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GUIDELINES
COMMUNITY
ACTION
BUILDING
PARTNERSHIPS
4
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I
STRENGTHENING
MANAGEMENT AT
DISTRICT LEVEL
WHO SEARO
OCT.
2000
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4
ROLL BACK MALARIA
GUIDELINES FOR WHO SEARO
REGION
GUIDELINES
Set I
Enabling Community Action and
Building Partnerships
Set II
Strengthening Management at
District Level
COMMUNITY HEALTH CELL
[Based on h>o
Department <
Edited by Cor
<
for
Library and Information Centre
No. 367, Srinivasa Nilaya, Jakkasandra,
I Main, I Block, Koramangala, Bangalore - 560 034.
THIS BOOK MUST BE RETURNED BY
THE DATE LAST STAMPED
ROLL BACK MALARIA - WHAT IS NEW?
> A Social movement for better health and poverty alleviation;
> Promotion of health equity by focussing on disadvantaged
populations / community and building partnerships with them;
> Soliciting effective partnerships within and outside the health
sector;
> A path finder for health and human development;
> Activities that are mainstreamed into health sector development;
> An integrated approach to address malaria and other common
diseases;
> Plans that are country driven, evidence based and adapted to local
realities;
> Playing the role for leadership regulation and coordination;
> High level of advocacy for change;
> Promoting research and development for new tools;
i
CONTENTS LIST
SI.
No.
1.
1.1
12
13
Title
Page
No.
INTRODUCTION
1
Malaria Situation in South East Asia Region
Roll Back Malaria Initiatives
About the Guidelines
2
4
7
GUIDELINES
:
SET 1 - ENABLING COMMUNITY
ACTION AND BUILDING PARTNERSHIPS
2.
ENABLING COMMUNITY ACTION IN RBM
6
2.1
22
23
24
23
23
Partnership with the Community
Empowerment of Women
Diagnosis, Treatment and Referral at Community Level
Malaria prevention at community level
Elimination of Breeding places through Community Action
Sustaining Community level action and partnership
7
3.
BUILDING PARTNERSHIPS
38
3.1
32
33
34
Advocacy and Leadership for Change
Partnership with Non-Governmental Organisations (Voluntary Sector)
Partnership with Educational Sector
Partnership with Private Sector
Partnership with other sectors (Intersectoral Coordination)
Communications for Behaviour Change (IEC)
40
45
49
TJ
3?6
"16
27
35
37
5?
56
58
GUIDELINES
:
SET 2
STRENGTHENING
MANAGEMENT AT DISTRICT LEVEL
4.
STRENGTHENING MANAGEMENT AT DISTRICT LEVEL
63
4.1
42
43
44
45
46
Management and Referral of Malaria
Drug Supply and Logistics
Health Management Information System
Epidemiological and Entomological Surveillance
Epidemic Preparedness and Response
Research and Development
64
67
70
73
78
80
5.
STATE AND NATIONAL SUPPORT - AN OVERVIEW
6.
ACKNOWLEDGEMENTS AND REFERENCES
7.
APPENDIX : CASE STUDIES FROM INDIA
i
k INTRODUCTION
■T^eople of the worlds poor communities face many threats to their well being. 40%
JL of the world’s population are at risk of malaria and the disease is a particular
burden for the poorest countries.
There are as many as 500 million cases of acute malaria in the world each year - as
many as 5% of them causing severe illness associated with time away from work. The
risk of malaria is a constraint and threat to the economic development of communities,
nations and regions.
Malaria predominantly affects children, women and lower socio economic groups
including indigenous people and tribals. Communities inhabiting regions closer to
forests, dams, irrigation channels and water bodies and those living in mosquito infested
urban areas have a higher risk of malaria.
Malaria has been increasing over the last few years due to mosquito- friendly conditions
produced by many environmental and development strategies. In many parts of the
world it has emerged as the most important public health challenge.
Malaria can be tackled by effective, comprehensive and integrated public health action.
The time for action is now!
i
1.1 Malaria situation in South East Asia Region
►►
Malaria continues to be one of the most serious public health problems in
the South East Asia Region. 85% of the total population in South East
Asian countries estimated at 1,202.5 million people are at risk of malaria,
with 35% living in moderate to high risk areas.
Map of SEARO Region showing Malaria incidence and distribution
Source: WHO-SEARO
►►
In the South East Asian region - there are about 3 million malaria cases
annually (25.26 million clinically suspected).
►►
Malaria in South East Asia is unstable and causes epidemics as well as
high morbidity.
►►
Among the countries most affected and with the largest populations at risk
are India, Indonesia, Myanmar and Thailand.
Chloroquine resistant P. falciparum is reported from all endemic countries
(expect DPR Korea). Nearly 400 million people live in areas with risk of
contracting drug resistant malaria.
2
»
Sulpha - Pyrimethamine resistance is also reported from all endemic
countries except Srilanka and DPR - Korea with an estimated 140 million
population at risk. Multi-drug resistant P falciparum is highly prevalent
on the Thai-Cambodia and Thai-Myanmar borders.
►►
Deteriorating epidemiological indices are associated with drug resistance
and operational problems.
►>
In this region 80-85% of malaria cases are reported from India and the
bulk of the malaria deaths (55-65%) from Myanmar.
►►
Malaria has adverse effects on economic and social development in the
region. It has been identified as the single largest cause of poverty in
some countries. Morbidity caused by malaria reduces family earnings by
12% and an unhealthy workforce brings down productivity.
►►
The process of development itself contributes to the spread of malaria. As
roads are built, forests cut down, new mining areas opened, new dams and
irrigation channels are built, habitats which favor the breeding of
mosquitoes, expand. This is very common in the South East Asia region.
Some Malaria Statistics in SEARO region
1
Source : WHOSEA RO
3
V
1.2 Roll Back Malaria initiatives.
The Roll Back Malaria initiative launched by WHO in 1998 is an effort to
enhance the ongoing national programmes against malaria by additional
strategies that include:
e
□ Evolving Evidence
based programmes
□ Promoting community level action
□ Strengthening partnership with other sectors and development agencies.
□ Strengthening and further developing the health sector to address a range of
priority health problemsincluding malaria.
□
Evolving a social movement to tackle malaria backed by governments,
development agencies, NGO s, private sector groups, researchers and media
working together.
The Global Roll Back Malaria partnership has an overall goal of reducing
malaria .related deaths throughout the world by half, by 2010.
In the WHO-SEARO region the RBM programme was endorsed at the fifty
second session of the Regional committee of South East Asia on 22nd July 1999.
In keeping with the overall goal and strategies of the global initiative, RBM in
the SEARO region seeks to draw on the strengths of the past experience to fight
the disease but also promote some new thinking. It focuses on :
□ Community empowerment and mobilization
□ Working through the Primary health care system for effective action.
□ Promoting Intersectoral linkages.
□ Partnerships with community, voluntary agencies, NGO’s and the private
sector involving both health and development programmes.
□
□
□
Finding local solutions to local problems while drawing on potential
resources outside the health sector.
Emphasizes decentralization and district level planning and strengthening
district health systems.
Creation of a forum for joint advocacy and resource mobilization as a
common ground to bring malaria to the forefront in health sector
development.
The National Malaria programme then
'
‘
assumes roles
of leadership,
facilitation, coordination, regulation and not ofsole implementor.
4
c
1.3 About the Guidelines
>
These simple, action oriented guidelines have been developed to promote the
Roll Back Malaria initiative in the South East Asia region.
>
They are addressed to the District malaria programme managers, who may be
from diverse backgrounds including doctors with or without public health
degrees; senior public health nurses; non-medical programme managers with
science or social work degrees and others.
>
They are designed to be applicable and suitable for use in the field and have
been arranged as far as possible in a logical and chronological sequence of
activities.
Additional information is provided wherever applicable or required.
When
locally adapted additional case studies, examples, illustrations can be
introduced.
>
They have been evolved to keep them as generic as possible so that they can be
adapted to each country situation in the region.
At the same time specific
details arb also provided wherever possible.
>
A broad rtinge of issues were identified and addressed during the interactive
*
participatory workshops that were organised to evolve these guidelines. These
have now been grouped into three specific action thrusts.
❖
Enabling Community Action
Building partnerships.
❖
Strengthening management at District Level.
These guidelines are not complete. They are a starting point and stimulus for
action in various areas crucial to malaria control.
evolve
locally . nationally,
experimentation and evaluation.
5
regionally
through
They must continue to
action,
adaptation,
c
ENABLING COMMUNITY ACTION
AND BUILDING PARTNERSHIPS
IN MALARIA CONTROL
GUIDELINES
SET - I
0
2. ENABLING COMMUNITY ACTION IN RBM
Enabling the active involvement of the community in efforts to tackle the malaria
problem is a cornerstone of the Roll Back Malaria initiative. Drawing on the Primary
Health Care Strategy, (WHO) endorsed at Alma-ata in 1978, the involvement of the
community as active participants in the process rather than as passive beneficiaries is
an important challenge.
The guidelines that follow are based on certain principles that are crucial to the
successful evolution of a partnership with the community.
The community and its representatives both formal and informal must be involved
in all aspects of the programme from planning, to organisation, to monitoring and
to evaluation.
The focus of activities should not be just providing packages of services but
enabling and empowering the community to participate in decision making and
taking responsibility.
The large range of untapped human and material resources in the community must
be mobilized.
<>
The malaria programme must not be compartmentalized or selectivised but must
become an integral part of all the ongoing health and development programmes.
A major thrust should be to demystify the problem at community level; build
confidence, skill and capability at community level to tackle the problem; and
help community to identify the programme as their own .
The process should also be facilitated with a certain humility so that the health
team is willing to leam from local experience, wisdom and culture. New
approaches or alternatives can emerge if this Teaming from the people’ and
‘working with them’ rather than ‘for them’ becomes a team commitment.
\ fl
‘We need not only to persuade the people to accept the professionals wisdom, but also the
professional to understand the peoples wisdom’
6
I
c
2.1 Partnership with the Community
What:
2.1.1
■
It has now been demonstrated throughout the world that when a
community participates effectively in a health programme with full
understanding and involvement then the achievements of that health
programme are sustainable and long lasting.
■
This partnership should include the involvement of the community in all
aspects and stages of the programme and in an increasing sense of
ownership by them of the programme.
■
This partnership will be built by all members of the primary health care
team under the leadership and direction of the district Malaria Programme
Manager.
[The community may be of different types: A village, a tribal hamlet; an urban
slum; a small township. Within each of these there may be clusters based on
class, caste, occupation, ethnicity or other characteristics. Some form of
village or community selfgovernment may be available. Partnership with all
these types may have to be evolved gradually in an area or region. The
process will differ depending on the levels of cohesion and the types of
diversities/plurality within each community]
2.12
How:
The partnership with a community can be evolved through five generic steps :
♦
Step one : Identifying potential leadership in the community 4------------
♦
Step two : Evolving a local health committee to support malaria control
♦
Step three: Sensitizing and empowering the community
♦
Step four : Building capacity of local community and its volunteers
I
Step five : Organising and managing and sustaining the
programme.
7
X
■
2.1.2.1
S/ep One: Identify potential leadership in the community
Informal discussions should be held with various individuals and groups
within the community to identify individuals who form and mould the
opinion of the community and undertake leadership roles on various
occasions.
These may include one or more of the following:
> Leaders - both elected and traditional
> Leaders of community clubs and organisations of farmers,
women and youth.
> Religious and socio-cultural group leaders.
> Teachers
> Retired defence services or government personnel living in the
area.
> Village health workers and development workers, who stay in
the area.
> Informal opinion leaders.
. > Others in the community who could assume leadership roles.
2.1.2.2
Step Two : Evolve a health committee :
Organise a committee at the community level with involvement of the
potential leaders and orient the committee to the local malaria situation and
the potential malaria control activities to get their help in sensitizing the
community. This can be done through one or two informal discussions and
dialogue.
Caution:
O Ensure adequate representationl of women and socio
economically marginalised sections on these committee..
O If there is already a health committee in the community then
integrate malaria as one of its functions^ If there is no committee
thAn start a community malaria committee which will tackle
other health problems as well, gradually.
The functions of the committee will be :
a) Organise meetings to sensitize the community
b) Help to identify community volunteers
c) Plan the local community based activities for malaria control
d) Monitor the local community based activities.
8
c
2.1.2.3
Step Three : Sensitizing and empowering the community :
With the help of the committee conduct community level meetings to
sensitize the community to all aspects of malaria situation and the
malaria control programmes.
These meetings should stress at least three things:
a) Create awareness of malaria situation and programme at village /
community level ’
b) Emphasize and define community’s role in the programme by
stressing
•
That they are partners not only passive beneficiaries.
•
That their active participation to tackle the problem will
ensure benefits to the community.
c) Invite some of them to volunteer to help the programme as
active local volunteers who can be trained for specific roles
and functions.
The health team members can do an informal survey in the community
to assess the existing knowledge of malaria in the community; to
understand what the people do when they get ‘malaria like’ fevers
(attitudes and local health practices); and then evolve a programme with
the help of the local committee which builds on local strengths i.e.
positive local beliefs and local health practices that are conducive to
malaria control and counters ‘weaknesses’ i.e. beliefs and local health
practices that are not conducive for malaria control.
The community should be empowered through active interaction with
the local committee members to:
+ Understand the local situation
+ To identify the existing resources in the community including
volunteers and material and other resources.
To identify the external resources that can be mobilized from the
programme especially the malaria health team.
> To de\ elop a local plan of action that will include:
•
Health awareness building activities
•
Promotion of early diagnosis and treatment
•
Measures for prompt referral when required
•
•
Prevention activities at individual and community level
Role of volunteers
+ To develop a simple programme for implementation and for
regular monitoring of the programme so that problems
identined can be solved and the local experiences will improve
the programme and evolve further plans.
9
2.1.2.4
Step Four : Building capacity of local community volunteers
>
The local community based volunteers identified by the committee
should be trained to build their capacity to participate effectively in the
programme. This training should include:
> Knowledge of all the essential aspects of malaria control (see box
on Malaria primer Page 11)
> Practical skill development to do some or all of these ten potential
functions:
■
Make local community members aware of all aspects of malaria
situations and the programme.
■
Identify a case of malaria at community level.
■
Make a blood smear and send it for examination
V—C r«j
r :•* V
!» /*• I.
4
1
Note:
■
Treat uncomplicated cases of malaria locally
■
Identify problem or serious cases and arrange suitable referrals.
■
Some form of simple community surveillance of malaria type
fevers.
■
Promoting preventive measures at individual and at community
level.
■
Mobilizing community to support vector control activities at
community level
■
Helping to ‘monitor and evaluate’ programme at community
level by facilitating community feedback.
The types of skill taught to local community volunteers will differ in different
countries of the region and in different states of the same country since the levels of
health care services are varied and the components of the malaria control
programmes will be varied. However practical skill development will be the key to
success in the programme.
10
A Malaria Primer - A to Z
In each country or region depending on the local ‘malaria situation’ and ‘epidemiology’ and
the type of health care services including malaria control programme, a small primer which
we have called ‘A to Z’ should be prepared in simple vernacular or local language with
adequate simple illustrations and diagrams. This should then form the basis of all health
education and awareness building and training programmes at community level. The primer
should at least include answers to the following common questions that people may have:
(a)
What is Malaria?
(b)
What are its symptoms?
(c)
How is it caused?
(d)
Where do mosquitoes come from?
(e)
Where do they breed?
(0
Who are most at risk of suffering from malaria?
(g)
How can we test for malaria?
(h)
Where can these tests be done?
(i)
What can be done to treat malaria?
0)
Where is this treatment available? Who can treat?
(k)
What are the complications of malaria?
(1)
How can these be recognized?
(m)
What should be done in case of complications?
(n)
Whom should we inform when there is a case.
(o)
How can we prevent mosquitoes from biting us?
(P)
How can we comrol the mosquitoes?
(q)
How much malaria is there in our district?
(r)
How much malaria is there in our state?
(s)
Are there any special reasons for malaria being common in our area?
(t)
Are there other mosquito borne diseases in cur area? If so what else should we do?
(u-z) Any other questions relevant to area/district or country.
BastataMBCi* wjw
11
I
2.1.2.5
Sfep Five : Organizing, managing and sustaining the
programmes
Once the plans of the local malaria programme is drawn up by the malaria
programme manager by interactive dialogue with the local malaria/health
committee and the local volunteers are trained then the programme must be
organized and managed in close collaboration with the local committee and
the volunteers.
