CONCEPT NOTE ON

ACCELERATED URBAN MALARIA CONTROL PROJECT FOR ROUND 7 GFATM SUPPORT

1 PREAMBLE

Malaria is a major public health concern in India. During the late 1940s, at the time of Independence of the
country, there were an estimated 75 million malaria cases and 0.8 million deaths annually. High malaria
burden had adverse effect on agriculture, industrial development and national economy. The cost-effective
intervention measures for malaria control with the use of insecticides became available in fifties and global
experience in malaria control indicated then that malaria could be controlled or even eradicated within a
short period, if available measures were implemented effectively. On these considerations, a National
Malaria Control Programme (NMCP) was launched in 1953 for malaria control in endemic areas and the
programme was modified to a countywide National Malaria Eradication Programme (NMEP) in 1958 in view
of spectacular success of NMCP. Initially, NMEP was effective in preventing deaths due to malaria and also
brought down annual malaria incidence to relatively low level of 0.1 million cases by 1965. However, the
gains could not be sustained for various technical, administrative and financial constraints and resurgence of
malaria became perceptible by the seventies, which reached the peak in 1976 with 6.47 million cases that
necessitated launching of the Modified Plan of Operation (MPO) in 1977 with the immediate objectives to
prevent deaths and reduce morbidity due to malaria. The programme was integrated with primary health
care delivery system in rural areas. The MPO successfully brought down the annual incidence of malaria
substantially, viz., reduction to a level of 2 million cases per annum by 1984.

However, once again due to several constraints like rapid unplanned urbanization with inadequate water and
solid waste management and increasing developmental activities like construction, river valley and irrigation
projects, mega-industry projects, etc. with no or grossly inadequate provision for mitigating measures
against mosquitogenic/malariogenic conditions led to increased incidence. Population migration as a
consequence of developmental projects and improved communication as well as unabated population
growth also had adverse effects on the programme performance.

In view of resurgence and outbreak of malaria in several states, an Expert Committee reviewed the
programme and a Malaria Action Programme (MAP) was drawn up in 1995 for prioritizing the high risk areas
and implementation of strategy accordingly. The programme was changed from NMEP to National Anti
Malaria Programme (NAMP) during the year 1998. In 2003, all vector borne diseases including malaria were
brought under the umbrella of National Vector Borne Disease Control Programme.

Currently, the risk of malaria is unevenly distributed, with 20% of the population reporting 80% of the cases
in the country. High disease burden due to malaria is localized in relatively less developed, forested, forest-
fringed and hilly areas with poor infrastructure and communication facilities and predominantly inhabited by
rural marginalized tribal population. Therefore, high priority is given in these rural, tribal areas. In 2006, the
reported malaria cases were 1.8 million and deaths were about 1000 deaths, although the figures could be
higher as in some areas, data capturing is not fool proof.

To address the malaria problem in urban areas, an Urban Malaria Scheme (UMS) was launched in 1971
with the objective to control malaria by reducing the vector population by way of recurrent anti-larval
measures and detection and treatment of cases through the existing health services of the State/Urban
Local Bodies. The scheme was sanctioned for 181 towns spread over 17 states and two union territories.
However, it has so far been implemented in 131 towns only covering a population of over 100 million.

Since the malaria problem in towns/cities is not perceived as a major threat, no structured health care
delivery system like the primary health care system as in rural areas has been established. Funds are also
allocated for larvicides/adulticides only and the operational costs of malaria control activities are met by the
State/Urban Local Bodies. The coverage by anti larval measures however, limited and do not extend to the
entire towns/city limits. The source reduction drives in domestic areas are hampered by denial of entry to
public health personnel on security reasons, limited community mobilization and multi-sectoral collaboration
and absence of appropriate civic legislations.

Surveillance, integrated vector management (including promotion of alternative measures like insecticide
treated mosquito nets), awareness campaigns, inter-sectoral partnerships, capacity building through
trainings, Monitoring & Evaluation, enactment and enforcement of legislatures to prevent mosquito breeding
in domestic and peri-domestic areas or work places, government/commercial buildings, construction sites,
etc. are the responsibility of multiple authorities and often not implemented in a coordinated manner. No
proper resource allocation is also made for most of these components, even though these are extremely
critical to achieve the desired health objectives of health and well-being in urban areas.

