Health systems & surveillance

Photo: Maud Majeres Lugand / MMV

Health system and strategic plans

Health system 

Since independence, India has built up a vast health infrastructure at primary, secondary, and tertiary care levels in public, voluntary, and private sectors. The strengths of India’s extensive health care system, as identified in an assessment done by the World Bank, are: 

  • A well-developed administrative system,  
  • Good technical skills in multiple fields  
  • An extensive network of public health institutions for research, training and diagnostics, which provide free health to people below the poverty line.  

However, several weaknesses in the system have also been highlighted:  

  • Non-availability of critical manpower especially in periphery,  
  • Lack of community-ownership of the health care,  
  • Inequity in health care service delivery with respect to gender, caste,  
  • Different income groups and skewed availability of public resources between the advanced and less advanced states.  
Strategic plans 

The country developed a National Strategic Plan for Malaria Elimination (2017–2022) together with key partners such as WHO, state actors, Regional Offices for Health and Family Welfare, research institutions, civil society and several others.[1] 

The main levels of health care infrastructure are organised along the lines of primary, secondary and tertiary care levels within public, voluntary and private sectors.[1] 

Additional human resources: A new generation of communicable disease workers at the sub-centre level has been proposed to support disease control activities for communicable diseases including malaria.[1] 

Accredited Social Health Activists (ASHAs):  who have been selected by the community, provide the linkage between the community’s health needs and the health facility. ASHAs are incentivized for correctly using various services e.g. using RDT and preparing blood smear slide and providing correct and complete treatment for malaria.[1] 

Community ownership: In order to deliver comprehensive need-based health and medical care services, the National Health Mission is enhancing the health delivery system to make it functional, community-owned and decentralized.[1] 

Under the National Health Mission, all health facilities are to have an empowered board (Rogi Kalyan Samiti) that includes representatives from civil society, health workers, political leaders, women groups, among others. The committee will decide on budget allocation and utilization.[1] 

Health system strengthening 

The government is equipping all district and sub-district hospitals with facilities to manage severe malaria cases in endemic areas.[1]  Rapid transportation services are being made available to transport severe malaria cases to the nearest health facility. Referral centers are being equipped with diagnostics and anti-malarials for the management of severe malaria cases as well as life-saving support systems.[1] 


The country is strengthening its sentinel surveillance to capture trends on in-patient malaria cases, severe malaria cases and related deaths.[1] Fever alert surveillance tools for malaria have also been put in place as part of the Integrated Disease Surveillance Program (IDSP). This alert is communicated to medical officers at primary health care (PHC) levels and enables them to pay attention to weekly/monthly trends.[1] 

To curb or identify epidemics/outbreaks on their onset, local/field level workers are being trained on the early detection of signals including: 

  • increases in fever rates 
  • increase in malaria incidence 
  • increases in severe malaria cases in the population 
  • increase in total positivity rate 
  • percentage of P. falciparum 
  • proportion of gametocytes to other stages 
  • increase in resistance, and 
  • increase in malaria mortality.[1] 

Key population-based factors hindering the control and elimination of malaria  

Factors include [1]: 

  • Hard to reach areas such as hilly and forest areas as well as large conflict-affected areas with poor access and inadequate health infrastructure; 
  • Marginalisation of some ethnic groups; 
  • Low community awareness on malaria prevention and control among tribal and marginalised populations; 
  • New threats from artemisinin resistance and insecticide resistance 
  • Critical challenges within the healthcare system 

Challenges include: [1,2,3,4] 

  • Inadequate resources, both human and financial: A rapidly growing population, and static levels of public health expenditure put stress on India’s welfare-oriented healthcare system. Limited manpower in the health services sector significantly impacts surveillance and service delivery, particularly in remote and difficult to reach areas. Other human resource limitations include non-availability of critical manpower especially in periphery areas; 
  • Inequality in health care service delivery with respect to gender, caste, different income groups; and tilted availability of public resources to favour more advanced states in comparison to less advanced states. 
  • Large gap in the allocations for scaling up specific interventions, e.g. LLINs, RDTs, and ACTs as well as for positioning health care delivery. 
  • Inadequate public health infrastructure and training facilities 
  • Procurement and supply chain management (PSCM) issues: These include procedural delays, storage challenges, shortfalls in the distribution system especially in remote, hard to reach areas; manual inventory management and inadequate tracking system; absence of implementation guidelines and manuals; inadequate communication between PHCs, districts, states; 
  • Inadequate regulatory frameworks: Public health laws need to be framed to regulate the private sector to optimally utilise their services and improve upon the malaria case reporting sector, which is currently deficient. 
  • Inadequate micro-planning, monitoring and evaluation especially at secondary and primary care levels: The capacity to analyse, interpret and use data for decision making is often inadequate. 
  • Ownership by civil society and developing/strengthening community systems: This includes empowering and organizing key populations/community at large for consensus building, dialogue and advocacy at local and national levels. 
  • Minimal collaboration between health programs and non-health programmes / corporate sector 
  • Inadequate reporting systems which result in delays in outbreak detection, warning, investigation and control.