Strengthening malaria service delivery through supportive supervision and community mobilization in an endemic Indian setting: an evaluation of nested delivery models

Globally, malaria control programmes have experimented with innovative strategies aligned with the healthcare delivery system status of each country[1]. One of the foremost strategies involves the introduction of community-based management of malaria through the deployment of community health workers[2–6]. During the last decade, India’s malaria control strategies under the aegis of the National Vector Borne Disease Control Programme (NVBDCP) introduced this strategy among other innovations to strengthen its fight against malaria[7] as the disease burden remains high – India continues to contribute around two-thirds of confirmed malaria cases in the South East Asia region of the World Health Organization[8]. The endemic eastern and central regions of the country, in particular, experience adverse socio-economic impacts due to their malaria burden[7, 9].

Under the community-based approach, the village CHW, known as Accredited Social Health Activist (ASHA) is designated to address early detection, management and prevention of malaria at the community level[7, 10, 11]. The ASHAs have been trained to test for Plasmodium falciparum malaria cases using rapid diagnostic tests and to treat these cases with artemisinin combination therapy (ACT). To further prevent any delays in the diagnosis or treatment of malaria, the ASHAs have also been provided with the requisite supplies of Rapid Diagnostic Test (RDT) kits and ACT[7, 10]. In addition, long-lasting insecticide-treated bed nets (LLIN) have been distributed free of cost to populations in high endemic districts to strengthen prevention activities[7].

The global evidence on malaria management suggests necessary preconditions to ensure the effectiveness of community-based approaches[12]. For instance, the community should engage at the inception and planning stage rather than being mere recipients. Developing intervention modalities at the community level through institutions and individuals further enhances the community's participation and ownership. Communities should be empowered to regularly monitor and evaluate the effectiveness of interventions[8]. In terms of the involvement of CHW, the global evidence suggests that regular and systematic supervision with clearly defined objectives can improve the performance of community health workers involved in primary health care[13–16]. Such evidence for India, however, is lacking and insufficient community capacity, trust, and coordination may keep the new malaria control strategies from meeting expected outcomes[9, 17, 18]. Hence, without addressing these community level impediments, ongoing control efforts may lead to diminished outcomes and the wastage of resources.

These interventions provide evidence not only on effectiveness but also possible scale up to similar settings. More generally, the findings should inform the development of a pragmatic policy approach to malaria control.

A community-based intervention targeting prevention and management of malaria in Odisha, India, attempted to (1) empower CHWs with training and support; (2) utilize intensive community mobilization with reliance on the traditional media considering the local social and cultural norms; (3) build local capacity through community based organizations and groups to enhance the effectiveness of malaria case management by CHWs; and (4) demonstrate a public sector programme model of partnership between the public sector, private not-for-profit sector, and the community to enhance sustainability. These interventions led to significant improvements in reported bed net use, especially for vulnerable sub-groups, and timely care-seeking from a trained health care provider. Results show significant increases in the reported utilization of bed nets in treatment arms relative to controls, which is particularly encouraging because the surveys were conducted towards the end of the high transmission season and there were no significant differences in the ownership of bed nets between households in treated and control villages. The increases in utilization were somewhat more pronounced among the villages where community mobilization was supplemented with supportive supervision of the community health workers.

The studied intervention sought to strengthen the Indian CHW (ASHA) programme through supportive supervision. While the ASHA have been integrated into the national malaria control programme, they are female volunteers with only primary education, selected by the rural communities they reside in, and do not have any formal training in healthcare prior to their selection. Their low levels of formal education and lack of experience with the health sector suggests the potential for hands-on support of specific management of diseases and health conditions. This study demonstrates that a supportive intervention on malaria case management by CHWs shifted care-seeking behaviour and bed net use in desirable ways in two highly malaria endemic districts. The supportive supervision by NGO workers through semi-monthly visits provided them with a structured learning process. Similar to other low- and middle-income country settings, more hands-on support through supportive supervision imparted more confidence, knowledge and skills in CHWs and thereby improved their motivation to perform[13–16]. Further, the supervisors provided the conduit for efficient communication between the CHWs and the formal health system to maintain an uninterrupted supply of commodities. Through supportive supervision, the study brought in considerable change in the community’s acceptance and response towards CHWs in contrast to the situation in control communities[10]. Indeed, in a particularly encouraging sign, treated households moved away from seeking fever care from untrained providers to the ASHA. Interestingly, other trained providers also noticed a drop in the proportion of total cases compared to the control villages due to the care-seeking from the CHWs, which may benefit the health system by allowing more prompt diagnosis and treatment of fever and by letting trained providers devote their time and skills to the management of more complicated health conditions as CHWs deal with uncomplicated fever cases at the village level in a cost-effective manner[24].

