states and the nomadic nature of many of its tribal groups contribute to the high number of malaria cases in that region of the country.
Some 80% of the malaria cases reported in India occur in these states which are home to only 20% of the population. Internal conflicts and increasing population mobility pose additional challenges to eliminating malaria in the region.
Despite these challenges, India is working – and making progress towards the elimination of malaria. Since 2000, the country has more than halved the number of malaria cases, down from 2 million to 882 000 in 2013. And, the trend is continuing.
Zero malaria cases – that is the aim of India’s National Vector Borne Disease Control Programme
“The success of our programme is a result of our implementation of all the World Health Organization’s recommended tools to defeat malaria,” says Dr A C Dhariwal, Director of India’s National Vector Borne Disease Control Programme. “Through rapid diagnostic tests, artemisinin-based combination therapy, long lasting insecticidal nets and indoor residual spraying, we’ve been able to bring down the rates of malaria and reduce the number of deaths.”
“The success of our programme is a result of our implementation of all the World Health Organization’s recommended tools to defeat malaria,”
Dr A C Dhariwal, Director of India’s National Vector Borne Disease Control Programme
Reducing malaria cases significantly – and sustaining those levels over a period of time – is an important prerequisite for malaria elimination in countries. WHO defines elimination as the reduction to zero malaria cases in a defined geographical area. The path towards malaria-free status includes 4 distinct programme phases: control, pre-elimination, elimination and prevention of reintroduction.
India is in the control phase, but is working to reach pre-elimination by 2017 and to complete elimination thereafter.
In order for the country to reach pre-elimination or halt local transmission to less than 1 case per 1000 population at risk, the National Vector Borne Disease Control Programme is targeting the areas hardest hit – the north and north-eastern states – with a key role being played by women from the local communities.
Reaching the most remote and vulnerable populations
The expansion of community-based diagnostic testing and treatment has been a key driver of progress.
Since 2005, India’s Ministry of Health and Family Welfare has trained and deployed more than 900 000 female volunteers or Accredited Social Health Activists (ASHA) to every village with a population of at least 1000 people. Chosen from their local communities, ASHA are trained to act as health educators and promoters – encouraging residents to seek treatment and protect themselves against diseases like malaria.
“Accredited Social Health Activists are trained to perform rapid diagnostic tests and administer artemisinin-based treatments,” says Dr Dhariwal. “The community knows to call her when they have a fever, and she is responsible for walking door-to-door to screen and monitor the health of her village.”
ASHA receive performance-based incentives for conducting home visits, tracking fever cases and submitting blood slides to the community health centres, among other assigned tasks. And, their work is helping control the disease.
Shifting efforts toward elimination
Outside of ASHA’s work, strong anti-malaria campaigns, increased availability of and accessibility to rapid diagnostic tests and use of artemisinin-based combination therapies are helping contain the spread of malaria.
To reach pre-elimination, all states in India will need to have annual parasite incidence (API) of less than 1 per 1000 and all districts within the state will also need to be less than 1. Currently, 74% of India’s more than 650 districts have achieved an API of less than 1.
“The country has committed to eliminate malaria so we’re now re-orienting our efforts to focus on elimination,” says Saurabh Jain, National Professional Officer at WHO India. “Our focus areas will remain the same, while our approaches will change as we are working to strengthen treatment and surveillance in the areas with the highest disease burden.”
Strong financial support, increased surveillance, more health workers, and further programme integration in all levels of the health system will be needed for the country to reach elimination.
A regional commitment
The country’s commitment to regional malaria elimination is timely. Emerging multi-drug resistance in the Greater Mekong subregion is threatening the substantial progress made toward elimination. At present, no alternative antimalarial medicine is available with the same level of efficacy as artemisinin-based combination therapies. India is monitoring resistance and working to change the main drug used in the country.
India has endorsed the goal of an Asia-Pacific free of malaria by 2030 and is participating in the work of the Asia Pacific Leaders Malaria Alliance.
The National Vector Borne Disease Control Programme also launched a partnership with the Indian Medical Association. Now, more than 250 000 Indian doctors are mandated to follow common guidelines for preventing, diagnosing and treating malaria.