Malaria is a life-threatening infectious disease that is preventable and curable. It is mainly caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. Common parasites that cause malarial prevalence in India are Plasmodium viviax, and Plasmodium falciparum. It is not only prevalent in India, but also in south-east Asia, Africa, and a few areas of the American continent (National Vector Borne Disease Control Programme, 2017). Various techniques, strategies, and intervention methods are used to control and manage the prevalence of malaria.
One of the most important strategies is an effective implementation of public healthcare policies. Other intervention methods include awareness programme, healthcare programmes, and drug development. However, these are possible with insights from epidemiological studies. For this purpose use of trend-based analyses, geospatial analyses, inferential analyses, forecasting analyses, and meta-analyses are essential to explore ways to reduce the malarial prevalence.
Malarial prevalence in different states of India
India accounts for 6% of all malaria cases in the world, 6% of the deaths, and 51% of the global P. vivax cases. Trend-based assessments estimate that the total cases of Malaria in 2017 in India tallies for 1.31 million and deaths at 23990. However, the cases of malaria in 2012 in India were estimated to be 9.7 million, with about 48,660 deaths. There has been a whopping decrease in cases of malaria and deaths. The malaria incidence as per the NVBDCP incidence records is prevalent in most of India. Moreover, >90-95% cases reported from rural areas and <5-10% from urban areas on an average from 2010 to 2017 (Ministry of Health and Family Welfare, 2017).
However, in certain scattered regions of Rajasthan, Gujarat, Karnataka, Goa, Madhya Pradesh, Chhattisgarh, Jharkhand, and Orissa and the Northeastern states were greatly prevalent. The proportion of P. vivax and P. falciparum varies in different parts of India. Although mostly Indo-Gangetic plains and northern hilly states, northwestern India and southern Tamil Nadu state have less than 10% P. falciparum cases, and the rest are P. vivax infections in India. In the forested areas inhabited by ethnic tribes and remote areas, and the P. falciparum cases is 30–90%, and in the remaining areas, it is between 10% and 30%.
A high proportion of P. falciparum, up to 90%, is seen in zones inhabited by ethnic tribes in forest ecosystems where stable malaria conditions occur. According to the statistical findings, Orissa has a population that alone contributed to 25% of the total of 1.5–2 million reported annual malaria cases, 39.5% of P. falciparum malaria and 30% of deaths caused by malaria in India.
The poor economic condition poses a major risk in the prevention of Malaria
The study identified a wide variety of risk factors; socio-economic, environmental, and demographic. The most important risk factor causing malaria is the poor economic condition of the rural and below poverty population in India (National Vector Borne Disease Control Programme, 2017). As the majority of the rural population and below poverty population suffer from malaria infections, their economic conditions lead to poor lifestyle and living conditions. Poor income compels them to live in unhygienic conditions, poor sanitation, poor toiletry conditions, and congested living. In addition, poor income leads to poor eating habits or diet, which is another cause for the prevalence of infections in rural and slums (Roser and Ritchie, 2017).
Education and level of awareness improve the level of awareness and therefore a person in the high epidemic zone will seriously consider in taking protective measures against the risks of malaria (CDC, 2016). Economic conditions also impact the literacy level of the people living in rural and remote locations. Illiteracy in rural areas also comprehends the capability to improve their income level and thereby impacts its social aspects.
Intervention methods opted by the government of India
Two types of interventions are important for malaria control and reducing the number of deaths from Malaria in India. One is a national healthcare policy intervention mentioned in the 5-year plan and the other is healthcare expenditure annually by the government. The national strategic plan (NSP) is a part of the 5-year plans by the government in the guidelines of National Vector Borne Disease Control Programme (NVBDCP) for malaria control and intervention (Ministry of Health and Family Welfare, 2017). Until 2017, four 5-year plans have passed since the implementation of National Vector Borne Disease Control Programme.
The rate of malaria cases has decreased since 1998, along with mortality rate from malaria. These policy interventions have attempted to improve the backward, poor and remote parts of the country, and improve control interventions for better healthcare (Directorate General Of Health Services, 2018). The budget allotted to the education and health sector of the country, improvement in the health care facilities and increasing awareness in the population of India regarding the control and prevention of malaria; are all the major aspects of Government’s healthcare policy intervention.
