More Tests, Fewer Cases: Tracking India’s Fight Against Malaria

India’s decisive expansion of its malaria surveillance, the core intervention in its elimination strategy, is gradually reshaping the epidemiological profile of the disease. As India aims for zero indigenous cases by 2027 and complete elimination of the disease by 2030, there has been a sharp focus on diagnosis, treatment and prevention- all fundamental components of surveillance. The statistics now reflect this positive trend.

India first articulated its time-bound targets in the National Framework for Malaria Elimination (2016-2030), launched in February 2016. That year, the country conducted 124.9 million malaria tests, according to the data from the National Centre for Vector Borne Disease Control (NCVBDC). By 2024, the number of tests had risen to 181.6 million, a 45-percent rise compared to 2016. Despite this expanded detection, positive cases declined by 76 percent, from 1,085,823 in 2016 to 255,500 in 2024. The Test Positivity Rate (TPR) dropped from 0.87 percent to 0.14 percent, while deaths fell sharply by 74 percent, from 331 to 86. The COVID-19 pandemic disrupted this progress, with testing plummeting to 97.2 million in 2020. However, the malaria programme recovered quickly, and by 2022, testing surpassed the pre-pandemic levels (Table 1).

Table 1: Trends in Malaria Testing and Cases in India (2016–2024)

Source: NCVBDC

Despite encouraging trends, India’s malaria-free ambition appears challenging. Although case numbers have dropped, the overall annual caseload is still substantial (Graph 1). Underreporting from the private sector continues to mask the true burden of the disease. Malaria also remains concentrated in a few hard-to-reach districts, while high population density and migration across regions complicate surveillance and control. Other risks include a rapidly changing urban landscape and climatic conditions that favour mosquito proliferation and parasite survival. Unless these structural weak points are addressed, India will remain vulnerable to resurgence and outbreaks, undermining the elimination goals.

Source: NCVBDC

Historical Perspective

Historically, malaria was one of the biggest public health crises. Under the British Raj, nearly 1-2 million died annually in the early 20^th century. Following India’s independence, 75 million people were reportedly infected, and 800,000 died, making malaria a barrier to economic development and nation-building.

The National Malaria Control Programme (NMCP), launched in 1953, later expanded into the eradication programme, and relied heavily on dichlorodiphenyltrichloroethane (DDT) spraying. Over time, policy shifts (Table 2) focused efforts from ‘control’ to ‘elimination’. However, challenges such as insecticide resistance, irregular DDT supply, and a rural bias in strategy triggered several outbreaks through the 1980s. By 1995, cases had fallen to 2.93 million with 1,151 deaths- far fewer than at independence, but still a heavy burden.

Table 2: Anti-Malaria Policies in India

Hidden Burden of Malaria in India

In 2018, the World Health Organization (WHO) launched the High Burden to High Impact (HBHI) initiative to target high-burden settings with tailored strategies. India was included along with 10 sub-Saharan African countries, as together they accounted for 70 percent of the global malaria burden in 2017.

Under HBHI, India focused on high-burden districts in states like Odisha, Jharkhand, Chhattisgarh, and West Bengal with increased distribution of mosquito nets treated with long-lasting insecticides (LLINs), indoor residual spraying (IRS) of insecticides on inner walls and ceilings of homes, tracking every malaria case and other mosquito control activities. By 2023, over 120 districts reported zero malaria cases, and India left the WHO’s HBHI group in 2024.

Despite progress,  malaria in India remains underreported. The World Malaria Report (WMR) estimated 6.4 million cases in 2017 and 2 million in 2023, compared to official figures of 0.84 million and 0.22 million. While the gap between WMR, which uses mathematical modelling to estimate cases and deaths, and national data has narrowed, it remains substantial, indicating persistent underreporting. Deaths show similar gaps, with WMR estimating 11,100 malaria deaths in 2017 and 3,500 in 2023, against national data of 194 and 83.

India’s malaria data gap stems largely from the absence of private sector reporting, where 70 percent of Indians seek treatment. While malaria is notifiable in 34 states and reporting is shifting to real-time digital platforms, the epidemiological picture remains incomplete.

