World Malaria Day | Eliminating last mile challenges critical

India’s experience and success with polio eradication and progress with measles-rubella elimination has showed that programmes need to evolve and adapt

April 25 was instituted as the World Malaria Day by WHO Member States during the 60th World Health Assembly of 2007. African governments have been observing this day since 2001 though. It is marked to raise awareness of the global effort to control, and ultimately eliminate malaria.

In its quest for a malaria-free world as an important public health and sustainable development goal, the WHO launched the Global Technical Strategy for Malaria 2016-2030, to eliminate malaria in at least 10 countries by 2020. The ambitious new target of reducing the global malaria burden by 90 per cent by 2030 was envisaged as a major contribution to implementing the post-2015 sustainable development framework.

This needs to be understood in the backdrop of the success in achieving Target 6.C of the Millennium Development Goal 6: ‘Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases’. Fifty-five of the 106 countries that had malaria transmission in 2000 set a target to reduce malaria incidence by 75 per cent by 2015. The target was “met convincingly”; the rate of new malaria infections declined by an estimated 37 per cent during 2000-15 and the malaria death rate fell by 60 per cent.

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India Strategy

Aligned with the current global vision, India’s National Framework for Malaria Elimination 2016–2030 sets two goals: eliminating malaria i.e., zero indigenous cases throughout the country by 2030; and, maintaining malaria-free status in areas where transmission has been interrupted and prevent re-introduction.

This is sought to be achieved sequentially through four key steps: By 2022 — eliminating malaria from all 26 low (Category 1) and moderate (Category 2) transmission states/union territories (UTs); By 2024 — the incidence of malaria to less than one case per 1,000 population per year in all districts of Category 1 and 2 states and UTs; By 2027 — interrupting indigenous transmission of malaria throughout the entire country, including high transmission states and UTs (Category 3); and, by 2030 and beyond — preventing re-establishment of local transmission and maintaining national malaria-free status.

Pandemic Years

India made significant progress in the two decades prior to the to the Covid-19 pandemic marked by a 71.8 per cent reduction in malaria cases, and a 73.9 per cent decline in deaths during 2000-19. India was conspicuous as the only high-endemic nation to register a decline of 17.6 per cent in 2019 compared to 2018 and a further decrease in cases by about 45 per cent between 2019 and 2020.

The World Malaria Report 2022 notes that among the countries supported under the high burden high impact (HBHI) approach, India did not distribute any insecticide treated bed nets (ITNs) planned for distribution in 2021. Pfhrp2/3 gene deletions, signifying increased risk for rapid diagnostic tests (RDT) failure that would lead to less detection, were reported from India.

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Last-mile Challenges

A recent district-level analysis indicated that that half of the districts in India (307) have either reported zero cases of malaria (117 districts) or have only negligible (<50 cases) that are expected to be reduced to zero within two-three years. Fifteen districts may stretch beyond 2030 for zero case status; these include two megacities (Greater Mumbai and Kolkata) and those with sizeable tribal population.

Tribals living in forested areas accounted for 21 per cent malaria cases in 2019, while constituting only 6.6 per cent of India’s population. Forty-two per cent of malaria-related deaths were reported from these areas during 2000-19. The challenges identified in these districts include increasing insecticide resistance, a high proportion of sub-microscopic infections, and barriers to ‘test and treat’ communities.

Malaria is currently notifiable in 33 states and UTs, and the remaining three (Bihar, Andaman and Nicobar Islands, and Meghalaya) are expected to follow suit. Notification by private sector practitioners and institutions shall be critical in the final phases of elimination in any state or district. Ensuring availability and accessibility of effective and responsive primary care services urban poor and peri-urban populations have emerged as key challenges to even the best-performing health programmes such as immunisation.

With extensive migration across India, these sub-populations can pose serious last-mile challenges. Gathering harmonised data on cross-border malaria epidemiology is increasingly being recognised as a key ingredient for implementing cross-border co-operation for malaria control and elimination.

India’s experience and success with polio eradication and progress with measles-rubella elimination has amply demonstrated that programmes need to constantly learn and undertake implementation research to provide evidence for effective implementation of elimination strategies, and address emerging challenges.

(Rajib Dasgupta is Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, and Editor, Indian Journal of Public Health)

(Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH)