भूतान, तसं बघितलं तर भारतासमोर एक टिकली एवढा देश. आपल्या गडचिरोली इतकीच त्याची लोकसंख्या. पण या छोट्याश्या देशाने गेल्या काही वर्षात खूपच कमाल करून दाखविली. २०१६ च्या डिसेंबर महिन्यापर्यंत या देशाने जवळपास ९९ % मलेरिया हद्दपार केला. भौगोलिक दृष्ट्या भूतान आणि आपल्याकडील परिस्थिती वेगळी आहे त्यामुळे अर्ध्यापेक्षा जास्त भूतानमध्ये मलेरियाचा प्रभाव नाहीच्या बरोबरच. मलेरिया बद्दल अभ्यास करत असताना जेव्हा वाचलं तेव्हाच या छोट्याश्या देशाची करामत कळली. वाटलं हेच ते जे आपण शोधतोय. वास्तविक बघता भूतान ने मलेरिया संपुष्टात आणण्या करिता वेगळं असं काहीच केलं नाही. तिथे ज्या सोयी सुविधा आहेत त्या आपल्याकडे पण आहे. फरक इतकाच की देशपातळीवर चालवल्या जाणाऱ्या अश्या उपक्रमांमधें, त्या कामाची वैज्ञानिक दृष्ट्या आखणी, नियोजन, आणि अंमलबजावणी हि महत्त्वाची असते. यासोबतच गरज असते ती कामाची नियतकालिक देखरेख आणि मूल्यमापन करण्याची. उपक्रमातील सहभागी व्यक्तींची त्या कामामागील प्रेरणा व निष्ठा देखील तितकीच महत्त्वाची!
याच विषयानुरूप असा हा अभ्यासपूर्ण लेख...
Review of successful Malaria control, intervention strategy – BHUTAN
Case Study
2016 - 2017
Compiled by – Suvarna Khadakkar
BACKGROUND
1. Bhutan has made great strides within a short period of modernization, as shown by both objective and subjective indicators.
2. Bhutan became a signatory to the Alma-Ata declaration in 1978. Since then, Bhutan has endorsed the utmost importance to the health of its people. In addition, Bhutan adopted Gross National Happiness (GNH), which puts the happiness of the population at the core of developmental policies.
3. Article 9 of the Constitution of Bhutan prescribes that “the state shall strive to promote those conditions that will enable the pursuit of Gross National Happiness.”
4. The fourth king of Bhutan, His Majesty Jigme Singye Wangchuk, in 1974, realizing the mismatch in the trajectory of growth-oriented market economics as a developmental philosophy, formulated the concept of GNH.
5. GNH in Bhutan is based on four principles, i.e. sustainable and equitable economic development, conservation of the environment, preservation and promotion of culture, and good governance.
6. On a 10-point scale (1 - not a very happy person, 10 - a very happy person), the average happiness score was 6.2 for Bhutan residents. Both good health and access to the health infrastructure and facilities are considered important sources of happiness
7. The Centre for Bhutan Studies, as mandated by the Royal Government of Bhutan, has developed a GNH index under nine domains
8. Article 9 of the Constitution of Bhutan states that “the state shall provide free access to basic public health services in both modern and traditional medicine.” This constitutional responsibility is delivered through a three-tiered health system, i.e., primary, secondary, and tertiary levels that provide preventive, promotive, and curative services via 31 hospitals, 178 basic health units, and 654 outreach clinics scattered throughout all 20 districts and 205 sub districts of Bhutan.
9. 69.1% of the Bhutanese population lives in rural areas. There are no private medical facilities, and all treatment, including referrals to facilities outside the country, is provided free by the government. Currently, the government is spending about 5.7% of its total planned budget on health.
10.Bhutan eliminated iodine deficiency disorder in 2003 and leprosy in 1997, and achieved universal childhood immunization in 1991. In 2004, Bhutan became the first country in the world to ban the sale of tobacco. The incidence of malaria also decreased from 12,591 cases in 1999 to 972 cases in 2009.
11.World Health Organization awarded its fiftieth anniversary award for primary health care to Bhutan in 1998.
12.Traditional Bhutanese medicine, known as “gso-ba- rig-pa,” is well integrated into the modern health care system. This form of traditional Buddhist medicine, currently practiced in Tibet, Mongolia, and Bhutan, dates back about 2500 years. In Bhutan, this traditional service is available in all districts. In most districts, these two systems are located in the same hospital and people can choose either type of service to use.
13.Bhutan is divided into twenty dzongkhags (districts), administered by a body called the Dzongkhak Tshokdu. A gewog refers to a group of villages. The gewogs in turn are divided into chewogs for elections and thromdes "municipalities" for administration.
(Ref : Tashi Tobgay et al. Health and Gross National Happiness: Review of current status in Bhutan. Journal of Multidisciplinary Healthcare. 2011:4 , 293–298)
INSIGHTS OF MALARIA ELIMINATION PROGRAM OF BHUTAN
PHASES OF MALARIA ELIMINATION PROGRAM
1. Eradication (1964 – 1970)
2. Control period (1971 – 1995)
3. Reinvesting in control (1996 – 2005)
4. Towards elimination (2006 – 2012)
How did Bhutan progress to pre-elimination status between 2006 and 2013?
1. ORGANIZATION AND PROGRAM MANAGEMENT
a. Decentralization
b. Free Diagnosis and treatment of malaria
c. Use of Medical technicians, Mobile Malaria Clinics
d. Foundation of University of Medical Sciences of Bhutan—an autonomous body—in Thimphu in June 2012
e. National Centre for Tropical and Zoonotic Diseases under the Ministry of Health
2. POLICY AND LEGISLATION
a. Compulsory Medical screening for all foreign national laborers
b. Local legislation: In one community, for example, a small fine is levied on anyone who fails to contribute labour to the Community Action Group during campaigns to rid the area of mosquito breeding sites. Fines gathered are used for community health activities.