The programme will consist of atleast five major components:
1. Empowerment of women in the community endorsing their role as the
main health care providers at family level (See 2.2)
2. Organizing diagnosis, treatment and referral at community level (see 2.3)
3. Organizing malaria prevention at community level (See 2.4).
4. Organizing the elimination of breeding places through community action
and campaigns (See 2.5).
5. Sustaining the community level action and partnership which includes
community based surveillance, monitoring and evaluation (See 2.6).
As the programme evolves and all these five components are organized and
managed, then through^ contiifeus interactions with the committee and the
volunteers and members of the community, the programme managers can seek
feedback and suggestions for modifying and improving the programme. This
can feed into the planning cycle for the programme so that newer and newer
ideas, innovations and changes take place in the malaria programme and the
community partnerships.
I
'a
8
ii
:•
<3 J
0
j. I I
12
II
-v
c
♦
2.2
Empowerment of women
An important challenge for the Roll Back Malaria initiative i^ each country is the
recognition and involvement of women in the programme as important health care
partners.
2.2.1
Why:
o Women have been traditionally the main health care providers at family
level and community level. They take family responsibilities that include
nutrition, care of the children,, care of the sick and elderly and this has
provided them more local knowledge, skills and attitudes to undertake
health care tasks.
o
They have also to play a more active role in the community as educational,
occupational and social/political status improves giving them
opportunities to participate and be more involved in decision-making.
o
In many parts of the world, women have shown greater potential and
ability, collectively to sustain programmes and movements especially
related to health. They support each other more effectively than men.
Greater involvement of women through an active empowerment process
that provides them the knowledge, attitude and skills for participating and
organizing community and family based action for malaria control is
therefore an important step.
[Caution: In many societies and communities women already face the triple
burden offamily, work and childcare. It is therefore necessary to involve
them in malaria control, recognizing their potential and their status but not
necessarily adding to their burdens. Empowerment of women must be closelv
complemented by the involvement of men to share the responsibilities of
malaria control at both family and community level.]
J
I
2.2.2 What:
Women can be empowered to play a variety of roles that are required for
effective community based malaria control. These are:
(i) .
Diagnosing and management of malaria at family level (home care)
(ii) . Identification of family members that need referral
(iii) . Health education and awareness building about common health problems
and their management with locally available resources.
(iv) . Management of cleanliness in and around the house.
(v) . Use of preventive measures at home level.
(vi) . Special needs of women who are pregnant and very small children when
they fall ill, including malaria
(vii). Involvement in organizing / managing malaria programmes as
community volunteers.
13
(viii).Involvement in organizing / managing malaria programmes as members
of women’s organizations or community health committees.
For all these roles they need empowerment training that provides them
knowledge and skills to play their roles and also knowledge and awareness
about existing health care structures and alternatives.
2.2.3 How:
Women should be reached preferably in groups to help the interactive and
participatory process between and among them.
They can be reached at and or through :
(a) .
(b) .
(c) .
(d) .
(e) .
Women’s organizations or clubs (e.g. Mahila mandals)
Informal community level groups of women
Religious and social organizations and gathering
Weekly community markets
Voluntary organizations working with and for women
14
C
Special groups of women who are already paying leadership or other roles
in society can be involved to take greater interestjpr^jhobilizing and
empowering other women in the community. These may be :
a) Women members of local bodies/village self government
b) Women teachers
c) Women staff of banks, post offices and other services.
d) Women health and development workers.
Where such organizations/groups do not exist then the primary health care/
/ malaria teams can initiate the formation of such informal or formal
women’s groups in the area.
All the members of the above groups can be trained in the functions listed
above through regular local training sessions that use effective IEC
materials.
A home care package that can be particularly focused on women
volunteers and participants should stress the following :
1.
Fever as a symptom to be taken seriously and presumptive
treatment for malaria to be given preferably after taking blood
smear for malarial parasite.
2.
Symptomatic treatment like sponging, plenty of fluids and
antipyretics.
3.
Identification of complications which need immediate referral to the
hospital, (see 2.3.3.f)
4.
Pregnant women / infants & children with fever to be dealt with as a
potential emergency and immediate treatment io be given. .
5.
Prophylaxis for pregnant women especially in high endemic areas.
Women involved in social development work including malaria
control should be recognized and honored by the local bodies /
NGOs. This would act as an incentive for involvement of more
women.
15
9
2.3 Diagnosis, Treatment and Referral at Community Level
Another important challenge for the Roll Back Malaria initiative is the
demystification of ‘Malaria’ so that its treatment and control do not remain the
monopoly of health workers, but is common knowledge among the people so that they
can be better equipped to access Malaria treatment and control as a ‘right’ as well as
actively participate in it as a ‘responsibility’.
2.3.1 Why:
O All individuals in a community should have basic and adequate knowledge
of malaria so that they are able to recognize it when it occurs; take wise
decisions on what to do; ask for help from those who may be better
informed or better skilled and tackle it effectively at both home and
community level. Mothers, volunteers and community members can all
play a significant role in managing malaria at home/community level.
O In many parts of South East Asia as in many parts of the world, the crisis of
changing economic/political situation; war and ethnic clashes; natural and
other manmade disasters and the continuing problem of inadequate access
in remote areas to both health professionals and health care, means that
efforts to make communities and people more autonomous in managing
uncomplicated fevers like malaria is an urgent necessity.
O Also in order to enhance the neighborhood or community level confidence
in managing malaria which has become a major public health problem it is
imperative that as many people as possible are trained in each community,
who can learn to distinguish malaria from other illness; help to detect the
seriou^ forms of the disease and help to reach the nearest and appropriate
treatment facility. Some groups like traditional health workers, teachers,
shopkeepers and local practitioners may be particularly useful.
IZ1 What
To enhance diagnosis and treatment skills at family (home) and community
level more and more community members and especially, health volunteers
should be trained to be skilled in the following:
a.
Hoyv to recognize malaria?
b.
What to do when a case of *malaria’ occurs?
c.
What tests can be done for patients locally?
d.
Hoyv to manage and treat at home level?
e.
Hoyv to manage and treat at community level?
Hoyv to identify a severe or complicated ‘malaria case9 that needs
referral?
gh.
Hoyv and where to refer?
What to do in case ofpregnant women or very small children?
16
c
2.3.3 How:
The simple guidelines for each of the above action points is as follows and
should be stressed in community training sessions:
a) How to recognize malaria
♦ Every case of fever in highly endemic areas or in persons with a
history of travel to ‘malarious areas’ (highly endemic areas) should be
presumed to be due to malaria unless proved otherwise.
♦ Some of the signs and symptoms of mild or uncomplicated malaria are:
■
Chills
-
Joint pains
■
Sweating
-
Anemia (pallor)
■
Headaches
-
Jaundice (yellow coloration)
■
Body aches
-
Enlarged spleenor liver (lump in higher
part of abdomen!)
O
b) What to do when a malaria case^occurs?
♦ Patients with any of the above symptoms should visit the nearest health
centre or health facility or treatment source for further diagnosis and
treatment for malaria.
17
♦ There may be different treatment sources in a community
□ A traditional healer
□ A shop with malaria drugs
□ A private practitioner
□ A trained community health volunteer
□ A village dispensary run by a voluntary agency
□ A government health centre or subcentres
♦
<Other than the government centre any or all of these may be designated
as fever treatment depots and giveni some training / orientation and
helped to stock malaria medicines.
♦ Ideally one or more of these centers should be situated within a short
distance of any community i.e. short enough that a lone woman with a
sick child can access easily.
c) What tests can be done for patients locally?
♦ The commonest test for malaria is a blood smear examination. If
facilities for blood smear examination are available locally or nearby
and results can be obtained within 2 hours, then treatment can be
deferred till blood smear examination results are available
• *If facilities for blood smear examinations are not available nearby
then treatment for malaria can be given presuming it is malaria fever
(presumptive treatment).
■ Community health workers and volunteers can be taught to make
thin and thick blood smears examination. If such a trained health
worker is available in the programme, in that area then teach
him/her to make a blood smear and then give presumptive treatment
(see diagram). Also give instructions of how to send slide for
testing at health centre.
Skill One: How to prepare a thick and thin blood Smear for
malaria microscopy
Equipment required
•
•
•
•
Clean glass slides
Pricking needle (Hagedorn
triangular No. 12)
Specimen tube with cork for
fixing pricking needle
Spirit or antiseptic solution
Small bottle with cork for
keeping spirit or antiseptic
solution
Cotton
Clean handkerchief
Slide box for 25 to 50
slides
18
•
•
•
•
•
Lead pencil
Register and forms
Carbon paper
Ball point pen
Antimalarials for giving
presumptive treatment.
Method
1.
□ Third finger of the left hand of the /
patient should be held with left
hand between thumb and finger by
blood slide collector at the first
phalangeal joint.
□
□
Wipe fingertip with swab dipped in
spirit or antiseptic solution.
'I
Allow the fingertip to dry. (Refer
Figure 1)
-
2
2.
3.
□
Hold the pricking needle in the
right hand and prick the finger.
□
Allow blood drop to ooze out.
(Refer Figure 2)
□
□
Take a clean slide.
□
J
Take 3 drops of the blood
(sufficient blood) 1cm. From the
edge of the glass slide.
Take another drop of blood one cm
from the first (Refer Figure 3)
4
4.
□
□
□
Take another clean slide with
smooth edges to use spreader.
Make thick and thin smears
Allow it to dry
5
(Refer Figure 4 & 5)
5.
□
Put the slide number on thin smear 6
with lead pencil - Refer Figure 6
Mote 1
19
■
In high risk areas where facilities for blood smear examinations are not
available then facility for dipstick test for P.falciparum should be
provided at fever treatment depots for early diagnosis by health workers.
•
Where dipsticks are made available but health workers are not available,
efforts should be made to train some responsible community members,
such as teachers and volunteer health workers to diagnose P.falciparum
infections.
If dipstick kits are available in limited stock then priority for diagnosis
should be given to children, pregnant women and seriously ill patients.
Private practitioners, NGO’s who run health centers and other locally
available health facilities should be encouraged to provide diagnostic
facilities for malaria at no cost/reasonable cost to support the programme.
In high risk areas, if laboratory tests for malaria are negative and fever
persists than the laboratory tests should be repeated on 3 consecutive
days.
I
Cann<2!K While it is good to diagnose malaria properly and treat it, treatments should
never be delayed because of the absence offacilities for laboratory diagnosis or for
delays in availability of results of test done.
d)
How to manage and treat at home level?
As soon js a case of malaria fever is suspected then:
> Fever should be brought down as quickly as possible with cool water
sponging and paracetamol (500gm to 1 mg for adults and lOmg/kg per
dose for children may be used.)
> Patients should be given plenty of fluids. Glucose or sugar solutions must
be given to the patients, particularly to children and pregnant women.
> In case of children, continue breast-feeding.
> Seek medical care in the nearest treatment centre, as early as possible.
e)
How to manage and treat at community level (treatment centre)
At the community level there may be different alternatives for treatment centres
for malaria (see 2.3.3b)
In all these treatment centers the following could be done :
>
A blood smear is taken and sent for examination (if the centre has
laboratory facilities the smear can be examined there itself).
Presumptive diagnosis is made and treatment given accordingly^ to the
standing instructions in each country programme (see box) on page 21) for
one example of simple treatment schedule.
20
Skill Two : Simple Schedule for Treatment of Malaria at Home
Table 1
-------------- How many chloroquine tablets you should give if each tablet contains
chloroquine 100 mg*
Age (years)
Day
under 1
1-3
Day 1
I
: Day 2
4-6
7-11
over 11
ffi®
©®
®g
©®
®®
®@
®@
®©
®®
®®
©
®a
®®
®<3
g
@g
i
; Day 3
*
g
yK,Ur pa"e?1 'V99d ^rwMn 7 and ” *6ans- y°u would give
on day 1.3/2 tablets on day 2. and 1 ’ZZ tablets on day 3.
Table 2
How many chloroquine tablets you should give if each tablet contains
chloroquine 150mg4
Age (years)
Day
under 1
1-3
4-6
Day 1
a
©
@g
Day 2
g
7-11
over 11
®®
©®
©©
©®
g
Day 3
g
g
GQ
* nnrttt3? o?;/. y°,ur 5a,'e^, is aqed betw9en 7 and 11 years, you should cr.-e 2’/Z
on day 1, 2'/2 .aoiets on aay 2. and 1 taoiet on day 3.
21
>
The patient/care providers are advised tg)
■ S Provide supportive therapy as required (paracetamol for fever and
headache, plenty of fluids etc)
>
f)
■
About nutrition, home care, the need for treatment adherence and
when to report back
■
To look for signs of serious illness and refer the patient to a health
centre or hospital if these occur.
Primaquin is to be given in all cases when the laboratory tests come
positive. This is usually done under the supervision of a trained member
of the primary health care/ malaria team. However there is no benefit of
giving Primaquin to all patients in a hyper endemic area.
How to identify a 'severe9 or complicated malaria case that needs
'referral9
> The community members, health committee members, the volunteers and
others can be trained to identify severe or complicated malaria so that
he/she can be referred immediately for treatment and management at a
higher centre with better facilities.
> A reasonably aware person can be taught to identify and recognize the
following signs:
g)
►
Very high fever
►
Agitation
►
Very pale colour
►
►
Much vomiting
Delirium
state)
►
Dehydration
►
►
Little urine of dark colour
Feeling
very
(somnolence)
►
►
Restlessness
responding
to
►
Coma (not
stimulus)
Refusal to take feeds in children
►
►
Inability to
malarials
swallow
Signs of shock i.e. cold/clammy
skin, low thready pulse and
rapid breathing.
anti
►
Failure to respond to previous
antimalarial treatment
(malaria recurs within 3-4
weeks of treatment)
(confused
mental
sleepy
How and where to refer:
The Health committee and trained health volunteers should be encouraged
to know of all the alternatives available in the area which may be used to
transport a serious patient for treatment to a higher health facility. This
may be a local bullock cart, jeeps, vans, cycle, ambulance, stretcher or
palanquins, tractor with wagon etc. This is important since pre-planning
will ensure that there is no delay when the emergency transport is
required.
22
They should also know in advance about the government health centres
and private or NGO health institutions in the area to which severe or
complicated case of malaria can be referred.
>
These must have all the facilities for treatment of severe cases i.e.
intravenous quinine infusions, or other appropriate drugs like Quinine,
Sulphadoxine - pyrimethamine, sodium artisunate / arteether, and other
facilities to manage other systemic complications of malaria.
The minimum facilities required in a referral centre should be:
Tablets and injectable antimalarials
Facilities for :
1/v and oral quinine
\ 1/v; fluids
Oxygen
Oral and injectable antipyretics,
anticonvulsants, diuretics and
antibiotics.
Blood smear examination
Hemoglobin Estimation
Urine-routine and microscopy
lk
If all these centres with different levels of care are:
►► Properly oriented,
►► Provided with standard national treatment guidelines, and
►► Linked effectively in a planned referral service mechanism
then the primary health care management of malaria at community level
will be greatly supported by the prompt and efficient management of
referred severe and complicated cases. This will greatly enhance the morale
and confidence of the primary health care/malaria team and the community
based health committee and volunteers.
h)
What to do for malaria in pregnant women and in very small children?
Malaria in pregnant women is often more severe and causes worsening of
anemia and increased risk of abortions, new bom deaths and low birth
weight babies.
Except for the first 3 months of pregnancy (when any type of medical
treatment is preferably avoided) chemoprophylaxis can be given
throughout the last 6 months of pregnancy if the danger of malaria in the
area is high.
>
Approved doses of chloroquine or Quinine may be given in any trimester
of pregnancy for curative treatment of malaria.
Sulfadoxine- pyrimethamine combination may be given after first
trimester of pregnancy and upto one month before delivery.
23
>
Primaquin should not be given during pregnancy or to infants below one
year.
A
E®:
1
2.3.4 Health education: Regarding early treatment
To support efforts to establish a programme of early diagnosis, treatment
and referral at family and community level the following important but
simple messages must be .included in the health awareness building
initiatives by the health committee and health volunteers.
►► Treating severe malaria costs much more than treating malaria early.
►► Take proper and complete treatment
►► See a trained health provider if a person is not better in two dayjor if
becoming worse.
►► See a trained health provider if signs of malaria return a few weeks
after full treatment.
►► Some antimalarial drugs can be very dangerous if taken in the wrong
dose.
Even when a person suspects that he or she or a member of their family
have malaria, there are still many factors that may delay them in seeking
early treatment e.g.
►► Lack of money
►► Lack of time
►► Fear of loss of daily wage required for daily survival
►► Decision needs concurrence of other elders in the family.
►► Beliefs systems that make patient hesitate to access health centers etc.