Presently, in view of increasing constraints, as mentioned below, many urban towns/cities are facing a huge
risk of malaria:

 Increasing urbanization: The proportion of urban population to the total population is increasing in
the last few decades, triggered by rural “push” (for earning livelihood) and “urban pull” (for availing
medicare/education opportunities) phenomena. The labour congregation/colonies in construction
sites particularly report focal outbreaks of malaria on account of mosquitogenic conditions and
migrant labourers/families.
 Haphazard growth of towns: Haphazard and unplanned growth of towns has resulted in creation
of “urban slums” with poor housing and sanitary conditions, promoting vector mosquito breeding
potential for malaria.
 Drinking water supply: Deficient water supply has led to water storage practices in artificial
containers, which have generated breeding potential of Anopheles stephensi - vector for urban
malaria.
 Health Impact Assessment (HIA) of Development Projects: Developmental project activities
without health impact assessment have resulted in malaria outbreaks in short-term and endemic
malaria with foci of P.falciparum resistance strains in long-term.
 Inadequate health infrastructure: With rapid growth of population in urban towns/cities, existing
staff strength in State/Urban Local Bodies (Municipalities) has not been strengthened
correspondingly leading to inadequate service delivery.
 Drug resistance: In urban areas, no systematic study has been undertaken till date although
chloroquine drug resistance has been reported from certain towns/cities. In urban areas, a large
number of migrant laborers coming from different malarious areas import different strains/genotypes
of P.falciparum and over a period of time mixed population of different strains/genotypes infect
individuals. Differential susceptibility of genotypes to drugs lead to build up of multi drug resistance
and malaria related deaths. Elimination and containment of multi drug resistant pockets, therefore
becomes not only essential to prevent mortality in urban areas but also to prevent the spread of drug
resistance strains back to rural areas.

In this context, an “Accelerated Urban Malaria Control Project” is proposed in high endemic 28
towns/cities with GFATM support as depicted in the figure below:

TOWNS/CITIES SELECTED FOR ACCELERATED URBAN MALARIA CONTROL PROJECT

1. Delhi
2. Faridabad
3. Ahmedabad 16. Berhampur
4. Morbi 17. Sambalpur
5. Godhra 18. Rourkela
6. Rajkot 19. Kolkata
7. Gandhidham #
Y 20. Bokaro
8. Vadodra #Y 21. Chaibasa
9. Gandhinagar 22. Hazaribagh
10. Mangalore 23. Daltonganj
11. Mumbai #Y 24. Agartala
12. Dhule #Y #Y #Y
#Y #Y
13. Pune #Y #Y #
Y #
Y
14. Ratlam #Y #Y #Y #Y Industrial/mining belt in
#Y
15.Shivpuri #Y West Bengal, Jharkhand &
#Y #Y Orissa
#Y
#Y
#Y 25. Vijaywada
Industrial belt/Agro base 26. Chennai
Belt in Gujarat, #Y 27. Vellore
Maharashtra, Madhya 28. Bangalore
#Y
Pradesh, Haryana & Delhi
#Y #Y
#Y Industrial & water 0-2
scarcity areas in 2-5
Tamilnadu,
Andhra Pradesh & 5-10
Karnataka >10
Of the total reported malaria cases in the country, about 10% are contributed by cities/towns. Of these, the
proposed project towns/cities contribute 87% of total malaria cases, 91% of Plasmodium falciparum cases
and 98% deaths. However, these data are based on the reports from health facilities in public sector only.
Most of the urban areas record unstable malaria with seasonal variations.

Presently, urban malaria can be stratified into five sub-contexts: urban centre, peri-urban, construction sites,
industrial estates/mining areas and market areas. These sub-contexts have variable receptivity, vulnerability
and potential for outbreaks.

The proposed project envisages bringing in paradigm shift, i.e., shift from macro level to micro level
prevention and control strategies and interventions. These would be evidence based and sub-context
specific and would include use of such additional tools as Artesunate Combination Therapy in drug resistant
areas, Insecticide Treated Bed Nets (ITNs)/Long Lasting Insecticide treated mosquito nets and bio-larvicides
with focused attention to each sub context. Effective inter-sectoral partnerships with NGOs, Private and
Corporate sector and Communication for Behavioural Impact (COMBI) approaches would be the new
additional features.

The project would particularly focus on the poor and vulnerable groups in urban slums with high risk of
malaria. The planning and implementation of the project would be participatory involving various
stakeholders including the vulnerable populations to ensure that maximum ownership and benefits are
achieved.

The proposed project would also contribute to the achievement of Millennium Development Goals.

PROJECT GOAL

To reduce malaria morbidity and mortality in the project population (in 28 towns in 12 states) by 50% by
2015.

PROJECT OBJECTIVES

1. Increasing the access to diagnosis and treatment in project areas, with particular focus on slums,
construction sites/industrial estates/market areas with floating population. Majority of the population at
risk at focused sites are poor and marginalized families, living below poverty line.
2. Malaria Transmission Risk Reduction through Integrated Vector Management mode (IVM).
3. Enhancing awareness towards behavioural impact about malaria prevention and control and promoting
community, NGO and private sector participation.

