Implementation Fidelity of Accredited Social Health Activist (ASHA) Workers in Malaria Case Management in a High-Burden District of North India

Background Strengthening the fidelity of community-based fever case management remains pivotal to reducing malaria morbidity and achieving India's goal of malaria elimination by 2030. Objective To assess the implementation fidelity of accredited social health activist (ASHA) workers in malaria case management, including diagnosis, treatment, and follow-up, in a high-burden district of North India. Methods A community-based cross-sectional study was conducted from May to September 2019 in the catchment area of PHC Ujina, Nuh, Haryana, India. Using multi-stage random sampling, 440 mothers of under-five children and 30 ASHAs were interviewed with pre-tested tools. Implementation fidelity was assessed across four WHO-aligned domains: reach, treatment initiation, treatment completion, and follow-up. Data were analyzed in Epi Info™ version 7.2.2.16 (Centers for Disease Control and Prevention, Atlanta, USA), with programme benchmarks tested using Z and exact binomial tests. Results Half of the under-five children (222/440, 50.5%) experienced fever in the preceding month. Among them, only four (1.8%) mothers sought care first from ASHAs, significantly below the benchmark of 80% (p < 0.05). Malaria testing was delayed in most cases; only nine children (4.0%) were tested within 24 hours of fever onset. Among malaria-positive cases (n = 8), ASHA fidelity was high: treatment initiation and completion were achieved in all cases (100%), and follow-up was conducted in seven children (87.5%). While maternal knowledge of transmission was high (92.1% identified mosquito bites), three-fourths (73.6%) still preferred informal providers such as Hakims and traditional healers for fever management. Conclusion ASHAs demonstrated strong adherence to malaria case management protocols, but remain underutilized as the first point of care. Strengthening community engagement, ensuring rapid diagnostic access, and enhancing supportive supervision are critical to improving ASHA reach and accelerating India's malaria elimination agenda.