In 2002, malaria was a major public health concern in Bangladesh, and the year saw 588 deaths from the disease. In 2009, this figure had come down to 47. What has made for this remarkable turnaround?
If you put this question to Dr. A. Mannan Bangali, National Professional Officer, Vector Borne Diseases, WHO Bangladesh, pointed several major disease control strategies that were evolved in 2007 with financial support from Global Fund. These helped to change the scenario considerably.
“Bangladesh has 64 districts, and it was decided to focus on the 13 high malaria endemic ones with a total population of 10.9 million. More specifically, attention was trained on the three hill tract districts of Khagrachari, Rangmati and Bandarban, which together accounted for more than 80 per cent of the cases, 75 per cent of which were the deadly Plasmodium falciparum malaria.”-Dr. Bangali.
These districts are on the border of the Indian states of Assam and Meghalaya and a part of Myanmar and have similar malaria transmission potentials across the border, he adds.
“The hurdles were many. For one, malaria patients had inadequate access to quality diagnosis and effective treatment, especially in remote areas, where there had been no adequate lab facilities to speak of, and a weak referral system. Additionally, the existing public hospitals did not have adequate facilities to treat severe malaria.”- Dr. Mohammad Jahirul Karim, Programme Manager, Malaria, Directorate General of Health Services
In order to make full use of existing facilities and bring the private sector into the national programme, the Bangladesh government entered into a partnership with a network of 21 community-based organisations, headed by BRAC, with the overall coordinating role played by the government. This approach both systematised and energised malaria control initiatives, with the WHO providing technical support, especially in terms of planning, implementation and operational research.
Bangladesh always had a good network of health infrastructure and grassroots level workers, numbering about 3,000 across the affected districts. Now about 8,000 additional health workers have been mobilised through local community-based organisations, each of them trained in the use of rapid diagnostic tests and armed with artemisinin-based combination therapy (ACT) medication.
Earlier, microscopy facilities essential to detect the presence of Plasmodium vivax malaria were available only in district hospitals and upazila (sub-district) health complexes. With funding available, an additional 120 microscopy centres small labs in hired houses run by local NGOs were established to complement the 80 government facilities.
Distribution of Long Lasting Insecticide treated Nets (LLIN) was also streamlined. The approach demanded careful planning, including understanding sleeping patterns. For instance, given that the average family size was five to six persons, it was decided to distribute two nets per family, with the poorest getting the LLINs. It also required mobilising local people. Here again the presence of local community groups made a huge difference. Bed net distribution and bed net dipping camps became cultural events to send out messages on malaria control. The community response was very encouraging, indeed.
By the end of 2009, over 1,700,000 LLINs had been distributed and 412,500 rapid diagnostic tests administered. The impact was noticeable. Malaria-endemic Khagrachari district, for instance, had accounted for 101 deaths in 2007. By 2009, the figure had come down to 12. Dr. Md. Nazrul Islam, a malaria Evaluator attached to the Directorate General of Health Services, explains the significance of this decline.
Dr. Md. Mahbubul Hoque is the Health and Family Planning Officer (UHFPO) in Haluaghat. The existing 31-bed hospital has now been upgraded to a 50-bed hospital. He consults his register to reveal that in 2009 his hospital treated 434 cases of malaria, and recorded only three deaths.
As we drive through the newly harvested fields in Haluaghat, we stop off at a tribal welfare community centre in Surjapur village, where Hitaishi Bangladesh member of the NGO consortium since 2007 maintains a microscopy facility to test blood slides. The organisation has also recruited 24 female health workers to deliver healthcare in the area. They are required to make 30 house visits a day, conduct regular ‘uthaon baithaks’ (courtyard meetings) to talk about the disease to the community, and maintain registers. Hard work this, and all for a modest honorarium of 1,500 taka.
So it seemed, as we watched Selina Khatoon address an ‘uthaon baithak’ on malaria protection, using pictures and placards, in a tiny hamlet dominated by Garo tribals that straddles a small local dam. The rivulet on which the dam lies meanders lethargically on its way, leaving behind large puddles of water which become active breeding sites for the villain of the piece, the anopheles mosquito.
“Malaria levels spike in this area in the post-monsoon period because the river no longer flows with force.” -Dr Hoque
This, of course, makes Selina’s contribution as a health care deliverer very crucial. She regularly visits the people of the area, checking bed net use and getting an update on their health profile, especially that of expectant mothers and children below five who are particularly vulnerable to the ravages of malaria. In her bag she carries educational materials, a weighing machine, a thermometer, rapid diagnostic test kits that can identify the presence of Plasmodium falciparum malaria within 10 minutes, and standard ACT medication. Her additional qualification is that she can speak the Garo language.
Reaching healthcare to communities living in the three remote hill tract districts, however, is far more difficult, given the lack of motorable roads. Now there are three mobile teams in the region, comprising a Surveillance Medical Officer, a para-medic and an ambulance driver, which visit villages in these districts by rotation after the local communities are informed of dates and venues.
Bangladesh, fortunately, has no urban malaria as Khalilur Rahman, an entomologist with the WHO, points out. But the fact that all its malaria prone districts happen to lie along the country’s borders with India and Myanmar raises its own set of challenges.
“The malaria programme has to focus more on empowering communities to take part in the control activities and protect themselves. We need to get rid of this potentially life-threatening disease, which has been with us for centuries.”-Dr. Bangali