10 commandments to eliminate malaria

If there is one disease that captures the intimate relationship of the classic epidemiological trial of agent, host and environment, it is malaria.

A scourge since centuries, the United Nations’ Sustainable Developmental Goals identifying the theme for this year’s World Malaria Day (Apr 25) as “End Malaria for Good;” it is evident that this is impossible without India fulfilling its own malaria elimination commitment till 2030. Contributing 70% of malaria cases and 69% of malaria deaths in South-East Asia, India evidently is the most important theatre in this battle.

What is the way forward to achieve this ambitious goal? Especially reaching the tribal and forested areas of the country where malaria is more prevalent, signifying an unambiguous cultural and geographic predilection of the disease?

First and foremost is establishing a robust surveillance system, including focused strengthening of the Infectious Disease Surveillance Programme, which currently remains the languished stepchild of the health system. There should also be a constant effort to have disaggregated data, as region specific as allowed by statistical strength. This will prevent the summary statistics hiding the significant variation in data providing specific clues. It may also lead to Simpson’s paradox completely changing our prevalent thinking as to the nature of the burden.

Second, make India self-reliant in weaponry against malaria, focusing on developing and manufacturing a high quality long lasting insecticide treated bed net and a new range of anti-malarial. The ‘Make in India’ campaign may not find a better cause célèbre than this.

Third, beware of the emerging challenges on our frontiers, such as artemisinin resistance crossing national borders and entering India through North East. India is unprepared for this impending national emergency and efforts on war footing need to be undertaken for it.

Fourth, significant institutional strengthening as well as complete revamping of the National Vector Borne Disease Control Programme (NVBDCP) is an urgent prerequisite. Why has it happened that there is no tribal specific malaria control action plan developed by the NVBDCP even after 50 years of being in existence? Or that the Flexipool of the National Health Mission has turned into a rigid line item budget sheet? This strangulation of fresh thinking needs to be addressed immediately, through synergising of the several frontline organisations and the government.

Fifth, a mass education drive focusing on educating the communities about malaria. There should be specific emphasis on identifying the demand, influencer, motivator and barrier as done in the case of any modern marketing campaign methods. In this context, the tribal residential schools should be explored as a driver of spreading the message.

Management methods

Sixth, use of modern management methods in implementation of the programme. The Malaria Control Programme can be an ideal platform to implement the Expenditure Information Network outlined by Nandan Nilekani in his book ‘Rebooting India’ focusing on outcomes based financing and bang for buck.

Seventh, take lead in the race to transfer almost miraculous new technologies like the CRISPR–Cas9 for vector modification from the West, train Indian human resources and explore early field trials. Do the same post learning appropriate lessons from the shrill and vitiated debate similar to that of the GM crop in the country.

Eighth, attend to health systems strengthening. Health professionals can learn from Aadhaar which was designed as a platform, serving several needs, and applying the principle of asynchronicity in which every part of the ecosystem was able to function independently, preventing any dependence on one critical step as the bottleneck which can result in the failure of the entire programme.

Ninth, implementation of appropriate public health engineering techniques, learning again from the West which controlled infectious diseases with such intervention including modern sanitation system and waste water management.

And 10th, implementation of simple interventions, such as the engagements of ASHA and other frontline workers in diagnosis and treatment using rapid diagnostic kits and antimalarial. If the cadre of vaccinators helped India to achieve victory over small pox, the inadequate use of the ASHA in the fight against malaria reflects incompetency.

(The writer is Advisor (Health), Tata Trusts. He previously worked as a Senior Consultant at Union Ministry of Health and Family Welfare)