Shweta Raj Kanwar
Shweta Raj Kanwar is a Media & Communications officer working with the Government of Meghalaya. She is currently engaged in documentation of COVID-19 activities in the State.
The year 2020 came with its own set of unprecedented challenges in the form of the COVID-19 pandemic which, for the first time, exposed administrations across the globe to a novel coronavirus that transmitted like wildfire. With little knowledge and extensive evolving research to guide policy decisions, countries across the world tried their best to tackle the pandemic and most importantly, save lives without compromising on basic and essential health services. In this regard, Meghalaya stands out in terms of not only containing the pandemic but also achieving important milestones during the pandemic period. During the COVID-19 period itself, as per a news report, the State topped the list in reducing malaria cases by 59 percent in the country, as per the World Malaria Report 2020' prepared by the World Health Organisation (WHO) (Ref: M'laya tops list in reducing malaria cases in the country, says WHO report). This achievement comes just a few months after the State ranked second alongside Kerala, only after Telangana, in terms of immunization coverage in India with 90 pc coverage (Ref: Meghalaya Turns Crisis Into Opportunity, Ranks Second In Nationwide Immunization Coverage).
The occurrence of Malaria in Meghalaya has been endemic. Due to its peculiar climate, topography, and terrain, there is a rich diversity of Malaria vector distribution. As per a published report titled Malaria in Meghalaya: Entomological Perspective (Dr.S.Lyngdoh, Dr.Sangma et.al; 2020), out of the nine malaria vector species prevalent in the country, eight are found in the State. Even though Malaria occurs in almost all areas throughout the State, there are significant differences in occurrences between regions. It is more endemic in the foothills and flood plains bordering Assam and Bangladesh and the entire region of the Garo Hills districts.
An analysis of the State Epidemiological Situation from 1997 to 2019 reveals that the State reported the highest deaths caused due to malaria in the year 2007 with 237 deaths. Out of this, 117 deaths alone were reported from West Garo Hills District. This sudden spike in the number of deaths demanded immediate intervention as it was noted that despite technical assistance from the Centre to contain malaria, the number of deaths remained significantly high, especially in the Garo Hills region. It was in this year that the then Deputy Commissioner of WGH district, Sampath Kumar, IAS along with the team of health professionals devised and implemented an innovative strategy that not only led to a drastic reduction in malaria mortality but set precedence for building state capability to tackle critical issues. This eventually came to be known as the 'Tura Model'.
What is the Tura Model?
Initiated in the year 2007, the innovative Tura Model was driven by the objective of saving lives of hundreds of poor people in the interior villages of the district affected by Malaria. It was an established fact that the entire Garo Hills region was severely endemic to Malaria leading to large number of deaths occurring every year.
To begin with, efforts were made to assess the magnitude of the problem by encouraging doctors and health functionaries to report, without any fear of departmental action, the correct number of deaths due to malaria. This was followed by an extensive mobilization exercise of the entire machinery and the community including school children while educating them about the preventive aspects.
Brainstorming sessions were conducted during meetings with important stakeholders including reputed practitioners from both Government and Missionary Hospitals in the region, to bring out the critical reason for malarial deaths i.e. lack of an effective system for early detection of the parasite. It was seen that poor indigenous people living in the remote villages visited health centres once a week on a market day and gave the blood sample for malaria test and they got the results only the following week. This delay resulted in severe irreparable complications caused by the malaria parasite.
To tackle this identified problem, The DC and his team brought out an idea of facilitating the detection and treatment of all fever cases with symptoms of malaria at the village level itself (EDPT – Early Detection and Prompt Treatment) by providing training to newly identified Accredited Social Health Activists (ASHAs), the Community Activists identified under National Rural Health Mission (NRHM) --to ensure Ante Natal Care and immunization. As a first step, the ASHAs in the identified hyperendemic PHCs were given training in malaria testing though RD (Rapid Diagnostic) Kits and were provided with medicines (SPACT). They were also expected to ensure that the entire course of medicine was taken by the patients (similar to the monitoring under DOTS programme of TB).
The results were indeed spectacular. In the first year, out of 7,280 patients, the ASHAs diagnosed 2653 Pf +ve cases and treated them with SPACT. Not a single casualty was reported in the villages covered by the trained ASHAs. Malaria deaths significantly declined.
Active engagement of ASHA workers - A breakthrough in reducing malaria in WGH region
Sr. Claire from Holy Cross Hospital, Tura, who has been an integral part of Tura Model recalls, "I still have vivid memories of that first summer in Garo Hills when malaria was causing such havoc, almost wiping out families and we were like helpless onlookers because many of them came at a terminal stage.The decision to equip ASHA workers was a very risky yet crucial and significant decision that influenced not only the whole course of malarial infection, but the life and longevity in Garo Hills Districts. Initially, the medical fraternity, at least some of them, may have doubted the wisdom of entrusting ASHAs with this huge responsibility. But time proved otherwise".
In 2006, for the first time in Meghalaya, the ASHAs were entrusted with a major responsibility of conducting active surveillance in remote areas of Garo Hills to fulfil the objective of, as Dr. Rilynti Lyngdoh, Joint Director in charge of State Vector Borne Diseases and Malaria Control, puts it, "Early detection and complete treatment" of malaria.
Philomena Marak, an ASHA worker from 2005-2019 in Sotgre, Babadam village of Garo Hills region recalls that she was active during the Malaria outbreak in Garo Hills in 2006-2007. Recalling her engagement as an ASHA worker, she stated that she followed the procedure for taking blood samples from people complaining of fever by going to their homes and seeking the results then and there through Rapid Diagnostic Tests (RDTs). She stated that these proactive measures of detecting Malaria patients helped in early treatment, reducing death rate and presenting them with cure. This has helped in containing malaria which has proved to be beneficial till date. She also stated that currently, there has been a considerable decline in cases of malaria reported in the region.
