TREPAR 2079 No.
of Pages 4
Trends in
Parasitology
Forum
Digital Health Care
Services to Control
and Eliminate Malaria
in India
Shrikant Nema ,1,2
Anil Kumar Verma,1
Archana Tiwari,2 and
Praveen Kumar Bharti , 1,*
In the rural and tribal areas of India,
poor healthcare services for ma-
laria are posing a great challenge
to malaria control and elimination.
Digitisation in malaria healthcare
services, including surveillance,
diagnosis, and treatment, may be
helpful in malaria control and,
subsequently, may move towards
the elimination goal of India by
2030.
Where We Stand Now: Malaria
Burden and Population at Risk
Malaria is a leading cause of death due to
parasitic infections worldwide. More than
40% of the world’s population and nearly
90% of India’s population is at risk of
malarial infectioni. In India, Plasmodium
falciparum and Plasmodium vivax have
contributed almost equally in 2019ii, with
low prevalence of other parasite species.
The Government of India’s efforts have re-
sulted in a 49% decline of total malaria
cases in 2018 as compared with 2017i,
while still 0.33 million confirmed cases of
malaria were reported in 2019ii. However,
persistence of malaria in rural and tribal
populations is posing a serious problem
in India [1]. Therefore, supplementation of
digital technology for delivery of healthcare
services in rural and tribal areas [2] may
bridge the rural–urban divide of malaria
control to achieve the malaria elimination
goal in India.
The Roadblocks in the Malaria
Management System
The healthcare services in rural and tribal
areas of India are provided mainly by
public sector (state-run healthcare unit)
with limited contribution from the private
sector. The Government of India manages
the vector-borne diseases, including ma-
laria, through the National Vector Borne
Disease Control Programme (NVBDCP).
In every district, the NVBDCP is imple-
mented by the District Malaria Officer
in consultation with physicians stationed
at the district hospitals and community/
primary health centres. Community health
workers known as Accredited Social
Health Activists (ASHA) work at village
level to provide malaria diagnosis and
treatment as per national guidelines [3]
(Figure 1). Malaria surveillance is con-
ducted by community health workers
through a paper-trail system, which raises
the issue of data accuracy and reliability as
data discrepancies between various
sources have been noted in India [4].
Diagnosis of malaria is mainly conducted
by either microscopy or rapid diagnostic
test (RDT) in peripheral areas. The results
of microscopic diagnosis are time con-
suming and depend on the quality of
blood smear, staining, fixation, and micro-
scope and, most importantly, on a skilled
microscopist. Further, RDT is used in
places where microscopy is not feasible.
Moreover, RDTs also have limitations in
cases of low-density parasitaemia and
prolonged stability of histidine rich protein
2 (HRP2) in blood may give false positive
results. However, in high-malaria endemic
areas, tribal people/villagers are frequently
exposed to malaria infection but are un-
able to reproduce medical history (time of
infection, type of malaria parasite, treat-
ment prescribed and outcome) due to
lack of proper storage of heath records.
These medical records may play a very im-
portant role in treatment and in controlling
the spread of drug resistance, as un-
treated false negative patients serve as a
reservoir for transmission of malaria and
treatment of false positive patients pro-
motes antimalarial drug resistance. Further,
the reluctance of tribal people to seek
medical care, fuelled by the unavailability
of healthcare centres in proximity to their
villages, loss of wages, and cultural belief,
complicates the control and management
of malaria in tribal areas. Moreover, socio-
political conflict in some areas discourages
the presence of healthcare workers and
limits the access to healthcare facilities by
tribal people [3]. Additionally, inconsistent
reporting of essential malaria commodity
consumption affects service readiness
and results in major stock outs and delays
in issuing of new stock, leading to patient
downtimes.
Digitisation of Malaria Services:
Time to Switch Over
Digital Healthcare tools hold tremendous
opportunities in the form of mobile
healthcare, remote diagnostics, telemedi-
cine, wearables, electronic medical records,
cloud-based analytics, etc. (Box 1). The use
of smart phones/digital handheld tablets
and online application software to record
the clinical sign and symptoms, diagnosis,
treatment, and drug compliance may im-
prove the quality and quantity (real-time
reporting) of malaria surveillance data [5].
The utilisation of digital platforms with
proper training and a ‘track–test–treat–
track’ strategy will allow the quick dispensa-
tion of surveillance data from the field
(Figure 1) [6]. Artificial intelligence and ma-
chine learning-based systems, together
with microscopy, can read the blood
smear to provide quick morphological-
based detection of the malaria parasite.
RDT result interpretation may be improved
by using an optical reader coupled with a
mobile phone [7]. Additionally, diagnostic
activities can also be improved by using
hemozoin-based digital malaria diagnostic
devices, such as Gazelle [8]. Therefore, de-
ployment of easily accessible and transport-
able online platforms for malaria could be
Trends in Parasitology, Month 2020, Vol. xx, No. xx 1
 Trends in Parasitology

