|Year : 2011 | Volume
| Issue : 2 | Page : 83-87
Assessing perceptions about malaria among the elected representatives in rural India
Rajan R Patil1, SK Ghosh2, SN Tiwari2
1 Community Health Cell, Bangalore; Division of Epidemiology, School of Public Health, SRM University, Chennai, India
2 National Institute of Malaria Research (ICMR), Bangalore, India
|Date of Web Publication||31-Oct-2011|
Rajan R Patil
Division of Epidemiology, School of Public Health, SRM University, Potheri, Kattankulathur - 603 203, Greater Chennai
Source of Support: ICMR, New Delhi, Conflict of Interest: None
| Abstract|| |
Objective: The short-term objective of our endeavour was to understand the perception of Grama panchayat presidents and secretaries on the issues related to malaria and its control, being the key leaders of the Panchayat Raj Institutions (PRIs) at a Grama panchayat level. This was necessary to achieve the long-term objective of the role of PRIs in malaria control and their enhanced participation/partnership with the public health sector. Materials and Methods: Grama panchayat presidents and secretaries representing all the 28 Grama panchayats of Chikkanayakanahalli taluk Tumkur district in Karnataka were invited for a 1-day workshop. Deliberations with the participants (n = 32) shed light on their perceptions with respect to knowledge, attitude and practice vis-a-vis malaria and its control strategies. Results: Their knowledge of malaria as a disease was fairly good as they were well aware of it being a communicable disease and its transmission by mosquitoes. However, knowledge about the breeding sources of malaria mosquitoes (Anophelines) was very poor. Many practices in vogue to control mosquitoes at the community level were unscientific. There was a general negative attitude toward the government's handling of the malaria problem and the credibility of the health care system. Conclusion: Existence of health committees in every Grama panchayat coupled with their jurisdiction and responsibilities toward sanitation, water supply and health care resources makes PRIs a natural partner to the health sector. While health education and public health intervention strategies should be based on generic principles of science, the implementation and operational specifics should definitely be based on a sociological perspective of the stakeholders.
Keywords: Grama panchayat , intersectoral, KAP, malaria, social factors, rural governance
|How to cite this article:|
Patil RR, Ghosh S K, Tiwari S N. Assessing perceptions about malaria among the elected representatives in rural India. Trop Parasitol 2011;1:83-7
| Introduction|| |
Malaria is one of the reemerging diseases that has baffled public health professionals all over the world, and India in particular. Although a good amount of research has been performed on malaria, yet, it has largely been lopsided, with an overemphasis on the development of biomedical products, e.g. drugs and vaccines. Social factors have been demonstrated to be important determinants in the malaria control strategies. The socioeconomic costs of malaria have been enormous, especially in third world countries like India. Resistance of malaria parasites to chloroquine and resistance to insecticides among malaria vectors have exacerbated an already vexed situation. Failure to view malaria in a broader perspective as a manifestation of flawed developmental strategies and inertia of the public health system to address the emerging challenges have led to a perception that the public health system in itself is resistant to malaria.  The success of malaria control programmes has been directly proportional to the awareness of the community; hence, government/research centers have made efforts to involve the community in malaria control.  Professional resource groups and NGOs on their part have come up with different innovative concepts and programmes to mobilize the community in malaria programmes. 
Chikkanayakan Halli (CN halli) is one of the severely malaria affected taluks of Tumkur district in Karnataka, in the southern state of India, with an incidence of 10,137 cases in the year 2000-2001. It contributes 36.8% of the total malaria cases for the entire Tumkur district of Karnataka. This taluk is predominantly rural in nature, with 300 villages and a population of 2,14,072,  divided into 28 Grama panchayats. Coconut is one of the major sources of income for the region. It shares the sobriquet as the "coconut bowl" along with the neighboring districts, leading to major economic activities with significant migrations. Tumkur district is one of the five districts in India selected in the WHO-SEARO's Roll Back Malaria initiative. 
A Grama panchayat in the Indian democracy represents a local elected body at the village level. Typically, a Grama panchayat covers a population of 5000-7000, with 12-15 members, covering as many villages. A village community representing 400 populations elects a Grama panchayat member. All the elected members of the Gram panchayat elect a Gram panchayat president and a vice president. Each Gram panchayat will have a Gram panchayat secretary responsible for administration. Each Grama panchayat will have a health committee represented by three elected Grama panchayat members to oversee the health work in their concerned Grama panchayat area.
The short-term objective of the workshop was to understand the perception of Grama panchayat presidents and secretaries on the issues related to malaria and its control, as they are the key leaders of the Panchayat Raj Institutions (PRIs) at a Grama panchayat level. This was necessary to achieve the long-tem objective of the potential role of PRIs in malaria control and their enhanced participation and partnership with the public health sector.
| Materials and Methods|| |
- Community Health Cell (CHC), a Public Health professional resource group, and Malaria Research Centre of the Indian Council of Medical Research were the resource teams for the workshop organized by the Rural Development and Panchayat Raj Department of Tumkur district.
