Using Design to Solve India's Wicked Malaria Problem

One of India's earliest success in public health was against malaria. Malaria deaths were brought down to zero by the late 1960s. This was remarkable given that India was losing nearly a million people to malaria every year at the time of independence. Malaria cases too were brought down significantly. Fast forward to 2019. India, while much admired for its recent progress, still accounts for the largest malaria burden in Asia. It is the only non-African nation in the top 10 highest burden countries in the world. Meanwhile, India's neighbours have made impressive gains. Sri Lanka was certified as malaria free in 2016 and China has been at zero cases since 2017. Can India get there?

India has made a firm commitment that it will eliminate malaria by 2030 and launched the National Framework for Malaria Elimination 2016-30 in support. Implementation has matched that commitment. India managed to reduce malaria cases by 28 per cent and 24 per cent in 2018 and 2017 respectively. Malaria deaths too have fallen. It is then reasonable to expect that India will eliminate malaria by 2030. We have a second chance, and a very realistic one, to eliminate a disease we should have gotten rid of nearly fifty years ago.

Source: Firstpost

What is a 'wicked problem'?

There are many definitions of 'wicked problems'. A simple way to think about a wicked public policy problem is one that is very hard to solve and requires complex solutions. This is in contrast to a "tame" problem, which might be very hard but can eventually be solved by deploying relatively straightforward techniques given enough time and resources. Wicked problems have complex origins or roots, often shift as they are tackled, and generally require multiple stakeholders with (sometimes) divergent interests to come together and solve it. Conventional methods rarely work when solving wicked problems.

Writing for Deloitte Insights, William D. Eggers and Anna Muoio propose that "with problems as sprawling and complex as these, progress depends on having some capabilities that are themselves challenging to put in place. Problem-solvers need to be able to comprehend the dynamics of the system, coordinate their responses, and commit the necessary resources." This is very much true of malaria in India.

What is so wicked about India's malaria problem?

Lifestyle diseases, road traffic deaths, and TB get more attention than malaria in India. And, rightly so. Cardiovascular diseases, diarrhoea, chronic respiratory diseases, injuries, and cancers are now the leading causes of deaths in India. So, why the fuss about malaria especially when cases and deaths are going down with existing efforts?

Source: Times of India

We know that malaria bounces back if you are not careful. Complacency and reduced funding led to a resurgence in India in the 1970s. So, policymakers face a wicked choice. They can double down on malaria and eliminate it for good. Alternatively, they can refocus their attention towards other leading causes of death and morbidity. The first choice will benefit India in two ways. Once malaria is eliminated, India can redirect some of the resources being currently spent on malaria control efforts towards more pressing health needs. Also, it will enable India to avoid the economic losses due to malaria related morbidity and deaths. Going with the second choice however means risking another malaria resurgence, which will be very costly to contain. Malaria is truly a wicked problem for India.

• First, according to Sunil Dhiman, Vijay Veer and Vas Dev, "India is ecologically vast and has close to a billion-population living at risk of malaria." Almost all states are recording some malaria cases, malaria transmission is heterogeneous (with different types of mosquitoes), and 80% of malaria cases are reported by 20% of the population living in forest, tribal, border, and other hard-to-reach areas. The nature of malaria differs across states and even within states. Maharashtra's challenges are very different from those of Odisha. Even within Maharashtra, different approaches are needed for Mumbai and Gadchiroli. So, malaria is really hard to fight.
• Second, as a result of weak surveillance and non-reporting of malaria cases seen in the private sector, India’s malaria burden is significantly under-reported. We do not know the true burden of malaria. According to WHO's 2017 World Malaria Report, "countries with weak malaria surveillance systems include India, with only 8% of cases detected by the surveillance system."
• Third, drug resistance (drugs becoming less effective) has reportedly been found on India’s borders with Myanmar and some other parts of India. If resistance spreads, it may become harder to treat malaria in the future.
• Fourth, there is significant variation in the capacity to respond to malaria at sub-national levels. This is problematic. Malaria does not respect boundaries and imported malaria (from high-burden areas) is always a risk for areas that are able to control malaria.
• Fifth, malaria control and elimination strategies must change as the burden shifts. Constant upskilling of malaria program staff is also required. However, it is unclear if states are adequately prepared for the same.
• Sixth, there are many stakeholders involved in malaria control and elimination efforts in India including several ministries across central and state governments, research institutions, armed forces, NGOs, and the private sector.
• Seventh, operational constraints (e.g. ensuring availability of quality diagnostics and drugs, access to hard-to-reach areas) are constant challenges.

