Slowdown in fight against malaria

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An effective concerted effort to strengthen malaria control globally in the last decade has had the greatest impact in countries with high malaria transmission. Close to 60 percent of the 1.1 million lives saved during this period were in the 10 highest burden countries. However, the expansion of funding for malaria prevention and control has leveled off in recent years, and progress in the delivery of some life-saving commodities has slowed. These developments are signs of a slowdown that could threaten to reverse the recent gains in the fight against one of the world’s leading infectious diseases, according to the World Malaria Report 2012.

World Malaria Report 2012The number of long-lasting insecticidal neets delivered to endemic countries in sub-Saharan Africa dropped from a peak of 145 million in 2010 to an estimated 66 million in 2012. The expansion of indoor residual spraying programs also leveled off, with coverage levels in the World Health Organization (WHO) African Region staying at 11 percent of the population at risk (77 million people) between 2010-2011.

The malaria burden is concentrated in 14 endemic countries, which account for an estimated 80 percent of malaria deaths. The Democratic Republic of the Congo and Nigeria are the most affected countries in sub-Saharan Africa, while India is the most affected country in South-East Asia.

The report indicates that international funding for malaria appears to have reached a plateau well below the level required to reach the health-related Millennium Development Goals and other internationally-agreed global malaria targets.

While the plateauing of funding is affecting the scale-up of some interventions, the report documents a major increase in the sales of rapid diagnostics tests, from 88 million in 2010 to 155 million in 2011, as well as a substantial improvement in the quality of tests over recent years. Deliveries to countries of artemisinin-based combination therapies (ACTs), the treatment recommended by the WHO for the treatment of falciparum malaria, also increased substantially, from 181 million in 2010 to 278 million in 2011, largely as a result of increased sales of subsidized ACTs in the private sector.

The report summarizes information received from 99 countries with on-going transmission and other sources, and updates the analyses presented in the 2011 report. Malaria is an entirely preventable and treatable vector-borne disease. In 2010, an estimated 219 million cases occurred globally, while the disease killed about 660,000 people, mostly children under age five years.

1. World Health Organization. World Malaria Report 2012. Geneva, Switzerland: WHO, 2012.

Successful approaches to retaining skilled health workers in India’s rural areas

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Uneven distribution of health workers can be solved.

The lack of skilled health care providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74 percent of whom live in urban areas where they serve only 28 percent of the population, while the rural population remains largely underserved.

A new study indicates that the problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programs have shown promising results in India, according to the study.

The availability of doctors and nurses is limited by a lack of training colleges in Indian states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Initiatives under India’s National Rural Health Mission to reach out to the rural populations include an increase in sanctioned posts for public health facilities, financial incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82,343 skilled health workers to the public health workforce.

Before 2005, the most common strategy to reach out to rural populations was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programs.

1. Sundararaman T, Gupta G. Indian approaches to retaining skilled health workers in rural areas. Bulletin of the World Health Organization 2011; 89: 73-77. (open access)

New estimates of malaria deaths in India

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A study has found that approximately 205,000 deaths due to malaria occur in India every year. The majority of malaria deaths occur in people age 15-69 years (120,000), followed by children under age five (55,000) and age 5-14 years (30,000).

India is the most populous country in which malaria is common. The cases and deaths reported by the Indian government are concentrated mainly in a few states in east and northeast India (the so-called high-malaria states; mainly Orissa but also Chhattisgarh, Jharkhand, and the states in the far northeast of India).

These new results greatly exceed the World Health Organization’s estimate of only 15,000 malaria deaths per year in India. “This low estimate should be reconsidered, as should the low WHO estimate of adult malaria deaths worldwide,” the study said.

The methods of the new study, which used “verbal autopsies” to assign the cause of death, have been criticized by WHO.

1. Dhingra N, Jha P, Sharma VP, et al. Adult and child malaria mortality in India: a nationally representative mortality survey. Lancet, published online 21 Oct 2010. (open access: free registration required)

Traditional birth attendants in India lack basic HIV information

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Traditional birth attendants in rural India lack basic information about HIV/AIDS and safe delivery practices, according to a study conducted in 144 villages in the Indian state of Karnataka.

Only 12 percent of traditional birth attendants in the study reported awareness of HIV/AIDS, a surprising finding given that the HIV/AIDS epidemic in India is more than two decades old. Of those who had heard about HIV/AIDS, only 72 percent correctly reported that the virus could be spread from mother to child; 74 percent identified unprotected sex as a mode of transmission; and 51 percent correctly said healthy looking people could spread HIV. Just 44 percent knew that infected mothers could lower the risk of transmitting the virus to their infants.

The level of knowledge about safe birthing practices was also low among the traditional birth attendants. Considering that obstetrical hemorrhage and sepsis are still the leading cause of maternal death in India, researchers said it was not surprising that only 13 percent of of the traditional birth attendants referred mothers experiencing excessive bleeding following birth to a medical center, and that only about half sterilized equipment prior to deliveries.

Other unsafe procedures still practiced among traditional birth attendants included sucking secretions out of a baby’s mouth and nose with their mouth, applying cow dung, ghee (clarified butter) and other preparations on the umbilical cord, and inducing vomiting by stuffing hair in a woman’s throat to stimulate contractions of the uterus to clear the placenta.

Even more concerning, traditional birth attendants appeared to have low levels of awareness about when clients should be referred to a hospital. Less than five percent said they would refer a mother to a medical center if the umbilical cord was wrapped around the baby’s head, and just over half (57 percent) would refer the mother if the baby was coming out the wrong way. Most but not all (70 percent) would refer the woman if the baby was stuck inside the birth canal.

1. Madhivanan P, Kumar BN, Adamson P, Krupp K. Traditional birth attendants lack basic information on HIV and safe delivery practices in rural Mysore, India. BMC Public Health 2010; 10: 570. (open access)

Non-communicable disease risk factors in rural India

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India’s current epidemic of non-communicable diseases has resulted from increased urbanization, changing lifestyles and people living longer. But a study has found that non-communicable disease risk factors, including tobacco smoking and obesity, are strikingly high even among rural populations.

The study focused on rural populations because two thirds of India’s one billion people still live in rural areas. Rural populations have limited access to health care and can least afford to pay for the high treatment costs associated with chronic conditions.

The prevalence of non-communicable (NCD) risk factors was the following:

  • Tobacco use (40 percent men, four percent women)
  • Low fruit and vegetable intake (69 percent men, 75 percent women)
  • Obesity (19 percent men, 28 percent women)
  • High cholesterol (33 percent men, 35 percent women)
  • Hypertension (20 percent men, 22 percent women)
  • Diabetes (six percent men, five percent women)
  • Underweight (21 percent men, 18 percent women)


1. Kinra S, Bowen LJ, Lyngdoh T, et al. Sociodemographic patterning of non-communicable disease risk factors in rural India: a cross sectional study. BMJ 2010; 341: c4974. (open access)