This month, the Health Ministry will unveil an ambitious new plan to eliminate malaria from the country by 2030. A malaria-free India certainly sounds like a dream, or maybe an early campaign promise: the disease is one of the worst public health crises the country has ever faced, endangering one in every six Indians and costing the economy $2 billion in lost productivity each year. Malaria terrorises the Adivasi areas in particular, where the sickness routinely pulls children out of school, plunges countless families into crushing debt, and leads to agonising, expensive death. All this for a disease that costs only a few hundred rupees to prevent and cure.
A spotty track record
India’s record on malaria doesn’t exactly inspire optimism about the Health Ministry’s plans. The disease has been a low political priority for decades, rendering the current malaria control programme ineffective and confusing to implement. No one even knows exactly how many Indians suffer from malaria, let alone die from it each year: last year the government confirmed just under 300 deaths from malaria, while independent researchers at the British health journal The Lancet estimated 50,000 deaths annually. Even Indian malaria control officials acknowledge that there are severe limitations to the official statistics that depict steady progress on fighting the disease, claiming that new malaria cases dropped by half between 2000 and 2014.
Under-reporting is a global problem because malaria tends to reach where health workers don’t always do. It is a disease of the poor and powerless — the families sleeping under, if it all, mosquito nets that no longer work, miles away from doctors and nurses. Indians living in the forests and hills of the Northeast, or of Odisha and Chhattisgarh, who watch their loved ones waste away to a disease they don’t understand, while tired health workers write down that they just have a fever.
And the gap between India’s official malaria narrative and this ground reality is especially stark. Over two years of tracking malaria deaths from remote Adivasi villages in Odisha and Andhra Pradesh to the ministry headquarters in Delhi, we found that unreliable data effectively obscured a well-planned but broken malaria control programme.
Threadbare and chronically understaffed clinics often turn sick patients away or refer them to overcrowded district hospitals. Mosquito nets and pesticide sprays are seldom deployed on time or in sufficient quantities, ruining their efficacy. Overworked laboratory technicians race to keep up with unexamined stacks of blood tests for malaria in public health laboratories. The country also faced a shortage of anti-malarial drugs in 2014, and a longer shortage of life-saving mosquito nets — both apparent during our field visits. Meanwhile, we learned that government officials responsible for the programme succumbed to a culture of fear, afraid to report poor progress to their supervisors.
“Why does under-reporting happen? A very simple reason: wanting to please your bosses,” said V.P. Sharma, a former director of the National Institute of Malaria Research who received a Padma Bhushan for his groundbreaking work on the disease. He passed away last October.
Ultimately, the programme’s worst failures came down to neglect and poor governance, including a massive mismanagement of funds by the Central government and international agencies. For instance, medicated mosquito nets, also known as long-lasting insecticidal nets (LLINs), are essential tools in the global war on malaria, saving millions of lives throughout the developing world. India and the World Bank had initially agreed to distribute free nets to the 250 million people considered most at risk for malaria by the end of last year, which would have drastically cut down the number of people getting sick from mosquito-borne diseases.
Instead the nets have reached less than 1 per cent of the population, largely because the government did not purchase a single LLIN between 2012 and 2014, as dubious controversies between net manufacturers and the government repeatedly derailed auctions. As a result, India ended up returning nearly $200 million to the World Bank — enough to provide nets to 80 million people — and most of the country’s most malaria-prone districts never received the nets they desperately needed. According to one World Bank researcher we interviewed, this botched operation ultimately resulted in about 5,000 preventable deaths.
Policy and promise
Eliminating malaria is, and should be, a priority for the country, but grand pronouncements are meaningless as long as manipulated data distort our knowledge and bad governance impedes genuine attempts to fight the disease. Even if we take the official data at face value, India’s malaria efforts lag behind other those of most Asian and many African countries. According to the World Health Organization, India spends by far the least malaria control per at-risk capita (that is, on each individual living in a highly malaria-prone area) than any other country in the region, including Bangladesh and North Korea. And over 90 per cent of national spending on malaria control in 2014 went towards administrative costs, salaries, and expenses other than the nets, medicines and insecticide sprays that make a concrete difference. The average global spending on administrative costs and salaries, meanwhile, is just 35 per cent. One wonders why the Narendra Modi government suddenly wants to eradicate malaria before fixing these fundamental issues first.
The new malaria elimination policy does include some promising measures, like a greater emphasis on community participation in fighting malaria and, crucially, inviting non-profits to monitor the malaria programme. Currently, malaria control officials are responsible for reporting their own progress, creating an incentive to hide the bad news, especially in tribal areas with minimal government oversight. Independent reporting of malaria cases and deaths can eliminate this conflict of interests and help provide more reliable data. Another ray of hope is the budget: despite lower overall health spending, national spending on malaria control increased from Rs.400 crore to Rs.500 crore last year, and a new procurement policy has gone a long way towards speeding up the purchase of nets and pesticides. G.S. Sonal, additional director at the National Vector Borne Disease Control Programme, which coordinates the malaria programme, also told us there is a study underway to better measure the number of malaria deaths. “We don’t have the funding to do the things we want,” conceded Mr. Sonal. “Malaria is ultimately not a high-priority disease. If it was, we wouldn’t have to be in this situation.” But things, he added, were improving.
As a sprawling, diverse and highly populous country, India faces unique challenges that spared smaller countries, such as Uganda and Sri Lanka, that have achieved impressive reductions in their disease burden. The public health experts we talked to agreed that we would need to fill the empty slots on health clinic staffs, and train and incentivise community health workers. India would need to invest a much larger chunk of its domestic budget in overall health care, since the malaria programme on its own can’t prevent and treat disease. And the interventions would have to step outside the realm of the government health model. As Health Ministry officials will point out, some challenges are not in their hands: unqualified rural medical practitioners peddle inappropriate treatments, people refused to use mosquito nets, private clinics don’t report their malaria cases. This can only be combated with education and public awareness — the kind that allowed India to tackle polio.
Malaria strikes the hardest in the Northeast, in places like Bastar, in Chhattisgarh, or Koraput, in Odisha, that are already torn by the state and separatist violence and by the hold of corporations. Ultimately it can only be eliminated once the people in these areas are included as participants in the country’s development who can hold the state accountable to them. That would require shameless transparency from the government, and a focus not on its global image but instead on the actual people dying across the country every single day.
(Vivekananda Nemana is a freelance journalist based in Hyderabad who writes about rural culture and development. He is currently working on a book about how young people from tribal villages navigate new exposure to global markets. Ankita Rao is a health reporter and producer at WNYC.)
