Controlling Malaria in India

The Bank has financed malaria control efforts in South Asia through stand-alone projects, such as in India (ongoing), component of a health project, such as in Sri Lanka (closed in 2002) and SWAps (Sector Wide Approaches), such as in Bangladesh. 

Bank financing has been largely directed at supporting India’s National Anti-Malaria (now called the National Vector Borne Disease Control Program).  The support to India began in 1997 with the approval of the Enhanced Malaria Control Project (IDA credit of about US$119 million).  In 2001, the project was restructured, with a revised credit of US$86 million.  The closing date of project has been extended to October 31, 2005.

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Project Development Objectives (DO). The medium-term objective of the project is to help India create an enhanced and more effective malaria control program by: (i) using a better mix of effective malaria control interventions responsive to local needs; and (ii) strengthening of the National Program.  The long-term objective is to reduce death, morbidity, and social and economic losses from malaria.

The project initially covered 1045 tribal blocks (PHCs) in 100 districts in 8 states, namely AP, Chhattisgarh, Gujarat, Jharkand, MP, Maharashtra, Orissa, and Rajasthan.  In 2003, it expanded to cover 200 PHCs, and added 2 states, Karnataka and West Bengal. 

EMCP has five components:  (i) Early Diagnosis and Prompt Treatment (EDPT); (ii) Selective Vector Control; (iii) Insecticide-treated Bed Nets (ITNs); (iv) Epidemic Response and Inter-Sectoral Collaboration; and (v) Institutional Strengthening.

Progress To Date:  What has worked
Reduction in morbidity and mortality due to malaria:   In 2004, approximately 650,000 malaria cases were reported in EMCP Districts, which represent a 45 percent decline since 1997.  In addition, mortality in these districts fell by 58 percent.  With the project support, Gujarat, Andhra Pradesh, and Maharashtra have lowered malaria morbidity by 65 percent to 70 percent, and Madhya Pradesh and Chattisgarh by 50 percent - 55 percent.   Nationwide, the malaria morbidity declined by 38 percent during the same period.

The success of EMCP was the result of several factors.  Among these were adopting a sound technical strategy based on a package of proven, cost-effective interventions, which India effectively scaled up.  Heavy reliance on indoor residual spraying was replaced by massive expansion of early diagnosis and prompt treatment at the village level, scaling up of insecticide treated bed nets and larvivorous fish, health promotion, and improvements in disease surveillance.

-Use of IRS continues to decline from year to year.  In 2004, less than 25 million population was covered with IRS, almost 50 percent less than in 1997

-2 million bed nets have been distributed and additional 3 million to be procured and distributed in the next six months.  NGOs and community based organizations are involved in promotion of bed nets and re-treatment.  In Assam, bet net use was reported to be over 90 percent in 2002, whereas in other states with high malaria burden, such as Jharkand, Orissa, and MP, the use remains relatively low, at 55 percent, 50 percent, and 20 percent respectively.

-For early diagnosis and prompt treatment, more than 316,000 Drug Distribution centers, fever treatment depots, and malaria link volunteers are functional in all project districts.

-About 470 district-level and 21,000 block-level hatcheries of larvivorous fish have been established through community groups and local governments.

Targeting areas with the highest disease burden and vulnerable populations (i.e. tribal populations) was critical to EMCP success.  The selection of the blocks to be included in the project was based on: (i) API of more than 2 for the past 3 years; (ii) P. falciparum more than 30 percent of total malaria cases; (iii) 25 percent of the PHC population is tribal; and (iv) reported deaths due to malaria.  In addition, states with low performance with high burden, such as Orissa and Jharkhand, were given greater attention and supervision.  Orissa improved significantly over the past year, whereas Jharkand remains stagnant.

Giving state health departments’ responsibility and resources to support district-level implementation after the mid-term review greatly accelerated implementation and innovation.  Decentralizing implementation support also permitted the National Program to focus their technical support to those states and districts where implementation progress was slow (e.g., Orissa). Capacity to plan, budget, and implement has been greatly strengthened at the national level, seven of the eight original states (except Jharkhand), and in almost all districts. The speed and quality of implementation in almost all EMCP districts has greatly improved, although delays in procurement and financial management have on occasion impeded progress. 

Relying on surveillance data to guide programs and policies.  The Government of India has deployed the computerized National Malaria Management Information System (NAMMIS) at National, State and District levels.  The system is being used not only to inform programmatic decisions, but also to exchange queries and lessons between malaria officers and others involved in control efforts.

Emerging Issues and Challenges
In October 2004, the Government submitted a proposal to the Bank for an operation that would support the country in meeting the National Health Policy goals of controlling malaria, and in addition, four other vector borne diseases—Lymphatic Filaria (LF), Dengue, Kala-Azar, and Japanese Encephalistis (JE).  The new operation would build upon successes and lessons learned from the EMCP and address the following emerging issues and challenges.

While drug resistance can cause treatment failure, not all treatment failure is due to drug resistance.  Factors causing failure—such as incorrect dosing, non-compliance with duration of regimen, poor drug quality, drug interactions, poor or erratic absorption, and misdiagnosis—contribute to the development and intensification of true drug resistance.  About 25 studies of treatment using chloroquine were carried out in India between 1996 and 2004, and they indicate a median of 34 percent for treatment failure.  Studies show that with SP combination about a median of 18 percent treatment failure to SP. 

Controlling malaria in urban settings.  Incidence of malaria, as well as other vector borne diseases, is increasing in urban areas. Given the autonomous governance of larger urban areas and the failure to achieve any progress in these areas during EMCP, a separate approach is needed.  Intersectoral collaboration and partnership with the private sector would be critical to bring about impact in the urban settings.

Addressing state variations in performance and disease burden.  Experience from EMCP demonstrated wide variability in implementation capacity and resources between the states.  States, such as Maharastra, Gujarat, and Andhra Pradesh, have a more established health infrastructure and significant financing from their state governments.  Implementation in these states took off rapidly and impact was dramatic.  Malaria burden dropped more than 70 percent during the project period.  In contrast, infrastructure and financing in states like Orissa, Jharkand, and Chhattisgarh were less well established.  Implementation was slow or nonexistent until aggressive TA was provided by the National Program.

Streamlining and simplifying procurement, financial management, and environmental safeguards.  Implementation continues to be hampered by procurement and fund flow bottlenecks.  There is a need to explore how streamlining and simplification can be carried out, particularly in the context of increased decentralization, and at the same time improving transparency and accountability for results.