Maharashtra’s continuation of the National Filaria Control Program (NFCP) and its effective implementation of the Elimination of Lymphatic Filariasis (ELF) program reflects the state’s strong aspiration toward eliminating the disease. Over the last 15 years, Maharashtra successfully launched and implemented the ELF program, which enabled 11 of 17 endemic implementation units (IUs), to reach various stages of clearing the transmission assessment surveys after mass drug administration (MDA).
Five key strategies enabled Maharashtra to achieve and sustain its remarkable outcomes: (1) adherence to national guidelines with local adaptations, (2) collaboration among departments and stakeholders, (3) effective leadership and human resource management, (4) local influencers and social mobilization campaigns, and (5) learnings from previous public health interventions. In this section we explore each strategy in detail.
“A good management introduces seriousness into the program, then the people down the line from district to taluk, to PHC to sub–center to village everybody will take it seriously. If you have very good leadership, you will be able to motivate the people down the line at different levels”.
- Dr. K. D. Ramaiah, LF Expert & Ex-Scientist E, Vector Control Research Centre (ICMR) (Puducherry)
The National Vector Borne Disease Control Program (NVBDCP), the governing body for ELF, is responsible for framing and disseminating guidelines for ELF implementation across all states in India. The guidelines are based on extensive research and observation of LF interventions within and outside of India, and they incorporate practices and processes designed for effective program implementation.
Maharashtra’s strict adherence to the national guidelines, along with adaptations to the local context, enabled smooth implementation of MDA. Maharashtra communicated the guidelines effectively across all levels of implementation, which ensured understanding of the guidelines and greater compliance. NVBDCP officers and consultants trained the assistant director of health services, district malaria officer, and Taluka (block-level) health officer on national guidelines at least one month before MDA. Maharashtra also translated the guidelines in the local languages (Marathi and Urdu) and distributed them across districts, blocks, and health care facilities.
Maharashtra closely followed supervised drug administration, a key practice in the guidelines. Most states implementing ELF reported that drug administrators distributed drugs to the families for self-consumption, especially when the community member was not available during the visits by drug administrators. While this ensured MDA coverage, there was no guarantee or measure of compliance.
| To ensure high compliance, drug administrators in Wardha and Amravati ensured that every member of the community consumed the drugs in their presence. They marked all houses visited with the number of people who consumed drugs and the total number of eligible people, which allowed them to monitor which houses had been left out and needed to be revisited in the evening or the following day. This practice was initially adopted in Maharashtra and later included in the national guidelines. If community members had not yet eaten, the drug administrators returned to administer the drugs after they had eaten. |
Maharashtra not only effectively distributed and closely followed existing guidelines, but the state was also prompt in adopting changes introduced over time. For example, in 2008, NVBDCP’s national guidelines were changed to introduce new staffing protocols for the post of the Taluka health officer. Maharashtra exhibited agility in the adaptation of these guidelines and appointed Taluka health officers that same year. This helped Maharashtra streamline its training and capacity-strengthening efforts for the staff members at block and PHC levels. Previously, training sessions across all levels required staff members to travel to the state or district headquarters, which was a logistical challenge. With the introduction of the Taluka health officer post, training at the block and PHC levels was decentralized and conducted at their respective locations, which reduced the time and cost of training efforts, as intended by the national guidelines.
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All drug administrators reported supervising drug consumption and ensured none of the eligible population was left out. One of the community health workers mentioned that because she lived in the neighborhood where she was required to distribute the drugs, she knew the routine of the family members. She revisited the homes where she was unable to distribute drugs in a single visit. |
Stakeholder involvement and collaboration is key to the success of any national program as it ensures that all members are directing their efforts toward the realization of a common end goal—in this case, the elimination of LF. While the adoption of national guidelines set up Maharashtra for success, the effectiveness of the program depended on how well the IUs collaborated and implemented the program according to the guidelines.
In Maharashtra, collaboration between government departments and the community ensured that planning maintained a local perspective, enabled agility in implementation, and ensured support and acceptance from the community. This in turn paved the way for operational excellence of the MDA program and responsive stakeholder actions at all levels.
