Involvement of Mitanins (female health volunteers) in active malaria surveillance, determinants and challenges in tribal populated malaria endemic villages of Chhattisgarh, India

In the early 70’s, Government of India had first introduced the CHW Scheme in the country envisioning “provision of health services at the doorsteps of villager”. However, this scheme was changed over time from CHW in 1977 to Community Health Volunteer in 1980 and Village Health Guides (VHG) in 1981. In 2002, under the ambit of Family Welfare Program, VHG Scheme was completely supported and funded by central government.

To improve access to health care and the health status of rural communities in Chhattisgarh, the state government together with civic society conceptualized and implemented the community health workers (CHWs) programme in 2002. This program was the precursor of ASHA and key reference to developing ASHA program across India. In 2005, CHW programme was merged into National Health Mission (NHM). ASHA workers were then recognized as ‘Mitanin’ in the state which means ‘Female Friend’ in the local dialect. Currently, the state has engaged a total of 69,000 Mitanins. Mitanin Programme is implemented and monitored by Department of Health and Family Welfare, Government of Chhattisgarh in collaboration with State Health Resource Center (SHRC). SHRC is responsible for imparting training to Mitanins in implementing various health programs few of which are incentive based.

ASHA and Mitanin reside in close proximity to the beneficiary’s home, including services delivered at home or to the family and through outreach sessions. It is also expected that Mitanin can play an essential role in detecting problems at the earliest and help in improving overall community health status. In India, several studies have been conducted on various public health care programs related to maternal and child health such as immunization, Integrated Child Development Services, and Janani Suraksha Yojna (Safe Motherhood program) etc. [11‐14]. Limited information is available related to ASHA’s and Mitanins’ (Female health volunteers) perception, knowledge and work performance related to malaria.

Multi-country project collaborated by WHO on Implication of Insecticide Resistance (IIR) was carried out in Keshkal, one of the tribal populated sub-districts of Kondagaon district of Chhattisgarh, India aiming to assess impact of insecticide resistance in malaria vectors in presence of Long Lasting Insecticide treated Nets (LLIN) and Indoor Residual spray (IRS) intervention in controlling malaria transmission in malaria endemic area [15]. In this project, Mitanins’ were engaged to carry out surveillance in the selected households in the respective village. Mitanins working under IIR project were classified as ‘IIR Mitanins’. While rest of the Mitanins in the study area were categorized as ‘Non-IIR Mitanins’.

The current study was carried out with the following objectives:

The present study was carried out in 80 tribal populated villages of Chhattisgarh, India and 162 Mitanins were interviewed during October 2015 to February 2016. This study is a non-blinded randomized controlled trial (additional malaria training being the intervention), with a qualitative component in sub set of population.

Mitanins were recruited in two groups. The first group comprise of randomly selected 81 Mitanins (out of 124 Mitanins working under IIR project) with additional malaria training (training plus) and in second groups consist 81 Mitanins (were randomly selected from remaining 300 Non-IIR Mitanins) with routine training (standard). Second group Mitanins were age and villages matched with the group one Mitanins.

Performance of Mitanins was evaluated using pre-defined grading scores (9 point grades) which included various factors such as educational qualifications and knowledge about malaria, including its signs and symptoms and treatment. Nine points score based performance was then converted in to grades from A-E (Table 1).

Among all the study participants, purposefully those were selected who can best answer about the given research topic and enhance understanding about the challenges experienced by them. Total ten in-depth interviews (five candidates from each group) were conducted to explore the challenges and difficulties faced by the Mitanins. The topic of the interviews was “day to day challenges in Mitanins’ work”. All interviews were conducted in either Hindi and/or Chhattisgarhi (local dialect) by the trained investigators.

Table 4 illustrates the results of univariate and multivariate conditional logistic regression analysis. IIR group Mitanins performance were significantly better than non-IIR group after adjusting for socio-demographic determinants such as age, family type, marital status, literacy rate and prior work experience (p < 0.001).

