IPH

Policy Brief 1/2011 August 1 2011

Prashanth NS, Nandini Velho and Umesh Srinivasan

Addressing health system failure to improve malaria care in north-east India

Why this brief? Most remote and inaccessible areas, especially in north-east India, continue to remain highly endemic for malaria. Many such areas are in and around thick forests and the unique local conditions necessitate special measures to tackle malaria. The weak health systems in these areas are unable to implement the operational guidelines framed at the national level. The following brief outlines new and emerging Disproportionately affects the poor and evidence2 that would strengthen malaria control and prevention people living in and efforts in north-east India. around forests and inaccessible areas Who is this addressed to? Directorate of the National Vector-borne disease Control Programme, Health Secretaries and Director of health services and district malaria officers of north-eastern states and other decision-makers in all government departments in north-east Indian states and office of the National Rural Health Mission of Government of India. What we know: Malaria is among the top 10 reported causes of death among all age groups in India. Eighty per cent of malaria patients are reported in 20% of the population1. The brunt of the disease is borne by people living in remote and thickly forested areas. In such areas, in addition to the burden on the local community, frontline staff working within public services are adversely affected, thus further weakening the effectiveness of these services. This leads to a self- reinforcing cycle of poor public service delivery and increasing malaria death and disability (See figure). For example, the availability of teachers in primary schools in remote malaria-prone areas affects education services. Similarly, anti-poaching efforts are affected in and around forest areas,2 thus hampering forest management and wildlife conservation. Evidence-based and practical guidelines5 have not translated into timely and quality care for malaria at primary health centres (PHC) in such areas. This leads to increased dependence on expensive and irrational care at private clinics or hospitals, increasing both personal and institutional economic burden.
For further details, contact prashanthns@iphindia.org Institute of Public Health, #250, 2 C Main, 2 C Cross, Girinagar I Phase, Bangalore 560 085
http://www.iphindia.org

+91 80 26421929 mail@iphindia.org

IPH Policy Brief 1/2011 August 1 2011

Prashanth NS, Nandini Velho and Umesh Srinivasan

What can we do: At PHCs and district level 1. Prevention: Improve distribution and availability of Insecticide-treated Nets which are effective in preventing malaria-related deaths and infections3 especially in thickly forested regions in South-east Asia including Myanmar, Thailand and Cambodia. 2. Improve early detection and reporting by making available rapid test kits in remote settlements and temporary human settlements in and around forest areas such as anti- poaching camps. In villages more than 12 hours transit from the nearest PHC/subcentre, representatives of the local community and government departments (e.g. forest department staff, teachers, PWD engineers, block development officers) should be trained to administer malaria tests with rapid diagnostic kits, interpret results and begin treatment through a half day training programme as per the national guidelines.4 3. Diagnosis: Ensure microscopy/rapid diagnostic kit availability at every PHC or remote sub- centre as per the latest national guidelines5. 4. Treatment: Ensure availability of combination therapy drugs and other anti-malarials5 in sufficient quantities. Annual action plans prepared at the district level should take into account the rapid increase in malaria during the monsoons and post-monsoon seasons. Ensure availability especially in remote areas, which are likely to get cut off for months together - Use discretionary funds (NRHM untied funds) for this purpose if necessary. 5. Ensure staff availability and retention in remote areas through provision of appropriate housing and other incentives for all PHC staff. Thickly forested and remote areas should be brought under NRHM eligibility for remote area allowance. At State/national level 1. Improve coordination with other departments in expanding malaria prevention efforts in the community as well as among frontline staff of these departments working in malaria-prone areas. This should be done by local health departments by arranging half- day training camps for representatives from government departments. 2. Invest in malaria prevention within all state departments: All state-level departments (in addition to the health department) with staff in and around malaria-prone areas should budget for providing insecticide-treated nets to their front-line staff. 3. Implement the Clinical Establishment Bill6 in all north-eastern states to improve reporting of malaria cases treated in private sector as well as ensure treatment according to national guidelines in these centres.

Foundation of India, New Delhi

1 Strategic pathways for control of Malaria: Recommendations of Expert Consultation, 2009, Public Health 2 Velho N, Srinivasan U, Prashanth NS and Laurance WF, Human disease hinders anti-poaching efforts in Indian

nature reserves, Biological Conservation 144, pp 2382-85 Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev. 2004;(2):CD000363. 4 Guidelines for Rapid Diagnostic Tests, NVBDCP 5 NRHM & NVBDCP, National Drug Policy on Malaria, 2010, Government of India, New Delhi 6 The Clinical Establishments (Registration and Regulation) Bill, 2010 seeks to register and regulate private clinics through better reporting, accreditation and notifying standards of care for various diseases. It is presently pending in the Rajya Sabha and if passed would be in effect in all union territories and in four states (Arunachal Pradesh, Himachal Pradesh, Mizoram, and Sikkim).
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For further details, contact prashanthns@iphindia.org Institute of Public Health, #250, 2 C Main, 2 C Cross, Girinagar I Phase, Bangalore 560 085
http://www.iphindia.org

+91 80 26421929 mail@iphindia.org