Collaboration across departments enabled each stakeholder to voice their opinions and contribute to planning efforts. Multi-stakeholder coordination committees set up by the state were responsible for charting the course of MDA implementation and played an important role in enabling collaboration across departments for planning purposes. These committees held regular meetings that were attended by the ELF program team, along with members of various other government departments and local bodies such as the public health Department, Zilla Parishad, Panchayati Raj Institutions, education department, Ministry of Women and Child Development, Municipal Corporation, police department, irrigation department, forest department, universities, and nongovernmental organizations (NGOs).
| The ELF program staff worked closely with multi-stakeholder committee members to drive key decisions on resources allocation, communications, social mobilization, and management of activities planned for the program. This helped ensure all voices relevant to MDA implementation were taken into account, and planning maintained a local perspective. |
Maharashtra’s planning efforts for staffing and funding reflected many instances of collaboration between stakeholders. Staffing and training needs were estimated in these meetings by the district collector, Zilla Parishad CEO, and district health officer. These stakeholders worked closely to draw up the microplan and ensure accurate staff estimation, supplementary recruitment, and additional resources when necessary. If additional staff members were needed, stakeholders such as the Zilla Parishad CEO and representatives of the education department stepped in. The Zilla Parishad CEO pledged the support of the Anganwadi workers to help implement the program. School teachers and representatives of the education department also supported the program by planning school-level activities to drive positive student perceptions and improve uptake of MDA.
Even when fund requirements were not met according to the plan, other stakeholders in the state helped mobilize resources. For example, in Wardha the Zilla Parishad CEO secured funding from the Zilla Parishad funds to supplement budget shortfalls for communication and social mobilization activities, meetings, and honoraria.
Effective planning and stakeholder engagement enabled agility in implementation. Planning efforts of the coordination committees would have been futile if implementation of the program remained weak. However, the teams in Amravati and Wardha adopted effective internal collaboration, stakeholder engagement, and agile responses to mitigate any challenges faced in the implementation of MDA.
The effectiveness of Maharashtra’s communication and collaboration was reflected in its management of delays in drug delivery. The long supply chain for albendazole occasionally caused delays in the receipt of the drugs at the block level. In some instances, the dates for the MDA program had to be changed to accommodate these delays and the state government adjusted the dates for MDA while ensuring the changes did not affect implementation on the ground. Dates at the community level were communicated only after ensuring drug availability and a guaranteed buffer to prevent stockouts.
Similarly, the state worked closely with local stakeholders to mitigate any challenges surrounding drug storage. District-level officials stored both diethylcarbamazine (DEC) and albendazole, along with any buffer stock and unused drugs recovered after MDA in the local district or block-level stores. If local stores lacked storage space, the team collaborated with the offices of the local Zilla Parishad and district health officer to secure additional space.
Stakeholder collaboration was most critical during the drug administration phase. The district malaria officer and medical officer worked closely with staff members on the ground to respond to changing needs of the community and program and to take swift actions based on emergencies identified. For example, when coverage was less than adequate or staff members faced difficulties, the district malaria officer or the district health officer, together with the supervisors, would visit the area and counsel the community. Such collaborative efforts helped in solve the challenges and improve the implementation of the MDA round.
Collaboration with Community Stakeholders Ensured Their Support for Implementation
Community members were often hesitant to consume drugs because they were afraid of potential side effects or did not see value in taking medication in the absence of a visible sickness. These fears restricted their compliance with the MDA campaign. Maharashtra worked closely with key community stakeholders to overcome these challenges and ensure smooth implementation. A critical strategy was the swift response to adverse events. Rapid Response Teams were mobilized whenever serious adverse events were reported, ensuring the necessary medical treatment was provided, including admission to the hospital.
| At the community level, district filaria teams engaged with trusted community members to build credibility. The team worked with Panchayati Raj Institution members to disseminate information and spread awareness about the importance of the MDA program and drug consumption. The filaria teams also engaged the support of Panchayati Raj Institution members to alleviate any fears from community members about the side effects of drugs. |
Maharashtra leveraged community health workers (CHWs)—key stakeholders on matters related to health—to engage with the community for counseling. The filaria team also worked closely with the media and sensitized them through workshops on the temporary side effects of drugs to ensure that press coverage did not induce fear among community members.
Key stakeholders such as the district malaria officer, district collector, district health officer, and Zilla Parishad CEO all went above and beyond their predefined duties to ensure the success of the program. The district malaria officers were responsible for anchoring and supervising the filaria program at the district level and providing the requisite technical expertise for key MDA activities. In Wardha, the district malaria officer had the longest serving tenure from 2011 to 2015, during which Wardha cleared transmission assessment survey. In Amravati, the longest serving district malaria officer stayed from 2006 to 2011, which accounted for nearly half of the ten-year MDA campaign implemented by the state, and therefore both IUs were able to benefit from the strong institutional knowledge developed by the district malaria officers during this time. With repeated rounds of MDA and a greater understanding of the local context, district malaria officers were able to anticipate challenges such as community apprehension around drug consumption, areas requiring additional mop-up days, and the need for additional human resources in urban areas. They could mitigate challenges by proactively planning and executing critical steps of the campaign.
The district collector and the district health officer played important roles in ensuring community support through proactive measures. They were present at the inauguration ceremonies of each MDA round across the district, block, and PHC levels. They emphasized the importance of MDA and strengthened community confidence, as they consumed MDA drugs themselves to allay fears among community members.
