4. In which ways is the initiative creative and innovative?
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NVBDCP is implemented through the Primary Health Care Delivery system in Gandhinagar district.
Case detection and treatment: As case detection and treatment is mainly carried out through the active and passive surveillance agencies, the plan was to cover the entire rural population of the district while giving priority to the most vulnerable areas. This led to the need for strengthening the surveillance agencies in term of augmenting skill and knowledge of human resource through training, providing necessary equipments and drugs in time and informing the community about the services being rendered through the surveillance agencies. The first task of streamlining the surveillance machinery was achieved.
Subsequently efforts were made to have a regular mechanism for daily reporting of malaria positive cases and providing treatment as per drug policy within 24 hours. Laboratory Technicians of concerned institutions report a positive case when it is diagnosed, for initiating the treatment, and the Supervisor or MPHW concerned verifies compliance in the field and collects follow up smears at prescribed interval. Quality of Laboratory services was maintained by training all the Laboratory Technicians in malaria microscopy.
Integrated Vector Management (IVM): Vector control activities that were implemented as a part of IVM were two rounds of Indoor residual spray with Synthetic Pyrethroid during the transmission season by deploying daily wages workers, focal spray when a case of malaria is detected, and biological control as a long term measure, anti larval measures and source reduction through the members of the village level committee at weekly interval. Concurrent supervision was the hallmark of all these activities and regular monitoring was carried through district and Taluka level teams.
Capacity Building: This was taken up in right earnest and it was keenly followed up that all the Medical and para Medical personnel do get the required training to enhance their skills. Since 2005 22 batches of training for para-medical personnel has been taken up. The trained manpower of the district was a great asset to the programme and helped in effective implementation. External faculties were roped in to provide quality training. Sensitizing the Medical personnel in the private sector was also done regularly.
Inter-sectoral coordination: Under NBVBDCP, a proactive approach was taken to involve other sectors in the district like Education (for generating awareness among teachers and children so that they pass on to the community) Road and building ( for source reduction in public buildings and construction sites) , Women and child development ( for involving aanganwadi workers to provide services to the vulnerable group), Industries ( for involving them for screening of laborers and source reduction activities at construction sites) Panchayat ( for involving village panchayats) Urban development ( for involving local bodies like Nagarpalikas) and also NGOs ( awareness generation and donation of mosquito nets etc.). Periodic meetings were organized with different sectors for their support and coordination.
IEC/BCC activities; out of box thinking: Various innovative activities were done for generating awareness in the community. Some of them are messages through kites, calendars, diaries, blood donation cards and pens. Spreading messages in the form of Garba was also done. Every major event organized was having an exhibition stall and tableaus were also organized. Quizzes for school children were held in schools. Sensitization sessions for elected leaders were also kept.
Supervision, Review and Monitoring: Concurrent supervision was done from District, taluka and PHC level for each of the activity. Review meetings were organized periodically. Day to day monitoring of the situation was also carried by obtaining reports electronically and real time feedback was provided for corrective measures.
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5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The entire district administration took up the malaria control efforts as a challenge and the contribution of administrators, public health experts and medical and para medical personnel and community leaders ( elected as well as non elected) made the task easier.
At the district level the District Panchayat president and the District Development Officer provided the political commitment and administrative support. The Chief District Health Officer guided the malaria control efforts in the district. The District Malaria Officer and team ensured the smooth and effective implementation of malaria control activities in the field
The Taluka Health Officers, Medical Officers, Supervisors, Health Workers and volunteers like ASHAs were the key stakeholders in this campaign.
Services of other sectors like school teachers, aanganwadi workers were also involved at the village level for awareness generation in the community.
Community leaders at the grass root level played a crucial role in helping the community accept the services being delivered. NGOs were also roped in for implementing activities like distribution of insecticide treated mosquito nets.
The local media contributed a lot by disseminating messages to the community and also highlighted the positive achievement which was a morale booster for the team involved in tackling the problem of malaria.
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6. How was the strategy implemented and what resources were mobilized?
