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India Needs $18 Billion to Eradicate Malaria by 2030
Dec 14, 2016

According to a latest estimate by the health ministry and malaria advocacy groups, India with the highest malaria burden outside Africa, will need an investment of $18 billion to achieve its 2030 deadline to eliminate the disease.

Senior health ministry officials, World Health Organisation (WHO), funders and malaria advocacy groups met in Chennai recently to consider strategies to shrink the global malaria map and took stock of India's anti-malaria efforts.

Causes of Malaria
Severe malaria outbreaks in India, aggravated by poor sanitation and drainage, underline an urgent and growing need for financial commitment to deal with a menace estimated to inflict nearly $2 billion or Rs 13,520 crore in socio-economic losses annually.

Present Scenario

  • The need for more finance comes even as statistics show India has seen a remarkable decline in malaria cases as well as deaths.
  • Malaria cases in India almost halved between 2000 and 2014, from 20 lakh to 11 lakh, with around 7.5 lakh cases and 188 deaths recorded till September this year. 
  • The decline in the number of malaria cases in India is an indication for funding agencies and, more importantly, for the government to keep up the momentum because this is the most crucial stage.
  • According to government estimates, $18 billion will be required to implement the National Framework for Malaria Elimination, which includes development of healthcare infrastructure in rural areas, as well as improving basic sanitation and sewage infrastructure in urban areas.
  • This includes distribution of medicines, improving hygiene and sanitation conditions in rural areas, adoption of innovative tools, deployment of healthcare workers and, most importantly, disease surveillance. Besides, the government plans to spend a major chunk of the investment in running awareness campaigns and introducing new drugs to tackle resistance.
  • Emerging resistance will require continuous investments in R&D. There is evidence showing that pulling out investments would bring back malaria.
  • The scale of the challenge can be judged by the fact that India accounts for 70% of malaria cases in WHO-classified southeast Asia region, which includes countries like Bangladesh, Nepal, Indonesia, Sri Lanka and Thailand, among others.
  • While India has achieved substantial progress in reducing malaria cases and deaths, it remains endemic in some states; and the government has identified 40 districts accounting for 80% of malaria cases.
  • There are also around 15 low-and 11 moderate-burden states that have been targeted for elimination by 2022. 
  • With 596 cases in 2015, Punjab could be the first state to be declared malaria-free.
  • Tamil Nadu too has achieved a 60% decrease in malaria cases since 2011, a commendable achievement given its hot and often humid weather.
  • With vigorous action in the low-burden states, and renewed efforts in all states, India can reach the historic goal of malaria-freedom by 2030.

Financial Help

  • Bill & Melinda Gates Foundation is one of the largest philanthropic funders of the malaria programme in India
  • In 2015, Global Fund gave India's national vector control programme a three-year grant of $104.5 million (around Rs 706 crore) to boost malaria surveillance, early diagnosis and treatment. 
  • The Centre allocates approximately $45 million (around Rs 304 crore) a year.

How Sri Lanka did it?

In September 2016, the World Health Organisation (WHO) declared Sri Lanka malaria-free. Victory over the disease came after more than seven decades, during which the country also went through a crippling civil war. The long years of accumulated technical experience was bolstered by a solid public health system that provided an efficient network of reporting, information-gathering and surveillance, and almost full literacy, which made it easier for health workers to educate and mobilise the 22 million population against the disease.

In 1991, the number of malaria cases was nearly 400,000. In 1995, when the civil war broke out in Sri Lanka again after a 100-day ceasefire, 142,000 cases of malaria were reported which, in 1999, rose to over 260,000. The patients were mostly male. Soldiers serving in the North-east were identified as vulnerable—and because they travelled back to their homes in southern Sri Lanka, a high-risk group. In 1998, 115 people died of malaria. 

The 2002-06 ceasefire helped the government’s campaign, which was backed by international funding—and by 2007, the incidence of the disease had come down dramatically to under 200. That year, when the fighting began again, saw a minor spike in the number of cases.

At the end of the war in 2009, the Sri Lankan Ministry of Health launched a malaria elimination programme, funded in part by the Global Fund to fight AIDS, Tuberculosis and Malaria. 

History

Sri Lanka’s efforts at vector control go back to when it experienced its first malaria epidemic in 1934-35. DDT spraying was introduced in the 1940s, and this remained the main method of vector control. Entomological surveillance—the study of vector species, its distribution, density and susceptibility or resistance to insecticides—a labour intensive exercise, began around the same time. Reporting malaria cases was made a legal requirement.

In 1963, as a result of these efforts, only 17 malaria cases were reported. Sri Lanka dropped its guard. Spraying was discontinued. And by 1969, malaria was back. There were 500,000 cases, and the mosquitoes had developed DDT resistance.

In 1977, Sri Lanka switched to malathion, considered less harmful to humans than DDT. But it would be another two decades, until the introduction of a new insecticide group called Pyrethroid, before Sri Lanka would have better ammunition against malaria, and its fight against the disease would begin in right earnest. It was highly effective. Because of less smell and less residual staining of surfaces, 99% of households allowed spraying. 

Insecticide coverage increased. Alongside, the government also distributed insecticide-treated mosquito nets. Before money poured in from the Global Fund—Sri Lanka received over $30 million in three tranches—the nets were made locally, and programme workers went house to house, treating the nets with insecticide. During 1989-91, there was a big outbreak of malaria, followed by spikes in 1995 and 1999. 

Parasite surveillance consisted of three procedures: passive detection, in which anyone going to hospital or a health centre with symptoms of malaria had to get their blood tested; active detection, in which health workers in mobile malaria units went from house to house doing blood tests on pre-identified high-risk groups; activated passive detection, in which a blood test was done on anyone coming into a health centre for reason.

In the elimination phase from 2008, each case was reported to the anti-malaria control headquarters in Colombo within 24 hours by email. Details of confirmed cases had to be relayed back. The standard operating procedure for nearly a month-long follow-up included treatment with medicines, screening of family and places were the patient had stayed or visited, insecticide spraying in the neighbourhood, and keeping a watch on mosquito density in the area.

The country’s public health system, with its extensive network of free primary medical centres and health workers, was the backbone of the programme, which ensured no person was left out. Apart from the 3,000 health workers directly involved in the anti-malaria campaign, all other village-level public health workers, including midwives, too were actively engaged in educating people and mobilising opinion.

The army pitched in by not sending home soldiers who fell ill while posted in the North and East, in case it was malaria. They were treated in the camp, and given leave to go home only after they were better. This checked transmission and played a big role in eliminating the disease.


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