Inferential analysis of the impact of expenditures by the Indian government on malarial prevalence implies a positive influence on Malarial prevalence. The expenditure on public health has increased every year from 2009-2017. A significant relationship between health expenditure and cases of malaria and deaths from malaria with respect to % of total health expenditure is inversely proportional to the total cases of malaria (Directorate General Of Health Services, 2018). On the other hand, healthcare expenditure as % of GDP too implied an inverse relationship to total cases of malaria and deaths from malaria. Higher the cases of malaria, lower are the expenditure or a fall in cases of malaria and deaths from malaria. Therefore, expenditure based intervention by the Government has a significant impact on malaria prevalence and mortality.
A stable decrease in the malarial prevalence in India
In India, about 95% population in the country resides in malaria-endemic geographical locations. 80% of malaria is confined to areas of the population residing in tribal, hilly, and remote locations (National Vector Borne Disease Control Programme, 2017). National Vector Borne Disease Control Programme (NVBDCP) has framed technical guidelines and policies for the provision of resources to control the malarial prevalence in those locations.
The trend analysis presented shows that over the years the percentage of malaria cases has decreased significantly from 3.04 to 0.84 million cases of malaria incidences. There has been a sharp drop of 73.2% from the number of cases of malaria in 1995 to 2017. These are contributed by consistent efforts of the government and healthcare organizations to reduce the incidences of malaria in India. The contribution of pharmaceutical industries also justifies in this respect. There has been a constant change of approximately 6% drop in cases of malaria every year. Between the years 1995 and 2017 there were 5 five year plans in India, which mainly focused on the eradication and control programmes against vector born diseases, malaria specifically. Increasing amount of budgets was also formed during these years that led to the formation of effective management systems for management of malaria cases.
On the other hand, the risks of death from malaria have also fallen significantly over the past years. Although there were certain fluctuations, that rose during FY2006. This was contributed by viral encephalitis, swine flu, and avian flu outbreaks during 2006 and pre-2006. These viral outbreaks affected many people that indirectly contributed to increases in deaths from malaria cases. In addition, natural disasters like the tsunami in 2004 led to a drastic spike in the prevalence of malaria cases and deaths.
In 2004, the majority of the healthcare centres and emergency services were hit in the prime locations. The loss of health personnel caused a low number of physicians, nurses, and increased post-disaster deaths (Carballo, Daita and Hernandez, 2005). The blowback to the healthcare sector of the country and the region is one of the major reasons for a sudden spike in the number of deaths.
Tsunami also brought in many infectious diseases, malaria is the most prevalent. Lack of appropriate healthcare availability and relocation affordability by the government increased the prevalence of malaria cases during those years (Herper, 2011). Lack of sanitation and medication from poor funding by the government of India and lack of planning led to the sudden rise of malarial deaths during 2004-2009. A huge economic burden on healthcare services and local hospitals increased short-lived infections, viral fevers and diarrhoeal infections (Ramalanjaona, 2011). Postnatural calamity caused prolonged prevalence of diseases transmitted by the faecal-oral route was the main flood-related health impact. Such diseases include nonspecific diarrhoea, cholera, dysentery, and typhoid, mosquito-borne diseases and other infections.
The role of Government to curb rising malarial prevalence
Chhattisgarh and Jharkhand showed high percentage rise in cases of hospitalization in case of the rural population (Ministry of Statistics and Programme Implementation, 2018). On the other hand, Madhya Pradesh and Odisha show high cases of hospitalization in case of the urban population. In addition, medical expenditure in the states of Goa, Kerala, Maharashtra, and Andhra Pradesh has increased from increased cases of diseases and hospitalizations. They, on the other hand, are also some of the most endemic states of Malaria (National Health Accounts Cell, 2017). State wise malarial prevalence indicates a high number of cases in Odisha, Chhattisgarh, Jharkhand, Maharashtra, and Andhra Pradesh as in 2017. Thus, the healthcare expenditures by the government have been increased to curb the prevalence of malaria based on different economic and demographic aspects.