- Grama panchayat presidents of all the 28 Grama panchayats of CN halli taluk were invited to be part of this 1-day workshop on malaria. A total of 32 of them, including Grama panchayat presidents and secretaries, responded to the invitation.
- The participants were divided into four groups, each representing a Hobli (administrative unit) of the CN halli taluk. Each group had a facilitator from the resource team to facilitate the discussion.
- Two rapporteurs in each group noted the proceedings of the group discussions. The notes from the rapporteurs were collated and the analysis of perception on different aspects of malaria was performed.
- The perceptions of participants were categorized under different headings, visa vie malaria and its control.
| Results and Discussion|| |
Details of the perceptions of the members are given in [Table 1]. From the above perceptions, many interesting trends and conclusions can be drawn to help in the planning and implementation of the malaria control programme. Some of these are:
|Table 1: Knowledge, attitude and practices of rural pachayat-elected members about malaria|
Click here to view
Lack of information
There is a lack of awareness of the malaria mosquito (Anophelines) and its breeding places. The chaos is heightened when the ignorance is widespread even among medical officers of Primary Health Centres (PHCs) - a glaring observation,  because preventive education is one of the key components of PHC functioning. This erroneous impression is perpetuated by the lack of scientific accuracy in the government health department's health education booklets, where dirty water is still projected as a breeding place for malaria mosquitoes.  Consequently, this leads to a misperception that drains and garbage are breeding grounds. Small plants and bushes are very often mistaken as sources of mosquitoes, which are in fact only the resting places.
Exploitation by the medical profession
Participants brought up the issue of economic exploitation of the community by the doctors who are said to be charging exorbitantly for treatment. Part of the reason for heavy expenditure for malaria illness incurred by patients is due to irrational use of drugs. Intravenous fluids and injections are being used rampantly, which are generally not required in normal uncomplicated cases of malaria. It is often seen that people themselves insist on glucose IV fluids for "getting strength" during illness. Irrational use of drugs is also part of the reason for resistance to malaria drugs.
It is interesting to see how the community uses its own deductive logic. They have been witnessing the practice of disinfections of water by adding bleaching powder or potassium permanganate. The same understanding is extrapolated to get rid of mosquito larvae by adding germicides like phenyl or bleaching powder to the drains. Unlike the microbes, use of antimicrobial agents like bleaching powder or phenyl do not have the desired effects on larvae.
Community as a monitor/evaluator
The community makes its own observations, like "Use of malathion (insecticide) spraying has not led to reduction in mosquitoes." The observation fits in with the concerns of certain sections of programme administrators regarding the development of resistance against the insecticides. At the same time, it could be a manifestation of improper/unscientific spraying strategies. Another example of good community observation is their assertion about increased mosquito density after drainage works. It could well be true, because improper desilting results in creating large burrows and pits in the drainage system, which leads to water stagnation. It may be a good idea to add community perception as another indicator in assessing the impact of public health intervention programmes. Community observation may turn out to be a good research question worth exploring through analytical research methodologies in epidemiology as well as sociology.
Information education communication to be more scientific programme specific
The government should sensitize people on the utility of programmes before implementation of programmes and take the community into confidence for any major operational changes in the field. Panchayat representatives exemplify the issue of communication gap between government health programmes and community by raising questions about change in the insecticide spray policy. Earlier, cattle sheds were being sprayed along with human dwellings; later, cattle shed spraying was stopped, leaving the community confused. The logic was, spraying in the cattle sheds would drive the mosquitoes into human dwellings. Similarly, there are certain guidelines for spraying insecticides - the most basic of them is the annual parasitic index (API), which is an indicator of the incidence of malaria in a given area. Because of a resource crunch, the malaria programme officers are forced to take up villages with an API >50 and select villages from there downwards hence leaving villages with <5 API. Therefore, the IEC activity from government departments is very vital.
Information to the community
Public health work and decisions should be need-based and not based on political considerations. The case in point highlighted by the participants is the issue of construction of soak pits only in the scheduled cast and scheduled tribes (India) colonies in many villages of the CN halli taluk. This usually gives an impression of partiality by the government, whereas in fact it is prioritization of the government to reach to more marginalized sections of the society on a priority bases.
Maintaining a balance in multiplicity of roles of health workers
Auxiliary nurse midwife (ANMs) and multipurpose health workers have multiple roles, as suggested by their designations, in our health care system. These multiple roles are due to doing away with vertical programmes, as per the recommendation of the Kartar singh committee appointed by the Government of India in 1973 to improve the public health system. Earlier, in vertical programmes for health, there were separate workers for different disease programmes, e.g. Leprosy worker, TB worker, malaria worker, etc. In 1978, the WHO adopted the Alma Ata declaration, which emphasized on the primary health care strategy for achieving "health for all by 2000" (now extended). The strategy also called for integration of all health care services (horizontal) at the PHC.
