Theme: Supply and demand
Opportunities and challenges:
New Initiatives for Malaria Control
ASHAs: The changing face of malaria control
Dr G.S. Sonal , Additional Director
& HoD Malaria Division
National Vector Borne Disease Control Programme
Directorate General of Health Services
Ministry of Health and Family Welfare,
Government of India
National Vector Borne Disease Control
Programme India
Six diseases under NVBDCP:
Malaria Dengue
Chikungunya
Japanese Encephalitis
Kala-azar
Lymphatic Filariasis
Epidemic Prone
Targeted for Elimination
Gaps /Shortfall in surveillance - Human Resources
Institution/
Functionary
Requirement Sanctioned In Position Shortfall (%)
CHC 1/100000 7294 4809 4809 2766 (38)
PHC 1/30000 29213 23887 23887 7048 (24)
SC 1/5000 1,78,267 148124 148124 38762(22)
Lab Technician 28696 16153 16208 13611(47)
Sub-centre- MPW 148124 83241 52215 95909(65)
ANM - - 207868 -
Village level ASHA 727302 727302 653504 Trained
376017
in high
endemic area
Demand Annually > 100 million Blood slide collected /examined
Gape between BSC to BSE ~ 7days ( vary)
RDT (Pf specific) are being used in Pf predominant
areas
Bivalent RDT has greater scope and significant role
Scope of Bivalent RDT up to 40 million annualy which
reduce load on microscopy by ~ 40%
Still for 60 million Blood slide require microscopy Exm
Just for Cross checking (QA) 400 technicians are
required will reduced to 360 technician
Integration of Health Services
Multipurpose Health Scheme- 1976-77
Integrated Health Services- Primary Health Care System
Norms
CHC- for 80 thousand to 100 thousand population
PHC- for 20,000 / 30,000 population
Sub-centre- 3000/ 5000 population
Each sub-centre- one Male and one female Health worker
(MPW)
One Multipurpose Health Supervisor for 4 MPW
Fortnightly house to house visit for (Active Surveillance)
Sub-centre / PHC/CHC other HI – (Passive Surveillance)
Genesis of Community Volunteers
Village Health Guide- 1970’s
On recommendation Srivastava- Committee – 1979 Community
Health Volunteers Scheme
1981- Re- designated to Health Guide Scheme
Community outreach treatment Facility under
MPO-NMEP- 1976-77
Drug Distribution Centre (DDC)
Fever Treatment Centre (FTD)
World Bank Assisted – EMCP (1997)- I MLV for 3 FTD Distribution
NRHM 2005- Accredited Social Health Activist (ASHA)
ASHA involvement in Malaria work by providing incentive from
2008-09 in 257 districts of 24 states
At Present > 0.72 million ASHAs- Trained in malaria >0.35 million
MALARIA ENDEMIC AREAS
*Orissa, Jharkhand, Chhattisgarh, MP, Andhra Pradesh, Maharashtra Gujarat, Karnataka
PERCENTAGE CONTRIBUTION OF
POPULATION, MALARIA CASES, PF CASES
AND DEATHS in 2010
(Compared to the country total)
States
%
Popul
ation
%
Malaria
cases
%
Pf
cases
%
Death
N.E.
States 4 11 16 21
Other
high
endemic
states*
42 71 79 70
Other 54 18 5 9
API - 20100-1
>1-2>2-5
>5-10
>10
World Bank (Rs.1000 Crore: 2008-2013
GFATM: R-9 (Rs.417 Crore : 2010-2015)
Challenges
Deficient Health Infrastructure and manpower;
Much more in high malaria burden areas
Ecological /Environmental condition are conducive for vector in high malaria burden areas –Perennial transmission
Accessibility – limited in high malaria burden areas
Multiple ethnic group with different treatment seeking behaviour
Efficient vector prevalent in high malaria burden areas
Opportunities
NRHM strengthening the health structure and malaria control in rural
areas, at all levels.
National Urban Health Mission is expected to be launched as part of
National Health Mission in the 12th Five Year Plan will strengthen urban
malaria control.
Increasing commitment for funds from international agencies such as
GFATM and the World Bank
Good community organization (Panchayats, Self-Help Groups) for
promoting health present in most districts.
NGOs willing to be partners
Large scale introduction of RDTs in endemic areas for use by peripheral
health workers/ ASHAs.
Bivalent RDTs for Pf and Pv soon.
Large scale up-scaling of-RDT, ACT and LLINs
New Initiatives Use of ACT for treatment of Pf malaria cases
Use of RDTs (Pf) for Malaria by the community volunteers and peripheral health workers in areas with high Pf cases, and with poor microscopy facility
Planning for introducing bivalent RDTs
Distribution and scaling up of LLINs and treatment of community owned bednets with insecticide.
