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High Burden to High Impact ( HBHI ) Approaches-Country Perspective for Adoption and Adaptation in India

In India, a National Framework for Malaria Elimination (NFME) has been developed and launched on 11 February 2016 align with the Global Technical Strategy (GTS) for malaria elimination 2016-2030. Malaria elimination will be carried out in a phased manner. In accordance with the NFME, National Strategy Plan for malaria elimination 2017-2022 has been developed by National Vector Borne Disease (NVBDCP), MoH & FW, Govt. of India in collaboration with WHO Country Office India and launched in July 2017. The country has made significant improvement in the malaria situation in recent years. Reported malaria cases were reduced by 49 % and deaths by 50% in 2018 compared to 2017. However, India and ten countries in Africa contribute approximately 70% of the world’s malaria cases and deaths. These countries adopted the “High Burden to High Impact (HBHI) approach”. HBHI has four response elements: (i) Political will to reduce malaria deaths; (ii) Strategic information to drive impact, (iii) Better guidance, policies and strategies, and (iv) A coordinated national malaria response. India has adopted this approach in May 2019 to further accelerate and sustain the progress in the states with high malaria burden. Initially, HBHI approaches are being adopted by NVBDCP with the support of WHO in four high burden states namely Jharkhand, Chhattisgarh, West Bengal and Madhya Pradesh. During the first phase, an in-depth situation analysis on malaria in these states have been conducted using the tools provided by WHO. Key features of adaptation of HBHI approaches in India and detail analysis of one state Madhya Pradesh are presented in the article.


Introduction
Malaria is caused by parasites of the Plasmodium family and transmitted by female Anopheles mosquitoes. Despite being preventable and treatable, malaria continues to have a devastating impact on people's health and livelihoods around the world. However, malaria is both preventable J. Commun. Dis. 2020; 52 (3) ISSN: 0019-5138 DOI: https://doi.org/10.24321/0019.5138.202023

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and curable and increased efforts have yielded positive results, reducing the malaria burden in several countries. The World Health Organization (WHO) has developed the Global Technical Strategy (GTS) for malaria Elimination 2016-2030 1 . The strategy sets the targets of reducing global malaria incidence and mortality rates by at least 40% by 2020, at least 75% by 2025 and at least 90% by 2030.
While tremendous strides have been made over recent years in reducing the number of cases and deaths from malaria, the estimates in the World Malaria Report 2 demonstrate that progress has stalled in high burden countries. Approximately 70% of the world's malaria burden is concentrated in just 11 countries -10 in sub-Saharan Africa and India.
According to the World Malaria Report 2018 2 , there were 219 million cases of the disease in 2017, compared to 217 million the year before the report's finding that, among the ten highest burden African countries, there were 3.5 million more cases in 2017 over the previous year is cause for concern. So, in 2017, all the ten highest burden African countries reported increases in malaria cases over the previous year. Only India marked progress in reducing its disease burden (WMR, 2018) 2 .Global progress in reducing deaths has also slowed. Estimated deaths due to malaria fell globally from 585,000 in 2010 to 405,000 in 2018 as per WMR. However, the rate of reduction of malaria mortality was slower in the period 2016-2018 than in the period 2010-2015 (WMR 2019). 3 There was a great concern and the need for an immediate change in approach against a disease that is both preventable and curable.