Expenditure allocations by the government of India are made to the states and government missions and programmes such as National Health Protection Scheme, National Rural Health Mission, National Health Policy and government health and wellness centres (National Health Portal Of India, 2017). Allocations of expenditures to states for health is based on hospitalization cases, diseases incidences, economic conditions of the public, unemployment, treatment expenditure costs, rural and below poverty population, mortality rates, and income per capita of the state.
For instance in the most recent budget by the government for 2018, healthcare allocation to the state of Odisha was Rs 1,370 crore for the National Health Mission, and Rs 700 crore for the state-run healthcare mission, “Mukhya Mantri Swasthya Seva Mission” (Government of Odisha, 2018). The Mukhya Mantri Swasthya Seva Mission comprises of free treatment for the poor, free drug distribution, and healthcare awareness and education programmes. Infectious disease prevention programme comprises of distribution of commodities, healthcare awareness and education programmes and free healthcare services.
Increased Government healthcare expenditure helped to manage malarial prevalence in India
Healthcare expenditures by the government in India have been gradually increasing over the past few years. In the year 2011, healthcare expenditure was merely 96 crores, whereas it has increased by 54%, at 214 crores in 2017. It is estimated that the expenditures will rise to 400 crores by 2020. According to reports by Firstpost in 2018, the constant rise in expenditures is motivated by increasing the economy of the country, reduced cases of malaria reduce deaths from malaria, and increase awareness amongst the population of India. Increasing population and need for good health for all sections of the population has also motivated the government to allow more expenditure plans with respect to healthcare and the reduction of malarial prevalence. Forecasting of the expenditures indicates an increased impact of increasing economy of the country, livelihood, reduced cases of malaria and reduces deaths from malaria on budget planning.
The increasing trend of expenditures for healthcare in India is contributed by government policies, lifestyle changes, and the growing population of the rural and below poverty. Increase in access to healthcare services by approx. 170% between 2000 and 2016 has also spiked the increase in healthcare expenditures by the government (Ministry of Statistics and Programme Implementation, 2018). This is the total case for both rural and urban areas in India. Increase in access to healthcare is contributed by increased cases of hospitalizations and severe cases of illness. Another reason for the rise in healthcare expenditures in contributed by rising in GDP per capita.
According to statistical findings, the GDP per capita of India has increased by 121% from 2002 to 2016. This is indicative from the rise in hospitalization cases in India over the past decade. Estimations found that India spends on public health per capita every year is Rs 1,112 (National Health Accounts Cell, 2017). Demographic, socio-economic, health status and health finance indicators, human resources, and health infrastructure also defines the increase in healthcare expenditure by the government of India. Poor health status of India and increased mortality rates motivated the Government to increase the number of expenditures by the government. Although the expenditures for healthcare have reduced the cases of malaria in India, according to a report of Business Today in 2018 socio-economic and national health factors motivate the government to increase its expenditure capabilities.
Assessment of efficacy of healthcare policies improved 5-year planning over the years
The 5 year-plans in India implicates the total budget needed for the healthcare of the nation’s population (Government of India, 2013). Therefore, the government conducts efficacy assessments before the implementation of new policies and expenditure plans. Trend-based outcomes and forecasted outcomes help in assessing the efficacy of policy-based interventions against malarial control and management.
Statistical analyses found that the eleventh five-year plan for 2008-2012 the situation of malaria control become well. It was also evident from the trend analysis, cases of malaria during the years 2008-2012 had significantly decreased. This is accompanied by an improvement in the health care facilities and increasing awareness in the population of India. The level of national and rural programmes too increased (National Health Portal Of India, 2017). The remarkable increase in the performance of the policy was due to the fact that during the eleventh plan funding for health by the central government had increased by 2.5 times and for the state by 2.14 times as compared to the funding allotted to the health sector in the tenth five-year plan 2003-2007.
In a similar way the government of India, use these outcomes to assess the efficacy of the 5-year plan policy and its impact on the malarial prevalence. Similarly, an improved case of expenditure and malarial prevalence also impacted the twelfth five plans (National Health Portal Of India, 2017). The twelfth five plan the policy had a positive impact on the malaria condition in the country at that time and it helped in reducing the number of incidence and mortality cases.
