India is committed to eliminating malaria from the country by 2030, a pledge made by the Honorable Prime Minister at the 10th East Asia Summit in 2015. This clarion call led to the compilation of two national strategies to combat malaria – the National Framework for Malaria Elimination (2016-2030) and the National Strategic Plan for Malaria Elimination (2017-2022). Accordingly, India has showcased immense achievement against the disease and recorded a decline of 81.25%** in malaria cases and a 58.76%** decline in malaria-related deaths in 2021 (up to December’21) as compared to 2017.
Although tremendous progress has been made against malaria, these figures only account for the change in official government data. WHO, in their World Malaria Report 2021, estimated cases between 2.7 and 5.9 million* for India in 2020, whereas the official data recorded only around 187,000 cases**. This stark disparity in estimated and recorded numbers acts as a major concern for India’s malaria elimination journey. The World Malaria Report did highlight wins for India, noting a decrease in malaria figures in 2020 over 2019, albeit at a rate lower than before the pandemic, but the under-reporting of malaria in official numbers takes the joy out of reading such factoids.
One of the primary reasons for such disparity remains the malaria burden diagnosed and treated in the private health sector. The Indian healthcare system follows a collaborative approach with players across the private and public sectors providing services. Several patients tend to seek private medical care, and while malaria has been made notifiable in 31 states/union territories, meaning each diagnosed case needs to be notified in the official government data, the enforcement of this notification for the private health sector largely remains a challenge.
A statistic that may support this claim is that during 2012-2016, the total sales of anti-malarial drugs did not show a continuous decline, a decline which was captured in the official malaria cases reported by the government. Furthermore, during 2015-16, the officially reported cases of malaria decreased from 1.17 million to 1.09 million, however, the sales of anti-malaria drugs increased from 560.9 crore to 626.1 crore***. This implies that at least in the private sector malaria cases were not falling continuously, if sales of anti-malarial drugs are considered as one of the indicative figures. However, such cases diagnosed and treated in the private sector were failing to be recorded in the official data, as reflected by the decline in official figures during this period.
The private health providers are not solely responsible – in our country, there does not exist a centralized reporting system that can feed patient data from the public and the private sector. While both the public sector and private sector remain adept at maintaining data of patients diagnosed and treated by them, an integrated system for collective reporting is unavailable. This compromises the quality of data that is reported by the central government, which in turn showcases an inaccurate picture of malaria prevalence in India.
India has entered the endgame of its malaria elimination journey and is in the process of conceptualizing the final National Strategic Plan for Malaria Elimination (2022-27). This plan will be critical for achieving zero indigenous transmission of malaria in India by 2027 and for sustaining such zero transmission for 3 years till 2030, a requirement essential for receiving the certification of malaria elimination from the WHO. As per the World Malaria Report 2021, India accounted for 83%* of cases and 82%* of all malaria deaths in the WHO Southeast Asia, highlighting the dire need for concerted efforts to eliminate the disease. To achieve the goal of malaria elimination, strategies must be streamlined, and all malaria cases must be collated into a central system through the active involvement of the public and private sectors. This presents an opportunity for policymakers to ensure effective data management by the inclusion of a robust integrated reporting system that can collect disease data from all points of health service – whether public or private – and also ensure strict enforcement of reporting processes to help our country achieve this ambitious goal by 2030, in line with government priorities.
It is key for us to remain aware of the true malaria burden in India to be able to devise effective strategies and eliminate the disease. It is only with concerted and collaborative effort between the public sector and the private sector that we can truly make strides towards our goal of eliminating malaria-like has been done in the case of TB and HIV. It is also imperative to ensure intersectoral action, engaging all cross-cutting institutions such as Education, Municipalities, Women & Child Development, Panchayati Raj Institutions, Railways, Defense, Tribal Affairs, and so on in the fight against malaria to ensure a holistic effort toward the realization of malaria elimination in India by 2030!
Written by Krishna Mohan Jha, Analyst and Consultant, Directorate of Health Services, Madhya Pradesh