High Burden High Impact Approaches
To get back on track, stepped-up action is needed across all endemic countries, particularly in countries hardest hit by malaria. In May 2018, at the 71st World Health Assembly, the WHO called for an aggressive new approach to accelerate progress against malaria. Heeding the call, ministries of health in affected nations have been working with WHO and the RBM partnership to end malaria to map out a way forward -the "High Burden High Impact (HBHI): a targeted malaria response". 4 The new response has been prioritized by several partners; and the WHO Director-General has made it a flagship initiative of the Organization. Ten countries in Africa (Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and the United Republic of Tanzania) with the highest burden of malaria and India are the early adopters of HBHI approach.
The HBHI approach was launched in November 2018 by WHO and the Roll Back malaria Partnership to End malaria, as a country driven response to achieve rapid and sustainable malaria impact. 4 The country-led HBHI approach provides a response that can help to ensure future success in malaria control. Appropriate mixes of interventions will be scaled up using accessible and affordable frontline services. It is a mechanism to accelerate progress in countries that carry the highest burden of the disease. HBHI approaches demand high level political leadership, country ownership and commitment from a broad coalition of stakeholders. Actions focus on translating political commitment into tangible actions, better use of strategic information to drive impact, implementation of the best global guidance, policies and strategies as well as improved coordination.
Strategic information to drive impact: We are moving away from a 'one-size-fits-all' approach to malaria. Through better analysis and the strategic use of quality data, countries can pinpoint where to deploy the most effective malaria control tools for maximum impact. They can also use data to optimize the way tools are delivered to those in need through all conduits of delivery, including improved primary health care. The use of strategic information to pinpoint where to deploy the most effective malaria control tools for maximum impact.
Better guidance, policies and strategies: WHO will draw on the best evidence to establish global guidance that can be adapted by high burden countries for a range of local settings. This guidance will be continually updated and refined based on country experience and the development of new tools.

A coordinated national malaria response:
A key success factor is a more coordinated health sector response complemented by other sectors, such as environment, education and agriculture. Aligning partners behind this country-led approach will four ensure that scarce resources are used as efficiently as possible. We need better data, closer coordination among partners on the ground, and new and improved tools that will help us counter emerging resistance and other threats".
HBHI is a holistic approach, with the four elements feeding into tangible actions through NSP implementation and concrete outcomes.

Malaria Database Development
Countries that have launched the HBHI approach have already started developing national malaria database repositories to draw on health systems and other survey, research data and climate data to help understand the geographic distribution of the disease and the impact of interventions. 6 Strengthening the use of available data for decision making will help identify the best mix of interventions and drives continuous improvement of quality data.
In India, there is a need to develop a similar data repository or national malaria databases at the NVBDCP. The database would aim to improve the quality of information available and, consequently, help identify the most effective policies and intervention tools to control and reduce the burden of the disease. We need better data, closer coordination among partners on the ground, and new and improved tools that will help us to fight against malaria.

"Zero malaria starts with me" campaign
Other key response highlights from 2019 include the launch or strengthening of social mobilization and advocacy movements through the "Zero malaria starts with me" campaign''. 5 This is a grassroots campaign that aims to empower individuals and communities to protect themselves from malaria. On World Malaria Day 2020, WHO joins the RBM Partnership to End Malaria 7 in promoting "Zero malaria starts with me". In line with WHO's push for universal health coverage and primary health care, HBHI will play an important role in ensuring that people who are most in need get access to the right interventions, including insecticide treated nets and medicines. The Global Fund to Fight AIDS, Tuberculosis and malaria also encourages national malaria programmes to adopt the HBHI approach when requesting funding and use local data to identify the mix of interventions and optimal means of delivery. The "Zero malaria starts with me" campaign engages all members of society: political leaders who control government policy decisions and budgets; private sector companies that will benefit from a malaria-free workforce; and communities affected by malaria, whose buy-in and ownership of malaria control interventions is key to success.

Global Status of HBHI Approaches
Sub-Saharan African leaders in the highest burden countries are moving quickly to adopt the "HBHI approach to jumpstart progress against malaria. Political will and commitment are being revitalized. Actions focus on translating political commitment into tangible actions, better use of strategic information to drive impact, implementation of the best global guidance, policies and strategies as well as improved coordination. 8 Stratification to identify and prioritize the right mix of interventions has been done except in Mali (scheduled in April 2020). Malaria program review has also been done in most of the HBHI countries and most of them are also updating their National Strategic Plans. Nigeria has secured funding from World Bank to adopt HBHI. High level meetings are being planned in many countries in 2020 with Health Ministers and key partners.

