Be a planner, not a sprayer

On what makes the Enhanced Malaria Control Project unique:
The project is unique due to two reasons - decentralised planning and the adoption of a variety of strategies. Decentralised planning has changed the role of the National Malaria Eradication Programme (nmep) to that of a facili-tator, financier and evaluator. Actual implementation is to be done by the districts. Therefore, the programme will no longer be Delhi-based. Malaria eradi-cation began as a military programme in India. The influence had spilled over and made the nmep rather hierarchical in operation.

Secondly, the project relies on a variety of interventions and not solely on the spraying of ddt (dichloro-diphenyltrichloroethane), which has adversely affected the environment. Spraying will be reduced and even that which is done, will be focussed. Insecticides that are environmentally less harmful will be used. Such an approach will improve the chances of controlling malaria. Evidence from other countries suggests that a single strategy like spraying or just giving out chloroquine does not work. A combination of approaches reduces the risk of the failure of any one.

On whether the government of India has a mechanism for decentralised planning in place:
I think it does. We are witness to it. The government conducted several state and district-level workshops. The aim was presenting the contents of the programme, circulating questionnaires to elicit local responses and improving on the quality of the project to make it more effective. The first round of implementation has already been carried out. To be fair, the implementation has been terrible in some places and good in others, but the idea is to move everyone up by training. I am quite confident that this is not an idea on paper but will actually mate-rialise in every district.

Early detection and prompt treatment of malaria call for heavy reliance on an improved surveillance system. On the prerequisites for such a system:
It is indeed a crucial area. In my opinion, there are three needs. The district malaria officer has to be trained to conduct local surveil----lance. The officer ought to be a planner and think like an epidemiologist, not a sprayer. There is the need for a modest, paper-based information system, whose functioning can be evaluated before computeri-sation is introduced.

A third prerequisite would be a Geographical Information System ( gis ). The idea is to simply feed in the information and have tools that would analyse the geographical spread of malaria. The gis is a tool that holds promise and needs to be tried out.

Of course one cannot plan until one has the information. Work on that front has already been initiated. It is a task that needs caution and care. Otherwise, it could end up being a form-collecting exercise.

On his views about the free public distribution of medicated mosquito-nets, a feature of the programme:
That would be a big mistake to make at this stage of the programme. Once the mosquito-nets are distributed free of cost, one will never be able to charge people for something that benefits them directly.

On how the government will monitor the performance of the project:
There are 11 factors that will determine how the programme is working over the next five years. Among the indicators include the number of malaria cases reported. We anticipate a five per cent increase in the 2.85 million per year currently detected, in three years time, due to better detection. But five years from now, there would be a 10 per cent fall in the number of cases (in relation to figures obtained during the third year of the project).

Another criterion of success is the percentage of staff who acquire management skills. Also, the average gap between the time of collection of the blood sample and the recording of the diagnosis should be reduced from the current period of over two weeks to less than a week.

On whether the government of India will sustain this programme in the long run:
I think it will. Sustainability is to be monitored at three levels. As far as financial sustainability is concerned, the government will eventually finance the project independently. The large amount that is being spent on insecticides currently, can be used for other cost-effective measures like environmental management of vectors. So less money would be needed to sustain the programme.

The second aspect of sustainability is managerial. A competent district malaria officer who is well-trained and has all the resources can do a lot.

The third element is technical sustainability which I think relates to the mix of interventions. A number of control methods have been chosen so that one can judge what works and what does not, early on in the programme. These are admittedly paper constructs right now. However, the nmep has been around for 50 years and has the infrastructure of officers in every district. I think this programme has a good chance of meeting its objectives.

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