Maharashtra’s mass drug administration (MDA) program was remarkable in its adoption of best practices to drive the success of the program. Although the state faced many implementation challenges related to compliance, funding, and supply chain inconsistencies, Maharashtra took the necessary measures to address them, which other states can draw lessons from and adapt to their own context. In this section we look at challenges faced during the MDA program and how the state responded to them.
Funding for all MDA activities was covered under separate budget heads, but occasionally the program experienced a shortage of funds for communication and social mobilization activities. In such cases, the state raised funds through local practitioners, pharmacists, and Chikara funds granted by the Zilla Parishad CEO to supplement costs associated with printing materials, hiring vehicles to spread awareness in villages, and other activities. To further reduce costs, the state recruited nongovernmental organizations (NGOs), family physicians, local influencers, and distinguished social authorities within the community to spread awareness. For example, an NGO working on water conservation in Amravati worked toward spreading awareness about upcoming MDA rounds.
| Mr. Vivek was a student of mass communication. He engaged in various drama activities and street plays. One day, he came across a case of elephantiasis of a woman in his neighborhood. This hard-hitting truth pushed him to do something to help. Mr. Vivek began publishing pamphlets to raise community awareness on elephantiasis and the relevance of MDA. He also accompanied the drug administrators during drug distribution along with 50 students. Before the MDA rounds, he engaged with students during street plays and organized drawing competitions. The children were awarded with a certification signed by the district health officer and Mr. Vivek. His NGO also worked to generate community awareness and advocacy during the pulse polio immunization campaign. |
Surveillance activities—important for estimating microfilaria rates at sentinel and random sites and informing MDA decisions—frequently suffered from delays in the receipt of funds. When the teams experienced funding delays, they managed to reduce costs among themselves. For example, if funding for transportation was not available, teams paid for fuel expenses out of their own pockets and applied for reimbursement at a later time. Sometimes, visits to district-level offices were coordinated with surveillance activities and staff members coordinated travel with team members who owned vehicles to further reduce travel costs.
Additionally, there was a challenge in the disbursement of funds when two authorities—the district health officer and the Zilla Parishad CEO—had to provide their signatures in a short span of time. These authorities were often in the field, which posed challenges in fund disbursement and often resulted in delays. To address this challenge, funds can now be transferred through online banking. The impact of this solution has yet to be seen, however, because it was still unresolved during implementation.
Vendors delivered diethylcarbamazine (DEC) directly to all district stores, but delivery of albendazole was more complicated. From the National Vector Borne Disease Control Program (NVBDCP) headquarters in Delhi, the drugs moved to Mumbai and then to state headquarters of health services at Pune and finally to the district stores. The long, interdependent chain of procurement led to occasional delays in receipt of albendazole at the state level. In such cases the state government adjusted the dates for MDA, ensuring the changes did not affect implementation. Dates at the community level were communicated only after ensuring drug availability and a guaranteed buffer against stockouts. Timely stakeholder communication and agile responses to supply chain inconsistencies helped Maharashtra avoid delays in implementation.
Urban areas had their own unique set of challenges, with limited staffing, low community support, and low coverage due to people being unavailable at their homes during drug administration. Trained volunteers were brought in to help with the issue of limited staffing, but they had less technical knowledge than community health workers. This factor contributed to urban populations resisting participation in the MDA program. To address the unavailability of people at their homes during drug administration, which led to low coverage, the state filaria team aided the district team by performing an extended mop-up of five to six days in urban areas to ensure the required 65 percent coverage of the population. Such measures helped counter low drug compliance in urban areas.