Malaria Situation in India
Malaria is a major public health problem in India and one which contributes the highest malaria burden to the overall burden in Southeast Asia (WMR 2018). Historically, the highest incidence of malaria in India occurred in the 1950s, with an estimated 75 million cases and 0.  Figure 2 which shows a significant decline of cases as well as deaths in the country.
In 2018, the reported malaria cases nationwide declined by 49.09% (429928 cases) compared to 2017 (844,558 cases) and the malaria deaths were reduced by 50.52% (from 194 in 2017 to 96) in 2018. As compared to previous year, reported malaria cases (provisional reported data) declined by 21.2% from 429928 in 2018 to 338513 in 2019. The number of reported malaria deaths reduced from 96 to 73 (24%) in the country. In total, P. vivax proportion in the country during 2019 was 53.64% while P falciparum was 46.36%.
NVBDCP data shows that the map of malaria burden is shrinking in the country and more and more districts are shifting towards the lower API group. High burden areas have been significantly reduced. While this progress is highly commendable, the disease is still a major public health problem in many districts in several states.
India has made considerable progress in reducing malaria burden and has a vision of malaria free country by 2027 and elimination by 2030. World Malaria Report has also documented the remarkable decline in malaria cases and deaths in India (WMR 2018 and 2019).
However, the country still faces daunting challenges as malaria epidemiology exhibits enormous heterogeneity and complexity. The disease is mainly concentrated in tribal and remote areas of the country.

Strategic Approaches for Malaria Control
The NFME 9 serves as a roadmap for advocating and planning malaria elimination throughout the country in a phased manner across 36 states and union territories. States/UTs have been subdivided into four categories (Table 1) with Annual Parasite Incidence (API) as the primary criteria and milestone and targets are set for 2020, 2024, 2027 and 2030. Malaria incidence in high transmission areas (Category must be lowered first before it is possible and rational to investigate each case. As per NFME in India, there are ten high transmission states (Arunachal Pradesh, Chhattisgarh, National Strategy Plan for malaria elimination 2017-2022 10 has been developed by NVBDCP with the support of WHO country office, India in 2017 with focus on districtbased planning, implementation and monitoring of the programme for the five-year period to achieve the malaria elimination goals of NFME. The districts across all states and UTs have been categorized into four groups based on average reported API in the last three years ( Table 2).

High Malaria Burden States in India
As per NFME, there are ten high burden states in Category   3.

Category 2: Pre-elimination Phase
Districts/Units having API 1 and above, but less than 2 per 1000 population. These are positioned for elimination targeting in the subsequent years. 46 (6.8)

Category 3: Intensified Control Phase
Districts/Units having API 2 and above per 1000 population. These are positioned for elimination targeting in the subsequent years.

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Maharashtra (2.65%). Highest proportion of malaria deaths (34.00 %) has been reported from Chhattisgarh and this state also contributed highest proportion of (31.75%) of Pf cases in the country.

Progress -Adaptation of HBHI in India
In 2019, HBHI approaches are being adopted by National Vector Borne Diseases (NVBDCP) with the support of WHO in four high burden states namely Madhya Pradesh Jharkhand, Chhattisgarh, and West Bengal. The progress for adaptation of HBHI is given below:

Meeting on HBHI
The WHO Country Office and NVBDCP organized a meeting of high malaria burden states in India with participation of WHO HQ, Regional office and the RBM Partnership to discuss the adaptation of HBHI approach on 13 & 14 May 2019 at Bhopal, Madhya Pradesh. Eight States were invited for the review meeting i.e. Andhra Pradesh, Telangana, Maharashtra, Chhattisgarh, Jharkhand, Odisha, West Bengal and Madhya Pradesh. Odisha could not participate due to its on-going response to Cyclone "Fani" that hit 15 districts of the State. During the meeting, an in-depth review of the malaria situation in the participating states, was presented, identifying challenges and gaps and prioritizing issues for support under the HBHI approach. It was decided in the meeting, initially HBHI would be adopted in four states in the country.
Training on HBHI Approach: Two training workshops for district level officers and consultants were organized in Chhattisgarh from 13-16 November 2019 and in Madhya Pradesh from 2-5 December 2019 by WHO in collaboration with NVBDCP. The States were oriented on the HBHI approach, including "Zero Malaria Starts with Me". The main objectives of the training were: • To update the knowledge and skills of the participants on malaria control and elimination, including the HBHI approach. • To analyze state-and district-specific determinants of malaria and its control. • To identify best practices, lessons learned and the key challenges to be addressed in controlling malaria. • To develop context-specific approaches to accelerate malaria burden reduction in each district in the states included in the HBHI approach.

