In Odisha, strained health system in remote areas struggles to control resurgent malaria cases

On a sweltering June morning, Sumit Sisa felt extremely cold. His head hurt, and he had spiked a fever. After a day of struggling with fever, muscle aches and no relief Sisa, 25, who lives with his wife and a toddler in a thatch and clay tile hut in Bonda Hills in the Khairput block, roughly 80 km from Odisha’s southernmost Malkangiri district, visited the nearest primary health centre in Mudulipada, a kilometre away from his home, alone.

At the primary health centre, the doctor conducted a Rapid Diagnosis Test. This meant a drop of blood was taken from Sisa’s finger and immediately placed on a test strip. A few drops of a solution were added, and a couple of minutes later, two red lines appeared on the strip.

Sisa tested positive for falciparum malaria – for the third time in the last three years.

According to the National Vector Borne Disease Control Programme, India has recorded over a million laboratory-confirmed cases of malaria every year (except in 2013), Since then, the programme recorded a drop in cases from 840,000 in 2017 to 180,000 in 2022.

Malaria is a vector-borne life-threatening disease caused by the Plasmodium parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes which carry the parasite. The two major Plasmodium species causing malaria in India are Plasmodium falciparum (Pf) and Plasmodium vivax (Pv), and these are unevenly distributed across the country.

Plasmodium falciparum is more lethal. Government data show that across the country, since 2008, Plasmodium falciparum infections have accounted for over half the malaria cases in the country. In densely forested areas, this proportion is even higher – 77% in 2019 – research shows.

Home to about 3.5% of India’s population Odisha, with about 40% forest and tree cover and hot and humid climatic conditions, is highly conducive to malaria transmission. The state contributes to about 40% of India’s falciparum malaria burden, and 30% of deaths. Estimates suggest that 91.5% of malaria cases in Odisha are caused by P. falciparum.

Testing positive for P. falciparum malaria meant that Sisa had to be immediately treated with Artemisinin Combination Therapy for three days, and a single dose of Primaquine. Artemisinin Combination Therapy is provided across 19 other states and Union territories in India that are resistant to chloroquine, another antimalarial for preventing and treating the disease, as per the guidelines of the National Vector Borne Disease Control Programme.

Instead, Sisa was given a paracetamol tablet, a drug used to treat mild to moderate pain and fever, because the health centre did not have Artemisinin Combination Therapy and Primaquine in stock.

“I was shivering when I reached the health centre,” Sisa recalled. “After the blood test, they gave me paracetamol, probably to bring down the fever, and asked me to go to a community health centre in Khairput as they didn’t have the medicines for malaria.” Instead, Sisa travelled 12 km, crossing various stretches of forest and minor rivers down the hill, to reach a private clinic, where the treatment and medicines for three days cost him Rs 600.

“I knew that the CHC would have referred me to some other hospital, and it was 3 km farther than the private clinic. I didn’t want to delay the treatment, so I got myself treated at the private clinic,” Sisa said.

The lone primary health centre, situated in the midst of hilly Mudulipada, serves around 12,321 members of the Bonda community scattered across 32 remote hilltop villages in the Kondakamberu mountain range of the Eastern Ghats in Malkangiri. Found only in these 32 villages, the Bonda tribe is one of the 13 Particularly Vulnerable Tribal Groups living in the isolated mountainous range of Odisha, with limited access to transportation, connectivity, and healthcare.

Considered vulnerable due to their stagnant population, low literacy levels and mostly pre-agricultural economy, the Bonda tribe suffers from many health diseases, including diarrhoea, tuberculosis and malaria.

In 2023, Odisha topped the list of states for malaria cases, marking a resurgence in the state despite government efforts to control the disease through various measures. The rise in cases is attributed to frequent drug supply shortages, particularly in remote tribal areas like Mudulipada, and disruptions in the distribution of long-lasting insecticidal nets across the state.

As a result, malaria cases in Odisha rose 80% since 2022. The state reported 41,971 cases and four deaths in 2023, and accounted for over 18% of the country’s total malaria cases.

“For the last two months, we have been facing a significant drug shortage at the Mudulipada health centre, and we had to refer patients to the CHC [community health centre] in Khairput,” said Champeswar Panigrahi, a medical officer at Mudulipada’s primary health centre where Sisa had first visited for malaria treatment. Panigrahi was quick to add that the health centre never refers patients to any private clinic or hospital.

