Kavre, a mid-hill district in central Nepal, is full of wheat fields. Idyllic as the scene may be, the people here lead difficult lives, often rife with tragedies.
Kavre is one of the 65 districts of Nepal. It is malaria-prone area. It has slow moving rivulets and construction activity. It is potential breeding site of the hardy anopheles mosquito. The district has a population of 450,918, and at least two-thirds of them are at risk of contracting the disease. Like winter crops, malaria too has its season which stretches from May to November, with the monsoon period being bad.
So in many ways, a district like Kavre tests the effectiveness of Nepal’s oldest health initiative, the National Malaria Programme, which began in 1958.
Dr. G.D. Thakur, National Manager, Malaria, believes that the country is on the right track in terms of malaria control, “Nepal has already achieved the malaria control target set for 2015 under the Millennium Development Goals in 2010 itself, thanks to our health delivery network, the technical support we have been receiving from the World Health Organization (WHO) and financial support from the Global Fund.”
The figures speak for this: From 2000-2004, the reported malaria morbidity was more than 250 cases per year. In previous years it was even higher. However, during the last three years on an average two cases were reported. These cases had history of travel outside the district. What this translates into is malaria transmission inside Kavre has gone down. From a previously high risk district, Kavre at present is in malaria low risk.
But Dr. Thakur recognises that sustaining this achievement for reaching the elimination stage of malaria control will be tough. As he puts it, “After all, malaria is a vector borne disease and you cannot eradicate it.
The backbone of the malaria programme is a functioning basic health system. Dr. Thakur, explains, “In every village there are nine female community health workers who are trained to suspect malaria cases, refer them for confirmation and further action.”
So how does all this play out in malaria control? Dr .Shushil Pant, National Professional Officer, WHO Nepal, says, “Our approach in Kavre and other endemic areas is based on the evidence that if an infected person is treated promptly the transmission of the disease to others in the area is minimised. So, prompt response is vital.”
Rajendra Mishra, District Vector Control Officer, who is the focal person for the malaria programme in Kavre, explains how the Sensitive Surveillance System works.
“Female Community Health Volunteers (FCHVs) at the village level are trained to detect symptoms of malaria. They also understand the importance of knowing the history of travel of the patient. Once a case is detected, the patient is advised to go to the local community health facility.”-Rajendra Mishra
While the malaria programme is pro-active in terms of delivering treatment, a large part of the effort is in terms of malaria prevention, whether through the distribution of free bed nets, indoor residual spraying or Behaviour Change and Communication strategies (BCC) involving local communities, including school kids.
Information gathering and dissemination is the key. PSI Nepal, headquartered in Kathmandu, has been involved in the malaria programme since 2006.
Among PSI Nepal’s topmost priorities is the distribution of Long Lasting Insecticide treated Nets (LLINs) in the affected districts and between 2006 and September 2010, it claims to have distributed over 1.2 million LLINs – branded as Supanet – through partnerships with local NGOs and community organisations.
The actual bed net distribution begins with data collection, according to Dipak Sagar, Programme Officer, PSI Nepal, “For example, the government comes back to us saying there are 900 households in a particular area that require nets. Normally, the threshold aimed at is one net per two persons in a family and one net to every pregnant woman living in a high risk area at first ante natal care visit.”
According to Boner, bed net use is already high in the endemic regions – above 90 per cent – but bed net distribution has to be a continuous process because their efficacy lasts only for three to five years and 21 washes.
Nepal Malaria Control Programme’s Behaviour Change and Communication strategy was developed with assistance from National Health Education Information and Communication Center (NHEICC), WHO and PSI.
The target is the whole community. Sagar explains, “We put out messages on malaria control that even a child in Class 4 or 5 can read out to his or her parent. The programme also communicates these messages through 20 FM radio stations and the national channel.”
Despite the successes of the programme, there can be no letting up, as Dr Thakur knows only too well. “We have funding until 2016. Of course, we are conscious that we will have to sustain the programme and the government is exploring ways to do this,” he says.
Nepal’s oldest health programme has to keep fit in order to face new tests. A major one is about catering to migrant workers, since Nepal has about 50 lakh seasonal migrants who cross borders and there is a need to make treatment and diagnostic tools available to this section. Another is to improve malaria surveillance in urban areas, which is presently extremely inadequate.
Despite the challenges, there can be no denying that malaria control has enormous economic benefits as well. Dr Thakur puts it this way, “According to our estimations, every investment of a rupee in this programme yields Rs 18 in return.”
