Government policy effectiveness against malaria using meta-analysis

By Avishek Majumder on November 29, 2018

In India, the key strategies to curb malaria incidences gets revised in every five-year plan under the guidelines of National Vector Borne Disease Control Programme (NVBDCP). The Government of India focuses on two main intervention and control methods of malaria. Healthcare initiatives like Mukhyamantri Swasthya Seva Mission, and National Rural Healthcare Mission under the five-year plan and healthcare expenditure to support these missions. Malaria control and intervention are an integral part of these healthcare initiatives. In this regard, Meta-analysis study was conducted by using Comprehensive Meta-Analysis (CMA) to assess the government policy effectiveness under the 5-year plan scheme in accordance with the malaria incidence and deaths over the time span of last five year plans.

Directorate General of Health Services, MoHFW and the Government of India, is responsible for strategic planning, policy and decision making, providing technical guidance, monitoring and supervision of program implementation. Meta-analysis will help to find out the efficacy of the policies against the control of malaria incidence and mortality rates in the country.

Assessing government policy effectiveness

The data of cases of incidence and mortality due to Malaria in India to assess the government policy effectiveness were collected from the official site of NVBDCP (Ministry of Health & Welfare, 2017). The data collected from the 1998-2017 year time span which comprises the last four five year plans (9th, 10th. 11th, and 12th five-year plan). CMA software used the ‘unmatched groups’ of ‘rate’ function to categorize the data into four categories pre (incidence cases and mortality cases) and post (incidence cases and mortality cases). Forest plot was also constructed using CMA along with rate ratio as the effect measurement, lower and upper limit, Z-value and p-value to assess government policy effectiveness.

Table for pre- and post-incidence and mortality cases of malaria in India from the year 1998 to 2017:

Incidence Mortality Incidence Mortality
1998 2700000 879 2200000 664
1999 2200000 664 2300000 1048
2000 2300000 1048 2031790 932
2001 2031790 932 2085484 1005
2002 2085484 1005 1841229 973
2003 1841229 973 1869403 1006
2004 1869403 1006 1915363 949
2005 1915363 949 1816569 963
2006 1816569 963 1785129 1707
2007 1785129 1707 1508927 1311
2008 1508927 1311 1526210 1055
2009 1526210 1055 1563574 1144
2010 1563574 1144 1500000 767
2011 1500000 767 1310656 754
2012 1310656 754 1067824 519
2013 1067824 519 881730 440
2014 881730 440 1102205 562
2015 1102205 562 1169261 384
2016 1169261 384 1087285 331
2017 1087285 331 132216 31

Government policy effectiveness for 1998-2002 (9th five-year plan)

Policy efficacy 1998-2002
Policy efficacy 1998-2002

Analyses indicate that in the year 1998-2002, government policy effectiveness in the 9th five-year plan had no effect in the control and intervention of Malaria during this time. It is possible due to the resurgence of malaria cases in some states in 1994 due to the development of insecticide resistance in the vector species (Dash, Valecha, Anvikar, & Kumar, 2008). Lack of appropriate healthcare initiatives and fundings for public health also indicates the poor effectiveness of government policy. The government of India generated a mere budget of 19818.4 crores (2.31% of the total expenditure planned) from 1998 to 2002 (Planning commision, 1998).

Hence, the policy failed to make an impact on the burden of malaria in the country. The annual reported incidence of 1998 were 2-3 million cases causing massive continued to increase for the next 5 years. This failure led to the formation of National Rural Health Mission (NRHM) by the government of India in 2005 (10th 5-year plan) for future management and preparedness of malarial prevalence, especially in the rural areas.

Government policy effectiveness for 2003-2007 (10th five-year plan)

Policy efficacy 2003-2007
Policy efficacy 2003-2007

A similar result from the meta-analysis of the NBVDCP initiative was found for 10th five-year as in the 9th plan. The overall effect of the policy again falls on the line of no effect. This is due to the shift of focus from communicable disease to non-communicable disease under this 5-year plan according to the 10th five-year plan and the inception of  NRHM (Planning commission, 2002). The inception of new policy needs time to be effective with respect to public health. Although the expenditure increased by 31020.3 crores during 2003-2007, the percentage share of total budgets fell to 2.09%.

This clearly indicates the inefficiency of the policy implementation and malaria prevalence. This finding also corresponds to the data table, whereby the prevalence of malaria had gone up along with the rate of mortality. The failure of government policy effectiveness obligated the government to enforce objectives like free healthcare awareness camps for the poor and the rural, and also increased the expenditures.

Government policy effectiveness for 2008-2012 (11th five-year plan)

Policy efficacy 2008-2012
Policy efficacy 2008-2012

Government policy effectiveness found significantly effective for the 11th five-year plan. The efforts of malaria control for the rural and the poor on the basis of NBVDCP policy and NRHM started to improve. This is facilitated by improved objectives since its inception in 2005. The remarkable increase in the performance of the policy can also be due to the fact that during the eleventh plan funding for health by the central government had increased to 2.5 times and state to 2.14 times as compared to the funding allotted to the health sector in the 10th five-year plan (Planning commission, 2007).

The total healthcare expenditure for 11th five-year plan attributed to 3.15% off the total budget. Increased expenditures improved rural health care services and integrated disease surveillance of malaria. This assessment helped to incept and improve the existing objectives for better control and management of malaria in India. Government policy effectiveness allowed the association of another objective, which was the reduction of malaria mortality rate by 60%.

Government policy effectiveness for 2013-2017 (12th five-year plan)

Policy efficacy 2013-2017
Policy efficacy 2013-2017

In the 12th five-year plan major emphasis laid upon the improvement of the infrastructure of the health care facilities and increasing the health care personnel mainly for vector based diseases (Planning commission, 2013). Moreover, objectives of the NRHM also increased since its inception, the most prominent being, implementation of Janani Suraksha Yojana (JSY), cash assistance for treatment, free medical education, medical emergency training, and reduction of malaria by 60%.

Increased public healthcare expenditure budget also increased for the 12th five-year plan. Therefore, the meta-analysis indicated a forest plot indicating a positive effect of the policy under 12th five-plan in controlling malaria. Further, initiatives and policies indicted the efficiency of NHRM towards malaria control. Hence, the government of India focuses mainly on expenditures and healthcare policy implementations.

Policy effectiveness against malaria

Government policy effectiveness
Government policy effectiveness

In order to keep the positive effectiveness trend of policy and expenditure intervention, the government will continuously analyze the amount of money spent and forecast for the next five-year plan. This is a continuous process whereby the government forecasts the expenditure value and the malarial prevalence and strategizes NRHM’s objectives and expenditures accordingly. The government of India, therefore, follows a statistical cycle of effect size and forecasting for management and control of diseases and improvement of public health. A forecasting of malaria prevalence and expenditures that the Government of India must make for the next -year plan has been presented in the previous article.