►► Lack of relative to accompany patient
In poor and marginalized communities these are very real problems. In
health education programmes/sessions with the community these need to
24
c
be discussed. There is need to emphasize the problems that can relate to
delay in seeking treatment and the complications that can arise with late
treatment.
Volunteers can help to bring patients, early for treatment!
2.3.5 Package delivery for common diseases
Malaria treatment should not be part of a vertical compartmentalized national
programme but should gradually be integrated with other common diseases
and control programmes in the area, district, region or state.
An essential services package of drugs for common endemic diseases
especially communicable can be prepared keeping disease prevalence in the
area and the felt need of the community. 5 to 6 diseases can be selected.
depending on the priority health problems in the area.
Then a drug kit can be preparedfor different levels, e.g.
O Multipurpose health workers (nurse midwife etc)
Community health workers
Community volunteers.
The drug kit or package will have other preventive drugs, equipments,
materials that will enhance the quality of the service rendered by the primary
health care workers and health volunteers in the region.
>
The essential package or kit may include some of the following :
Preventive drugs/equipment
1. Tab Iron & Folic Acid
2. Tab. Chloroquine
3. Vit A solution/capsule
4. Chlorine tablets
5. Disposable pricking needle
6. Gauze / Bandage
7. Microslides
8. Sputum cup
9. Thermometer
10. Health Education Materials
11. Simple monitoring records
>2
25
Curative
1. ORS packets
2. Cotrimoxazole tablets/syrup
3. Paracetamol tablets/syrup
4. Anthelminthics tab./syrup
5. Cough expectorant syrup
6. Amoxycillin tab./cap /syrup
7. Diazepam tab/syrup
8. Tab. Primaquine
9. Tab. Sulphadoxine/
Pyrimethamine
10. Tab. Quinine Sulphate
11. Tab. Ergometrine
12. Antispasmodics
13. .Anticoagulant tablets
14. .Anti-emetic tablets, e.g.,
Prochlorperazine/Metoclopramide
>
The essential package or kit will have additional information which will
include proper drug information, details of dosage, mode of
administration, side effects, and expiry dates and cautions regarding
storage and transport. Different combinations of these 26 items can be
prepared for different levels depending on what and how much each of
the workers at different levels are expected to do, for malaria and other
health problems in the context of the country's health care guidelines.
2.3.6 Additional Administrative Support
How: To support the home and community level diagnosis and treatment, the
primary health care and malaria team needs to initiate a series of
administrative and organization measures that support and keep up community'
level action and confidence.
3 Establishment of functional fever treatment depots in each village and
urban slum.
O Ensure timely'replenishment of antimalarial drugs and glass slides or
needles for smears etc.
O Continuing training and education of health workers and volunteers in
malaria diagnosis and treatment.
O Clear standing instructions for chemoprophylaxis and treatment of simple
and complicated cases according to national/state guidelines that take into
account availability of drugs, patterns of drug resistance etc.
O Continuous technical updates for private practitioners, NGO’s and other
health care providers in the region.
O Provision of required drugs, preferably in age-group wise packets with
instructions in local languages.
O Formulations for small children should be made available.
O Mechanisms to monitor quality control of antimalarial drugs.
♦ ♦ ♦ ♦
26
X
2.4 Malaria prevention at community level
There are four ways by which people in the community can protect themselves
from malaria and also prevent malaria.
1. Preventing mosquitoes from biting people by personal protection, (avoiding
mosquito bites)
2. Controlling mosquito breeding by elimination of breeding places in and
around the house and in the community.
3. Killing adult mosquitoes by house spraying or thermal fogging.
4. Chemoprophylaxis by regular intake of drugs taken to prevent malaria.
For Malaria prevention to be effective at household and community level, the
local health committee, community volunteers, other members of the
community particularly women should be made aware of all the simple and
effective methods to prevent malaria by all these four ways.
2.4.1
Why:
►►
In addition to preventing malaria, preventing mosquito bites and
reducing mosquito breeding sites in the community also help to
prevent other mosquito borne diseases like Dengue, Filariasis,
Japanese Encephalitis and others.
►►
Mosquito bites also disturb sleep and have great nuisance value
leading to increased stress and irritability.
►►
Teaching the community to take measures to prevent malaria and
reduce mosquito breeding has additional advantages of teaching
people to take more personal responsibility for their own health as
well as encouraging collective action to tackle some of the health
problems at the community level.
2.4.2 Methods of Malaria prevention
2.4.2.c)
Measures to prevent mosquito bites
What : There are four major methods to prevent mosquito bites.
They include mosquito proofing of human dwellings; sleeping under
mosquito nets - both plain and or treated by insecticide; mosquito
repellant cream and mosquito coils and pellets.
27
Some details of each method including active ingredients, side effects and
advantages and disadvantages are shown in the accompanying tables.
Table 1 : Measures to prevent mosquito bites : An overview
Method
1. Mosquito
proofing of
human
dwelling
Suitable for
Permanent
dwellings
Advantages
Disadvantages
1. All members of household are
protected once they are inside the
house
1. Thatched houses with eaves
cannot be made mosquito
proof by screening
2. The method is costly to install
but usually very little recurrent
expenditure.
3. Not effective if the family
members sleep outdoors.
2. Collateral
benefits
such
as
protection from flies and other
insects.
3. A person can perform normal
household activity inside the house
without restriction.
2. Sleeping under
i mosquito net plain / treated
with
insecticide
Used by an 1. Suitable for use by an individual
1. An individual remains exposed
individual or 2. The effectiveness as a protection
to mosquito bites after dusk till
members
of
he goes to bed
against mosquitoes depends on
family while
sleeping time
2. tao other collateral benefit.
sleeping
3. Costly at beginning only for plain 3. Net has to be chemically
indoor
or
net.
treated regularly
outdoor
3. Mosquito
repellent
cream
Can be used '
by individual
on joumey^Dr
external j
duties.
4. Impregnated
coils / pellets
1. Suitable for use by an individual
2. Action last<for a short time. Repeat
application is required during the
night.
3. Local herbal alternatives should be
encouraged. E.g. Neem oil /
citronella oil
For use by 1. Most effective in confined sleeping
individual or
area
by group of
2. If used in all rooms of the house
people
from
dusk
onwards,
usual
sleeping
household activity can be carried
indoors.
out by family members with very
little exposure to mosquito bites.
1. Some
individuals . may
experience adverse reactions
due to skin sensitivity.
2. Rate of acceptance is low
because repeated applications
are required every night.
3. Some individuals do not like
greasy material on their skin.
1. Efficacy is adversely affected
by direct air current
2. Impregnated coils and pellets
are costly.
3. Effect of long term exposure to
chemical vapour used in coils,
etc has not been studied.
3. Efficacy differs from one product
to another and is estimated as 60 to
80% protection only.
Source : Malaria Action Plan (MAP) Manual NAMP, India 1997.
28
Table 2 : Personal Protection Measures
Additional Information
Active Ingredient /
Principle
Personal Protection
• Measures
Likely side-effects
Mats
Synthetic Pyrethroids
Respiratory / eye problem
including asthma, itching,
rash, etc.
Mosquito Coils
Herbal/synthetic
pyrethroids
Respiratory / eye problem
including asthma, itching,
rash, etc.
Insecticide Treated Nets /
Curtains
Synthetic Pyrethroids
Respiratory / eye problem
including asthma, itching,
rash, etc.
Vaporizers
Synthetic pyrethroids
Respiratory / eye problem
including asthma, itching,
rash, etc.
Light Traps
Light attraction
Nil
Mosquito proofing/
window screening
Mechanical barriers
Nil
Mosquito Repellent
Creams
Herbal /Chemical
Skin irritation or rash
Lotions (DEET)
Chemicals
Skin irritation
Eucalyptus Oil
Natural oil
Nil
Citronella oil
Natural oil
Nil
Protective Clothing
Natural oil
Nil
Neem Oil
Neem derivatives
Nil
2,4,3. a)
How:
The manager of the Malaria control programme along with the primary
health care team and the health committee should explore the options
for making available repellants and nets at community level.
>
These can be made available through the following:
•
•
•
•
•
Shops and public distribution systems
Health centre and field staff
Women’s organisations and other community organisations
Local NGO's and health centres; health practitioners
Any other outlets/organisation
29
>
These materials can be procured and distributed through various
schemes:
•
Purchase on payment
•
Subsidized purchase through local cooperatives and autonomous
societies.
•
Subsidized and
programme.
or
free
distribution
through
government
The health care team, local community volunteers, NGO’s local
government institutions, educational institutions and others should be
involved in IEC activities which inform the community about the
different methods of personal protection.
These distribution programmes of protective measures should be
monitored by a local committee and regularly evaluated by it on a
regular basis.
>
Where the availability of personal protection particularly bed nets treated or othenvise is limited then the priority should be given to
pregnant women, infants and children in a community.
Some quality control mechanisms should be introduced to ensure that
substandard, fake or poor quality repellants and protective devices are
not thrust on an uninformed public.
>
2.4.3.b)
The organisation of programmes to procure and distribute personal
protection measures especially bed nets - treated or otherwise can be
very effective mechanisms to build community confidence and
experience in taking greater responsibility for their own health.
Elimination of mosquito breeding places in andaround houses :
While the mosquito spreading malaria is usually a clean water breeder
measures to eliminate mosquitoes in homes and the community should
focus on all mosquito' breeding sites and not only the site for
anopheles.
A. In the Homes
How:
Major mosquito breeding sites within the house, comprise water
storage container, animal drinking pans and flower vases, roof gutters
and pit latrines. Mosquito breeding in these habitats could be checked
by taking the following preventive measures that need to be made
public knowledge through IEC campaigns :
30
<
>
Water storage within the household should be reduced to a
minimum. However, this may not be possible in areas without a
piped water supply or with intermittent supply. In such cases,
mosquitoes must be mechanically excluded by keeping all
domestic water storage containers covered.
Unwanted standing water should be cleared and the containers
inverted. This is required because mosquito larvae dive to the
bottom of the container when disturbed, and may survive in the
residual water at the bottom of the container.
Choked roof gutters should be cleared of debris, so that rain
water does not stagnate.
Water in animal drinking pans, flower vases, etc., should be
replaced every day.
Sullage should be removed from the premises through properly,
designed drains.
Breeding of mosquitoes in pit latrines could be controlled by
treating with malaria oil to cover the w'ater. Another novel
method is placement of polystyrene balls to form a complete
physical barrier over the water to prevent oviposition. These
balls are cheap, non-toxic, virtually indestructible and have little
attraction or value for people to steal them. Proper design and
maintenance of sanitation systems is essential for eliminating
mosquito breeding in these habitats.
Access of mosquitoes to the interior of the house could be
prevented by screening doors and windows with 18 inch guage jp" < <
wire mesh screens.
B. Around the House
Hoyv :
Mosquito breeding habitats around the house include
rai
-------- rainy
water
collected in waste articles dumped in 1vacant plots, underground
cisterns and water storage tanks, wastewater drains, cesspits, and
septic tanks. Mosquito breeding in these habitats could be eliminated
by adopting the following preventive measures.
Oot,
31
M
) I
>
A thorough search oi yards and vacant plots must be made for
discarded articles and rain water collection sites.
>
Tree holes should be filled with mud or cement to prevent
accumulation of rain water. If solid waste disposal services are
inadequate, articles that may collect rain water could be dealt with, in
other ways, e.g., cans could be cut open and crushed, pans and trays
could be turned over, discarded tj^res could be cut and turned over, etc. • ’
Underground cisterns and water storage tanks should be covered with
18-guage mesh screens. If possible these may be stocked with
mosquito-eating fish such as Gambusia affinis for clean water and
Poecilia reticulata for dirty water.
Drainage arrangements should be made.
Cesspits should be avoided completely and replaced with proper
soakage pits.
Septic tanks should be sealed properly and the vent pipes furnished
with screens. Effluent from the septic tank should be discharged into a
soak-away and not into the open.
C. In the Community
How:
In the community, major mosquito breeding habitats comprise spillage
around water supply sources’, wastewater drains, storm water drains,
cesspools, ponds and other large water bodies, and low-lying vacant plots.
These jfabitats should be dealt with as follows'.
<
Water spillage around community water supply sources such as hand
pumps, wells, public stand posts, etc., should be checked and drainage
arrangements made.
Wastewater and storm water drains should be maintained properly and
dumping of solid wastes into these areas should be forbidden.
Undesirable water collections in the community could be eliminated
by drainage or filling. Cesspools and low-lying vacant plots are best
dealt with by filling with rubble, earth or refuse. Ponds, borrow pits
and ditches could be filled or, alternatively, these could be drained.
However, small and temporary habitats such as small pools and
puddles, roadside ditches, water-filled vehicle tracks and cattle hoof
prints may be too numerous and scattered to fill or drain.
Mosquito breeding in large water areas could be eliminated through
environmental modification e.g., construction of public irrigation
works that allow control of the water level and shore conditions
(impoundment).
Drainage, filling and impoundment are methods that usually give long
lasting effects. However, these may have other ecological
repercussions and therefore should be undertaken only with expert
advice.
32
Note : For Malaria prevention and mosquito control to be successful then environmental
management by individuals, family, community and the government, separately or in
partnership is a very important component of concerted and collective action.
Table 3 lists out the action, the action site and action to be taken by whom. This is a good
check list for organising the programme and for focussing health education efforts and
messages on specific groups.
Table 3 : Methods for Mosquito Control through Environmental Management
(Individual / Family / Community / Government)
Action
Action site in
Cover domestic water storage containers; tight fitting lids; empty
water once in 7 days
Clear unwanted standing water
Action to be taken by
The house
The individual, the family
The house
The house
The individual, the family
The individual, the family
The individual, the family
Clean roof gutters/sun shades
Replace water once in 7 days in animal drinking pans, flower
vases, etc.
The house
Ensure provision of properly designed sullage drains
The house
Ensure proper design and maintenance of sanitation / cover vent
pipes with mosquito netting
Store used articles and other refuse in closed containers
Screen doors and windows
The house
Tne house
Tne house
Use mosquito nets and repellents
Clean yards and vacant lots
The house
The surroundings
The family
Tne individual, the family
The individual, the family
Cover with lid tightly; screen underground cisterns and water
storage tanks, or stock them with mosquito eating fish
Ensure proper drainage
The surroundings
The family
The surroundings
Control water supply sources and ensure proper drainage
The community
Provide properly designed waste water drains and storm water
canals
Tne community
Drain or fill undesirable water areas like cesspools, puddles,
ditches, etc. tap pits
Modify large water areas by impoundment
Tne community
Ensure adequate solid waste collection and disposal
The community
Tne family, the community,
the local government
The community, the local
government
Tne community, the local
government
The community, the local
government
Tne community, the local
government
Tne community, the local
government
Construction site
Building site
Coconut shells to be cut m 4 pieces
Community'
Family,
Community
Community
Tne contractor; the building
laws by government
| Tne vendor, community
The family, the housing
society
Tne family. Community
Community
Tne family, the community
House
The family
Mosquito proofing of overhead tanks (OHT), make OHT
accessible for inspection, demolish discarded tank completely.
Unused wells may have water covered by EPS beads, crude oil
or larvivorous fishes
Used wells may be covered, screened with net or use larvivorous
fishes
Coolers / air conditioners may have water changed once in 7
days or a dry day observed each week
3
Tne community
The family, the community,
the local government
The family, the community’,
the local government
Tne family, the community
Larval Control:
Larvae control can be carried out if breeding sites are 1within
*' ’ the flight range of
mosquitoes from the community and breeding sites are limited and accessible,. The
following options can be used in larvae control:
«> Chemical larvicides are useful as an instant larval kill and may be used even in
potable water.. p--1- )
Use of larvivorous fish which are cheap, can be linked with edible fish production
and can provide long term control, if proper supervision is maintained.
Covering/scrcening of water tanks are effective but may be expensive though it is
long lasting.
Biolan'icides are specific for mosquito larvae, do not kill predators and are not
prone to illicit sale for other purposes. However resistance develops against them.
• Use of expanded polystyrene breads (EPB) to cover the water surface is also long
lasting in sites which are confined and without wind and overflow.
[Each country programme will have its own policy for larval control. This muGh be
informed to the local community through suitable IEC and other materials].
2.4.3.c) House spraying and thermal fogging
These are methods aimed at killing the mosquitoes and require careful
planning. Knowledge relating to the vectors, breeding season, epidemics,etc
are necessary. Therefore house spraying and thermal fogging should be done
by well-trained health personnel. Communities should assist in house spraying
operations and fogging by :
>
Providing volunteers for spraying and
>
Motivating people to accept house spraying.
[Each country' programme will have different spraying schedules. This must he
informed to the local people through suitable IEC and other materials].