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National Vector Borne Disease Control Programme is implemented by the State with the support of Government of India. It is a partially centrally sponsored programme. As regards financial support for the programme is concerned State Government bears 90-95% of the total expenditure incurred under the programme, while Government of India provides assistance to certain activities. State Government bears the expenditure for all the human resources deployed in the district. Supply of logistics (drugs, insecticides, larvicides and other materials) is also made by the State Government. Government of India provides support for Monitoring and Evaluation, incentives for ASHAs and Dengue control. The average per annum expenditure under NVBDCP is approximately Rs 93.00 lakhs. Due to the avenues available for synergy with other programmes, financial resources could be mobilized for IEC/BCC activities as well as inter sectoral coordination etc. Detailed analysis of the expenditure incurred under the programme revealed that >75% of the total fund available is made for human resources, while 10-15% is made for vector control activities and remaining for other activities like Monitoring and evaluation, IEC/BCC and training. There were instances when some NGOs and community leaders donated for certain activities such as mosquito nets.
Technical support and guidance is received from State NVBDCP cell, ICMR institution like NIMR Nadiad and Regional Office for Health & FW located at Ahmedabad and Medical colleges. The support is in the form of external faculty for trainings, assessment in the field, monitoring the quality of laboratory services and undertaking entomological studies. Chief District Health Officer provides technical guidance on a day to day basis.
As already mentioned in the earlier portions, NVBDCP is integrated with Primary Health Care delivery System and therefore except few staff at District level all other personnel have multiple tasks to perform and the activities under NVBDCP are among them. The district is currently in a comfortable position as regards human resources. 100 % of the medical and 98% para medical personnel are filled up. 910 ASHAs are also deployed against the strength of 981. At present 30 Medical officers, 23 AYUSH doctors, 27 Laboratory Technicians, 25 Pharmacists,26 Supervisors and 293 Health Workers (Male and female) are in position in the district. The four talukas in the district are having a total strength of 424, while the district NVBDCP cell has a District malaria Officer and 12 supporting staff.
To implement the various activities under the programme the district authorities have not left any stone unturned for mobilizing the resources. Inputs under NRHM have been a great boon as it strengthened the net work of the health facilities in the district. Provision of incentives and funds for monitoring and evaluation further enhanced the effectiveness of the programme. It could be observed that issues of financial, technical and human resources were tackled in an appropriate manner to achieve the objectives laid down under the programme. This helped to reduce the malaria burden in the community and to sustain the achievement.
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7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The five most important outputs that lead to the success of reducing malaria burden are as under.
Surveillance: This activity is the back bone of any disease control programme and therefore malaria cannot be an exception. Previously as per Government of India norms (till 2012) 10 % of the population was to be screened for malaria every year through surveillance agencies. But the later on (in 2013) the target was enhanced to 18%. Improving surveillance was given priority and the Annual blood examination rate (ABER- parameter to assess the surveillance) was monitored in each village and urban area of the district. ASHAs deployed under NRHM since 2009 were optimally utilized to improve surveillance. The ABER which was 15.76 in 2005 could be increased up to 24.14 in 2014 (Up to October). This ensured detection and treatment of malaria cases in the community and thereby reducing the parasitic reservoir.
Indoor Residual Spray: This activity is the major vector control option to interrupt the transmission particularly in high burden areas. Since 2005 meticulous planning was made to cover the eligible population under spray and achieved room coverage of > 85% in all the years. Concurrent supervision from District, taluka and PHC ensured good quality and coverage. This intervention broke the chain of transmission.
Biological control: As a long term sustainable solution to address the problem of vector mosquitoes, 498 hatcheries were established in 25 PHCs of the district. 52 of them were natural water bodies, while 441 were constructed. Larvae eating fishes were transferred to permanent water collections. This safe vector control option prevented mosquito breeding in 493places throughout the district. Survival of the fishes is monitored through field visits.
IEC/BCC: Even with limited resource, activities for awareness generation could be implemented by mobilizing the resources from other programs. 22 exhibitions during major events could be organized since 2005. 36 Exhibition panels were provided to the health facilities 523 Programmes were organized in schools, 10 rallies were organized, 20 Tableaus were arranged. Further, messages through FM channel were transmitted and success stories were published through news papers.
