National framework for Malaria Elimination (NFME) 2016-2030

In February 2016, the Government has launched National framework for Malaria Elimination, which outlines the strategies for eradication of the disease by 2030. The framework defines goals, objectives, strategies, targets and timelines which are developed to serve as a road map to eliminate malaria and improve health and quality of life of the people.

Key strategic approaches defined by NFME

States/UTs are classified into categories depending upon their Annual Parasite Incidence (API) or malaria endemicity. API number gives the number of cases affected by malaria per 1000 population per annum.

• Category 0: prevention of reintroduction phase.
• Category 1: Elimination phase. States falling under this category have the API equal to 1 at both state and district levels. 15 states/UTs fall under this category: Haryana, Goa, Kerala, Himachal Pradesh, Jammu and Kashmir, Manipur, Punjab, Rajasthan, Sikkim, Uttarakhand, Chandigarh, Daman & Diu, Delhi, Lakshadweep and Puducherry.
• Category 2: Pre-elimination phase. States falling under this category has the overall API less than 1 but has greater than one in some districts. 11 states fall under this category: Nagaland, Gujarat, Andhra Pradesh, Assam, Bihar, Karnataka, Maharashtra, Tamil Nadu, Telangana, Uttar Pradesh and West Bengal.
• Category 3: Intensified control phase. States which has API>1 at both state and district levels falls under this category. These states are Madhya Pradesh, Chhatisgarh, Arunachal Pradesh, Meghalaya, Mizoram, Odhisha, Tripura, Andaman and Nicobar Islands, and Dadra and Nagar Haveli.

The districts are considered as the unit of planning and implementation and the high endemic areas are specially focused. Special strategy has also been designed for the elimination of P.vivax. The accredited social health activists will be provided special kits for immediate diagnosis of the disease. In addition, distribution of mosquito nets will also be increased.

Objectives of NFME

According to NFME, the following are identified as the objectives:

• Elimination of malaria by 2022 from all low (Category 1) and moderate (Category 2) endemic states/UTs (26);
• Reduction in the incidence of malaria to less than 1 case per 1000 population in all States/UTs and the districts and elimination of malaria in 31 states/UTs by 2024;
• Interruption in the indigenous transmission of malaria by 2027 in all States/ UTs (Category 3);
• Prevention of re-establishment of local transmission of malaria in areas where it has been completely eliminated and by 2030 maintaining the malaria-free status of the country.

Short term milestones

• Under the 12^th Five Year Plan, the target has been set to achieve API<1 at both the state and district levels by 2017.
• All states/UTs are expected to include malaria elimination in their broader health policies by the end of 2016.
• 15 states/UTs falling under category 1 (elimination phase) are expected to interrupt transmission of malaria and achieve zero indigenous cases and deaths due to malaria by the end of 2020.

Primary advantages in eliminating malaria

It is estimated that annually in India alone more than 1 million cases are reported to have been affected by malaria and it has emerged as one of the worst public health crises that India has ever faced. The disease endangers the life of 1 in every 6 Indians and the economy loses $2bn in lost productivity each year. In India, the tribal areas are particularly the most affected from malaria, which pulls the children out of school, burdens the family by pushing them in to debts and further leads to the death of many people.

Eradication of malaria will result in reduction in the expenditure on diseases control programme and will also reduce the out of pocket expenditure which needs to be made currently by the poor people. The elimination will help to fight other mosquito-borne diseases as well. According to the experts, investment made on malaria control and prevention activities will ultimately result in almost 20 times gains in reducing expenditure on healthcare along with bringing down the burden of diseases.

When it will be deemed that malaria has been completely eradicated?

The area will be considered malaria free if it records no indigenous transmission of Plasmodium vivax and Plasmodium falciparum, which are responsible for causing the disease. Once all the districts achieve this, then the country will be declared as malaria-free.

Constraints in implementing

Neglect of malaria and unreliable data:

Though, malaria is viewed as a public health crisis, eradication was assigned a low priority for decades. This has made the current effort ineffective and confusing to implement. In addition to this, there is no reliable data to know how many people suffer from this disease annually as estimates do not take into account the 60-80% patients in the urban area who gets treatment from private hospitals. Although malaria is made as a notifiable disease, penalities are not imposed on doctors and hospitals if they are not notifying.

Efforts taken by India to control malaria are less than most of the Asia and African countries. According to the WHO data, India spends the least on each individual living in a highly malaria prone area than any other country in the region including Bangladesh and Bhutan.

Other inadequacies:

The anti-malarial programme suffers from mismanagement of funds as a result of poor governance by the implementing agencies. Insufficient mosquito nets and pesticide sprays have undermined their efficacies.

Steps that need to be taken to address the constraints

With the availability of medicines and diagnostic kits, the delivery mechanism has to be streamlined to enable access to them. Overburdened staffs tend to underperform. So, more community health workers and supporting staffs need to be appointed and trained to function effectively. Budgetary allocation for the programme in specific and overall health care in general has to be increased. Also, steps have to be taken to create awareness among the people so as to ensure their active participation. Lastly, there is a need for community mobilization and sustenance of efforts to make this program successful.

Endnotes

With successful eradication of diseases like Polio and Maternal and Neonatal Tetanus, proper efforts with effective implementation may help in malaria eradication by 2030 as aimed by NMFE.