2.4.3.d) Chemoprophylaxis
The community should be educated by the District officials whether or not to
take Chemoprophylaxis and which drugs to be used for the same. In special
circumstances, chemoprophylaxis should be offered as per national guidelines
to special groups such as pregnant women in endemic areas and short-term
non-immune travelers to endemic areas.
[Each country1 programme will have its own guidelines about chemoprophylaxis. This must he
informed to the local people through suitable IEC and other materials]
34
2.5
ELIMINATION
OF
BREEDING
PLACES
COMMUNITY ACTION / CAMPAIGNS
THROUGH
Community action is essential for the successful elimination of mosquito breeding
places. This is possible only if the community is made aware of the mosquito cycle
and the points at which community can intervene.
2.5.1 What:
> Community action is required to eliminate breeding places as most of the
breeding habitats are man made and hence it is the responsibility of the
community at risk of vector borne diseases to eliminate the source of
breeding. This action may be organised as campaigns.
Methods of elimination of breeding places are :
►►
Source reduction by eliminating or changing the breeding places to
make them unsuitable for developing larvae.
►► Making the breeding places inaccessible Uadult mosquitoes for laying
eggs.
►►
Releasing fish/predators that feed on larvae and pupae.
> Apply the operational area principle of eliminating breeding places in an
area with a radius of 1.5-2 kms, and around hifman settlements i.e. the
flight range of target mosquito species.
> Elimination of breeding -places can be on permanent (long term) basis
through environmental modification or on a temporary basis through
environmental manipulation and release of bio-control agents.
2.5.2 How:
1. Identify the target community; rural, urban and developments project area,
(stratify if there are diversities in the socio-epidemiological situation of
malaria in the area)
2. Motivate the community through awareness campaign using appropriate
IEC materials, (see’4.6)
3. Carefully identify breeding places at community level and map them.
4. Evolve guidelines for community action to eliminate breeding places
(depending on local mosquito species and choice of methods for specific
breeding habitats identified locally/)
5. Establish a committee^with a chairperson. Active members such as
teachers, women postm’asters, retired employees, development workers,
religious leaders can be included with one person assuming the leadership
role.
35
6. The activities of the committee should include
•
Motivation of the community through interactive meetings
•
Identify solutions - including those from community experience
•
Planning the campaign
•
Monitoring and reviewing the campaign.
7. Small groups with active members can be formed to generate collective
force in filling low lying areas. Such reclaimed areas can be used for
public use such as playground, etc.
8. School children and youth can be motivated in planning trees in the
reclaimed marshy low-lying areas in the effort of developing social
forestry.
9. Technical skills in masonry, plumbing and constructing of soakage pits
need to be developed so as to make the community self-reliant especially
in construction of proper drains etc.
10. Potential avenues can be explored for resource mobilization from local
sources and from other sectors and departments to enhance the campaign
nature of activity.
11. If the campaign has to be successful then all sections of the community
should be involved - children, youth, women, teachers, others. The
campaign committee should identify the roles of each of these groups and
orient them to those roles to ensure that the campaign goes smoothly.
12. Other departments who can help the campaign are :
• Local administration
• Sanitation / water supply
• Agriculture department
• Fisheries
• Public works department
• Forestry etc.
Cooperation and resources from all of them especially their field workers
should be mobilized.
* * * * *
36
2.6
Sustaining community level action and partnership
To eliminate malaria as a problem in the community, action at community level
should be sustained on a long term basis. Community participation can be sustained
by the following measures in the programme :
1.
Involve community right from planning in all stages of programme
2.
Frequent interaction with community, providing solutions to the problems in
carrying out control activities will also sustain the interest of community in
malaria control activities.
3.
Promote socially acceptable and viable solutions that are
•
Culturally acceptable
•
Low - cost available / affordable by all
•
Socio-epidemiologically sound and need based.
4.
Ensure that supplies are constantly available (insecticides, fish, nets, medicines,
neem oil, equipment, microscopes, stain, slides). This will also greatly help the
sustainability of the programme.
5.
Develop dynamic leadership and encourage self reliance
6.
Minimize conflicts by keeping organisations small; restricting memberships to
persons with harmonious objectives; defining objectives; in a focussed way and
distributing benefits equally.
# .
7.
Increase popular awareness of the value and the benefits of a malaria
programme.
8.
Encouragement of income generating vector control activities, e.g., social
forestry plantations will also help sustainability of the community involvement.
9.
Provide some incentives for the community from the district administration in
the form of
a)
Declaring malaria-free or healthy villages
b)
Developmental inputs.
* He * * *
37
r
3 BUILDING PARTNERSHIPS
Partnership building is a major challenge for the Roll Back Malaria initiative.
National malaria programmes have often been, till recently the sole responsibility
of the National Ministries of Health and their Malaria or communicable disease
control directorates. There is urgent need to build new partnerships within and
outside the health sector to make malaria control a collective responsibility.
Partnerships are built on :
Common interest
>
Mutual respect
>
Clear manageable common objectives
>
Commitment to contribute time, resources, energy
>
Mutual trust
Partnerships should lead to :
>
Significant health gains or reduction in the problems which the partnership seeks to
tackle
>
Strengthening of the programmes role as a catalyst for heaiyi sector development
>
The efforts involved in establishing and maintaining the partnership should be worth
it.
. •
Partnerships are alliances in which individuals groups or organisations agree to :
>
work together to fulfill an obligation
>
undertake a specific Task
>
meet a shared objective
>
share the risks as well as the benefits
>
review the relationship regularly
>
revise the agreements as necessary.
!
Partnerships in Malaria control must be built on all these principles and criteria as
gradual process with skill, care and enthusiasm
>
To begin with there should be an Advocacy process at the district level supported
by similar processes at state and National level to generate enthusiasm and identify
and develop leadership at all levels (refer 3.1)
38
Partnerships should then be built with a wide variety of partners identifying there
specific and special contribution to the malaria control programme. These would
include:
1. Partnership with the Voluntary / NGO sector (refer 3.2)
2. Partnership with the Private sector (refer 3.4)
3. Partnership with the Educational sector (see 3.3)
4. Partnership with other sectors / departments (refer 3.5)
through intersectoral coordination.
>
The most important objective of all the different partnerships is to increase the
community awareness of the malaria problem and encourage them to be actively
involved in tackling it and participating in all the strategies and action
programmes that are organised for malaria control.
Communication for
behaviour change is therefore a major challenge and a comprehensive health
education strategy (IEC) should be a collaborative effort with all the partners (refer
3.6).
39
3.1
Advocacy and leadership for change
For the Malaria control strategy to be really effective there is need for commitment
and participation from a variety of people outside the health sector. The causes of
malaria are not just biomedical but deeply linked to the development, environmental
and other policies of the government. Different sectors contribute to the problem.
All sectors must be therefore contribute to the solution.
To make this happen there has to be an active process of Advocacy and leadership
development at all levels starting from National level; to state or sub-national level; to
district and municipal level; and finally to community level (described in section 2.1).
This process of Advocacy and leadership development should precede and also
complement all efforts to build new partnerships for malaria control.
3.1.1 Who : At the District level this Advocacy and leadership development must
be focussed on :
>
Political commitment of District level leadership (District and Municipal
administration)
>
All government departments and programmes especially their field level
officers and functionaries at District and sub-district level.
>
Leadership of educational institutions; NGO’s.private sector; professional
associations; and civic society organisations and associations at district
and sub-district level.
>
Medig and communication groups at district and sub-district level.
>
Local public or private sector industry and related services or
establishments.
>
Any other organisations that the Malaria programme manager or Primary
health care team, consider to be a resource for the programme.
3.1.2 What :To strengthen the process for Advocacy and leadership development,
the following should be first evolved at the District level by the District
Malaria manager in collaboration with the primary health care team.
a) Comprehensive Analysis of the local malaria situation and the problems
to be tackled.
To understand the Malaria situations in the District find out some details of
each of the following :
• Characteristics of malaria (epidemiological)
• Number of people at risk
• Type of people at greatest risk
• Vectors (Anopheles)?
• Plasmodium species?
• Annual OPD attendance due to malaria in government health
institutions, others
• Percentage of all OPD attendance due to malaria
• Potential for epidemics
• Types of environment and malaria transmission
40
b) Designing the framework of^strategy
[While a national or state level control strategy may be available, this
should be adapted to the local social and epidemiological realities and to
the local health care development situation and constraints]. The strategy
must atleast include:
• What all need to be done?
• Who can do them and how?
• What sort of information or techinical or training support is needed for
the tasks to be done.
i
• Who will provide these supports?
c) Identification and mobilizing of resources
An exercise to identify all the sources of human, material, monetary and
other resources must be undertaken. ’All these sources should must be
undertaken. All these sources should be tapped formally and informally.
i
d) A programme should be planned with details on
• Implementing Action - (By whom and how)
• Monitoring and evaluating (By whom and how)
• Planning for review and maintaining continuity of Action.
e) An Advocacy strategy
Planning who should be reached with what messages and how to seek their
support and involvement.
The strategy should be
i.
Informal : Personal interactions with all the identified important /
significant people at political / administrative and other levels is very
important. An informal approach helps to understand the power
structure and the decision making process (i.e. who influences whom
and how) which can help in the planning of the strategy.
ii.
Formal : This is a planning of meetings, events, activities, that will
help the Malaria manager involve everyone concerned who needs to be
reached and involved in the programme.
f) A leadership strategy
The most effective strategy beyond the formal and informal advocacy
strategy is to bring together all the key decision makers and potential
partners into a malaria or a Health coordination committee at a District
level which will then support and promote malaria control programmes at
district level (refer 3.1.3)
41
3.1.3
How:
The key leadership development strategy at the District level is to evolve a
Malaria Health coordination committee at the District level and supporting,
facilitating and evolving development of local leadership potential through
working together.
a)
The Malaria core/coordination committee (Leadership)
The malaria programme activities at the district level needs the
involvement of atleast the following:
►► The District Administrator
District Health Officer
►>
Health Officer designated for malaria, if available.
►►
Education Officer
►>
Agricultural Officer
►► Public Works engineer
►►
Representative leaders of local / village self government
►►
Selected NGOs
►>
Representative of health care providers associations if any
►►
Public / private industry if any
►►
Officers in charge of:
•!
•
•
•
►►
b)
water and sewerage
irrigation
rural and urban development
social welfare
F-
bevpl"
(The composition of this coordination committee will vary in each
country and state and will depend on the resource persons available
at district level)
Evolving the role of the coordination team.
These will include the following steps:
Step One
A coordination committee chaired by the district administrator and
health/malaria officer as secretary will be the first step to develop
leadership at the district level. In keeping with the new philosophy of
RBM, representatives of leaders of the community, NGOs, private
practitioners and industry should also be included in the committee so that
the ownership and the stakes of a much wider group are facilitated.
42
Step Two
The committee should evolve mechanisms for :
♦ Promoting participation - meetings, working groups, subcommittees
focussed on special ideas.
♦ Sharing information - communications, newsletters
♦ Formulating strategic action plans for each department, sector, partner
represented on the committee
♦ Implementation and its monitoring
♦ Fostering new partnerships - (new partners will keep joining as the
programme evolves and spreads)
♦ Interdepartmental, intersectoral and inter-partner coordination.
♦ Reviewing partnership through regular monitoring and review
Step Three
Prepare IEC materials applicable for the district to motivate participation
by all these sectors. Each member of the committee must be encouraged
to plan IEC events in his/her own sector and increase awareness and
involvement'of the sector (Also refer 3.6).
Step Foor
Communicate integrated malaria control plans for the district to various
sectori and partners involved in the programme through regular meetings
and update.
Step Five
All members of the committee should facilitate the participation of the
community as the central theme of the programme, (refer section 2);
Community mobilization will therefore be a shared responsibility.
Step Six
Constantly review the malaria situation and programme with all partners,
especially the community.
c)
Developing capacity of leadership
>
The success of RBM will rest on the capacity of district level officers
placed in charge of the programme to carry out the above steps. For
this purpose, they will need training /orientation to develop the
following skills:
•
Managerial and leadership
•
•
Strategic planning
Monitoring and evaluation
43
Communication
Networking and partnership
Advocacy
Community mobilisation
Resource mobilisation
Rapid appraisal procedures
>
Suitable resource persons and training centres from governmental
and non-governmental sectors should be identified for this capacity
building process through regular workshops and skill development
sessions.
"Public policy advocacy is the effort to influence public policy
through various forms of persuasive communication. Public
policy includes statements, policies, or prevailing practices
imposed by those in authority to guide or control institutional,
community, and sometimes individual behaviour."
!
i
44
3.2
Partnership with Non-Governmental organisations (Voluntary sector)
The role of NGOs especially the voluntary agencies (not for profit NGOs) is
being increasingly recognised in planning and policy circles as an effective
complementary/ supplementary strategy in health care programmes and
malaria programme is no exception.
■>
In the past, they have played this role without much governmental support. In
recent years a greater degree of collaborative effort is emerging as a policy'
alternative.
3.2.1 Why
♦ The Voluntary agencies (Volags) have their Strengths
a)
They are closer to the people and usually more aware of grass root
realities.
b)
They often work in more interior and inaccessible areas with more
marginalised groups and the underprivileged.
c)
They tend to be idealistic and committed to certain values and principles.
They often have a stronger development orientation and awareness
building.commitment and skill.
I
♦ The Voluntary agencies (Volags) have their Weaknesses as well
d)
a) They are very dispersed and individualistic and not often linked by any
integrated network.
b) They are often inadequately aware of governmental programmes having
their own programmes and agenda.
c) They are very diverse in their size, type, ideology, focus, distribution,
linkages and professional competence.
d) They often lack adequate professional expertise being stronger in
motivation rather than in skills.
e) They often follow fund driven or donor driven agendas.
It is a very important development that the opportunities of government - non
governmental collaboration are being increasingly promoted in recent years and
malaria control should be a new opportunity. The evolving process of partnership
should build on NGO strengths, and capabilities.
45
3.2.2 What - The Avenues and Areas of Partnership are many
a) Building Community awareness
As the NGOs work with the local communities, they understand the
community dynamics and the local culture. Any community awareness
programme should be relevant to the local context and hence working with
the NGOs as partners could greatly enhance the efficacy in the community
awareness programmes. Developing IEC material relevant to the local
context and carrying health messages through indigenous and local
methods will have greater acceptability and adoption and could be a major
role for NGOs.
b) Involvement of community in planning
Most of the organisations promote participatory methods of problem
identification and planning. This favours bottom up planning and
ownership of the programme by the community. In the area of vector
borne diseases, this will be a good strategy for control mechanisms and the
government could use this expertise available with the NGOs.
c) Community mobilisation for community action
As mentioned earlier this is one of the great strengths of the NGOs. A
recent example of this has been the pulse polio programme. Similar
strategy could be adopted for vector control and promotion of personal
protection measures.
d) Early Diagnosis and prompt treatment
As the NGOs are the first level contact in the community, access to
diagnosis and treatment could be made available nearer to the community.
They also could be involved not only in case finding but also on follow up
of patients. (A few NGOs could be trained in this direction as an approach
to partnership). They could be helped to set up fever treatment centres and
stock malaria medicine.
e) Epidemic preparedness
A few NGOs could be built as resource centres for epidemic preparedness,
as they are closer to the scene of action. Here the partnership will enhance
the effective control of the epidemics in epidemic prone areas. They could
be trained in surveillance and monitoring the malaria problem and
initiating a response when the problem begins to increase.
f) Building malaria profile in area
NGOs could help in building a profile (socio-epidemiological) of
malaria in the area using interactive participatory approaches and
appraisal methods. These would help to understand community
behavioural pattern and health seeking behaviour which could be useful
for effective strategy formulation.
46
3.2.3 How:
The Partnership with NGOs could be gradually built up by the
following steps
a) Identification of NGOs in the districts
The District coordination committee (refer 3.1) will develop simple means
for partner identification to ensure that the right type of partners are
involved in the programme.
b) Setting up district coordination committee
The district health malaria officer will form this committee with some
NGO representation. The basic function of this committee would be to
appraise the NGOs, look at proposals and budget screening, and working
out a time plan of activities.
c) Sensitization and capacity building of the NGOs
The committee will conduct a workshop for the identified NGOs to
sensitize them on the issues of vector borne diseases and do a need
assessment to look at gaps in the skills. This committee will also identify
resource persons in the district to build the skills of the NGOs, especially
in areas of diagnosis, treatment and vector control.
d) Information dissemination through the NGO’s
The district committee will develop appropriate information and
programme guidelines for various activities for the NGO partners on the
health issues identified. This in turn will be further simplified by the
NGOs for community level dissemination.