Capacity building: No programme can succeed without a skilled manpower with adequate knowledge. Minute care was taken to train all the Medical and para-medical personnel in the district. 98 % of the Medical Personnel and 100% of the para-medical personnel were trained under NVBDCP, which can be termed as highly satisfactory.
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8. What were the most successful outputs and why was the initiative effective?
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Regular supervision and monitoring is the key to success. So the first and foremost thing that was done was to develop calendar of activities in the form of an activity plan with time frame and monitoring the progress on a monthly basis at the district level. This ensured timely implementation of important activities and helped in equipping the authorities at various levels to meet the challenge in a professional and scientific manner.
The monitoring mechanism that was put in place in the district can be listed as under.
Fever rate/Malaria case: Fever rate, malaria cases detected are updated daily by collecting the information from all PHCs, CHCs and Hospitals. The reports are electronically transmitted from PHC to taluka as well as district.
Treatment: Treatment given to malaria cases (within 24 hours) are monitored at PHC level and cross checked from Taluka and district level. Treatment card is maintained at PHC level for verification.
Preventive measures: Within 72 hours of diagnosis of a malaria case preventive measure are undertaken by the team from the PHC. The activities being undertaken are focal spray, anti larval measures, fever and contact survey and source reduction.
Cross checking: District level team headed by DMO cross check all field level activities and 4 days in a week are spared for this purpose. The activities being cross checked are treatment provided to malaria cases, performance of ASHA, weekly anti larval measures being done by ASHAs, use of LLINs/mosquito nets, coverage under spray, maintenance of hatcheries and quality of surveillance and laboratory services.
Review: Periodic meeting of the staff is organized for the review of various activities at the district and Taluka level. Highest authorities of the district review the performance and takes appropriate measures for improvement.
Parameters/indicators: The important paramerts/indicators being monitored are ABER, API, SPR, SFR, % of PF, Case fatality rate, time lag between blood smear collection and treatment, no of instances of stock out, room coverage for IRS, user rate for LLIN and discrepancy rate in case of blood smear cross checking and % of fund utilization.
Feedback mechanism: In addition to the above regular feed back to poor performing institutions and staff is also done from the district level on a regular basis. Observations of field visits are also communicated regularly for initiating the corrective steps.
Evaluation: Programme evaluation is normally done by independent agencies like Medical colleges, NIMR and directorate of NVBDCP.
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9. What were the main obstacles encountered and how were they overcome?
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The main problems encountered during the implementation of the preventive measures for the control of malaria in Gandhinagar are summarised as under.
Treatment compliance: Under NVBDCP drug policy for the malaria is modified periodically depending up on the needs of the programme. Duration of the treatment for P. Viavx was changed in 2007 from 5 days to 14 days. Similarly drug regimen for P. falciparum was also changed in 2011 and ACT was introduced. Due to the long duration of treatment, compliance was poor among the patients detected as P. vivax. The problem of compliance and delayed treatment was the major constraint for malaria control in 2005.
The district utilised the resources of 910 ASHAs deployed under NRHM for this purpose since 2009. Due to the involvement of ASHAS for providing treatment to malaria cases, 100 % compliance could be achieved in the district in subsequent years and now treatment reaches the door steps of malaria patient with in 24 hours.
Insecticide Resistance: The insecticide which was being used for Indoor Residual Spray till 2004 was found to be in-effective in 2005. This issue was tackled by switching over to Synthetic Pyrethroid which gave the desired impact.
Insufficient wages for spray staff: Another obstacle was in sufficient daily wages for the staff being deployed for Indoor Residual Spray. District adopted a PPP approach and convinced local leaders to contribute towards this cause.The State Government increased the wages in 2014.
Migration of labourers: Several construction projects came up in the district recently, which acted as the focal points for transmission of malaria and other vector borne diseases. To tackle this problem, highest authority of the district (District Collector and District Development Officer) was involved and the contractors were compelled to take the required precautionary steps.
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