~ Prachi Thatte
Malaria is a major public-health issue in India. The World Health Organization estimates that India accounts for 75% of all the malaria cases in South East Asia. Although a life threatening disease, malaria can be prevented and cured. The National Framework for Malaria Elimination, launched in 2016, aims to make India a malaria-free nation by 2030. However, there are many challenges for malaria elimination in India due to diverse and complex socio-environmental conditions across the country. While mortality and infection have declined in many parts of India over the last decade, tribal regions of India continue to have high prevalence and mortality. About 80% of malaria reported in the country is restricted to tribal areas which are home to just 20% of India’s population. Understanding and addressing the reasons for this regional disparity would be critical to ensure successful elimination of malaria in India.
Radhika Sundararajan and colleagues sought to identify the reasons that might impede the success of malaria control programs in tribal areas in their 2013 study titled ‘Barriers to Malaria Control among Marginalized Tribal Communities: A Qualitative Study‘. The study was carried out in the tribal-dominated Gadchiroli district in Maharashtra, India. Forests cover more than 75% of the geographical area of this district and tribal communities make up nearly 40% of the population. Government health-care infrastructure in the district comprises of 1 district hospital, 12 rural hospitals, 45 primary health centres (PHCs) and 375 primary health units. The National Vector Borne Disease Control Program (NVBDCP) is implemented in the district through doctors stationed at PHCs and Community Health Workers (CHWs) who travel to villages to provide preventive care, testing and treatment. Despite having such extensive health-care infrastructure in place, why were malaria control programs less successful in the district?
In order to answer the question, the researchers carried out two different sets of interviews. 1- with the tribal villagers and the traditional healers to assess their knowledge about malaria and their experiences with infection and prevention of malaria. 2- with the CHWs, medical officers and district officials to understand the barriers to treating and preventing malaria among tribal populations. They also examined the health-care access and delivery among these populations. A total of 84 individuals participated in the interviews.
The interviews revealed that the tribal villagers had basic knowledge about malaria. They knew that it was transmitted through mosquitoes and that monsoon and winter were high risk seasons. Those who had suffered from malaria had more knowledge about the disease. However, when symptoms arose, the villagers preferred to consult traditional healers or informal medical practitioners and not a CHW or a doctor. Traditional healers were highly regarded in the community. There was at least one traditional healer in each village. The healers did not charge for the treatment. Tribal communities believed that illness can be caused by evil spirits or unfulfilled ancestral commitments, and the healers performed rituals to ward off evil and resolve conflicts. Interviews with the healers revealed that they recognize that such rituals cannot cure malaria. And hence, if the symptoms persist for more than a couple of days, they refer the patient to a doctor or an informal health-care provider.
Informal health-care providers lack formal medical training. However, they perform blood tests, initiate anti-malaria treatment in some cases or often inject non-steroidal anti-inflammatory drugs to relieve symptoms. Interviews with the villagers revealed that the informal health-care providers visit villages regularly, carry out active surveillance and canvas for potential clients. In contrast, active surveillance of fever cases among tribal villages by CHWs was inadequate, the study found. CHWs visit the villages once in a week or a fortnight. According to the NVBDCP protocol, malaria testing needs to be done within 24 hours and if positive, the results need to be communicated to the patient within 48 hours in order to begin anti-malarial medication. Interviews with the CHWs revealed that maintaining the timelines was difficult for them. They cited the long distances between villages, naxalite activities prevalent in the district and lack of adequate staff as the reasons. This also makes it difficult to follow-up on patients who begin anti-malaria treatment. Adherence with anti-malarial medication is a problem in these areas, the study finds. Based on the interviews with all the participants, researchers identified areas within the NVBDCP program to improve malaria control in tribal regions. Firstly, owing to the heavy reliance of the villagers on the traditional healers, researchers recommend that NVBDCP should consider working with the traditional healers and also informal health-care providers. Researchers emphasize the need to educate the tribal villagers, informal health-care providers and the traditional healers about the importance of early treatment of malaria. They suggest beginning concurrent treatment by the traditional healer along with blood testing and initiation of anti-malarial treatment. Secondly, researchers recommend improving surveillance and diagnosis of malaria by strengthening the network of village-level health workers. The National Rural Health Mission launched in 2005, made a provision for creating a network of Accredited Social Health Activists (ASHA) at the village level. Training one ASHA in each village as health educator and promoter can ensure village-level diagnosis and initiation of malaria treatment. Thirdly, researchers recommend providing culturally appropriate health education to the villagers in the local tribal language (Gondi). Currently education material that is distributed is in the principal language of the state (Marathi) which is not common in the study region. Such initiatives, researchers suggest, would improve adoption of preventive strategies and also adherence to antimalarial medicine. Researchers argue that the barriers to successful malaria control are inextricable from socio-historical processes of cultural, economic and geographic marginalization. While the historical and cultural context in this research may be unique to the study area, researchers argue that the insights gained from this study can be utilized to improve the malaria control programs in other areas with tribal communities which have high prevalence of the disease. The Tribal Malaria Action Plan, an initiative under the National Framework of Malaria Elimination 2016-2030, does refer to the economic and cultural aspects which need to be considered while designing control measures. Implementation of such measures would be critical for achieving the target of making India malaria free by 2030. Original paper: Radhika Sundararajan, Yogeshwar Kalkonde, Charuta Gokhale, P. Gregg Greenough and Abhay Bang. 2013. Barriers to Malaria Control among Marginalized Tribal Communities: A Qualitative Study. PLOS ONE. Available at: https://doi.org/10.1371/journal.pone.0081966
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