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Participants from each district drafted operational plans to define specific responses to key challenges, prioritize them (as high, Medium or Low), indicate the timelines, define the expected outputs and link as whenever feasible to one or more of the four response elements in the HBHI approach ( Figure -3 & 4). Experts from WHO and NVBDCP supported the districts to finalize operational plans aligned with HBHI approaches.

Situation Analysis
It has been decided to adopt the HBHI approach initially in four high burden states Chhattisgarh, Jharkhand, West Bengal and Madhya Pradesh. Each state will be supported to develop its state specific strategic plan and operational plan. The strategic plan will be based on an in-depth situation analysis in each of the four states using the HBHI approach.
Four consultants were deputed by WHO country office during the year 2019, one assigned to each state to conduct are situation analysis by applying WHO tools and to identify the gaps/challenges. These will be helpful for developing state strategic plans aligned with four pillars of HBHI, which will also include costing for the new activities to be borne from GOI/ state funds/WHO and for appropriate reflection of funds accordingly in state Program Implementation Plan (PIP). The institutionalization of the approach will help accelerate and sustain the progress in reducing the malaria burden and achieve malaria elimination in India. This will require, among others, strengthening the technical and managerial capacities in malaria program at all levels of the health system. Situation analysis has been carried out in all four states. The situation analysis of malaria in one of the states i.e. Madhya Pradesh is provided in this paper.

Madhya Pradesh
Madhya Pradesh is India's second largest state with an area of 3,08,252 sq. km. The present Projected Population of the state is 80.15 million, having 51 districts. The state, has 14.7 percent of India's total tribal population There are Multi-Purpose Workers (MPW) male, ANM along with 64,105 ASHA workers at periphery, who are engaged in recognition of fever cases with symptoms of malaria and their diagnosis either with microscopy at DH/CH/CHC/ PHC level or with RDT at village level.

Malaria Situation Analysis
Madhya Pradesh contributes about 6.5% population and 6. There are five entomological zones (Bhopal, Indore, Jabalpur, Gwalior & state Headquarter) in the state. Entomological surveillance needs to be strengthened in the state.

Stratification
During year 2015, 5 districts namely Jhabua, Sheopur, Dindori, Mandla and Alirajpur were highly endemic, showing API 10.48, 8.02, 6.36, 4.03 and 4.0 respectively. All these districts have forest areas, with predominantly tribal populations. Another five districts namely Balaghat, Shivpuri, Anuppur, Sidhi & Betul where API was in between 2 to 3. During year 2016 only three districts namely Jhabua, Sheopur & Dindori were highly endemic having API 6.46, 5.05 & 4.44, respectively. Only one district Shivpuri is having API 2.04, other 13 districts were less than 2 API, while 34 districts were below 1 API. During year 2017 only two districts namely Sheopur & Anuppur were highly endemic having API 6.34, & 4.53 respectively, Annupur district was having API less than two during year 2016 but have shown increase to 4.53 API during year 2017. Only one district Jhabua is having API 2.01, other 4 districts were showing API less than 2, while 44 districts were below 1 API. It clearly indicates that the incidence of malaria is going down every year. Proportionate malaria cases in high burden districts during the year 2016, 2017 and 2018 is given at Figure 4.   (Table 1)  Based on 2015 data, the state of Madhya Pradesh was kept in Category 3 (more than 1 API) in NFME, but after that it is found that malaria burden is continuously declining in the state. As shown in table, districts are gradually shifting to  (Table 2). On further stratification during year 2018, 1 block is above 10 API, 2 blocks are between 5 to 9.9 API, 5 blocks are between 2 to 4.9 API, 12 blocks are between 1 to 1.9 API. Thus, 20 blocks are above 1 API in 2018 where focused attention is required to implement the appropriate preventive measures on to reduce the disease burden further. The remaining 293 blocks (93.6%) are below 1 API during year 2018 where case-based surveillance and foci investigation to be carried out in a systematic way.