Need to be sensitive and empathetic
Mobility of health workers is definitely limited in the field, mainly for the sheer number of people to be covered, i.e. a population of 5000 by each health worker, without a vehicle. The Task Force on Health constituted by the Government of Karnataka has recommended two workers for a population of 5000. Another reason is 50% vacancy  in health worker posts; as a result, health workers are being redeployed from non-problematic areas to problematic PHCs for short durations. Health staff complain that they do not get reimbursement for their travel; moreover, old TA reimbursement claims are pending since 5 years. There is increasing demand to transfer health workers permanently rather than redeployment. The problem with permanent transfer is that PHC health staff, including doctors, are under the jurisdiction of panchayats and not under the health department. Hence, the local panchayats do not agree to lose workers where replacement is not assured due to a ban on recruitment.
Drug supplies and logistics
PHC/government hospitals are said to be given adequate basic drugs, but not all the drugs listed in the essential drug list. Very often, there is delay in the release of drugs from the state to districts to talukas to the respective PHCs. This administrative delay often affects the image of the PHC and the popularity of the medical officer. Anganwadi workers (voluntary worker for Integrated Child Development Scheme programme in India) are not part of the malaria programme. Only few of them are involved with Drug Distribution Centers, which are established for distributing malaria drugs in high-risk malaria villages.
Need for continuous IEC
Health awareness activities by the health department are perceived to be very limited, and usually take place only during the malaria month, i.e. in June every year. Health education is limited to pamphlets, posters and some symbolic events, which are often highly politicized. People often contrast IEC activities of malaria to that of family planning in earlier decades, when the awareness on small family norms and population control were taken on a war footing, with the ubiquitous inverted red triangle, punchy captions on large hoardings, house to house visits by ANMs and large tubectomy camps with street plays and songs etc.
Need for intersectoral approach
Another important observation made by panchayat representatives strike a chord with concerns raised by public health experts on intersectoral coordination for malaria, the neglect of which lead to problems of mosquitogenic conditions. Engineering issues like improper construction of drainage, soak pits, hand pumps, etc. lead to stagnation of water. Malariologists lament the lack of public health engineering as it used to be in the first half of this century. Karnataka had achieved malaria control during the construction of KRS dam by good public health engineering bioenvironmental control.
Problems in reporting
Malaria cases often develop jaundice as a complication. Panchayat representatives are of the opinion that, very often, malaria deaths may be recorded as due to jaundice. There is international coding of death reporting, which is not followed strictly in PHCs, leading to reporting bias, which undermines the validity of malaria surveillance. There is a general feeling that PHCs underplay deaths due to malaria, fearing media attention and political pressures thereof.
Financial resource management
Grama panchayat s get to utilize only 4% of their budget for health and sanitation, which is considered insufficient. They are expected to perform sanitation, purchase of insecticide, constructing and maintenance of drain, construction of soakage pits, etc. Budget provision is not sufficient. Very often, most of the allocated funds get utilized for organizing events like inaugural or valedictory function graced by a politician. A very meager amount is left for actually carrying on the health work.
| Conclusions|| |
- Some of the perceptions of the presidents and secretaries of the Grama panchayat were not correct. Every Grama panchayat will have health committees who should be responsible to create awareness and take action toward sanitation water supply and health care to reduce the incidence and prevalence of communicable diseases.
- While health promotion and public health intervention strategies are based on principles of science and technology, the implementation should be based on a sociological perspective of the community. The community should be involved at every stage of the programme, from conception though implementation to evaluation.
- Intersectoral coordination to control malaria was emphasized by the presidents and secretaries of Grama panchayats by raising issues like construction of soak pits, borewells and drains. Besides, they are ready to print health education materials, posters and other vocal media to sensitize rural people.
- Perceptions of the community can be useful in programme planning as follows:
- Right perception as a bridge in communication
- Wrong perception as a focus for heath education
- All perceptions as a stimulus for field research
| Acknowledgment|| |
The authors acknowledge the Indian Council of Medical Research, New Delhi and Community Health Cell, Bangalore for technical and financial assistance.
| References|| |
|1.||Narayan R, Sehgal PN, Shiva M, Nandy A, Abel R, Kaul S, Resurgence of Malaria, Towards an Appropriate Malaria Control Strategy: Issues of concern and alternatives for action. Voluntary Health Association of India/Society for Community Health Awareness, Research and action. New Delhi: 1997. |
|2.||Sharma VP, Community Participation in Malaria Control: Malaria Research Centre. New Delhi: ICMR; 1993. |
|3.||Community Health Cell, A Short Report on the malaria Kala-Jatha at Mathigatta PHC Area, Tumkur District in Dec. (Report to Directorate of Health services) 2001. |
|4.||National Anti Malaria Report, 2002. |
|5.||Malaria Research Centre, Situational Analaysis of Malaria in District Tumkur under Roll Back Malaria. Malaria: Malaria Research Centre; 2001. |
|6.||Patil R, Patil RR, Ghosh SK, Tiwari SN. et al. KAP study among PHC medical Officers of South Canara district. 2000 (unpublished) |
|7.||Government of India,National Malaria Eradication Programme, Operational Manual for Malaria Action Plan(MAP): Director General of Health Services Ministry of Health and Family Welfare. New Delhi: 1995. |