The value of 'Design' in tackling the wicked malaria problem

Writing for McKinsey & Company, Montana Cherney, Tania Holt, Tony Lee, and Sunny Sun define design (in the context of global health) as "an iterative and creative approach that can be used to shape global health products, services, and programs that meet the needs of users and other critical stakeholders."

Design approaches have a human-centered core and a strong focus on feasibility. IDEO, a global design company, says that "in employing design thinking, you’re pulling together what’s desirable from a human point of view with what is technologically feasible and economically viable." This is why design approaches can be effective in finding solutions for wicked problems that are not easy to solve with more conventional approaches.

As a first step, design approaches involve developing a better understanding of the needs and perspectives of all stakeholders involved and identify the problem clearly. These insights are then used to come up with new solutions and ideas. One or more of these maybe tested and subsequently discarded, improved upon, or implemented. The stages are often repeated till the right solution is found. It is important to note that often stakeholders develop a more nuanced understanding of the problem or solution during the testing stage. Thus, design approaches necessarily require that the stakeholders are willing to fail, adapt, and improve solutions or ideas over several iterations.

Design approaches can be used to improve both the malaria elimination strategy-making process at the central or state level and implementation at the ground level. This makes it a particularly handy tool for key decision-makers, from the political leadership in Delhi to state and local malaria program teams.

First, a design approach could help to develop a more comprehensive understanding of the needs, perspectives and challenges faced by the myriad stakeholders involved in malaria control and elimination. Efforts are already being made in India at the national level to bring together key stakeholders. The National Malaria Elimination Task Force created in 2016 and MERA India Alliance launched in 2019 are two such bodies. The Task Force, chaired by the Health Secretary (Ministry of Health & Family Welfare), includes representatives from relevant National Ministries, WHO, NGOs, Private Sector, Research Institutions, Academia, and Donors. The MERA India Alliance brings together researchers from across the country and is coordinated by the Indian Council of Medical Research (ICMR). While both are well intentioned multi-stakeholder initiatives, thinking consciously about a design approach will help them become more effective than traditional multi-stakeholder initiatives.

Second, a design approach will be useful at the local level in gaining insights into the malaria problem through two groups that are central in this fight - communities that constantly battle malaria and frontline health workers. A design approach will seek to engage them from the beginning to help identify the core problem and then identify solutions with their help. Conventional policy-making, research, and implementation processes unfortunately often fail to take their views into account and mostly assume that the problem is already well understood.

Tribal people who constitute less than 10% of India's population account for more than 50% of malaria deaths. Yet, they are rarely consulted when responses to malaria are determined. A design approach can help us to move from community engagement to community leadership by amplifying the voices of those who are often left out of decision-making processes. India's success against malaria would not have been possible without the efforts of frontline health workers such as the Accredited Social Health Activists (ASHAs). Their voices too are rarely heard in rooms where decisions are made. A design approach will encourage ownership by making groups such as tribal populations and ASHAs a part of the decision-making process. It will not limit them to being just beneficiaries or stakeholders who simply need to be sensitized or informed.

Source: Indian Express

Finally, a design approach is useful in developing a more accurate picture of malaria challenges. A number of biological, ecological, environment, and social factors need to be factored in when developing a response to malaria. These also change over time. One example is climate change. In Odisha, studies are showing that weather conditions favourable for mosquitoes to breed, bite and infect have extended to nearly half the year. Drug resistance is another example. Off-the-shelf and cookie-cutter strategies that are static in nature are therefore useless in tackling malaria. The iterative nature of design approaches makes them ideal for tracking malaria as it changes over time in a location.

India is well poised to eliminate malaria by 2030. Its recent track record demonstrates what can be achieved when political commitment is matched by a robust technical framework and rigorous implementation. It is also true however that the "low-hanging fruit" has already been plucked. Already, we see that states are finding it tough to cross the finish line. Punjab was expected to be one of the first states in India to eliminate malaria by 2020. The State Government, partnering with WHO, has even prepared a micro-strategic plan to get there. It is however quite unlikely that Punjab will reach the 2020 goal. In 2019, the state recorded the highest number of malaria cases over the previous five years. Odisha, the star performer, also saw a spike in cases in July-August 2019. While health workers blamed the officials, the latter blamed the people, for this setback. These examples demonstrate that India cannot take success against malaria for granted and that the fight will only get tougher. The only way we will win is by working together and adopting novel approaches that are more inclusive and dynamic.