Information from the community also will be received, sometimes through
the NGO at the district level for follow-up. This may be documented
systematically or could be taken up for policy advocacy work.
e) Preparation of IEC materials / Planning of IECprogrammes
The committee will encourage production of community specific IEC
materials, which can be used in the local context. This committee can
over a period of time review the impact in the community due to this IEC,
which may then be documented. Local artists, school teachers and school
children can be involved in generating local materials. Local folk arts and
folk media may be used to evolve themes relevant to the malaria
programme, which will be used by the NGO’s. (Also refer 3.6).
f) District level action plan
The district coordination committee will ensure that each district or even
sub-district has an action plan worked with the help of NGO partners.
This may be presented to the committee and queries clarified and
approved. Since malaria is a local disease decentralized local strategies
based on local malaria situation will be the most effective strategy.
47
g) Participatory planning and monitoring
The NGOs will be encouraged to use participatory tools for programme
planning and monitoring. Other than this, they will also develop
indicators as MIS for bringing out reports and to measure outputs.
f-
.A
,.f.
!_•
... )
fl) Monitoring and review
The committee along with the partner and community will conduct this
review at regular intervals to give direction to the programme.
i) Advocacy
The committee along with the partners and networks will take up local
issues for advocacy. This may be at the local government level or at the
district level. They may be specific malaria campaigns or general health
campaigns, which include action on malaria.
J) Documentation
Enhancing the documentation skills of NGOs involved in the programme
are an important adjunct activity and should be promoted. Learning from
field experiences both positive and negative are an important adjunct to
group learning and NGOs and the government health team should be
encouraged to do so, constantly.
48
3.3 Partnership with educational sector
Why : Children and youth are a very important group to be reached by IEC and other
programmes because
o
They are the future citizens who should be made more aware of health as a
responsibility and a right
o
They are eager to learn scientific concepts and have great energy and enthusiasm
that can be harnessed for field programmes and campaigns
®>
Elder children and youth can be motivated to get involved in civic society
campaigns to sensitise them to civic and social responsibility.
o
Children can carry messages home and pass on information to parents and other
members of the family including persuading them to change their ideas and
attitudes
■>
The role of children and youth in Health programmes and campaigns are
increasingly being recognised all over the world and in the region.
3.3.1
♦
♦
What
The partnership with the educational sector should be aimed at the following
target population
•
School children and college going youth (6-21 year)
•
School dropouts
•
Children with no formal education
•
Child labour and working children
The partnership will therefore focus on all the locals schools - primary,
middle and high schools; colleges and vocational training centres and
polytechnics; non-formal education programmes for school dropouts and
working children.
What is expected from children and youth :
• know cause and control of malaria,
change attitude and
practice
preventive measures
•
involve
in
health
campaigns to create
among community
•
participate in mosquito breeding
preventive measures (in and around
Awareness of Malaria
For School Children
education
awareness
educational institution)
What is the role of partners?
• Inclusion of health education in school / college curriculum including
malaria control and prevention.
• Motivate the students
• Mobilize their participation in preventing mosquito breeding
• Involve them in community / family awareness programmes.
49
3.3.2 How :
i)
List out all the educational sector institutions in the district finding out
details of the levels Jhe number of children, teachers etc.
ii)
Invite them to some meetings and workshops to sensitize / orient them to
all aspects of malaria control programme and how children and youth
can be involved in them.
iii)
The Education Department / Directorate should also send a circular to all
schools / colleges to join the Malaria control initiatives in the district.
iv)
Involve the education department in celebrating a malaria event by
carrying out anti-malaria activities on the occasion.
v)
Exposing students and youth to various aspects of malaria by including
malaria related activities and experiments as project work in the
curriculum.
vi)
Involve science clubs and science networks in increasing awareness
about anti-malaria activities amongst children and youth.
vii) Conduct seminars / guest lectures / demo-exhibitions / field trips / essay
competitions / debates appropriate to the level of schooling / education.
viii) Initiating debates / competitions between schools, colleges, and
universities on malaria control and on vector control to create
widespread awareness.
ix)
Including the practice of vector-control activities by students and youth
in scout movements, national defense and social service auxiliary corps.
x)
Explore the possibility of inputs by teachers and students into fairs and
festivals.
xi)
To support all these activities a small booklet on how children / youth
can be involved in malaria control should be prepared supported by
posters and charts for wide distribution, (all the items in the primer A-Z
should be covered in the booklet see 2.2)
To sustain the above activities :
xii) Regular meetings with teachers and staff involved in education should be
held.
xiii) Capacity building/training sessions for volunteers, teachers and high
school students should be organised.
xiv) Organize events at regular intervals to maintain the interest and tempo of
awareness activities in the educators and the students / youfn. E.g. a
Malaria Day; a Malaria week or a Malaria month.
xv) Evolve separate Guidelines For Partnership with Agencies Involved In
Non-Formal Sector of Education
Agencies like NGOs, Slum Welfare Boards, Social Welfare Boards and the
educational department that are involved with street children, child labour
and school dropouts must also be encouraged to increase awareness about
various issues regarding malaria through appropriate efforts from those
mentioned in the guidelines above and those given in section on partnership
with voluntary agencies (Refer 3.2).
50
3.4 Partnership with Private sector
The Private Sector include the following at the District level:
Health care providers
♦
General private practitioners of all systems of medicine
♦
Private dispensaries, health centres, nursing homes, hospitals
♦
Laboratories and diagnostic centres
♦
Chemists and pharmacists
Health product manufacturers of
♦
drugs and pharmaceuticals
♦
insecticide manufacturers
♦
Bed nets and personal protection equipments.
Non-health private sector
Which includes
♦ Local industries
♦ Small-scale industries
♦ Construction companies and contractors
♦ Engineering firms and
♦ Other private companies.
3.4.1
Why
Today evolving partnerships’with the private sector is an important challenge
because:
•
The public health sector and government programme cannot reach all the
people or make all the health gains on its own.
•
The private sector already runs a large number of health related services
that reach a large number of the population.
•
The private sector has management, marketing, organizational and
communication skills that can be harnessed to enhance a government
programme.
•
There are financial resources from the private sector that can be harnessed
to support government programmes as their social/community
responsibility.
•
In some cases like very large coiporate sector establishments or private
industrial establishments they may provide townships for their own
workers and their involvement to ensure that these townships do not allow
mosquitogenic conditions to develop due to poor environmental
management is necessary.
• SO
U ) l
.;*if
51
Io (
0^
*
Caution: The partnership with the private/corporate sector should be evolved very'
carefully since the profit motives ofprivate sector are strong and the government
malaria control programme must not become a vehicle to sell specific goods or
services or become compromised in any h’aj’ due to financial support and any
unhealthy practices related to their deployment. To avoid conflicts of interest
whether real or perceived - the concerned government programme while evolving
the partnership must establish procedures that will ensure.
a)
b)
c)
Final normative decisions are free from undue influence.
Industry fmding is not used for salaries of staff involved in
normative decisions.
Consultations and other normative activities never have
their majority financing from the concerned industry.
Source: Partnerships for Health Promotion (6)
3.4.2 WHAT
While the partnerships should gradually explore all sectors of the private
sector - each group must be involved in those aspects of the programme in
which they have specific expertise interest and skill.
I
a) Health care providers
r
All health care providers should provide scientific diagnosis and
rational treatment of malaria cases under their care.
All of them should be made aware of the different types of malaria in
the district and how to identify severe or complicated cases that need
referral to centres that are equipped to handle these complications.
All of them should be involved in health education and IEC activities
that provide all their, patients and the communities from which the
patients come simple knowledge about the do’s and don’ts for malaria,
prevention, treatment and control.
■>
All of them should be encouraged to notify the health authorities about
malaria cases they diagnose or treat so that suitable public health
measures can be taken including enhancing epidemic preparedness and
response.
b) All Health Care product manufacturers
♦
They must be encouraged to produce low cost products
appropriate to local needs. These include:
Nets
Mosquito repellents
o
IEC materials on Health including malaria
©>■
Drugs
52
c)
♦
They should adopt good manufacturing practices including
quality control, fair pricing, and ethical marketing and sales of
all malaria prevention and control products.
♦
Drug manufacturers in the region should be encouraged to
provide rational formulations and produce single ingredient
drugs in the recommended dosages only.
Non — Health private / industrial sector
They could be involved at district level to provide the following
supportive services to the programme.
Financial resources for the programme
Promotion and distribution skills
Supporting IEC activities.
Taking steps to provide healthy work place and nonmosquitogenic conditions in their institutional environs.
3.4.3 How
The partnership with the private sector should be built gradually
through the following steps.
a) Identify all potential partners in this sector in the district
List out all the health care providers and institutions; the health care
product manufacturers; and all others in the non-health private /
business/industrial sector in the district.
, •
Identify all those who are likely to be positive partners in the malaria
control programme giving priority to those who are already doing
some activities, that can be supportive of the programme.
b) Involve in District coordination committee
Involve some of the key representatives of associations of the health
care providers and the private sector in the local Health/ Malaria
coordination committee described earlier (refer 3.1.3a)
c) Sensitize all the potential partners
Involve all the potential partners by sensitizing them to all aspects of
the malaria control programme through
•
•
Informal personal interaction
Formal meetings
•
Communication - handouts and news letters.
Those who show specific interest and enthusiasm can be further
oriented/trained through workshops and skill orientation sessions.
53
d) Identify the role and contributions they could each make to the
programmes.
They could adopt malaria control activities in their own work places.
They could join malaria control activities at the community level.
They could participate in IEC campaigns, events, exhibitions and
programmes.
e) Provide assistance to all the partners
If these partners require they should be offered technical information and
training support to enhance their partnership in the programme.
J) Monitor and review the private sector partnership
Each partnership should be reviewed regularly and the representatives of
the health care providers and the private industry sector in the district
coordination committee should participate in the monitoring / review of
the control programme at the district level.
3.4.4 Private practitioners and malaria - A special challenge.
In many South Asian countries the treatment of Iv/alaria has become quite
irrational.
A wide variety of irrational combinations and regimes often at high cost
are prescribed for patients suspected to have malaria.
♦
The illness episode is often exploited by the use of injectable preparations
and other adjuncts not in consonance with rational malaria care
guidelines.
♦
The standards of clinical diagnostic facilities are falling and very often
practitioners prefer symptomatic treatment rather than after sending for a
confirmatory laboratory diagnosis.
♦
Quality controls and checks are poor in laboratory facilities and drug
procurement systems.
♦
Some degree of medical misinformation also prevails due to medical
representatives from some companies making unscientific claims about
the superiority of their anti-malarial products over others available in the
market particularly generic drugs in the government programmes.
Irrational medical practice is therefore a major problem, which should be
urgently tackled.
54
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How:
a)
Regular continuing Medical Education sessions on Rational Malaria care in
consonance with National Malaria Treatment guidelines,
These can be
organised by :
«> The malaria control manager (district level)
o Local professional associations
o Local medical colleges and other health training institutions.
b)
Rational Malaria treatment guidelines should be prepared as pamphlets,
booklets, charts, calendars or handouts and widely distributed to all the
practitioners and pharmacists in the District.
c)
All practitioners should be encouraged to notify cases of malaria which they
diagnose and treat, to the district or sub-district level health authorities so that
suitable follow up measures can be taken by the malaria manager and his team.
55
©
3.5
Partnerships with other sectors (Intersectoral Coordination)
3.5.1 Why.
Intersectoral coordination is another important challenge in the RBM
initiative. Today there is greater knowledge about the development and
environmental strategies that can lead to mosquito friendly environments
especially if environmental impact or health impact assessments are not done
before development programmes and strategies. Various other departments be
it agriculture, industry, forestry, mining, power and irrigation, rural and urban
development etc. can contribute to the problem.
Many departments like Railways, Transport and Communication, Defence,
Industry and others look after large sections of the population usually their
own staff and their families in small and large townships. They can help in
the malaria control programme by making their work places and their
environments unfriendly to mosquitoes and by protecting their own work
force.
Intersectoral coordination therefore aims at involving all other sectors outside
the health sector who contribute to the problem and who can also participate
in the solution and the programme. This intersectoral partnership is therefore
urgent and crucial.
3.5.2 What :
It is important for the programme managers to identify all the sectors in the
district who can contribute both to the problem and to the problem solution.
The partnership with each of these sectors will seek to:
Orient them to all aspects of the malaria situation and control strategy
Identify ways and means by which their activities may be contributing to
the problem.
Identifying ways and means by which they can contribute to the solutions
Evolve malaria control strategies at their work places or for the
populations / workforce they cover.
Identify skills, capacities and other resources they may have which can be
tapped to support the district level malaria programme.
3.5.3 How
a) Identify all the sectors in the district that need to be involved in an
intersectoral partnership. Identify their functions and their functionaries at
district level.
b) Dialogue with each of these departments / sectors through personal
interactions and visits. In these discussions and visits identify all the
activities they can do to support malaria control in the district. Also
identify the information they need and the capacities / skills that may need
to be developed.
56
c) Invite them to join the coordination committee and be part of the planning
and strategy development process for the district.
d) Through regular meetings the partnerships can be evolved
operationalised.
and
e) Training and or orientation or specific skill training sessions can be
provided for staff of these sectors if they are required.
f) Through regular meetings monitor and evaluate these programmes and
constantly renew, adapt and make the partnership more effective.
[Different types of sectors will participate in malaria control in different ways.
District level partnerships should be evolved with each of them gradually.]
Two examples are given in this section. Agricultural department and urban
development department. These are only illustrative not exhaustive.
A) Agriculture
The agriculture department can be involved in:
•
•
•
•
IEC activities for agricultural community
Source reduction to decrease mosquitogenic conditions
Promotion of larvivorous fish hatcheries
Introduction of larvivorous fishes in water bodies in
selective high-risk areas.
B) Urban Development
Urban development department can help in:
•
Awareness of bylaws/legislation
•
Source reduction drive
•
IEC activities particularly for slum dweller and migrant labour
•
Promoting guidelines for construction and maintenance of
Roads
Safe drinking water supplies
Sewerage systems
•
Orientation of engineers from different sectors for their
involvement for the malaria control activities.
Note
Similar partnerships can be evolved at local /district with all the other
ministries and departments as well -including Forestry, Industry,
Mining, Social Welfare, Railways, Defence, Irrigation, Power, etc.
Specific guidelines for these have not been outlined. These will vary
from country to country.
57
3.6 Communications for Behaviour change (IEC)
Health communications
The most important challenge in Malaria control is :
•
•
•
To inform the community and new partners
To change knowledge, attitude and practices and
To build skill, confidence, capacity and trust.
This process is called in different names in different programmes; Health education
programme; Information campaign; Awareness building initiatives; and now more
commonly IEC activities (Information, Education and Communication)
3.6.1 Why
People in a community have different knowledge and belief systems, which
determine attitudes and practices in health and support or modify health
seeking behaviour. These may be adults, men and women, youth and children.
Some people in the family and the community are:
•
Informal or formal
•
Influences attitudes and practice.
If the community has to be encouraged and involved in family level and
community level action
•
To promote health
•
Prevent disease including malaria, and
•
Take appropriate action when illness including malaria takes place (action
may include early diagnosis, treatment, management or referral) and
•
Participate actively in community initiatives and campaigns
•
then IEC activities must form the core of all our efforts. Every opportunity,
every resource, every event should be mobilized to make it an opportunity
for communication for behaviour change.
3.6.2 What
a)
IEC or Health Education methods will consist of different types of
information materials used to reach messages to a community
Z Posters and charts
Z Hand bills or handouts
Z Flash cards and flipcharts
Z Booklets and pamphlets
Z Video cassettes
Z Audio cassettes
Z Radio and television programmes
Z Educational films
Z Newspapers, magazines and local media.
58
Awariessof Malaria
■
••
■;
For School Children
b) Interactive communication methods will also need to be evolved and
utilized in the process. These could be :
Z
Z
Z
Z
Z
Z
c)
Role plays
Street theatres
Folk songs / folk media
Exhibitions
Puppet shows
Village events like fairs / festivals events
Whether information materials are used or interactive communication
methods are utilized some general principles for health communications
must always be kept in mind. These include:
J
J
Communication should be a two-way process between communicator
and target group
Choices of language should be simple, in local vernacular (mother
tongue); jargon free; and with colloquial expressions and usages
Significant by local events and lives of well-known people should be
used in the communications. Local cultural / folk stories should be
adapted and used.
Communicators should be encouraged to listen to what the
community says, feels or does before planning messages.
Communication must be focussed on all the four phases of awareness
knowledge, attitude and practices.