“Although Mudulipada sees a high number of malaria cases, especially between May and July due to the monsoon, last year we received fewer,” Panigrahi said, adding that authorities used the 2022 case figures to estimate the medicines required, and the supply ended up falling short because of a spike in cases.

A May 2021 paper in BMJ Global Health noted that malarious regions in Odisha have reported 79% asymptomatic infections and 30% of subpatent infections, which are undetectable by the current Rapid Diagnosis Test kit.

This suggests that a significant number of people with malaria in these categories remain undetected. Asymptomatic cases involve individuals infected by the parasite but without symptoms, while subpatent cases have the parasite in their blood at levels insufficient for detection through testing.

The existing Rapid Diagnosis Test kits for malaria screening are based on a protein called HRP. A May 2022 paper in The Lancet points out the inability of Histidine-rich protein II (HRP II)-based Rapid Diagnosis Tests in detecting P. falciparum strains with HRP2 and HRP3 deletions. The paper also identified prevalence rates of P. falciparum with HRP2 and HRP3 gene deletions ranging from 0%-8% in Odisha and other highly malaria-endemic states.

This means that the present estimates for using the tools for clinical screening and Rapid Diagnosis Test for malaria, likely underestimate malaria cases considerably.

“Merely focusing on vector control is not enough; reduction of parasite density, or cleansing a community of malaria parasites is also necessary, as it decreases the chances of patients contracting the disease again and of spreading the infection to others,” said John Oommen, a community health doctor at the Christian Hospital, Bissamcuttack in Rayagada district of Odisha, who has worked for over three decades with community-based malaria control.

“In many cases, patients show no symptoms but yet are harbouring malaria parasites from a previous infection, which can still be transmittable and even dangerous,” Oommen added.

Sisa could not ask the doctor why he has contracted malaria thrice and – as a farmer who works year-round growing millets to sustain his family of three – he could also not visit the private hospital after he started feeling better in four days. “The clinic is far and takes time and money to reach so I could not go there again though I wanted to,” Sisa told IndiaSpend. “I am tired of falling sick of malaria every year.”

Shortage of life-saving nets

Since his most recent malaria infection, Sisa has resorted to actively using his semi-torn, soiled long-lasting insecticidal nets every time he goes to bed. “I got this net almost five years ago, and we could barely use it for the first month,” Sisa said, pointing toward the net, which had been hand-stitched by his wife after a rat gnawed it. “I’m not sure if the net is even working now because it used to feel very hot sleeping under it. Now it feels like a normal net,” he added.

Indoor Residual Spray and the use of insecticide-treated mosquito nets are long-term measures that target adult mosquitoes, recommended by National Vector Borne Disease Control Programme as part of the Integrated Vector Management strategy.

The programme is gradually shifting towards reducing areas under Indoor Residual Spray and increasing coverage with a new type of insecticide-treated net, long-lasting insecticidal nets, which remains effective for up to three years.

Against the backdrop of widespread chloroquine resistance in Odisha, particularly among pregnant women, long-lasting insecticidal nets have proven to be the most effective preventive measure against malaria. As far back as 2009, around 1.9 million long-lasting insecticidal nets were initially distributed to pregnant women and children up to five years of age across Odisha as part of the “MO Mashari” – Our Bed Net – scheme.

Subsequently, under Odisha’s flagship Durgama Anchalare Malaria Nirakaran programme launched in 2017, over 11 million long-lasting insectidal nets were distributed. This initiative also targeted locally identified high-endemic pockets in 30 districts and conducted mass screenings twice a year to control and prevent malaria cases.

However, Odisha has been grappling with long-lasting insecticidal nets supply issues since then. Despite the state government's request to the Ministry of Health and Family Welfare to supply 15.6 million fresh long-lasting insecticidal nets early last year, the consignment has yet to reach Odisha. Experts are concerned that this delay is likely causing an increase in the state’s malaria cases.

“While insecticide-treated nets were widely used in Africa and other malaria-affected regions for decades, India was very late in adopting this tool,” Oommen said. “Even now, LLINs [long-lasting insecticidal nets] are not easily accessible to the public. One can’t just walk into a shop and buy an insecticide-treated net, like we can get various less effective mosquito repellents. It’s important to question why the most effective anti-mosquito product has not yet reached the market, and why providing insecticide nets remains the sole prerogative and a procurement issue for authorities. When something as crucial as this suffers a supply challenge, it’s the people who suffer.”