Further study on the prevalence of Dengue
Dengue is another form of vector-borne diseases prevalent in India caused by a virus belonging to family Flaviviridae carried by the Aedes mosquito (National Vector Borne Disease Control Programme, 2017). According to Mutheneni et al., (2017), “For the past ten years, the number of dengue cases has gradually increased in India” (p.1). This contradicts the status of the prevalence of malaria in India. In a comparative study by the National Vector Borne Disease Control Programme (NVBDCP), the cases of dengue are rising whereas the cases of malaria are decreasing as the same rate. Likewise malaria, dengue too is prevalent from factors of lack of awareness, temperature and rainfall (Siva et al., 2018).
In this regard, the government of India have initiated various programmes and expenditure plans. One such programme is the formation of the National Dengue Day, and the National Dengue Control Programme (National Health Portal Of India, 2018). In addition, the government also funds for effective education and awareness programmes, drug development, and healthcare services to the population at risk. Even after multiple efforts by the government and other healthcare organizations, there is a constant rise in cases of dengue. Furthermore, an in-depth epidemiological study about dengue can help assess the factors causing dengue prevalence and the efficiency of the intervention methods. This future assessment shall lead to the efficacy of the Government policy in the prevention and intervention of the disease.
- Business Today (2018) Budget 2018: Insufficient allocation for the health sector. Available at: https://www.businesstoday.in/union-budget-2018-19/news/budget-2018-insufficient-allocation-health-sector-heathcare-scheme/story/269449.html (Accessed: 13 November 2018).
- Carballo, M., Daita, S. and Hernandez, M. (2005) ‘Impact of the Tsunami on healthcare systems’, J R Soc Med, 98(9), pp. 390–395.
- CDC (2016) Malaria Information and Prophylaxis , by Country. Washington D.C. Available at: http://www.cdc.gov/malaria/travelers/country_table/m.html.
- Directorate General Of Health Services (2018) National Rural Health Mission (NRHM) report 2017. Available at: http://dghs.gov.in/.
- Firstpost (2018) India’s per capita expenditure on healthcare among lowest in the world; govt spends as little as Rs 3 per day on each citizen. Available at: https://www.firstpost.com/india/indias-per-capita-expenditure-on-healthcare-among-lowest-in-the-world-govt-spends-as-little-as-rs-3-per-day-on-each-citizen-4559761.html (Accessed: 13 November 2018).
- Government of India (2013) Twelfth Five Year Plan (2012–2017): Faster, More Inclusive and Sustainable Growth, Volume I, Planning Commission Government of India. Available at: http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol1.pdf.
- Government of Odisha (2018) Odisha Budget Analysis 2018-19. Bhubaneswar. Available at: http://budget.odisha.gov.in/.
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- Ministry of Health and Family Welfare (2017) National Strategic Plan for Malaria Elimination (2017-22). Available at: http://pib.nic.in/newsite/PrintRelease.aspx?relid=167379.
- Ministry of Statistics and Programme Implementation (2018) Health in India. New Delhi. Available at: www.mospi.gov.in/.
- Mutheneni, S. R. et al. (2017) ‘Dengue burden in India : recent trends and importance of climatic parameters’, Emerg Microbes Infect, 6(8), pp. 1–19. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583666/.
- National Health Accounts Cell (2017) Health Sector Financing By Centre and States/UTs in India. New Delhi. Available at: https://mohfw.gov.in/.
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- National Health Portal Of India (2018) National Dengue Day. Available at: https://www.nhp.gov.in/national-dengue-day_pg.
- National Vector Borne Disease Control Programme (2017) India | National Vector Borne Disease Control Programme | Malaria.
- Ramalanjaona, G. (2011) ‘Impact of 2004 Tsunami in the Islands of Indian Ocean: Lessons Learned’, Emergency Medicine International, 27(6), pp. 11–14.
- Roser, M. and Ritchie, H. (2017) Malaria – Our World in Data. Geneva. Available at: https://ourworldindata.org/malaria.
- Siva, P. et al. (2018) ‘Malaria , dengue and chikungunya in India – An update’, Indian Journal of Medical Specialities, 9(1), pp. 25–29. Available at: https://doi.org/10.1016/j.injms.2017.12.001.
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