It should be learner or audience oriented. not teacher or
communicator oriented
Role-plays and real life situations should be utilized more and more
to help people understand how they can change in the ways they do
things.
While communications is a significant skill, it can be taught to health
workers and community volunteers by those who have done it
themselves.
Communications must focus not only on content but also on the
process of interactive and participatory methodology.
59
/
Newer and innovative methods of communication need to be evolved
and experimented with all the time. Some recent examples are :
• Coloring books or sheets on mosquitoes and mosquito control for
little children.
•
Educational toys and models around the theme of malaria
control.
•
Activity modules for science experiments and science
through interactive activity.
•
Adaptation of folk media and folk arts to spread malaria
control messages.
d) Communications for Malaria control should explore all the above methods
and approaches and build on the principles outlined. The scientific
content must however be focussed on :
/ Health promotion including personal protection
Z Prevention including preventing breeding sites for mosquitoes
/ Early diagnosis and management at home and community level
and at health centre.
/ Early referrals of severe and complicated cases
/ What can people, volunteers, local health workers do for all the
above.
/ What can be done as
•
A community programme;
•
School health initiatives;
•
Community campaigns;
•
At family level in individual homes?
•
How can these be done?
Z The emphasis must always be that Health Action is a
responsibility for every person and that the availability of health
care services is also everyone’s right.
Z How can every member of the community develop this
responsibility?
f How can every member be empowered to assert this right?
3.6.3 How
The main steps to evolve an effective communication (IEC) programme for
behaviour change in a community are as follows:
a) Define clearly what ideas you are trying to promote or what actions you
want people to take in the community.
b) Identify whom in the community you wish to reach and with what
specific or general messages.
c) Learn about the existing knowledge, beliefs and behaviour of groups in
the community.
Design your messages building on knowledge and beliefs that are
supportive to malaria control.
60
d)
Find out more about all the sources of information on health for the
community groups in your district, which are the sources they
believe in most? Or who influences them most.
e)
Review all the communication channels, media and methods and
decide on which are the most useful or capable of reaching all the
community groups.
(Some methods / media may be better for some community groups)
Interactive channels
Doctors, nurses, community health workers and
volunteers, women and youth organisations, religious and
community leaders, school teachers and school children,
development workers, union leaders, NGO's government
staff and civic society organisations.
9^
Mass media
Local newspapers, magazines, radio, television
Small media
Posters, charts, booklets, pamphlets, flashcards, flip
charts, videos, audio cassettes, small displays and
exhibitions
Traditionalfolk media
Puppet shows,. dramas, street theatre, songs, folk story’
telling sessions, and folk dances.
CT
Decide on content of the messages to be used in the programme. These
must definitely include :
• Information that the community needs but does not have
© Actions that the community group may need to take
® Suggested ways to overcome obstacles to taking action
61
3/3 ■
g)
Create messages for different information channels selected in (3) some
may be short messages and slogans. Others may have many messages.
This will depend on each channel. .
h)
Pretest the messages that you select, on small groups to check whether :
• They understand the message
• Is it culturally acceptable and appropriate
• Is it relevant to the community group
These can be found out by focus group discussions and interviews and
the messages can be suitably modified by community feedback.
i)
Produce and distribute the materials
• Production should as far as possible,be local.decentralized and low
cost.
• Sometimes special skills and equipment may be required. These may
be identified in the district or elsewhere.
• Requirements should be estimated realistically
• Distribution channels and means should be clearly identified.
j)
Coordinate your communication programme and services with different
partners to reach as many members of the community as possible.
k)
Evaluate the effect of your messages (Also look at the strengths and
weaknesses of all the methods and the activities)
1)
Repeat and adjust the messages and methods at frequent intervals by
active learning from the field and through experimentation.
m) Develop a new schedule, and plan for conducting your communication
programmes based on your evaluation (k) and (1).
[This section has been adapted from Partnerships for change and
communication: Guidances for Malaria Control: WHO/Malaria consortium
UK]
62
c
STRENGTHENING MANAGEMENT
AT DISTRICT LEVEL
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4. Strengthening Management of the District Health System
The National Malaria Control Programme has always had a national strategy; nationally
evolved guidelines; has often been funded nationally as a vertical communicable disease
control programme because of the epidemiological and public health significance of malaria;
and has been monitored and evaluated nationally.
At the state level, the governments have actively participated in the programme strategy
contributing state level resources and human power to complement the national strategy.
However it is at the district level where the main operational and epidemiological challenges
lie and hence in a spirit of decentralization there is need to focus at this level to ensure that
the District health system is geared to meet the techno-managerial and the socioepidemiological challenges of malaria control.
Malaria is now understood to be a more local disease; a focal problem that needs a local /
focal strategy. Epidemiological patterns and disease trends vary with ecological paradigms
and hence a District level strategy will probably be more effective and relevant than a
standard state or National level strategy.
For this capacity, for District level situation analysis and district level strategic planning
different systems and components of health care at district level need to be built up;
strengthened; or expanded. District level skill and capabilities of the Malaria control team
and the primary health care team need to be greatly enhanced.
Strengthening technical and Operational Management systems at the District level will
therefore be a major strategic challenge in our efforts to Roll Back Malaria.
63
4.1. MANAGEMENT AND REFERRAL OF MALARIA
It is unfortunate that in spite of having simple diagnostic tools, low cost and effective
drugs, it has not been possible to control the malaria problem. Early diagnosis and
treatment continues to be the key strategy of controlling malaria. Making drugs
readily available is the important mechanism. Providing foil course of treatment
backed by effective referral mechanism to take care of severe and complicated cases
are the other most important strategies in the management of malaria.
4.1.1
DIAGNOSIS AND MANAGEMENT
1
Ensure a blood smear is always examined for malarial parasites among
those with fever and suspected of malaria whenever possible. Train the
workers below Primary Health Centre level, to diagnose malaria by way
of symptoms alone and to presume malaria in an endemic area unless
proved otherwise.
2 I Promote the provision of foil course of anti-malarials to an individual
suspected of malaria according to national guidelines in an endemic area
when blood smear results cannot be obtained within 2 hours.
3
Educate all personnel to presume every case of fever with chills and
rigors occurring cyclically in highly endemic areas or a person coming
from malarious area in the past few weeks as malaria unless proved
otherwise.
4
Teach all health workers and volunteers the following:
Bring down fever either by sponging with tepid water or with
paracetamol (500mg to 1 gm. for adults and 10 mg/kg for children)
Breast-feeding should be continued for children. Sugar solution /
Rice water / or glucose water may be given.
>
Create algorithmic charts to differentiate local illnesses from
malaria and for treatment by all primary level health workers and
volunteers. They must be trained for using the same.
>
Urgently refer all patients of severe malaria recognised by Fever
accompanied by:
O altered mental state
O convulsions /fits
o unconsciousness
<>
blood in urine
high jaundice
severe pallor
64
5
Establish Fever Treatment Depots (FTDs) at short distances so that a lone
mother with a sick child can access it. Ensure the availability of approved antimalarial drugs down to the level of Fever Treatment Depots (FTDs) if
established so that they may be accessed whenever a presumptive diagnosis of
malaria is made.
6
Train doctors and other health workers to:
1. Confirm the diagnosis of malaria
2. Treat uncomplicated malaria with nationally approved drugs
3. Treat severe and complicated malaria cases with IV Quinine or other
drugs known to be effective in all severe malaria cases that are approved
nationally.
7
Ensure that all health staff are aware and practice the following relating to
pregnant women :
a. Approved doses of Chloroquine or Quinine may be given in any trimester
of pregnancy for treatment.
b. Sulphadoxine - Pyrimethamine may be given after first trimester and up to
one month prior to delivery.
c. Primaquine should not be given during pregnancy and to infants.
4.1.2
8
Ensure timely estimation of requirements, dispatching of indents and
procurement of diagnostics, insecticides and drugs so that the most peripheral
units are always stocked with anti-malarials, especially during the peak malaria
season. Train health workers and volunteers in malaria diagnosis and
treatment.
9
Co-ordinate with different government programmes - Reproductive and
Child Health (RCH), Integrated Management of Childhood Illness (IMCI) and
with other partners,( Private Practitioners, Non-Governmental Organisations
ISlGOs, Volunteers) to ensure rational malaria care for more people in your
district.
REFERRAL MECHANISM
10 Provide a referral system in the district for severe malaria cases, teaching
health workers to use the following criteria to identify persons for referral.
•
•
•
•
•
Severe and complicated cases of malaria.
Malaria in children with very high temperature
Malaria in pregnant mothers with P.falciparum infection and/or severe
anemia.
Cases of malaria not responding to known available anti-malarial drugs.
Malaria cases with continuous vomiting and inability to retain oral drugs.
65
11 Provide standing instructions for administering symptomatic treatment and
loading dose of nationally approved anti-malarials before referral.
12 Traill workers in sending a referral form with fever history and treatment
given, unfailingly.
13 Provide feedback from referral centre to referring centre after the disposal
of case.
14 Ensure that there are sufficient referral centres in the district having the
following:
a. Blood smear examination facility.
b. Blood Hemoglobin estimation.
c. Urine routine examination
d. Intra-venous Quinine / Oral Quinine
e. Intra-venous fluids
f. Oxygen
g- Antipyretics, anti-convulsants, diuretics, antibiotics.
Provide additional and extended support to disadvantaged population in
drugs and materials for the poor and marginalised living in :
♦ Remote areas
♦ Isolated areas
♦ Hard to reach areas
♦ Inaccessible areas
r.
*
66
4.2.
DRUG SUPPLY AND LOGISTICS
This is a crucial area for strengthening. Regular drug supplies; a good medical
audit and constant drug supplies; and constant monitoring of drug resistance is
crucial for the success of the malaria control strategy.
4.2.1 DRUGS- ESTIMATES & SUPPLIES
1.
Define common disease for Health Care Package for each district
or area using the following criteria :
2.
Select the diseases using the following methods
•
•
•
•
•
3.
Estimate the drug requirements based on 1 &. 2 and the quantities
required to be supplied at each level of the health care system.
4.
Ensure uninterrupted, adequate and timely supply of essential anti
malarial drugs, other equipment and supplies
•
Strengthen procurement procedures for drug supply
•
Remove bottlenecks in the procurement, storage and supply of
drugs
Ascertain drug needs for routine and complicated malaria cases
i
•
•
•
*
Study of existing records at district level and below
Special survey reports if available
Study of infrastructure including manpower, institution
Study the delivery system
Pattern of local administration and community system
(select five to six common diseases)
•
Train district level officers and staff in the management of drug
supply
Send random samples of drugs for quality check up to approved
laboratories
Regularly inspect peripheries for availability of:
a) Primary level (sub-centre / Forward Treatment Depot / Drug
Distribution Centre)
i)
ft
Tablet and syrup Chloroquine
H) Tablet and syrup Paracetamol
3 ■
iii) Tablet Anti-emetic Prochlorperazine/Metoclopramide! only for
sub centres
■
ft
ft
ft
iv) Tablet Antacid
v)
Tablet Primaquine
ft
ft
67
b) Secondary Level (Primary Health Centre/ sub-district)
i)
All above
ii)
Tablet, syrup and Injection Chloroquine
iii) Tablet, syrup and Injection Paracetamol
iv) Tablet, syrup and injection Quinine ( or as per national list)
v)
Injection 25%/50% w/v Glucose.
vi) Tablet and Injection anti-emetic.
vii) Intravenous Fluids
viii) A combination of Sulphadoxine and Pyrimethamine
c) Tertiary Level (Hospital / district)
i)
All above
ii)
Artemisinin and its derivatives
iii) Dipstick test kits for P.falciparum diagnosis.
4.2.2 MEDICAL AUDIT
5. Ensure that a system of medical audit is developed for the district
through the District Health Authority/Committee :
> Analyze systematically quality of medical care including
diagnoses, treatment, resource and outcomes initially in the
district hospital and then more peripherally.
> Involve committee consisting of District Health Authority public
health experts and clinicians.
> Audit specifically the prescriptions (or a sample of it) to check
whether malaria treatment is rational.
4.2.3 MONITORING DRUG RESISTANCE
AT 7ith malaria not being adequately controlled and with inadequate or
V V irregular treatment with Chloroquine and/or other drugs, resistance
to available drugs is becoming an increasing problem. Therefore
monitoring drug resistance becomes important in the control of malaria.
6. Establish links with a sentinel centre in any appropriate institution
located in endemic areas for carrying out the activities of drug
resistance monitoring.
> Carry out drug resistance studies in their own areas regularly.
> Collect material from different areas with the help of mobile
teams.
> Generate sufficient data to enable the district to scientifically
review and formulate its drug policy.
68
7. Identify all sources of information relating to resistance:
> Medical Practitioners treating large number of malaria patients
> Primary Health Centres
> Sub District Hospitals
> District Hospitals
> Teaching and Research Medical Institutions
8.
Investigate reported information on failure of treatment by using
the following parameters:
> Adequacy of treatment, whether
•
Complete
•
Incomplete
•
Irregular
> Whether drugs are substandard
> Host factors - such as other concomitant diseases like diarrhoea
which limit absorption
> Ensure testing of drug resistance through sentinel centres in
coordination with State Health Authorities
9.
•
In vivo tests
•
Therapeutic efficacy
Motivate malaria personnel to look out and identify earliest
occurrence of resistance of P. vivax by following therapeutic efficacy.
©w
10. Provide guidelines regularly to all concerned of how to handle drug
resistance.
t
69
4.3.
HEALTH MANAGEMENT INFORMATION SYSTEM [HMIS]
The National Health Management Information Systems are operating in most
countries. The District HMIS should collect data from all the PHCs and after
analysis should forward it to state/region/province/division levels to the national
level.
4.3.1
Improving existing HMIS
1. Review the existing HMIS so as to understand the present known
weakness of:
> Delayed Information
> Inaccurate Information
> Insufficient Information
> Scattered Information.
Reflect with your team how to tackle the reasons for the same and
how to overcome them.
2. Identify
the essential information needed with
appropriate to the national and local settings as to:
indicators
> Investigate and contain outbreaks of disease
> Provide corrective actions in areas with poor programme
performance.
Suggested list of Indicators
The information to be analysed and accessed at each level is indicated below as
a list of indicators.
Indicators to be monitored
Administrative Level
No. of fever cases treated
No. of slides prepared and sent for microscopy
No. of fever cases treated
Primary Health Centre (PHC)
No. of slides prepared and sent or examined
(These indicators will be No. of slides positive for Plasmodium vivax
analysed village-wise)
No. of slides positive for Plasmodium
falciparum.
No. of villages sprayed
No. of malaria cases treated
No. of treatment failures
No. of Health Education programmes_______
')
Annual Parasite Incidence (API)
District/Township
(These indicators will be Annual Blood Examination Rate (ABER)
Slide Positivity Rate (SPR)
analysed PHC-wise)
No. of Deaths due to malaria
Community Level Worker
70
t
3. Review and modify forms used for malaria surveillance according
to the purpose of each set of data and level of usage so as to:
>
Field test the forms before its wider use.
> Include all data for essential information
> Eliminate data not used
> Make it easy to use
> Provide enough space for recording the values
> Avoid ambiguous text
> Ensuring it contains all crucial instructions.
4. Facilitate the analysis of data at each level it is collected either
using computers or manually. Quality of data improves when those
who collect it also use it for planning at their own level.
5. Highlight deviation from the normal occurrence while reporting to
the next higher level. Disseminate analysed report to both higher
and loyver levels.
6. Validate the data received from various units periodically followed
by quality control of data.
7. Co-ordinate with other health sectors for enhancing the coverage
of information e.g.
> Private Practitioners
> Voluntary Agencies
> Private Dispensaries/Nursing Homes
> Government Health Institutions
> Railway Hospitals
> Armed Forces Hospitals
8.
4.3.2
Disseminate analyzed data that can be made available in the
public domain like the Internet.
Introduce Computerized HMIS if Feasible
9.
Use computers at the district level.
> Improve existing systems
> Enhance district network.
10. Implement integrated computer based Health Management
Information System at different levels based on factors such as
availability, cost, local expertise etc. Sufficient user documentation
and technical documentation is essential. Choose hardware to a
large extent, determined by the software that is to be used,
available finance, local support etc.
71
11. Identify the availability of manpower and training facility and
other support locally before finalizing the choice of software and
hardware.
12. Establish clearly the data flow from the most peripheral level to
the most central level taking into account the following factors:
>
Which forms are to be used at which level.
>
Which data items are to be forwarded to the next level, how
often and in what format.
>
Standardized format, compatible with the software.