Around 70 km away from Bonda Hill, in Malkangiri's Balakati village, a member of the Koya Particularly Vulnerable Tribal Group, Deba Padiami, unlike Sisa, cannot even use the two insecticide nets that he struggled to acquire back in 2019 for his family of eight.

One of the nets is completely broken and unusable. Padiami, who is a daily-wage worker and migrates to nearby cities in neighbouring Andhra Pradesh for work, worries as he has already fallen sick with malaria twice this year.

A father of four, Padiami does not have an insecticide net at his rented place in Andhra Pradesh. Malkangiri shares its southern border with Andhra Pradesh, making it convenient for many daily wage labourers like Padiami to migrate to the state in search of employment opportunities According to the India Employment Report 2024, released by the International Labour Organisation and the Institute of Human Development in March this year, Odisha ranked the lowest in employment rates among educated youth aged 15-29.

“Wahan kaun dega hamein net (who will give us the net there [in Andhra Pradesh]),” Padiami said. “I just ensure that my kids and wife sleep under the net. It’s difficult to convince my parents because they are not used to it, and we only have one net in a usable condition. I have asked the health workers several times when we will get the new nets but nobody has an answer,” the 32-year-old said.

Oommen believes it is crucial to consider several factors hindering the use of long-lasting insecticidal nets in Odisha too. “The nets are typically used at bedtime. The Anopheles mosquito that transmits malaria generally bites from sunset to sunrise. So how does a villager protect himself when he is not sleeping, or when he guards his fields at night? Nets are critical, but not a total answer in themselves. We need a more robust solution if we truly want to eliminate malaria,” he told IndiaSpend.

Disease of the poor

According to the World Health Organization’s World Malaria Report 2023, India accounted for 66% of 5.2 million malaria cases in the Southeast Asia region in 2022, becoming the country with the highest number of cases in South and Southeast Asia. Government data also highlight malaria as the second-most prevalent vector-borne disease in India in 2021.

To combat the disease India – in line with the World Health Organization’s Global Technical Strategy for malaria 2016-’30 – has committed to reach the goal of zero indigenous malaria cases by 2027 and completely eliminate the disease by 2030.

Several reports, such as those from the World Health Organization, have recognised significant progress made by India in the past decade in reducing malaria cases and fatalities.

The World Malaria Report, which provides global estimates through mathematical projections, indicates that in 2022, India had an estimated 3.3 million malaria cases and 5,000 deaths, marking a decrease of 30% and 34%, respectively, compared to 2021. Globally, the report estimates 249 million cases in 2022, which is five million more than in 2021.

In 2016, India launched an ambitious National Framework for Malaria Elimination Programme, which aims to eliminate the disease in a phased manner by 2030. It also ensures to keep areas where malaria transmission has been interrupted free of disease by preventing its re-introduction.

For that, all the states, especially high-endemic ones like Odisha, are responsible to implement National Framework for Malaria Elimination Programme and provide measures for early detection and prompt treatment, identify high risk areas and interrupt malaria transmission by spraying insecticide, distributing long-lasting insecticidal nets and making required medication for patients available.

As a result, malaria cases in India decreased by more than 40% by 2020 as compared to 2015 caseloads. The reduction was primarily credited to Odisha, which reported a 90% decline in malaria cases and 89% reduction in malaria deaths during this period.

Experts, however, attribute the dramatic reduction to unreliable data collection and underreporting of death caused by malaria. They say that the perception of malaria as a disease affecting the poor leads to its low priority in India’s public health agenda, and caution against making a simplistic picture of reduction in malaria cases, especially in Odisha which has had a history of recording large numbers of malaria morbidity as well as mortality rates.

“Anyone can report a death. It only gets technical when you ask about the cause of death,” Oommen pointed out. “Despite being a curable and preventable disease, malaria claims hundreds of lives in India every year, which makes it obvious that the disease is still inadequately addressed as a major public health crisis. This could probably be because the burden of malaria is mostly borne by the people of marginalised communities and regions,” he told IndiaSpend.