National vector-borne disease control programme Output

Diagnosis
Treatment
State program officer Burden
Resistance
Vector control
measure
Follow up

Telemedicine
Database
Track
Malaria commodities stock update

Quality Real-time
District malaria officer control checks reporting
Mobile clinic in market

AI-based new hrp2

diagnostic tool deletion

False
negative

Block medical officer

Mobile application
Diagnosis
Treatment
Track report
Health
questionnaire
Stock
Other
information
Submit

Trends in Parasitology

Figure 1. Data Flow and Information Exchange through Digital Platforms for Malaria Service Delivery in India. Abbreviations: AI, Artificial intelligence; ANM,
auxiliary nurse midwife; ASHA, accredited social health activist; GPRS, general packet radio service; hrp2, histidine rich protein 2; Neg, negative; Pos, positive; RDT, rapid
diagnostic test.

beneficial in rural and tribal areas for active
management of disease by ASHA and the
local medical officer. Moreover, develop-
ment of malaria-specific mobile-based ap-
plications (e.g., the Aarogya Setu app for
coronavirus disease 2019) may be used
for self-assessment and notification of
cases for diagnosis and treatment. Further-
more, the concept of telemedicine can be
utilised in emergency situations by commu-
nity health workers to provide immediate re-
lief to the patient and subsequently guide
them to the advanced care facility. This
may help the local medical fraternity in bet-
ter management of disease and in avoiding
medical errors to improve efficiency in the
delivery of curative services. Furthermore,
the national programme is stepping up for
the digital data collection of malaria informa-
tion using the Integrated Health Information
Platform to strengthen the malaria surveil-
lance in the country by establishing a
decentralised state-based surveillance sys-
tem and dissemination of real-time data.
Additionally, the malaria elimination demon-
stration project in the Mandla district of
Madhya Pradesh, India, reported the sur-
veillance data using digital data collection
tools such as ‘Solutions for Community
Health-Workers’ [6]. Moreover, South
Africa has set an example to curtail the ma-
laria outbreak using effective 24-h mobile
reporting strategy [9]. Singh et al. also re-
ported that mHealth systems reduced the
data collection time as well as data collector
costs [5].
Strengthening of Malaria
Surveillance: The Game Changer
Malaria surveillance using digital tools will
strengthen our capacity to understand
the dynamics of malaria parasites and
vectors in rural and tribal India. Several
futuristic malaria models may be helpful
in the malaria impact assessment (e.g.,
MIASMA, which allows the investigation
of climatic suitability for malaria transmis-
sion, and VECTRI, which can be used for