13. Introduce modern communication facilities such as Fax, E-mail,
other Internet services [World Wide Web (www), File Transfer
Protocol (FTP) etc.], to whatever extent possible.
'll
EPIDEMIOLOGICAL AND ENTOMOLOGICAL SURVEILLANCE
Surveillance is an essential activity that must aim to provide early evidence for
outbreaks, besides indicating the efficiency of anti-malarial activity and effecting
necessary changes in them. With the change of malaria scenario, it is necessary for
systems of surveillance to keep pace with the changes in agent, vector, environment
and the human host.
4.4.1 Epidemiological Surveillance
1. Include the following while planning malaria surveillance
1. Routine epidemiological surveillance
2.
3.
4.
5.
Entomological surveillance
Surveillance for forecasting and early detection of epidemics
System surveillance
Geographical Information System and mapping
2. Institute surveillance with reference to the following
1. Urban areas
2. Peri-urban areas
3. Rural areas
3. Strengthen the routine epidemiological surveillance at the district level.
Ensure necessary personnel and equipment are placed at the district level to
effect a good surveillance system in tune with Roll Back Malaria.
4. Tilt surveillance towards focusing on the following priority groups
> Migratory populations
!
> Seasonal workers groups
> Labour aggregations at construction sites
5. Include active, passive and mass surveillance in rural areas and modify
surveillance methods suitably to prevent higher morbidity, mortality among
infants, children and pregnant women.
6. Share the status of malaria and the anti-malaria operations after analysing
the continued surveillance data at regular intervals with all concerned.
4.4.2 Entomological Surveillance
7. Utilize entomological surveillance data
> To predict outbreaks and epidemics
> To guide the district in selecting vector control measures
> To draft IEC messages
> To propagate personal protection measures
73
8. Identify the person responsible for entomological surveillance and
forecasting at each level:
> Urban /peri urban
J
Entomologists/biologist
Z
Local body health officer
> Rural
J
Entomologist or other responsible authority
Z
Epidemiologist
Z
MO/ PHC
District Health Authority
9. Include the following in the regular monitoring and surveillance
> Vector population dynamics at rural/urban and rural / peri urban
interfaces
> Vector bionomics
> Vector density
> Susceptibility of larvae and adult vectors to insecticides/biocides
> Mosquitogenic conditions created by industries and irrigation
projects
10. Pick Up changes as highlighted below and initiate prompt corrective
action.
> Rapid increase in
Z No. of fever cases
Z Clinical malaria cases
Z Slide positivity rate
> Change in Plasmodium vivax : Plasmodium falciparum ratio in
favour of the latter
> Spurt in vector density
> Change in vector behaviour
> Change in vector population dynamics
> Change in susceptibility
insecticides/biocides
of larvae
and
adult
vectors
to
> Inter mixing of vector population at rural/urban and rural peri-urban
interfaces
> National calamities/mass influx
> Disarrayed intervention programme schedule
74
4.4.3 Operational Surveillance
11. Institute a system to monitor the surveillance of activities as well as
> Procurement and distribution of anti-malaria supplies
> Authorisation and placement of personnel for spraying and lab
activities
> Coverage
> Work quality
> Adherence to time schedules
Larviciding
Spraying
Surveillance
EDPT (Early Detection and Prompt Treatment)
> Effective response to epidemic situations.
12. Use the data to institute problem solving process through regular team
meetings and review.
MAPPING OF MALARIA & GEOGRAPHIC
RECONNAISSANCE (GR)
(Wherever feasible in region)
a.
Initiate a geographical information/rcconnaissance system (CIS) based on
programme objectives of the malaria control programme to:
> Map basic receptivity
> Serve as a guide for establishing control priorities
> Identity cost effective control methods
> Prepare monitoring and intervention schedule
b. Prepare inventory of existing material such as :
> Maps
> Survey reports
> Tabular information on entomological components
> Disease scenario
> Reports on control measures taken in the past.
c. Plot disease surveillance case data at the appropriate geographical locations of
the district.
75
d.
Collect information regarding topological and ecological parameters both at
macro and micro levels in rural areas.
Macro
Micro
Soil type parasite load
Vector species and breeding sites.
Surface water bodies
Contour map/altitude
Local temperature, relative humiditv
and rainfall
Drainage
Social, cultural &economic practices
Major projects forest cover
irrigation pattern crop pattern.
e.
Prepare a base district map with PHC or other such divisional boundaries
clearly marking:
>
>
>
>
>
>
Roads
Canals
Villages
Religious places
Swamps
Forest area.
f.
Classify geographical areas into well-defined ecological -geographic areas.
> Forested areas
> Foothill areas
> Swamp areas
> Riverine plains
g-
Include the following spatial (location ) data on the district map to correlate
the variations of malaria prevalence with geographical causck
> Boundaries
> Buildings
> Trails
> Streets & Highways
> Lakes
> Rivers
Streams
> Water reservoirs
> Land use / land cover
> Mountain peaks.
h.
Identify basic receptivity of each geographical area through data collected at
macro level.
i.
De» me the dynamics of transmission and build up locally adapted vector
control strategies based1 on identifying malaria foci using interactive analysis
of micro level data.
76
J-
Carry out a complete GR in urban areas to map all breeding foci for
planning an integrated anti-larval programme for control of malaria. Also
emphasize on peri-urban GR to determinate the foci of breeding places for
effective vector control.
k.
Include the following in the GR of border areas :
> Health infrastructure
> Drug resistance
> Uncontrolled populations migration
1.
Map periodically relevant attributes/tabular data to help in providing a visual
analysis of trends and impact of action taken.
> Choose appropriate scale of map.
m. Use computerized geographical information system (GIS) at the district level
and coordinate with other departments.
77
4.5. EPIDEMIC PREPAREDNESS AND RESPONSE
A Malaria epidemic is the occurrence of malaria in a community or geographical
area in excess of the normal (for the part of the year) that is of public health
significance.
1.
Identify malaria epidemics in the district when they occur by looking for:
>
Increased fever cases reported by Primary Health Centre / dispensaries.
>
Increased clinically suspected cases of malaria
>
Increased deaths reported due to fever.
2. Forecast and prepare for impending malaria epidemics based on the routine
epidemiological surveillance data using the following indicators:
>
Increase in clinical malaria cases/ slide positivity rate.
>
Change in Pv:Pf ratios in favour of the latter.
>
Rapid increase in mosquito/Anopheles density. A simpler way may also be
to monitor the increase in number of vector breeding places.
>
Influx of migrants from non-endemic areas to endemic area or vice versa
for wages, conflict, calamity; movement of labour to forests, for seasonal
agriculture or for large construction projects.
>
Early and heavy rains in pre-transmission period; intermittent heavy rains;
natural disasters like floods, cyclone and earthquake and large-scale
deforestation, etc. and large construction activities like dams and irrigation
channels having malariogenic potential.
3. Prepare for a malaria epidemic in an endemic area:
>
Establish a standing Epidemic Response Team (ERT)
>
Train this ERT team annually before the Malaria transmission season.
>
Maintain buffer stocks of anti-malarials and insecticides for epidemics.
4. Respond fast to an epidemic by taking the following steps
>
Investigate the epidemic
>
Confirm the epidemic by rapid assessment using the following parameters.
Assess the extent of involvement
Z Rapid fever survey
Z Mass Survey
>
Delineate the affected population and geographic area
>
Mobilize the ERT in the shortest possible time
>
Establish mobile field laboratories to make on-the-spot blood smear
Provide appropriate treatment to all cases
>
>
Convene a meeting of district officers,
action.
78
Discuss and develop a plan of
t
> Commence anti vector, anti parasitic and anti larval measures
> Complete the entire process within 10-15 days so as to prevent secondary cases.
5. Carry out following activities at the end of 3 and 6 week of initial
response
>
Sample village randomly
>
Carry out Rapid Fever Survey/Mass survey
> Resume prescribed malaria activities at the earliest
> Prevent a relapse by posting a full complement of staff
6
>
Disseminate malaria specific information using posters, Audio-Visual Aids
and public address system
>
Avoid speculative reporting by proactively informing the media about the
epidemic.
Train f
Epidemic Response Team(ERT) personnel in the district at regular
intervals ..i
in addition to the following category of personnel:
>
District Health Authority
> MOs Incharge of PHCs
> Other Medical Officers
> Paramedical staff
> Additional personnel who might be called in an emergency
7.
Provide initial and refresher training at regular intervals for Epidemic Response Team
i
> Ensure district specific training manuals and schedules are developed and ready
> Lay out clear, step-wise procedures
> Rehearse procedures frequently.
8
Increase access to early diagnosis, prevention and treatment for epidemic
affected areas
Sensitise community to seek early treatment
> Reinforce malaria control activities by all health staff
> Establish partnership with Non-Governmental organisations and private
sector
x Explore the use of rapid diagnostic test where available
> Update antimalaria drug policy periodically
> Identify disadvantaged population.
9.
Provide additional and extended support to disadvantaged population in
drugs and materials for the poor and marginalised living in :
> Remote areas
> Hard to reach areas
> Isolated areas
> Inaccessible areas
So that they are better prepared to handle sudden epidemics.
79
♦
4.6. RESEARCH AND DEVELOPMENT
1. Facilitate research on malaria at the district level in the following areas :
> Knowledge - attitude - practices - behaviour of people in rural, tribal and
urban areas.
Z Focus on Health practices and Health seeking behaviour for Malaria
type fevers and symptomatology.
2. Study Potential role / involvement and / or mobilization of the community,
community organizations, Panchayats (Village level elected bodies), general
practitioners, alternative systems of medicine and folk health practitioners,
voluntary agencies, and projects and networks of development environment
and women’s groups.
3. Review critically the role, training, and process of monitoring and continuing
education of village based health workers, community level resources* persons,
village guides etc.
4. Study the evolution and operationalisation of community based approaches
and alternatives to malaria control exploring viable, feasible, sustainable
options and strategies of malaria control in response to the diversities and
disparities that one finds at the community level.
5. Evaluate scientifically traditional systems of medicine and Folk medicine
practices to prevent/cure malaria as available in the respective area.
J Use quantitative and qualitative research methodologies
/ Evolve multidisciplinary research advisory groups and study teams
including resource persons from public health, entomology, clinical
pharmacology, social sciences, anthropology, traditional systems of
medicine, etc.
•!
/ Use more interactive, participatory and decentralized approaches that
validate local practices and uses.
RBM
80
ACKNOWLEDGEMENTS
/a
The first stage guidelines were evolved by CHC through interactive dialogue with:
Dr. V.P. Sharma - WHO-SEARO;
Dr. Rajaratnam Abel, Dr. Sunil Kaul - CHC Associates;
Dr. C.M. Francis, Dr. Thelma Narayan, Dr. Ravi Narayan, Dr. V. Benjamin,
Mr. S.D. Rajendran, Dr. Rakhal Gaitonde- Community Health Cell, Bangalore;
Dr. M.V. Murugendrappa, Dr. P.N. Halagi - Directorate of Health & Family Welfare
Services, Government of Karnataka, Bangalore;
Prof. N.J. Shetty - Bangalore University, Bangalore;
Dr. T.R. Raghunatha Rao - Community Health Education Unit, Bangalore;
Dr. P. Jambulingam, Dr. K. Krishnamoorthy, Dr. K. D. Ramaiah - Vector Control
Research Centre, Pondicherry;
Dr. S.K. Ghosh, Dr. Sathyanarayana, Dr. S.N. Tiwari, Dr. A.K. Kulshrestha,
Mr. R.R. Sampath - Malaria Research Centre, Bangalore;
Dr.K. Ravi Kumar - Regional Office for Health & Family Welfare-GOI;
Dr. Mira Shiva - Voluntary Health Association of India, New Delhi;
Dr. Mani Kalliath - The Catholic Health Association of India, Secunderabad;
Dr. Pankaj Mehta - Manipal Hospital, Bangalore,
Dr. B.S. Paresh Kumar - Mysore University;
Dr. Daniel - Action Aid; Bangalore;
Dr. J. Fernando - Institute of Vector Control and Zoonosis;
Dr. V.R. Muraleedharan - Indian Institute of Technology;
Dr. Prabir Chatterjee, Dr. Rajan Patil - CHAD, Christian Medical College Hospital;
Dr. Biswaroop Chatterjee - Himalayan Institute of Medical Sciences;
Dr. H. Sudarshan - Vivekananda Girijana Kalyana Kendra;
Dr. Prakash Rao - Drug Action Forum-Kamataka;
Dr. Anton Isaacs, St. John’s Medical College, Bangalore;
Mr. Suresh Shetty - Citizens Malaria Action Plan -Mangalore.
a
The guidelines were reviewed in WHO-SEARO and further modified and edited with the
participation of Dr. V.P. Sharma - WHO-SEARO, Dr. Ravi Narayan - Community
Health Cell, Dr. Rajaratnam Abel - RUHSA Department, CMC-Vellore; Ms. TavitianExley (Myanmar); Dr. B.N. Gultom (Indonesia), Ms. Jyotsna Chikersal, Mrs. Harsaran
Bir Kaur Pandey (Nepal); Mr. V. Alexeev, Mr. Omaj M. Sutisnaputra, and Dr. Sunil Kaul
- CHC Associate.
WE ACKNOWLEDGE THE CONTRIBUTIONS AND ACTIVE PARTICIPATION
OF ALL OF THEM.
a
Dr. Rajaratnam Abel, Dr. Sunil Kaul, Dr. Pankaj Mehta, Dr. Raghunatha Rao and the
VCRC team specially helped with the final editing of the guidelines. There support is
specially acknowledged.
Dr. V.P. Sharma and Dr. Omay Satisnaputra from WHOSEARO, saw many drafts and gave very helpful suggestions with their comments and
active involvement these guidelines took this user friendly shape. We are very grateful to
them.
Dr. Ravi Narayan
15th September 2000
Guideline Editor,
Appendix - Case studies
ENABLING COMMUNITY ACTION AND BUILDING NEW
PARTNERSHIPS
(Some illustrative Case Studies of initiatives in India)
In the last few years many interesting initiatives in Malaria control have evolved in India.
Focussing on innovative Strategies, new partnerships and involvement of new players in
malaria control, these case studies demonstrate that there are new ways of doing things and
effective ways in enabling community action.
The Case Studies focus on a range of initiatives:
i.
A School Health Education Programme in Goa;
ii.
An NGO organising a community based 'bed net' programme in Orissa;
iii. An NGO involved in a malaria campaign in Rajasthan;
iv. A research centre enlisting and sustaining community participation by adding an income
generating dimension to vector control in Pondicherry;
v.
An NGO involved in Health Education and Malaria Control in Gujarat;
vi. Involvement of School Children in. an Urban Campaign in Chennai, Tamilnadu and so
on.
vii. An NGO involved in tackling malaria in Rural Gujarat.
There are an increasing number of such initiatives all over the country. These have been
compiled to show that enabling community action and building new partnerships is possible.
These have been compiled from annual reports and bulletins and are therefore not exhaustive
but primarily illustrative.
Would you like to organise a similar initiative in your
district?
<> Would you like to share a similar experience in your
district?
THE TIME FOR ACTION IS NOWl
Case Study 1
School Health Education on Malaria in Goa - I
With an aim to make students in schools of Goa malaria literate, a systematic education programme was devised
and initiated in Goa, in 1992 by Malaria Research Centre, Goa, in collaboration with Indian Red Cross Society.
Goa. This programme was implemented in phases starting 1992 when 81 schools were enrolled targeting 16211
students from 8th to 10th standard. In 1994, this programme was extended to Higher Secondary classes up to
standard and by 1998, 227 schools participated in the programme targeting 53,462 students throughout Goa.
The aims and objectives of the programme were us under:
1. To introduce teaching on Malaria in the entire state of Goa in school children through Junior Red Cross (JRC)
and Youth Red Cross (YRC) components in Secondary' and Higher Secondary' classes.
2.
3.
4.
5.
6.
To train JRC and YRC counsellors (Teachers) to impart malaria education to the students.
To prepare curriculum on malaria and seek its ratification from Goa Board of Secondary and Higher
Secondary Education.
To reach community through these students and teachers so as to train and im oh e people in the vector and
disease control process.
To undertake field projects on malaria with the help of Red Cross counsellors and volunteers (students)
wherein the local community is exposed to the problem and its remedial measures.
To prepare a cohesive force over a period of time in the community who would practice the mosquito / vector
control in their day to day life and also continue to disseminate the self action idea to others in future.
Training of Red Cross Counsellors
Thirteen State Level Workshops have so far been organised by the MRC and Red Cross for imparting Orientation
training to 808 teachers with the understanding that organisational and technical responsibility will be shared by
the Red Cross and MRC Goa Field Station respectively.