Additional technical manpower
Scaling up RDTs
•At Present mono-valent RDTs (only for PF) are being used
•Training of community volunteers in RDT and drug delivery
•Used in inaccessible and remote areas
• Introduced in 2003-04 and gradually scaled up
• Planning to introduce bivalent RDTs
0
2000000
4000000
6000000
8000000
10000000
12000000
14000000
16000000
18000000
Yearwise Supply of RDT in India
*Under Pipline
Scaling up ACT
• In 2008, ACT roll out as first line treatment of Pf cases in 117 districts. Besides above, 252 PHCs in 45 districts of 11 states also qualify for change to ACT
• From 2010, all Pf cases in the country –treated with ACT
• From 10-11, ACT Blisters for all age groups is introduced
• About 6.7 lakh Pf cases treated in 2011
• Other ACTs are being evaluated for introduction
• Peripheral health workers (MPWs) and CHV (ASHAs) trained for treating the Pf cases with ACT at the field level after confirmation with RDT or microscopy
Scaling up LLIN
14.5 million community-owned bed-nets were treated in the
community during the years 2005 to 2010
From 2009 LLINs has been introduced and being scaled up
Till 2011, >10 Million LLINs have been distributed, protecting
25 million population in high endemic areas from malaria
Procurement of 11.2 million LLINs in pipeline
NGOs and public distribution system involved in distribution
Scaling up community level Diagnosis and Treatment Facility
020000004000000600000080000001000000012000000140000001600000018000000
Scaling up- RDT
*Under Pipline
0
2000000
4000000
6000000
8000000
10000000
12000000 Scalin - LLINs
*Under Pipline
The situation before creation of ASHAs
SC was the peripheral level service center for
healthcare services (6-8 villages)
MPW male involved in surveillance- Fortnightly visit
(active)
Gape between BSC to examination >7ays
Large vacancies in manpower at SCs – limited
facilities for diagnosis and treatment
Weak referral mechanism
ASHA – The changing face of malaria control
Village level Health volunteer
Introduced under NRHM from 2005
Usually a female local resident (Bahu /wife)
Engaged for local /peripheral healthcare services
mainly for MCH and
later on being tapped by other CD programmes
Involved in high-malaria endemic areas with specific
trainings for diagnosis and treatment
Gradually being scaled up with due trainings
State wise break up of ASHA (1)
S.No Name of the State No. of ASHA
Sanctioned
No.of ASHA In-
position
No . of ASHA
Trained In Malaria
1 Assam 29007 28387 22150
2 Arunachal Pradesh. 3862 3862 2592
3 Meghalaya 6255 6255 5307
4 Manipur 3878 3878 3120
5 Mizoram 1786 1786 1786
6 Nagaland 1700 1541 1195
7 Tripura 7367 7367 7367
8 Jharkhand 40741 39125 36659
9 Orissa 41773 41207 30037
10 West Bengal 58182 30114 1500
11 Andhra Pradesh 70140 67379 8020
State wise break up of ASHA (2)
S.No Name of the State No. of ASHA
Sanctioned
No.of ASHA In-
position
No . of ASHA
Trained In Malaria
12 Chattisgarh 59489 59489 18240
13 Madhya Pradesh 56941 50113 32033
14 Maharashtra 59619 58022 53012
15 Gujarat 33282 29675 24248
16 Bihar 87135 78350 53000
17 Karnataka 35428 32743 9044
18 Kerala 34000 31252 24000
19 Sikkim 665 637 150
20 Uttrakhand 16606 11086 0
21 Punjab 17360 16590 15893
22 D & N Haveli 150 150 150
23 Rajasthan 48026 42496 25714
24 Haryana 14000 12000 800
Total 727392 653504 376017
Outcome of their involvement
Village level service for diagnosis and treatment available especially
in project areas
>10 million fever cases tested at the community level
~.01 million Pf. cases now detected at community level and getting
same day
With Bivalent RDT introduction ,it may go up to 4 folds
Resulting in reduction of malaria cases, severity and mortality
Ultimately it will reduce malaria morbidity and mortality burdern
E.g. in IMCP-II Project implemented in NE states the API has reduced
from 4.3 in 2008 to 2.4 in 2011
Challenges today for increasing their involvement
Capacity – low literacy level in tribal remote area
Training load -Continued training
Sustaining their motivation-Incentives
Proper supervision, Hand holding
Acceptability accessibility due Caste issues
social issue
Efficient supply chain mechanism – replenishing
Way Forward
Expansion of ASHA services
Maintaining supply chain- RTD, ACT, microslide
Training / Reorientation / hand holding to ensure
policy and strategy oriented role
Enhancing Incentive
Single window payment of incentive for malaria
work
Thank You