3. ENABLING CONTEXTUAL FACTORS
a. Twofold increase in tourism revenue
b. Free essential health care 1998, WHO 50th anniversary award for primary health care as “one of the best in South-East Asia”
c. High annual per capita expenditure on health, spending up to US$ 75
d. Strong national supply and logistics system
e. No private medical facilities and only a handful of retail pharmacy shops, which are not allowed to sell antimalarial treatment
4. EPIDEMIOLOGICAL SURVEILLANCE
a. Case mapping, show distribution of malaria cases, malaria species and nationality of malaria cases
b. Using the maps as a baseline for monitoring, for evaluation and to guide interventions in targeted villages
c. Since 2011 mobile malaria clinics are introduced on an ad hoc basis
5. LABORATORY SUPPORT, EXTERNAL QUALITY ASSURANCE/QUALITY CONTROL
a. Monthly compulsory cross-checking of microscopic blood films
b. At-risk seasonal transmission and malaria-free areas, slides are sent to the VDCP for cross-checking every three months
c. 10% of negative and 50% of all positive slides are cross-checked for accuracy and quality
d. Malaria microscopy training is ordered if false-positive or false-negative rates exceed an acceptable limit—which is likely to be one false-positive or false-negative
6. ENTOMOLOGICAL SURVEILLANCE
a. Monthly Vector density studies, bioassay tests on LLINs and susceptibility tests
b. Starting in 2012, the VDCP collaborated with the environmental health program to expand vector surveillance to sentinel sites in malaria-free and epidemic areas as well as to additional endemic districts
7. VECTOR CONTROL
a. Use of IRS/LLIN
b. Spraying in both endemic (perennial) and epidemic (seasonal) transmission areas, based on case reporting
8. OUTBREAK MONITORING AND RESPONSE
a. The importance of dzongkhag and BHU staff being able to perform data analysis in order to fully investigate outbreaks and plans to strengthen this capacity
b. The response to outbreaks includes focal IRS
9. HEALTH EDUCATION, IEC
a. 1200 village health workers, trained to conduct IEC and behavior change communication (BCC) activities on malaria in addition to meeting other public health needs
b. Misconceptions in population: Malaria is caused by working under the sun, by drinking cold water in hot weather or by evil spirits, malaria symptoms could be aggravated by eating sour fruits. Local healers or religious leaders
c. Community engagement and empowerment through the formation of Community Action Groups at the lowest administrative level (chiwog)
d. Training for CAG members is provided by local health workers and monitored by local leaders
e. Funded initially by the Global Fund, CAGs were piloted in 2009 in Chhukha Dzongkhag and then expanded into all chiwogs in five dzongkhags; more than 500 people were trained in more than 30 communities
10. EXTERNAL SUPPORT AND COLLABORATION & CROSS-BORDER COLLABORATION
a. Government of India
b. WHO
c. Global fund
d. Asia Pacific Malaria Elimination Network (APMEN)
e. USAID, SEARO, SAARC
11. RESEARCH
a. Malaria Indicator Survey and exploratory studies on parasite strains
b. Transmission related to vector biology, the role of insect growth regulators and larvivorous fish, and studies on the use of mosquito repellents by farmers for prevention
c. The prevalence of haemoglobinopathies and their role in clinical manifestation of malaria
d. Clinical trial on parasitic clearance and recurrence rates among P. vivax patients treated with chloroquine and primaquine
e. Strengthening malaria surveillance using mobile technology, such as use of cell phones for reporting, for malaria elimination
SUMMARY -
1) Implementation – The level of decentralization and integration of the malaria programme, the health system in which the malaria programme operated its organizational structure and the accountability of the programme.
2) Motivation and incentives –
i) High level of motivation in implementers is important to sustain consistency and quality of interventions which depend on factors as working conditions, financial incentives, correct and prompt compensation, management of staff and possibilities for professional advancement
ii) As malaria cases decline, different strategies must be employed to keep staff committed, and prevent turnover and loss of institutional knowledge. Incentives may be used if specific and predetermined milestones are achieved.
3) Training - Programme activities were strengthened when training was increased with the injection of external funding or if an outbreak occurred.
4) Supervisory structure - to ensure the quality of interventions and to increase or maintain a high level of motivation in the workforce. Effective supervision should include regular visits to the periphery and activities to check information and supplies, problem-solving with the employee, and a feedback mechanism to encourage improvement
5) Monitoring and evaluation - Monitoring and evaluation (M&E) includes monitoring programme outputs, such as whether intervention coverage and quality was achieved, and evaluation of impact. An important part of M&E is analysis and swift feedback to the periphery, which should theoretically stimulate effective programme response, clearly M&E needs to be undertaken with a spirit of surveillance and response.
(Ref : Cara Smith Gueye et al 2016 The central role of national programme management for the achievement of malaria elimination: a cross case‑study analysis of nine malaria programmes. Malar J 15:488)
सुवर्णा खडककर, (निर्माण ५)
Published in 1960, Harper Lee's debut and which for many years remained her only novel, To Kill A Mockingbird addressed issues which resonate even in our current circumstances. The characters so delicately constructed and so warmly presented are etched in our minds and continue to inspire us every time we go back to them. A recent example is Barack Obama quoting one of the characters in his farewell speech a few weeks ago, he said "If democracy is to work in our increasingly diverse nation, each one of us should pay her to the advice of one of the greatest characters of American fiction - Atticus Finch. Who said, you never really understand a person until you consider things from his point of view. Until you crawl under his skin and walk around in it" 
