Promising Practics in Health Care  
* Malaria Samadhan Sibir
* Community Based Monitoring System

The malaria situation in India in recent years has shown some improvement, but also some worrying signs of persistent problems.  Between 1995 and 2009, the total number of reported malaria cases in India declined from 2.93 million to 1.56 million: a reduction of nearly half.  However, the number of reported cases caused by the parasite Plasmodium falciparum (Pf), which causes the most serious form of the disease, declined by much less:  from 1.14 million to 840,000.  Thus, Pf moved from causing 38.84% of cases to 54%.

LEPRA's activities to control malaria are primarily concentrated in Orissa, the highest-prevalence state in the country.  In 2009, a startling 24% of the total reported cases in India (375,000) occurred in Orissa, with 198 deaths (again 24% of the reported national total).  In 2009 Orissa also had 336,047 Pf cases, or 40% of the total Pf cases reported in the country (and 88% of the total cases in Orissa), and  Pf is resistant to chloroquine in many areas.  220 of the 314 blocks in the state are high-burden for malaria, and 20 of the 30 districts. The state annual parasite infection rate (API) is 9.1, compared to a national API of 1.6.

LEPRA's malarial interventions, in Orissa and elsewhere, build on its long experience of community outreach and BCC.  They are complemented by work to support the NVBDCP in filariasis control, in districts of Orissa, AP and Bihar. 

Education and Awareness

LEPRA's work on malaria is centred around engagement with communities.  LEPRA's projects in high-prevalence districts of Orissa and AP include malaria among their information, education and communication (IEC) activities.  In Kalahandi district, Orissa, in the course of 2009, 7,000 pieces of printed IEC material were distributed at 19 public meetings and 18 film shows about malaria.  Projects in Koraput and Baragarh districts of Orissa, and in the slums of Hyderabad, AP, also distribute malaria-related IEC material from their mobile IEC vans.  In Sonepur district of Orissa, 40 street plays were conducted for awareness generation during 2009, covering about 80 villages, and a vehicle designed as a Malaria Rath moved through all 959 villages of the district during “malaria month”.

LEPRA's most significant malaria-control project has been the Mayurbhanj Integrated Community Health Project (MICHP), which ran 2006-2010, covering all 26 blocks of Mayurbhanj district, Orissa.  MICHIP's IEC activities on malaria included flash cards, posters, stickers, and radio jingles and two films in the local language, as well as  teaching community groups to perform street plays on malaria.  Among its activities was the training of communities on information promotion on malaria through QUEST methodology, a participatory IEC/BCC development process that develops community ownership in the promotion of information suited to their own context.  This has been identified as a best practice.

Malaria Samadhan Sibir

MICHP also developed LEPRA's unique community initiative, the Malaria Samadhan Sibir (malaria consultation camp (MSS)).  This combines three elements:  health education using IEC vans; provision of diagnostic and treatment services to those presenting with fever ; and joint meetings of health functionaries and key community members to organise communities for vector control and programme-related problem solving.  MSSs are implemented in collaboration with the mainstream health institution of the district, particularly in remote and inaccessible areas. In 2009 51 MSSs were held in Mayurbhanj and 28 in Kalahandi, the latter providing diagnosis and treatment to 2,755 beneficiaries. 

In 2010, 14 MSSs were organised in Mayurbhanj, with 2,557 fever patients receiving treatment.  Panchayat Health Resource Centers (PHRCs) referred 8,955 malaria-suspect fever cases to different health care centers run by the health administration.

MICHIP is recognised by the Government of Orissa's National Rural Health Mission in its published report “Malaria Best Practices in Mayurbhanj – Identifying local champions

Vector Control

LEPRA has also worked to support vector control activities, especially through MSSs.  In Mayurbhanj, community participation was used to promote the use of bed-nets, IRS, and Gambusia fish (to eat mosquito larvae).  In 2010, 24,967 LLINs were distributed and their use monitored, bed-net distribution was promoted in 949 villages, and IRS spraying monitored in 945 villages.

In Adilabad district of AP, in 2009, 185 people were trained in treating bed-nets with insecticides.  To support the IRS programme in Sonepur district, 1,750 GKS members were sensitized on what to do before and after use of IRS and 9 monitoring meetings were facilitated and guided by the LEPRA at the villages targeted for IRS during 2009.

Future Plans

In the coming years, LEPRA intends to expand the scope of its malarial interventions, driven by community-identified need, in line with the increased efforts by government and donor agencies to combat the problem. Its approach to malaria control will emphasise:

• Social mobilization, especially through the MSS, and empowerment of the grass roots, to foster demand for services and participate in vector control measures;
• Capacity-building of government, NGOs and CBOs, particularly to strengthen the referral system; and
• Delivery of timely preventive and curative services (both diagnosis and treatment) where necessary.

It will seek to combine its malaria interventions with the control of Kala Azar, another vector-borne disease, primarily found in Bihar..
In AP, LEPRA will carry out mapping of high-burden malaria-prone areas, do structural analysis, and implement specific interventions where appropriate.

LEPRA's Blue Peter Public Health & Research Centre will carry out research on;

• Prevalence of Pf malaria in tribal and urban areas;
• Anti malaria drug resistance among Pv and Pf cases; and
• Incidence of malaria among alpha thalasaemia and sickle cell anaemia clients in tribal areas.
It will also carry out operational research on:
• the role of private health care providers and practices in the treatment of malaria in tribal areas and their linkages to NVBDCP; and
• The use of LLINs and their impact on malarial incidence.