In the analysis of In-depth interview, five major themes appeared and subsequently placed into framework analysis. It suggests that ‘lack of support from superior staff’, ‘delayed payments’, ‘lack of appreciation’, ‘less incentive’, and ‘intermittent medicine supply’ were major challenges for Mitanins which may affect their routine work (Table 5).

An accomplishment of the Mitanin programme largely relies on the individual Mitanin to support for and provide awareness related the meaning and necessity of healthy practices among serving the population. Minimum education level and representation of the local people are key selection criteria if we desire the Mitanin to retain and communicate information to their community members. However, our study showed that nearly 30% of the Mitanins did not have the basic educational qualification. This could affect the NHM program and criteria of basic education. There could be several plausible reasons such as non-availability of literate women in the study villages or reluctance by the young educated girls to join the Mitanin program. Similar findings were reported in a study by Shrivastava et al., 2012 [16]. As per the NHM-ASHA guidelines- 2005, [8] the age of the ASHA’s/Mitanins should be under 45 years. But in our study, we have observed that in some of the villages, age of the Mitanin was over 45 years. This could be a major reason for poor health care awareness in some of the area and may impact on the deliverables of government health care system in the study area.

Comparative evaluation of both the groups of Mitanins suggested that overall, group one Mitanins (IIR) performance was significantly better than the other group. Study findings imply the rationale of additional and focused training to improve the knowledge and practices related to malaria and surveillance work. Non-IIR group Mitanins can prepare slides as better as IIR Mitanins, but the knowledge about sign, symptoms, and treatment of malaria were significantly lower than the IIR group Mitanins. Apart from being IIR Mitanins, the literacy rate is a significant determinant in unadjusted analysis. This emphasizes the importance of education for female health volunteers for efficient learning and performing the given responsibility of health care of the society.

There are several key issues such as the financial incentive for community health workers contribute to improved motivation and performance [17]. A number of case studies have shown that regular CHWs are more likely to engage the society in grass-roots health-related issues than the well-trained, but unpaid volunteers [18]. In India, though a nationally prescribed incentive amount an ASHA/Mitanin receives for each activity exists, but varies between the states, and may be many do not actually receive these minimum incentives. Most of the respondents feel that the incentive amount did not meet their expectations. ‘Kabhi Kabhi hum man apan pass k paisa la dethanbimar man la aspatal le jai bar’ (Sometimes we give our own money to take the patients to the hospital) was the response by one of the Mitanin when asked how they bring patients to the hospitals during emergencies. In the year 2009, NHM Evaluation Report submitted by Bajpai et al. [19] suggested a minimal monthly salary in addition to the work incentives. However, to date, it has not been accepted. The report also argued that the financial incentive amount should be increased as it was not commensurate to the quantum of work being performed by the ASHA’s. Based on our findings, we can suggest revamping of financial incentive structure can be considered.

Secondly, many Mitanins asserted that cases referred by them get insufficient attention and they themselves receive insufficient support from the hospital staff which subsequently affects the credibility of their work among the community. Most of the Mitanins stated that they receive the intermittent medicine supply from the Govt. hospitals and is one of major barriers for routine work.

Current study was focused in one of the tribal populated malaria endemic state, Chhattisgarh in India. Results obtained from this study can be generalized but with a caution to other socio- geographic, − cultural and - demographic regions of the country.

These study findings are important for malaria control and elimination programs especially in the context of India that is going for elimination by the year 2030. This can be one of the components that needs immediate attention and also could be relevant to the countries which has similar situation for malaria control with respect to the operations and human resources for health care.

There are two major constraint of this study. First, as additional training is an intervention, blinding cannot possible from the participants as well as investigators. Secondly, Mitanins of both the groups usually reside in the same village and some time in proximity. Hence, there was chance of “contamination” of nonintervention arm? (i.e., Mitanins who were taught, might then teach Mitanins who were not.)