2 Trends in Parasitology, Month 2020, Vol. xx, No. xx

Trends in Parasitology

Box 1. Digital Health Pillars for Malaria Control and Elimination emergence and spread of antimalarial
1) SWOT analysis drug resistance in real time. Initially, the
• Strength probable drug resistance may be flagged
Telemedicine, less cost, real-time consultation, and suggestion
by local clinicians to the digital platform,
• Weakness
Lack of proper training, education, and management and limited resources in remote area
followed by therapeutic efficacy studies
(TES) by research organisations. The
• Opportunities
New technology, policies/services implementation, and flourishing mobile culture in villages output of TES should be regularly updated
• Threat to the antimalarial drug resistance dash-
Data security and management board. Using a smartphone-based alarm
2) Integrated, patient-centred care and prevention or SMS notification system to inform the
•Early diagnosis of malaria using point-of-care tools, mobile malaria clinics, systematic screening of patients about the timely intake of medi-
low-density parasitaemia: using artificial intelligence
• Treatment and suggestions of malaria in rural and tribal areas and where drug resistance is also a
cines may improve treatment compliance
concern: video-observed therapy for P. vivax [13] and can be helpful in
• Collaborative malaria activities and management of comorbidities: e-policy for stakeholders overcoming the issue of recrudescence,
• Preventative treatment for pregnant women and migratory workers: eLearning for staff re-infection, and relapse. Additionally,
3) Bold policies and supportive systems
counterfeited or substandard drugs have
• Political commitment with adequate resources for malaria control and elimination; e-communication
by stakeholders
also contributed to the development of
• Engagement of local communities and public and private care providers: e-liaising for patients resistant parasitic strains, which can
• Universal health coverage policy and regulatory frameworks for case notification: electronic notifica- be identified using handheld devices,
tion of cases
such as PharmaCheck, by competent
4) Intensified research and innovation
authoritiesiii. The Counterfeit Drug Foren-
• Discovery, development, and incorporation of new tools, interventions, and strategies: add-on
software to smartphone sic Investigation Network recommends
• Implementation of digital healthcare services: mobile devices for surveillance the use of systematic analytical processes
to detect and classify substandard and
falsified drugs [14].
the assessment of various climatic factors preferences, host-seeking, biting, and rest-
such as temperature, rainfall, surface ing behaviour). Hence, this vital information Interactive Malaria Dashboard for
hydrology, and terrain topography [10]. may be used for developing a counter strat- Improved Decision Making
Moreover, Geographic Information Sys- egy for malaria outbreaks. Although the The establishment of a malaria dashboard
tem can be used to demarcate malaria availability and digitalisation of vector-related in district headquarters could facilitate
hotspots in malaria-endemic regions and data at district level is troublesome in the better management of disease. The dash-
allocate adequate resources for better present scenario, a strong commitment board would display real-time information
management of malaria [11]. The vector from national/state vector-borne disease about stock availability of diagnostics
control measures, such as indoor resid- control program could make it accomplish- (RDT, microscopy supplies), antimalarial
ual sprays, are adopted from June to able. In the process of digitalisation, the medicine, status of vector control measures
September to curtail active transmission field staff/community workers need to be (insecticide resistance, frequency and
in India. However, the efficacy of vector rigorously trained in the use of various hand- coverage of indoor residual spraying, and
control measures can be improved by held diagnostic devices, operating the soft- long-lasting insecticidal net distribution),
gathering and sharing entomological data ware to generate, record, and share the type of prevalent malaria parasite, HRP-2
(insecticide resistance) via digital platforms data. deletion, and antimalarial resistance status
[12]. These platforms could serve as a in each and every district. The diagnostic re-
channel of communication between local Antimalarial Drug Resistance sults can be uploaded to a server and a link
entomologists and community members Dashboard to the website can also be shared with the
to intensify public engagement in vector- Human mobility across regions, poor drug local hospitals and diagnostic labs to get
control interventions. Additionally, devel- compliance, and substandard drugs are the real picture of malaria epidemiology in
opment of an online databank/map of the major reasons for development and the area [15]. Further, sharing of medical
distribution of different malaria vector spread of antimalarial drug resistance. history in real time would enable the system
species prevalent in the region may give an The development of an interactive dash- to combine data from various sources to
indication of the basic biology and behaviour board of antimalarial drug resistance may create a patient’s single snapshot, which
of a vector population (e.g., breeding site provide an opportunity to monitor the may ease clinicians’ examination of medical

Trends in Parasitology, Month 2020, Vol. xx, No. xx 3


records. The route of data collection from manuscript (PSC no- ICMR-NIRTH/PSC/41/2020).
the community and data management at S. N. thanks Indian Council Medical Research for
the district level, with sharing at state as ICMR-Senior Research fellowship.
well as national levels, must be managed
Resources
cooperatively (Figure 1). i malaria elimination through track-test-treat-track (T4)
Concluding Remarks
Digital health interventions are playing an
important role in easing diagnosis and man-
agement of various diseases globally. In a
similar way, digital intervention in malaria
control activities, such as strengthening
malaria surveillance, enhancing drug com-
pliance, improving policy and governance,
access, and service delivery, may support
malaria elimination in India. To make digital
health a reality, the country must use its
leverage in information technology and
ever-expanding telecommunication network
as tools. Digitisation in healthcare services
will build confidence among rural and
tribal people and may redefine the patient–
physician relationship in India.
Acknowledgements
The authors are thankful to the Publication Screening
Committee (PSC) of ICMR-NIRTH for reviewing the
4 Trends in Parasitology, Month 2020, Vol. xx, No. xx
www.who.int/publications-detail/world-malaria-
report-2019
ii
https://nvbdcp.gov.in/index1.php?lang=1&level=
1&sublinkid=5784&lid=3689
iii
www.eurekalert.org/pub_releases/2012-07/up-
ntr072612.php
1
Division of Vector-Borne Diseases, ICMR-National Institute of
Research in Tribal Health, Jabalpur 482 003, Madhya Pradesh,
India
2
School of Biotechnology, Rajiv Gandhi Proudyogiki
Vishwavidyalaya (State Technological University of Madhya
Pradesh), Bhopal, 462 023, Madhya Pradesh, India
*Correspondence:
saprapbs@yahoo.co.in (P.K. Bharti).
https://doi.org/10.1016/j.pt.2020.11.002
© 2020 Elsevier Ltd. All rights reserved.
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