Lessons from Bhutan: managing malaria in Assam

Rising concerns in Assam over malaria reveal a struggling state medical system, Deepanshu Mohan, Ayona Bhattacharjee, and Shivkrit Rai write.

Since 2016, every December, a group of research students from our university have been visiting certain areas of the north-eastern states bordering Bhutan and parts of Myanmar. The field visit pertains to a program focusing on development practices and challenges in border areas – more specifically on their local development plans concerning livelihood, healthcare, and education, as well as other community-led development initiatives.

Our recent visits and studies have highlighted a high incidence of malaria in certain parts of the state. This increase has impacted the implementation of affordable healthcare distribution in certain districts – particularly those close to the Indo-Bhutan Border.

Malaria has already been reported as a major health concern in Assam and other states in the north-eastern region of India. Though Assam has experienced an overall decline in the number of malaria cases, the reality in some areas remains critical.

A 2014 study highlighted the role of socio-economic factors in Assam exacerbating the transmission of malaria. Based on its findings and our own field observations, rural areas in parts of Assam – particularly closer to Bongaigaon, Modali, and Sidli – have remained worst affected by the disease.

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According to government reports, 15,557 and 7,826 cases of malaria were reported in Assam in 2015 and 2016 respectively. This places Assam next only to Andhra Pradesh and West Bengal. In 2017 alone, the state saw over 5,000 malaria cases. In comparison to earlier years these figures do reflect a decline in cases, but more than 40 per cent of the local population remains at high risk of contracting the disease.

The main reasons for the inability to address the rise of malaria are the lack of adequate medical infrastructure at primary and community levels, and the lack of political will to ensure consistent medical interventions and public awareness.

On a field visit to the health centres in the Chirang district of Assam, we observed that most dispensaries and community health centres (CHCs) were receiving a high number of patients with malaria fever. Many of the doctors at the centres spoke of inaction from state medical agencies in organising awareness-raising activities that warn people across villages to take precautionary measures.

An overwhelming number of local patients with related psychosis were also forced to go directly to CHCs and district hospitals (DHs) for diagnosis. Further, most schools have little or no information about how to educate children and parents on the problem. Local agencies are also greatly affected by the lack of medical infrastructure.

At sub-PHCs – facilities that often act as dispensaries to support primary health centres (PHCs) – local nurses and staff highlighted poor drainage systems across villages resulting in persistent water stagnation and clogging. A lack of government support for distribution LLINs (Long Lasting Insecticides Nets) for preventive care in these areas is also problematic.

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Another major problem is the physical distance between villages and most medical facilities. At the Deosri Forest Block area, close to the border, the long distance and lack of beds were causing high distress amongst local communities.

Further, most people living in these areas complained about the lack of medicine during monsoon season when the incidence of malaria peaks.

It is important to acknowledge how Bhutan, too, once battled a high incidence of malaria, especially in areas bordering Assam. In our visit to Gelephu – a town bordering Bhutan, even closer to Assam – we were informed of how the rise in malaria had affected local populations tremendously, lowering trade and market activity in monsoon months.

However, in the last couple of years, Bhutan’s medical system has not only reduced the incidence of malaria, but has also made conscious efforts to eradicate the disease from most affected areas. Bhutan’s proactive measures offer vital lessons for public health delivery in Assam and beyond.

Medical agencies across Assam have attempted to provide LLINs and indoor residual sprays, but have not been able to actively reach out to the entire vulnerable population. No additional steps are being taken to surveil malaria or spread awareness across local villages either.

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Indian law allows a lot more to be done – especially in Assam’s case.

Being one of the few Indian states with its own Healthcare Act since 2010, Assam offers residents a comparative advantage in claiming their rights to basic healthcare. With a rising need for healthcare services, its legislation enforces an obligation on state agencies to take measures against public health emergencies and epidemics. The fact that the state regards healthcare for all Assamese families as a fundamental right to be safeguarded also makes it more progressive.

Section 3 of the Act puts a two-fold obligation on the government: firstly, it must undertake budgetary measures as per the globally accepted norms, and secondly, it must not deny access to basic healthcare. Further, sub-sections also mandate education and access to information on issues related to methods of prevention and control by the government.

It seems only logical then to presume that legislation providing such extensive rights to citizens must also ensure the effective implementation of basic care at the grassroots level from the state. If claiming necessary affordable care for malaria-affected people remains a major legal hassle, as in parts of Assam, it is important to critically examine enforcement mechanisms and hold them accountable for their complacency or lack of capacity to enforce what is safeguarded by their own legislature.

Despite its limited economic capacity, the Bhutanese state continues to ensure improved access to more medical care for its people. Agencies across the border in Assam have much to learn.

This article is drawn out from field visits, as part of the Transboundary Policy Innovation Lab Programme, co-ordinated by Centre for New Economics Studies and Centre for Study of Political Violence, O.P. Jindal Global University.