OVERALL STRATEGY

Under the proposed project, Malaria Control strategy will comprise: (i) Surveillance, (ii) Parasite control, (iii)
Vector control, and (iv) Cross-cutting interventions.

(i) Surveillance: For early detection of malaria cases, passive surveillance would be strengthened by
building networks between existing public sector facilities and private practitioners, voluntary (NGO) sector.

(ii) Parasite control: Treatment will be strengthened through passive agencies viz. hospitals, dispensaries
both in public & private sector. It is proposed to strengthen the existing passive agencies with additional
inputs, viz., Blister packs of artemisinine + SP combination therapy (for treatment of chloroquine resistant P.
falciparum cases), Artesunate injections, microscopes and contractual manpower (Laboratory Technicians,
Coordinators for supervision and monitoring). Sentinel surveillance system will be established to monitor the
clinical response of confirmed P. falciparum malaria to existing anti malarial drugs.

(iii) Vector control: (a) Source reduction; (b) Use of larvicides; (c) Use of larvivorous fish; (d) Space
spraying; (e) Use of Insecticide Treated Mosquito Nets/Long lasting Mosquito Nets.

 Vector control activities will be evidence based and sub context specific comprising more than one
control strategies used synergistically in an integrated vector management mode (IVM).
(iv) Cross-cutting interventions: (a) Communication for Behavioural Impact for community empowerment
and participation for sustainability of source reduction and appropriate health seeking behaviour; (b) Inter-
sectoral linkages with non-health sector for implementation of appropriate prevention and control measures
including health impact assessment of development projects; (c) Capacity building of health/non health
sector through training at various levels; (d) Operational research particularly therapeutic efficacy studies; (e)
Monitoring & Evaluation particularly for strengthening this component by positioning one Project Coordinator
(preferably Epidemiologist) [one per town] and Public Health Specialist (one per town).

Implementation Modalities of Proposed strategy:

 The proposed project will be implemented by the Urban Local Self Govt, viz., Municipalities in
collaboration with the local NGOs.
 A Memorandum of Understanding will be signed between National Govt, State Govt and Municipal
body (Corporation/Council) for project implementation by Corporation/Council. The Municipal
Commissioner will be the signatory on behalf of the Municipal body.
 Constitution of Apex Coordination Committee under the chairpersonship of Mayor/Chairperson of
Municipal Body. Members will include elected representatives, civil society organizations, corporate
sector representatives, Indian Medical Association as well as non-health sector Departments
especially those involved in urban development. The overall function of the Committee will be
advocacy and review of agreed activities.
 Constitution of Registered Society as per NVBDCP Guidelines under the chairpersonship of Municipal
Commissioner or any other mechanism in Municipal bodies, through which funds can directly be
released from Govt of India. In case of the Registered Society the Municipal Health Officer will be the
Member Secretary. Members will include elected representatives, civil society organizations,
corporate sector representatives, Indian Medical Association, as well as non-health sector
Departments especially those involved in urban development, Social Welfare. The overall function of
the Society will be to oversee the project implementation, ensure timely release of funds and optimal
utilization.
 The project will be implemented through such infrastructure as: Municipal Commissioner > Executive
Health Officer > Zonal Health Officer > Ward Health Officer > Malaria Clinic In charge > Medical
Officer In charge of Dispensary/Health Post > Health Worker.
 Project Management Unit (PMU) – The executive Health officer will be the Project Director of PMU.
He/she will be supported by consultants and support staff. The PMU will be responsible for project
implementation, ensure timely disbursements, optimal utilization and review agreed activities and
generating reports as per requirements of the project.
 Zonal Coordination Committee chaired by Elected Representative of the zone and the Zonal Health
Officer will be the Member Secretary with representations from Indian Medical Association, Indian
Systems of Medicine & Homoeopathy, Civil society organizations, corporate sector, Residents’
Welfare Associations as well as non-health sector Departments especially those involved in urban
development, Social Welfare.
 Zonal Health Officers will be responsible for implementation and monitoring of project activities.
 Ward Coordination Committee chaired by Elected Representative. Medical Officer of
Dispensary/Health Post will be the Member Secretary. The members will include Ward leaders,
representations from Indian Medical Association, Indian Systems of Medicine & Homoeopathy, Civil
society organizations, Welfare Associations as well as non-health sector Departments especially
those involved in urban development, Social Welfare.
 Ward Health Unit – The Medical Officer/Chief Sanitary Inspector will be responsible for
implementation and monitoring of project activities. The contractual HW engaged under the project will
report to Ward Health Unit.
 Annual evaluation of the project performance would be carried out by independent agency.