The latest National Strategic Plan calls for mandatory private sector reporting, standardised data collection tools and training, but implementation remains limited on the ground.

Lessons for Elimination

India could draw lessons from Sri Lanka, which achieved malaria elimination in 2016, with strong private sector involvement and restricting anti-malarial drugs only through the national programme from the 1990s. The Sri Lankan government also attempted something unusual by coordinating with the Liberation Tamil Tigers of Elam (LTTE) on anti-malaria activities, despite the ongoing conflict. While there was no official agreement, the LTTE assured support to regional malaria officers to enter conflict zones to provide treatment, spray insecticides, distribute mosquito nets, and operate mobile units. Such interventions could be useful for combatting malaria in India’s conflict-affected regions like Chhattisgarh, which continues to have a high burden of the disease.

The Sri Lankan government also attempted something unusual by coordinating with the Liberation Tamil Tigers of Elam (LTTE) on anti-malaria activities, despite the ongoing conflict.

While Sri Lanka’s population is smaller than India’s, the country’s indoor use of DDT, case confirmation within 24 hours, and a non-complacent reactive case detection system that screened household members and neighbours of confirmed cases offer important pointers. Sustained funding from the Global Fund since the early 2000s has given crucial momentum to Sri Lanka’s malaria elimination efforts. Reactive case detection remains central to its prevention of the reestablishment phase, especially as incoming populations from neighbouring South Asian countries continue to pose a risk.

China, with a population size comparable to India, eliminated malaria in 2021. Its ‘1-3-7 approach’ has been a game changer in malaria surveillance. The country, with a top-down management style, started real-time, web-based malaria reporting in 2004, and mandated reporting within one day, confirmation and investigation in three days, and response in surrounding areas (foci) within seven days.

India’s subnational approach targeting malaria-free status at district and state levels requires similar prevention of re-establishment strategies, including cross-border surveillance, monitoring of migrants and travellers, intensive reactive case detection, drawing lessons from malaria-free countries like Sri Lanka and China.

Challenges and Way Forward

Malaria control in India is complicated by several factors, starting with the nine different species of the Anopheles mosquito, each with diverse breeding, feeding, and survival patterns. Among them, Anopheles stephensi has emerged as a key urban vector, and as cities expand and construction activity increases, it poses greater challenges. The types of parasites also play a role. Among five human-infecting parasites, Plasmodium falciparum (Pf) and Plasmodium vivax dominate, with P. falciparum responsible for 60 percent of cases and most malaria deaths (Graph 2).

Source: NCVBDC

The most effective treatment for P. falciparum is Artemisinin-based Combination Therapy (ACT), while P. vivax is treated with chloroquine, but drug resistance is a challenge. Over 80 percent of the funding for India’s malaria programme is domestic. The Global Fund has played an important role in funding bed nets, but as it transitions out, India faces greater responsibility to ensure sustained and increased funding. For instance, Odisha, which accounted for the highest case load in 2024, with 68,693 cases and 8 deaths, has struggled with shortages of LLINs despite a resurgence in cases since 2023. While there have been calls to make LLINs available through the private market, India needs to sustain government support and build on private alliances to accelerate malaria elimination.

Over 80 percent of the funding for India’s malaria programme is domestic.

Beyond policies and strengthening health systems, the Malaria Mukt Bharat dream also hinges on people’s participation and awareness. Encouraging behaviour change—prompt treatment seeking, protective clothing, identifying and eliminating breeding sites—is crucial, along with building malaria literacy among school children, women’s groups, and local leaders.

India has come a long way; however, elimination will not happen on momentum alone. India needs sustained funding, innovation, strong health systems and community engagement to turn this challenge into a public health victory.

Jyoti Shelar is an independent researcher, writer, and health journalist.

• Healthcare
• India
• malaria cases in india
• malaria control in india
• malaria elimination programme
• malaria free india
• malaria in india
• malaria testing in india
• national framework for malaria elimination

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