The technical aspects of training included lectures, preparing course material, hand outs, audio visual aids, and
films and exhibitions on malaria. 61 exhibitions were organised for 24,133 students in 232 schools.
The exhibitions on malaria included:
1.
Immature and adults of Anopheles, Culex and Acdcs mosquitoes explaining the life-cycle and their
distinguishing features.
2.
Models of domestic and peridomestic breeding liabitats. These focussed upon man's negligence and
indifference which may support the growth of mosquito populations.
The control aspects demonstrated, consisted of:
i. Larvivorous fish such as Aplocheilus blockii, Rasbora daniconius, Gambusia affinis and Poecilia
reticulata devouring mosquito larvae and pupae.
ii. Bacillus thuringiensis and Bacillus sphaericus samples.
3.
iii. Expanded polystyrene beads (EPS) forming a top layer on the water in the model of an unused well.
iv. Models of air-tight overhead tanks and sumps, highlighting the mosquito-proof arrangements such as the
lid assembly and the sieved overflow pipe opening.
v. Models showing efficient drainage of water from terraces and water channels to avoid stagnations
responsible for mosquito breeding.
vi. Personal protection methods such as mosquito nets and window screens.
vii. In addition, blood slides with P. vivax and P. falciparum parasites were shown under the compound
microscope. Charts showing the life-cycle of a malaria parasite, the need for early detection and
treatment of malaria cases and the importance of species-specific treatment of malaria were also
displayed.
viii. A set of panels highlighting various aspects of malaria
exhibited.
in the urban and rural settings were also
ix. Handbills containing tips on self-action for the prevention and control of malaria were distributed.
Source :(8)
Case Study - 2
A community based malaria control strategy
Bissamcuttack, Orissa, 1996
[The Christian Mission hospital in Bissamcuttack, Orissa has been recently involved with tackling the
malaria problem by involving the community from the villages served by the hospital as follows:]
Step One
We began with helping people to recognise their public health enemy No.1 - Malaria by
sharing with them the MIS data from the government PHC on Morbidity and Mortality. This
prepared the ground for step two.
We also did an informal survey to ascertain sleep habits and patterns, according to
community, age and gender.
Step Two
If the village so desired they invited us to explain to them the basics of Malaria. This
involved almost a full day when we met with as many of them as could get organised into
groups according to gender, age and community. The classes were quite intensive and
based on 4 questions:
1.
2.
3.
4.
What is Malaria?
How does one get it?
What can we do if we get it?
What can we do to keep from getting it?
We used teaching aids, flashcards, photographs, Neem oil, mosquito nets, synthetic
pyrethroids, etc.
An Oriya pamphlet was also distributed to those who could read.
We stressed environmental methods, neem oil, clothing and nets - as alternatives.
Step Three
The villages chose the options they wished to pursue,
impregnated nets.
Most opted for Neem oil and
The village decided who will take charge - usually 2 or 3 respected people. They would be
incharge of finalising the order, supervising the distribution and collection of money. Each
village decided on different schedules and modes of payment.
We supplied nets, taught the method of impregnation and taught 8 principles of using the
net. Our team members stayed over the first night to help sort out ‘teething problems’.
We got nets from Raipur and synthetic pyrethroids from Calcutta.
More than 50% of our investment has been repaid already.
Our investment had been in terms of time, energy and capital money,
chosen was slow but encouraging.
The approach
We have not raised the question of subsidy because most families spend around Rs. 80000 a year on Malaria and our nets are cheaper than local shops - so they opt for it.
To summarise:
Our strategy is an Alternative, people based, village level, sustainable strategy with 3 basic thrusts:
a)
b)
c)
Malaria Education
Promotion of personal protection measures - all methods including IBNs
Early clinical diagnosis and prompt treatment.
We then did a 2 day workshop for other NGOs to share our experience. The idea is that they will go
home and launch similar village level ‘wars’ against malaria!
Christian Hospital, Bissamcuttack, Orissa, India.
Source (1)
i
Case Study 3
Evolving a Community Strategy to keep villages Malaria-free
[The Uttari Rajasthan Milk Union Limited (URMUL) Trust is a farmers’ cooperative that
organises an integrated rural development programme with health care being an important
component of the diverse development package. They were actively involved during the
malaria epidemics in their area of operation in recent years and tried to evolve strategies to
keep their villages free of malaria deaths]
Aim : To keep our villages free of deaths from Malaria
Our limitations
1.
One lab technician for our 30000 population scattered over 2500 kms. and also doubling as
Health Coordinator.
2.
3 PHCs and 1 CHC as referral support and numerous RMPs and quacks - none of them
under our control.
3.
No data for 1994 but government data put API below 2 everywhere so no spraying could be
done.
4.
Literacy levels of women <5% and males below 20%.
Our Strategy
a)
Drug Distribution Centres with teachers who were trained for the purpose.
b)
Chloroquine taken from government and replacement made every month.
c) Modified Fever Treatment Depots with our own workers.
d)
Presenting our findings on fortnightly basis to CHC, CM & HO, Dy. CM & HO - Malaria,
District Collector and Divisional Commissioner to galvanise action on behalf of district
authorities.
e)
Posters procured from government and pasted all over.
0
Pamphlets in Hindi for all educated people and RMPs and quacks.
g)
Street theatre and puppet shows by our communication team in each village.
h)
Placing slides with RMPs etc., to help in monitor patients.
i)
Introduced larvivorous fishes in own campus to help staff gain confidence in method and
effect.
j)
Holding and referral facilities for the serious at our headquarters centre.
Results Succeeded in our pledge to prevent malaria deaths.
URMUL TRUST, Rajasthan, India.
Source : (1)
CASE STUDY - 4
THE PUDUKUPPAM INITIATIVE
“The Vector Control Research Centre (VCRC) demonstrated that vector control could be made into an
income generating programme, which is the only way to enlist and sustain community participation in
such endeavours. A success story of a research project, carried out from 1980 to 1985 in the coastal villages
of Pondiyheny in which malaria control was made a by-product of income generating activities is given
below:
Pudukuppam. a coastal village, in the Union Territory of Pondicheny, was meso-endemic for malaria.
The vector incriminated was Anopheles subpictus breeding in brackish water. The major source for
mosquito breeding was a backwater lagoon (approximately 3 to 5.5 sq. kms.) with the entire water
surface covered with Enteromorpha compressa a filamentous algae facilitating vector proliferation.
Removal of algae was the only practical solution to control the vector breeding. Vector Control
Research Centre explored the economic utility of this algae in paper industry and the technology'
developed was handed over to the hand made paper unit of Sri. Aurobindo Ashram, Pondicherry'. The
art paper made by the unit using this algae drawn world wide attention with an excellent export
market. This resulted in the creation of a self sustaining system for algae removal with economic
incentives to the local populace. Total elimination of malaria was thus demonstrated exclusively
through community action.
Feasible vector control measures
Source reduction : By the removal of algae which promote vector breeding
Quantity of algae removed in one year: 130 tons
Practical permanent solution : Economic exploitation of algae for manufacturing paper, file
cover, etc.
Teclmology developed by : Vector Control Research Centre
Technology transferred to : 1. Hand made paper unit of Sri. Aurobindo Asliram, the pioneers in
art paper manufacture. 2. Hand made paper unit of Mahatma Gandhi Leprosy Rehabilitation
Centre.
Benefits to the Community
Total elimination of indigenous transmission of malaria from the village.
Additional regular income to the villagers.
Employment opportunities to the unemployed youths, who collect and sell algae.
Reduction in the cost of production or mottled art paper, file covers, etc
A clean environment”
VCRC project - Pudukuppam, VCRC, Pondicherry; India.
Source (4)
Case Study - 5
Health Education for Malaria
(An experience in Rural Gujarat)
[The Trust for Reaching the Unreached (TRU) is a voluntary agency involved with health and
development services for marginalised rural communities in the Panchamahal areas and the bastis of
Gotri area in Vadodara City]
When TRU started its work in the Shivrajpur area of Panchmahals, 70% of our OPDs in July to October
were cases of Malaria. Patients would pour in from interior villages walking, on bicycles, or being
carried on shoulders or in a doly. For the first two years, we responded to this by a clinic based
approach.
In 1992 we decided to train our health workers for intensive health education work in malaria. The
training covered all aspects of clinical diagnosis, treatment and prevention. By 1993, their clinical skill
to treat and diagnose Malaria was adequate.
Since July 1993, our programme consisted of intensive door to door education on ‘how to recognise
the early symptoms’ and how to treat it effectively. The emphasis was on taking 10 tabs of chloroquin,
continued intake of food and not going to private practitioners for injection or for IV fluids. A few
leaflets were given out as aids to health workers for person to person health education. Public
programmes including role plays on malaria and a folk dance on malaria were added during the period.
School children between 8-15 years were taught elaborately about malaria including rational
therapeutics.
The children were our real messengers. They had a weekly class in health and
produced posters during the health camps. The school programme went on in 10 schools in the area.
Results
1.
While it is too early to claim a reduction in the OPD cases, people in general are more aware,
report fever earlier, and do not accept the private practitioners' arguments for injections.
2.
During the Malaria season, all the surrounding areas showed increased incidence of malaria but
the villages around Shivrajpur were happy with full chloriquin course.
Trust for Reaching the Unreached, Baroda, Gujarat, India
Source : (1)
Case Study - 6'
Madras City Experience
A seven-point action plan was prepared for malaria control. An action committee was constituted.
Students made house-to-house visits and interacted with residents. One of the main misconceptions
that was addressed was that overhead tanks should not be closed - it would make water stale,
therefore the overhead tank should be only partially covered so that air could enter and maintain the
water fresh. A student action group was formed under Prof. Swaminathan. The students were drawn
from various schools and colleges. They also monitored the status of the fish in overhead tanks after
they were released. All the schools in the city with grades 6th to 12th were targeted.
The handouts consisted of:
1.
2.
3.
4.
5.
Procedures for schools
Posters
Fact sheets for teachers
Handouts for the students
Pamphlets for the community
School principles were informed about the campaign through letters. One or two teachers per school
were oriented; they, in turn, oriented the students.
Source (12)
Case Study - 7
Tackling Malaria in Rural Gujarat
[SEWA - Rural is a voluntary agency that has provided health and development services
extending from the nucleus of a small rural hospital in Jhagadia. This case study highlights the
key features of the experience with malaria control]
As an NGO we had taken over a PHC and done mainly surveillance and presumptive /
radical treatment of fever just as any other PHC is supposed to do.
After four years we realised we were getting nowhere and malaria prevalence was
changing inspite of our efforts; so we decided to look at feasibility and efficacy of
introducing simple vector control measures.
We took a study and control population and monitored fever cases (smears) round the
year and vector density (standard procedures) fortnightly.
Interventions included simple engineering measures, fish, kerosene and very rarely
insecticide (for one-time use to curb exceptionally heavy breeding sites).
Interventions and Monitoring were done by Male Multipurpose workers and supervisor
after due training and alongside routine ‘PHC work*. The female health workers took on
some extra load (of other work) from the male workers.
\Ne also took the community’s help, especially school children, informally.
Ongoing informal health education was given to people about mosquitoes and malaria.
Result
Vector density never rose above critical in study area but almost always remained far
above critical in control area.
General confidence of health workers in other vector control measures rose.
People became more aware.
No adverse effects on excellent performance in other health fields (MCH-FP activities).
Next Step
Encouraged by vector control feasibility / efficacy, we are now introducing on condition of
community / panchayat participation, a mosquito control campaign in the area!
SEWA - Rural, Jhagadia, 1995, Gujarat, India.
Source : (1)
References and Additional Reading
These guidelines have included or adapted materials from all the following publications and
papers. For those who will be operationalising these guidelines in the country / state progrmme,
we suggest that some of these sources may be referred to an additional reading material.
1. Towards an Appropriate Malaria Control Strategy
VHAI / SOCHARA, Report, 1997
(Available from VHAI - New Delhi and / or CHC - Bangalore)
2. Operational Manual for Malaria Action Programma (MAP),
NMEP, 1995, 1996, Government of India, New Delhi.
3. Community Participation in Malaria Control (Ed. V.P. Sharma),
Malaria Research Centre (MRC), 1993, New Delhi.
4. A Success Story of Community Participation in Malaria Control
VCRC - Pondicherry, 1990, Misc. Publ. VCRC (18)
5. “A” Frame for Advocacy
Population Communication Services, Centre for Communication Programmes, John’s
Hopkins School of Public Health.
6. Partnerships for Health Promotion
Conference working paper at Fourth International Conference on Health Promotion,
Jakarta, Indonesia, July 1997. WHO handout :HPR/HEP/41CHP/PT/97.1
7.
Draft Guidelines on Community Mobilization and Advocacy
From Bangalore Workshop in December 1999
(Ed. Dr. Ravi Narayan, Dr. Rajaratnam Abel, Dr. Sunil Kaul, Dr. Pankaj Mehta, Dr. T.R.
Raghunatha Rao, VCRC team).
8.
RBM - Website - WHO-SEARO (Draft)
9.
RBM Action at Country Level : the inception process - notes for members of Global
Partnership, 13 August 1999.
10. Transmission Control through cost-effective and sustainable interventions in South East Asia
Region
V.P. Sharma, Malaria Research Centre, Delhi.
11. The CAP guide for Insect and Rodent Control through Environmental Management,
WHO/UNEP
12. Can we get rid of malaria? A community awareness and information gathering exercise Dr.
Rajan Patil, CHC.
13. Roll Back Malaria and mainstreaming of Anti-malaria activities in Health Sector
Development - WHO-SEARO (SEA.RC 52/7)
14. Malaria Education Campaign for School Children, MRC Pamphlet.
15. Draft Guidelines on Diagnosis, Treatment and Management of Malaria at Community Level
- workshop organised by PGI, Chandigarh.
16. Draft Guidelines on Strengthening District level Management - Workshop organized by
National Anti-Malaria programme, Directorate, New Delhi, India.
17. Malaria Control - An attempt - Booklet by NMEP, Ministry7 of Health and Family Welfare.
DGHS, Government of India, 1996.
18. A Guide to Malaria and its control - for PHC Medical Officers of Karnataka, Regional office
for Health and Family Welfare, Government of India,
19. Manual for Malaria Microscopists, Regional office for Health and Family Welfare,
Government of India, Bangalore, India.
20. Malaria Diagnosis and Treatment, Booklet of Malaria Research Centre, (ICMR), New Delhi,
India.
21. Partnerships for Change and Communication: Guidelines for Malaria Control, WHO/Malaria
Consortium. UK, 1998.
22. Malaria Diagnostic Treatment and Recording Charts - A Training module for Medical
officers. Malaria and Parastic District control unit, DGHS, Dhaka, Bangladesh.
23. Seven Point Action Plan for Malaria Control in Urban areas, Malaria Research Centre.
(ICMR), New Delhi. India.
24. Awareness of Malaria for School Children - National Directorate of Malaria Eradication
programme. DGHS, New Delhi.
25. Biolarricides. Booklet of Malaria Research Centre (ICMR). New Delhi.
26. Pvrcthroid impregnated mosquito nets, Booklet of Malaria Research Centre (ICMR). New
Delhi.
27. Larvivorous fish in Mosquito Control, Booklet of Malaria Research Centre (ICMR). New
Delhi.
28. Building Capacities of Women leaders on Women's Health village level manual, (Kannada).
CHC. CHETNA. Ministry7 of Health and Family Welfare, New Delhi.
29. Guide for Village level Malaria workers. Malaria Research Centre (ICMR). New Delhi.
30. Malaria. A Manual for Community Health Workers. WHO, Geneva, 1996.
For Back Inner / Outer Cover
TO
DISTRICT MALARIA MANAGERS
REMEMBER
THESE GUIDELINES ARE
TO HELP YOU IMPROVE YOUR
LOCAL PROGRAMME WITH
SOME NEW IDEAS AND
NEW PROGRAMMES INITIATIVES
THEY ARE GENERIC AND
INDICATE AN APPROACH ONLY
YOU WILL HAVE TO ADAPT
THEM TO SUIT YOUR OWN
LOCAL MALARIA SITUATION
AND PROGRAMME
►► LET
US
KNOW
IF
THESE
GUIDELINES
WERE
USEFUL AND PRACTICAL
►► YOUR ACTIVE PARTICIPATION IN USING THESE
GUIDELINES IN YOUR DISTRICT AND IN GIVING
FEEDBACK AND SUGGESTIONS WILL HELP US TO
REVISE AND IMPROVE THE GUIDELINES
---------------------------------------------------------------------------------------------------------- =—
LET US ALL ROLL BACK MALARIA TOGETHER !
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