This shift in care-seeking from facility based providers to community health workers is consistent with patterns observed from similar supportive supervision interventions in malaria endemic settings in Africa[25–29]. Since malaria is typically endemic in remote areas with hilly terrain, a tailored community health worker or volunteer model may be most suitable for disease control and management. However, care should be taken to ensure that the supervisors are adequately oriented and skilled on key aspects of malaria control and management of community health.

The intervention introduced globally proven methods (RDT, ACT and LLIN) with locally adapted delivery strategies to achieve the targets of "Roll Back Malaria" for women and children under five[2, 12]. The targeted vulnerable populations of children under-five and women of childbearing age benefitted in particular from a greater utilization of both bed nets and fever care services. The impact on these vulnerable populations could be an effect of the enhanced case management activities by the CHW, who was a female from the same village with an in-depth understanding of the socio-cultural context. The involvement of women’s groups in the intervention may have further facilitated prompt care-seeking among women and children, although the present study is unable to explicitly test this channel of impact. The deployment of female CHWs and women's groups in community health management is likely reflected in terms of community health awareness and behaviour[30–33]. The community’s health-seeking pattern for fever distinctly shifted from untrained to trained providers, which suggests the potential for minimizing inappropriate treatment regimens, catastrophic health expenses and consequent fatalities[3, 10]. These findings are consistent with the evidence from similar Asian and African settings about leveraging local capacity to ensure sustainability of community health approaches[34]. The thrust of the intervention was to identify and empower local stakeholders especially CBOs and women’s groups on building up social trust, cohesion, support, mutual capacity building and thereby improving positive health-seeking behaviour[35, 36]. Locally constituted women’s groups are well-poised to be cost-effective and sustainable change makers for community mobilization and gradual behaviour changes[30, 31, 33].

The studied intervention identified and built local capacity to enhance the effectiveness of malaria case management by CHWs and demonstrated a model for locally sustainable community based service-delivery and monitoring. The community mobilization relied on the traditional media and involved various community structures considering the social and cultural norms. The design and dissemination of the community mobilization strategy were based on a bottom-up approach with the participation of the community. Apart from engaging women’s groups, the intervention also capitalized on other community-level formal and informal associations, such as local self-government, village health and sanitation committees, men’s groups and youth clubs. Print and electronic media supplemented the group activities and community notices and the interventions were intensively aligned with the disease transmission season to maximize impact. Empowerment of community entities is a corner stone of the community focus for public health interventions and is also a mandate of India’s National Rural Health Mission[37]. However, community based organization for supportive supervision and management must be carefully chosen to be locally acceptable and possess adequate coordinating capacity. Transparency, clear delegation of responsibilities and coordination among various stakeholders, including CHWs, is essential to the success of such interventions. As the project suggests, linking the CHW with the higher levels of the health facilities to ensure uninterrupted supply of commodities, recording of health information and monitoring, is another key component of the potential success of such supportive interventions.

This project introduced a three-way partnership between the public sector, private not-for-profit sector, and the community, i.e. public-private-community participation (PPCP). The engagement of local NGOs enabled the easy rollout and monitoring of the project, allowed the intervention to be incorporated into the public sector programme, and led to sustained activities rather than duplicating or substituting for any pre-existing programme activity. However, as may be expected with such community mobilization interventions, the cost of implementation was high in our interventions compared to the standard programme. Note, however, that the total cost of the combined intervention was 97 cents per capita, which is slightly lower than the $1.06 per capita cost of similar a community mobilization programme involving shopkeepers and communities in rural Kenya[38]. The fixed nature of start-up and administration costs will further decrease the cost of this intervention if it is implemented over a longer period. As the community becomes more aware of the malaria control activities and changes its health-seeking behaviour, the intensity of the community mobilization activities could be scaled down, further bringing down total costs.

This study is not without limitations. In traditional rural Indian settings, informal sharing of information is common among the inhabitants of a locality; thus, informational spillovers might have contaminated the control group particularly since the treatment and control villages were often geographically contiguous villages. However, outcomes in neighbouring treated villages (weighted by distance to the treated village) do not seem to have a significant impact on outcomes in control villages. This lack of a significant relationship suggests that the results reported above are not contaminated by spillovers. Note that even if spillovers existed, they would have led to a downward bias in the estimated treatment effect since such spillovers would have improved outcomes in control areas. Secondly, while recall bias is not uncommon in community-based surveys, any such bias would have influenced all three study arms in a similar manner. Finally, self-reported preventive behaviour may have been biased by social desirability concerns. This type of reporting bias has been observed when contrasting behaviour recorded at the health facility and data reported through household survey, with survey data presumed to be the more accurate[39, 40]. Differential programme effectiveness observed by district suggests that desirability bias cannot fully account for the programme impacts measured here as certain implementers are more effective in achieving outcomes[41]. Nevertheless, any such reporting bias may results in an overestimation of programme effects for self-reported preventive behaviours.