The Malaria Elimination Demonstration Project has meticulously documented its operational and technical findings and disseminated them to the scientific community, malaria elimination programmes, and policymakers [4,5,6,7, 19,20,21,22,23,24,25,26]. While the scientific rigour is noteworthy, it was essential to assess the project's performance from the end user's perspective, i.e., the beneficiaries (community) of MEDP. Hence, the present paper is a first-of-its-kind study in India that describes the qualitative assessment of the beneficiaries (community) and the collaborators at the district level.
In the present study, the ASHAs expressed their concern over the loss of incentives due to the preference of the community to seek malaria services from MEDP staff. Under the National Health Mission, ASHAs receive performance-based incentives to deliver first-contact healthcare services such as immunizations, reproductive and child health referrals, diagnosis and treatment of malaria cases in the community, etc. Every ASHA is envisaged to champion community participation in public health programmes in her village [27]. The incentives given to the ASHAs are INR 15 [0.19 USD (INR 1 = 0.013 USD)] for diagnosis of malaria and INR 75 (0.98 USD) for providing complete treatment of each malaria-positive case as per national and state guidelines [28]. In comparison, the Village Malaria Workers and Malaria Field Coordinators of MEDP Mandla were paid a flat rate salary, which included diagnosis and treatment of any number of malaria cases along with IEC/BCC, monitoring of vector control interventions, assisting the state in other health programmes (within a defined geographical area) etc. [5]. It is worth mentioning that MEDP focused on building the capacity of ASHAs by performing a malaria elimination needs assessment followed by comprehensive training to ensure smooth transitioning of responsibilities after the closure of MEDP field activities [24].
Historically, tribal areas have been associated with poor health-seeking behaviour due to the lack of awareness, sub-par healthcare services and a below-average rate of satisfaction in the community [29,30,31]. MEDP meticulously enhanced the community’s knowledge and understanding of malaria and other vector-borne diseases [5, 6, 24]. Most of the respondents recognized that there was a positive change in the health-seeking behaviour of the community. This change in community behaviour is notable because of the extensive training and capacity building at the grassroots level by MEDP, which needs to be sustained and adequately funded to realize the 2030 target of malaria elimination. One of the reasons behind the success of polio elimination was a dedicated cadre of grassroots professionals responsible for administering immunizations and conducting surveillance [32]. A similar workforce strategy would be desirable in which the village-based ASHAs, who are responsible for almost all health programmes, are joined by a dedicated staff focusing only on malaria elimination, especially in high-burden districts. The modified strategy that strengthens ASHA’s capacity would also be useful in conducting Mass Screening and Treatment (MSaT) if required for malaria elimination in high burden districts in India. This new approach would ensure that all fever cases that test positive for malaria get the proper treatment.
Alongside the IEC/BCC strategy of MEDP and the continuous follow-up of every malaria-positive case under the T4 strategy helped build faith in the community [7] is also desirable for frontline workers for malaria elimination to consider. The high levels of satisfaction with the services of MEDP reported in the present study can be attributed to strict adherence to an Advance Tour Plan by the VMWs and MFCs, regular availability of diagnostic and drugs, robust training, monitoring and accountability framework, representation from the local community, and sustainability principles of the project [5, 23, 26]. Similar findings were reported by other studies conducted in Odisha and Madhya Pradesh [30, 33, 34].
As part of the operational strategy, MEDP achieved its goal of indigenous malaria elimination and ceased the field operations by March 2021 in a phased manner. Following this, community-level healthcare workers like ASHAs, ANMs and MPWs performed the diagnosis and treatment of fever cases. The findings of this study highlighted the issues arising due to the non-availability of MEDP services in the Mandla district in terms of rising out-of-pocket expenditures (OOPE).
There is a multifold increase in the OOPE accompanied by loss of daily wages and illnesses during crop cultivation/harvesting seasons. India is already struggling with the increasing OOPE costs the commoner bears. The mean annual OOPE is reported to be 14,660 INR (186.4 USD) and 21,564 INR (274.3 USD) for kids less than 1-year-old, against net national income (NNI) of 135,000 INR (1687 USD). These costs are split into 43% for pharmacies, 28.5% for private general hospitals, 7.42% for public government hospitals, 6.8% for medical and diagnostics and 6.26% for providers of patient transportation and emergency rescue [35].
MEDP Mandla has not only eliminated the indigenous transmission of malaria but would have eliminated the malaria component of the OOPE during its operations in the district. The project has developed a sustainable model that can replicate similar results in the state and the country without the additional cost of the human resources [23].
This study has also identified the critical role of capacity building of providers of health care in disease control and elimination programs. In the context of malaria elimination, the malaria transmission can be interrupted by focusing on the Prescriber community (physicians that use guidance provided by the program), Provider workforce (ASHA/ANM/MPW that conduct surveillance, treat patients, and make tools of vector control available to residents in the people), and the People, who are beneficiaries at the community levels. In this network, the Providers are the critical link between the Prescribers and the People. Therefore, continued capacity building and their performance assessment should be conducted periodically for any additional training needs and capacity building needed for malaria elimination and eradication.