Micro Stratification at Sub-Health Center (SHC) Level
There are 11,264 SHCs in the state, out of which 652 SHCs in 50 districts are >1 API during the year 2018, while 1,951 SHCs were >1 API during year 2016 (Table 3). On further stratification during year 2018, 5 SHCs are between 25 to 49.9 API, 13 SHCs are between 10 to 24.9 API, 46 SHCs are between 5 to 9.9 API, 204 SHCs are between 2 to 4.9 API & 384 SHCs are between 1 to 1.9 API.

Urban Malaria Profile
An Urban malaria Scheme is functioning in six towns Viz

Epidemiological Gaps
Since the proportion of P. vivax is more in Madhya Pradesh (2019 -74.5%; 2018 -74.4% 2017 -66%), there is challenges to follow complete radical treatment of P. vivax malaria and monitoring of relapses. Fourteen days radical treatment needs to be followed.

Human Resource
It is an enormous challenge to ensure that key interventions are delivered timely as M`PW male workers are not sufficient in number for optimal performance.

Surveillance
The state has yet to declare malaria as notifiable disease. Presently, total of 51 districts, 50 districts have a smaller number of malaria cases (below 1 API), there are challenges to accelerate malaria elimination activities by strengthening case-based surveillance and foci investigation.
There is need to strengthen surveillance system to ensure 100% parasitological diagnosis of all suspected malaria cases and complete treatment of all confirmed cases within 24 hours. Mapping of private sector hospitals and reporting need to be augmented.

Governance
The state Task Force Committee on malaria Elimination is not constituted in the state. However, the districts have already coordination committee on malaria under District Magistrate. It should be redesigned as District Coordination Committee on malaria Elimination.

Best Practices
• ASHA is actively involved for diagnosis and treatment at the community level. The Bivalent Rapid Diagnostic Kits (RDT), Chloroquine tablets, Artesunate Combination Therapy (ACT) and Primaquine (for radical treatment) are available up to the ASHA level. The state has been arranged training for ASHA workers to use of RDT.

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Before inception of IRS activities in villages community are well informed for better coverage and benefits of spray. Fever camps are also arranged in highly endemic villages.
• In 2017-18; a total of 1.37 million Long Lasting Insecticidal Nets (LLINs) were supplied by NVBDCP for high malaria endemic districts. Another 94.6 Lakh have been provided during 2018-2019 under GFATM support for saturation of all high endemic population in subcenters with API 1 and above in the entire state.

Way Forward
• Based on stratification, micro strategic plans will be developed to fulfill those gaps and to accelerate malaria elimination activities in the districts of Madhya Pradesh. This stratification ae useful for target intervention in low endemic areas and to chive universal coverage of intervention in high burden areas. Similarly, situation analysis of all other three states (Chhattisgarh, West Bengal and Jharkhand) have been also carried out. During HBHI training, participants (DMOs & DVBDO) have been trained for preparation for an effective district operational plans by analyzing of their own data to stratified areas up to village levels. These Operational plans need to be implemented timely and effectively in all districts to achieve target for malaria elimination and sustain reduction of malaria morbidity and mortality. Interventions and response would be different for low endemic areas as well as in high burden areas Mid-term review should be also carried out. • In all high burden states, there are low burden districts/ blocks/subcenters having API less than 1, so casebased surveillance and foci investigation need to be strengthened in low endemic areas. • Interstate border meetings with bordering states may be organized at a regular basis. • Entomological capacity needs to be strengthened in the state to scale up entomological surveillance and to generate data on vector susceptibility for updating the resistance status in the state.