In its quest to eliminate malaria, India focuses on Odisha and the tribal states

India’s goal of eliminating malaria by 2030 may appear at first glance to be easily attainable. Reported cases of the disease dropped by around half between 2001 and 2016 and, in nearly three-quarters of India’s more than 650 districts, the number of people falling ill from malaria is very low.

But India’s path towards elimination has proven to be particularly difficult in the remote and rugged tribal areas of the country’s north-east region and in the state of Odisha to the east – areas where malaria is one of the most common health problems. “Making advances against malaria in these areas is crucial, considering they represent the majority of the country’s malaria burden,” said Dr Henk Bekedam, the World Health Organization Representative in India.

The challenges are many. A forest-based economy in India’s tribal states means many people work in areas thick with the mosquitoes that carry the malaria parasite. Residents typically sleep outdoors, where they are easy targets for mosquitoes. In addition, people often wear inadequate clothing, which leaves them vulnerable to mosquito bites, and are often reluctant to seek medical help when they first develop symptoms of the disease.

What’s more, mosquitoes in these areas tend to transmit the disease efficiently and have developed resistance to as many as 3 of the 4 WHO-recommended classes of insecticides.

Massive scale up in the use of long-lasting insecticidal nets

To overcome these challenges and following the recommendations of WHO’s Global Technical Strategy for Malaria, Indian health authorities are increasing efforts to provide free access to bednets, expand the use of rapid diagnostic tests and provide early treatment for cases of the disease.

WHO’s global malaria strategy calls for early case detection and treatment as well as widespread use of measures to limit the population’s exposure to mosquitoes. “That means a massive scale up in the use of long-lasting insecticidal nets, indoor residual spraying and other mosquito-control measures,” said Dr Bekedam.

Much of the work is spearheaded by 900 000 trained Accredited Social Health Activists – or ASHAs. The ASHAs “are in each and every village” in tribal areas, according to Dr P.L. Joshi, former director of India’s National Vector Borne Disease Control Programme (NVBDCP). They serve as health activists, educators and promoters, providing villagers with information about the disease so that they can take steps to protect themselves.

In 2017, with financing from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the ASHAs helped distribute approximately 11 million bednets – enough to protect all of the residents in those areas of Odisha that are at highest risk for malaria, including residential hostels for schools. Across the nation, a total of 40 million bednets have been handed out or will be shortly.

Reducing malaria in these high-risk areas entails more than the widespread distribution of bednets. Just as important is ensuring that people who need them are using them. After going door to door in the tribal and village areas at night – when the mosquitoes bite – ASHAs and auxiliary nurses reported that more than 80% of the residents were using bednets properly.

Education as a public health tool

When ASHAs come across people who are not using bednets, they educate them about the life-saving protection the nets confer. For those who test positive for the malaria parasite, ASHAs issue health cards that keep a detailed record of their medication regimens and courses of treatment.

Public health officials have also enlisted the aid of folk troupes, which travel from village to village putting on performances that communicate the basics of malaria control.

After each performance, the actors engage their audiences with questions to ensure that their messages were both received and understood. They then encourage their listeners to spread the word among family and friends.

Taking messages to the most remote of villages

In some high-transmission areas, health workers drive vans equipped with loudspeakers to broadcast the messages. They play popular native tunes, their familiar lyrics replaced by new ones containing malaria messages that are also printed on pamphlets and distributed to villagers.

To reach people who cannot read, the ASHAs park their vans in the village centres, where they read aloud their health alerts in local languages and start a dialogue, soliciting questions and answering them.

ASHAs are not alone in carrying out such work. Numerous other groups have contributed to India’s success in slashing the incidence of the disease in tribal regions. They include malaria technical supervisors, the district vector-borne disease team, auxiliary nurse midwives and the state programme team.

Cases drop in Odisha and the north-eastern states

The numbers testify to the impact of their collective efforts.

In Odisha, the state with the greatest malaria burden in India, there were an estimated 295 000 reported cases from July through December 2016 – 56 of them fatal. During the same time period in 2017, the number of cases had fallen by nearly 50%, to approximately 156 000; fatalities fell by more than two thirds, to 16 deaths.

Similar progress has been made in the north-eastern states, where 7.2 million bednets were distributed in late 2015 and in 2016. Between 2016 and 2017, the reported number of cases of malaria fell from about 165 000 to fewer than 37 000, according to government figures.

Keeping track of cases is difficult

Yet obstacles remain. For example, keeping track of the malaria burden has proven to be difficult, since private doctors do not report their cases to the government database.

“We are optimistic that it can be done. If all the resources are there, then we can do it.”

Indian government official

As the number of cases has dropped, so have the funds needed to track down each case and to ensure it is properly treated.

And more difficulties may yet appear: though resistance to one of the primary weapons against malaria – artemisinin – has not been identified in India, it has been found in nearby Myanmar.

“This is a challenge,” one government official said. But, he added, none of the challenges to eliminating malaria from India are insurmountable, even in the states at highest risk. “We are optimistic that it can be done,” he said. “If all the resources are there, then we can do it.”