Matilda Sangma is an ASHA worker in the region since 2007. She was one of the members who was actively involved in the prevention methods taken up by ASHA in Garo Hills. Sharing the activities, she said, "We visited homes of sick people and took their blood samples for testing through Malaria RDTs. This granular monitoring method helped to detect the disease early and provided treatment to the sick on time; thereby saving the trouble of going to PHCs or CHCs. The cases of malaria has gone down in the village since then."
As Dr. Rilynti Lyngdoh asserts, "When it comes to malaria there are many factors like community, environment, the prevalence of mosquitoes, etc that affect the outcomes. Active surveillance is crucial for effective data analysis. It was important to detect all fever cases in deep pockets. The role of our ASHAs have been life saving in this regard and their contribution has been and continues to remain significant".
In fact, this strategy of engaging ASHAs as Barefoot Doctors for malaria eradication was even appreciated by the then Additional Secretary to Govt of India, Ministry of Health, who later deemed it as 'Tura model'. This further went on to be recognised as a good development model of convergence between NRHM and NVBDCP.
As per a report published on Malaria in Meghalaya: Entomological Perspective (Dr.Lyngdoh, Dr.Sangma et.al; 2020), to be more precise, deployment of new tools that remain crucial even today towards malaria elimination like - Introduction of World Bank assisted insecticide- treated mosquito nets (ITNs), Global Fund assisted Intensified Malaria Control Project (IMCP), which led to the introduction of long lasting insecticide nets (LLINs), introduction of ACT-AL as well as the Bivalent Rapid Diagnostic Test (RDT) among other interventions, definitely played an important role in containing incidences of malaria in the region.
However, coupled with the above tools, the key features that knitted the success story of Tura Model were- Active surveillance through granular monitoring, with emphasis on increased reporting; Understanding the root cause of the problem and addressing the issue at source; Building capacity at Decentralised level by empowering grass root health care workers; Working with a sense of urgency and Working in convergence with the public as well as private health functionaries.
In fact, as informed by Dr. R. Lyngdoh, the role of Non Government Organizations also proved significant in realizing the Tura Model. It should be mentioned that for the first time, the State Health Department adopted a convergence approach of tackling the endemic whereby the NGOs, like the Bakdil NGO in Garo Hills contributed immensely, along with the Government functionaries to contain the instance of malaria in the region.
Bringing more light into the unique Tura Model of tackling malaria, Sampath Kumar, who currently holds the portfolio of Principal Secretary to the Government of Meghalaya, in-charge of Health Department stated, "The West Garo Hills model has two important distinct innovations - We have taken the testing and treatment up to the village level - this is decentralisation of healthcare. This has helped in early detection of the parasite and prompt treatment of the positive malaria cases with close supervision of ASHAs who acted like barefoot-doctors. This has helped significantly in reducing fatality".
Dr. S. Hazarika, the then Medical Specialist of Civil Hospital, Tura states, " This case taught us an important lesson. A one size fits all approach seldom proves effective in addressing critical issues. For a long time, the State had been simply following the general guidelines set up by the Central Health Ministry to contain malaria but the results were far from satisfactory. A decentralized approach significantly helped to reduce cases of malaria in the State".
Emphasizing on the importance of granular level monitoring coupled with a decentralized working approach, especially the involvement of grass root healthcare workers in the form of ASHAs, he further said, " It is important to closely analyze and assess the reasons why a certain problem exists in a particular region, and this problem varies from region to region. A person's socio-economic condition, customs, religious beliefs and practices as well as the overall lifestyle which may be a consequence of various factors, greatly affect the results of various interventions and sometimes, needs to be addressed. This is even true for other interventions".
In fact, as informed by Sampath Kumar, the proposed Meghalaya State Health Policy 2020 derives its key principles from the Tura Model success story namely- Understanding the problem, Mapping the processes, empowering the health care systems at the grassroots level, addressing the issue of Public Health by focusing not only on the Curative aspects but more so, on the Preventive as well as Enabling aspects. One of the most important examples set by the Tura Model was the coming together of doctors from the public & private sector as well as missionary organizations and NGOs, working with a sense of urgency on the part of district administration and most importantly, building the capacity of the community through the ASHA workers at the field level to ensure that the last mile of the population is reached.
Emphasis is now being laid on empowering communities through the creation of Self Help Group platforms that would act as information and awareness disseminators. It is also being ensured that one active woman from every village household becomes a member of an SHG. This would greatly help to tackle the high MMR and IMR in the State, while also creating equal opportunities for women through the policy of reserving 50 pc leadership positions for women in village employment councils, which was approved by the State Cabinet in 2020.
The Tura Model has been a successful attempt at sustained intervention, not only in terms of containing the malarial outbreak but more so, at enhancing the capability of the State as a whole to tackle complex issues. In the end, as Bill & Melinda Gates Foundation's motto rightly states, "Every person deserves the chance to live a healthy, productive life".
In November 2019, the Ministry of Health and Family Welfare, Government of India recognized Meghalaya as a Best Practice State for Reduction in Malaria Burden under Intensified Malaria Elimination Project. This recognition was conferred on Meghalaya at the 6th National Summit on Good Governance and Replicable practices and innovations in Public Healthcare Systems in India held at Gandhinagar, Gujarat.
The State of Meghalaya may have set significant benchmarks, but its learnings are derived from its past experiences and challenges. And most importantly, a robust team of people who refuse to give up and continue to challenge the conventional norm.
About the writer: The writer is a Social Media Specialist with the Government of Meghalaya and is actively engaged in documenting Meghalaya's COVID-19 management process. For more information, she can be reached at email@example.com
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