Official malaria death numbers are released by state health departments and the National Centre for Vector Borne Diseases Control of India’s health ministry. India maintains a civil registration system for births and deaths, with medical certification of cause of death provided by the Registrar General of India for registered deaths.

In 2020, while the National Centre for Vector Borne Diseases Control reported 93 malaria deaths, medical certification of cause of death documented 1,438 registered malaria deaths, highlighting discrepancies. Odisha's malaria programme had reported nine deaths, a performance which earned it an award of appreciation from the Union government.

The medical certification of cause of death data, however, recorded 346 malaria deaths, with only16.3% of registered deaths in Odisha receiving medical certification. Experts believe the number of deaths caused by malaria could have been higher than reported.

Questioning the accuracy of malaria death data, Gouranga Mohapatra, state convener of Jan Swasthya Abhiyan, a nonprofit working primarily for the health and related policies for the tribal and marginalised communities in Odisha Mohapatra said, “While the malaria cases have come down in the last decade, the question still remains whether the malaria elimination programme units at different states and national level capture the true malaria deaths.

“If we consider the 2023 World Malaria Report,” Mahapatra pointed out, “it estimated 8,668 malaria deaths in India in 2020 within a range of 3,750 to 15,500. So there is clearly a huge discrepancy in data on malaria. When you don’t know the clear picture of how many people are actually affected and dying of malaria, it becomes more complicated to prevent and control the disease.”

IndiaSpend reached out to the Joint Director and State Joint Director of Health Services, as well as the Deputy Director of the Procurement & Supply Division in the National Vector Borne Disease Control Programme, to inquire about supply gaps, data discrepancies and fund utilisation for long-lasting insecticidal nets. We will update the story when we receive a response.

Unattainable dream

Since what is believed to be its inception in central Africa 10,000 years ago, malaria has spread globally and affected civilisations throughout recorded history. India, plagued by millions of cases for as long as one can remember, first attempted to control malaria in 1953 with the introduction of DDT – dichloro-diphenyl-trichloroethane – as a residual insecticide.

Since then, the country has implemented numerous programmes not only to control but also to prevent and completely eradicate malaria as a disease.

As India aims to achieve sustained zero indigenous cases and deaths due to malaria by 2027 and obtain “malaria-free” certification by 2030, scientists and public health experts deem this goal unachievable.

“If you examine the history of malaria, there is a cyclical trend in the numbers, with the curve rising and falling over the years. The recent sharp drop in cases in Odisha in 2020 was not just a natural or secular trend, but rather an intervention-driven decline in malaria cases,” explained Oommen.

“This should not be misconstrued as a permanent victory, causing complacency and leading to the easing of control strategies,” Oommen said. “We are once again seeing an upward trend in cases. Malaria is nowhere near gone. To my mind, an effective vaccine would have been the ideal tool to ensure elimination, along with the existing prevention and treatment measures.”

Research for a malaria vaccine has been ongoing since the 1980s, with trials beginning as early as 2004. The RTS,S vaccine was recommended and certified by the World Health Organization in 2021.

In July 2022, the World Health Organization officially approved the vaccine, which boasts a 75% efficacy rate, for use in a few African countries. However, the efficacy of this vaccine in India’s malaria-endemic regions is not clear and requires more research due to the prevalence of varying parasites.

A research paper published in PLOS Global Public Health in 2023 reveals that the majority of districts predicted to miss the target of achieving zero malaria cases by 2030 are situated in Odisha, Chhattisgarh, Uttar Pradesh, Jharkhand, West Bengal, Gujarat, and Rajasthan. Moreover, some districts, including Malkangiri in Odisha, have seen an increase in malaria cases.

Gournaga believes that India’s extensive malaria programme requires intervention similar to that used for Covid-19. “Malaria is no less serious than Covid-19. Elimination programmes must closely monitor patients, promptly isolate them upon symptom onset, and provide necessary care, along with active surveillance in affected areas,” he told IndiaSpend.

Meanwhile, both Sisa and Padiami have given up hope of receiving new insecticide nets. “I have to return to work in a few days,” said Padiami, who came to his village in Balakati in early June for treatment after falling ill twice with malaria. “I’m scared to go back because I still don’t have a net or any protection. But do I have a choice?”

This article is the first part of a two-part series focusing on malaria and India’s public health system. The series is supported by the Forum for Health Systems Design and Transformation as part of the HSTP Health Journalism Fellowship 2023.