The leadership also demonstrated flexible solutions when faced with staffing challenges during the MDA. For example, in the case of staffing gaps in Wardha and Amravati, the Zilla Parishad CEO employed Anganwadi workers as drug administrators in rural areas. Both IUs also mobilized college students and volunteers to fill staffing shortages in urban areas. In Wardha, the medical college supported the program indirectly through its community outreach program. The agility displayed by the leadership in supplementing staff members helped the Ius avoid disruptions in implementation.
The leadership also ensured the provision of differentiated role-based training at the district, block, and PHC levels to enable and motivate actors to effectively carry out duties. For example, paramedical staff and drug administrators also learned consumer-facing skills such as communication, management of side effects, rapid response, and supervision of drug administration.
| The leadership in Maharashtra adopted on-the-job training for field staff to prepare them for various scenarios. Health assistants accompanied the staff in communities during surveillance activities for NFCP field visits and MDA implementation, assisting them in identifying field-related challenges and gaining a clearer picture of the work. |
The outcome of any public health program depends on the response of the people. Maharashtra’s experience in mobilizing and engaging the community demonstrates the value of a robust communication and social mobilization strategy. Maharashtra not only adhered to the national guidelines but also customized local communication efforts for social mobilization. The state leveraged local influencers and multiplatform awareness campaigns to address community fears on the side effects of drugs and increase acceptance of MDA. Maharashtra rolled out the awareness campaign in three stages—communication and social mobilization activities were rolled out 30 days, 15 days, and 1 day before the MDA campaign, intensifying as it approached to ensure that communities were informed as close to the start of the MDA campaign as possible.
Communication materials and channels were tailored to ensure a wide reach. All posters, handbills, billboards, and ads were translated to Marathi, Urdu, and the local tribal dialects in areas such as Chilkahrada to ensure wide reach and adoption. Posters, billboards, and flash cards had visual elements for people who could not read (e.g., the flash cards carried by drug administrators had images of individuals affected with lymphedema to ensure that community members consumed the prescribed drugs). Announcements and advertisements about the MDA campaign ran on the local newspapers, radio, television, and movie theaters to attract people from all backgrounds. Counseling was also made available through meetings with family doctors and physicians. This multifaceted media strategy ensured increased awareness about LF and MDA in the community.
| CHWs were instrumental in Maharashtra’s social mobilization strategy. They leveraged their goodwill to counsel the community about MDA, and they adopted multiple approaches to engage and build credibility in the community. For example, they transformed cultural events including Dwandi, Haldi Kumkum, and Dohale Jevan into discussion forums, organized rallies and street plays, and circulated key messages about MDA through village-level programs such as Village Health and Nutrition Days. In Amravati, CHWs even organized a angoli competition depicting the life cycle of the parasite and the symptoms of LF. CHWs also conducted door-to-door reminder visits right before the MDA campaign, which ensured maximum participation. |
Social mobilization activities leveraged local influencers, the press, and community-based organizations to address community fears about the safety and side effects of drugs and for supplementing funds. Maharashtra engaged political leaders such as members of Panchayati Raj Institutions, religious leaders, district-level authorities such as the district collector, district malaria officer, district health officer, family physicians, and school teachers to further expand their reach through trusted individuals and to maximize the adoption of MDA. Family physicians counseled patients on LF and the importance of the MDA campaign. In Amravati, schools conducted essay competitions to make students aware of MDA. District officials such as the district collector, district health officer, and district malaria officer inaugurated the ELF program by consuming the drugs themselves to assure the community it was safe. These champions or influencers at district, community, and individual levels ensured comprehensive sensitization. Community-based organizations also distributed information and helped provide staffing and monitoring.
Both IUs had specific strategies to ensure communication and social mobilization activities were adequately funded. In Amravati, additional funds were raised through local practitioners, pharmacists, and rotary funds for social mobilization activities. Wardha mobilized additional funds through the Zilla Parishad.
Apart from ensuring that the various activities in the MDA process were implemented in the best possible manner, Maharashtra incorporated learnings, assets, and resources from preceding public health interventions to reinforce the ELF program, which improved efficiencies in cost, time, and staffing and avoided repeating past mistakes in program implementation.
Although NFCP was discontinued across India in 1960, Maharashtra continued to implement it and maintained NFCP staff members and activities under the state budget. Information about the effectiveness and performance of NFCP as a stand-alone program was not evaluated, but the program had a key role supporting ELF implementation. Maharashtra leveraged the knowledge, human resources, and surveillance efforts maintained under NFCP. The state’s reliance on NFCP was observed in critical aspects of ELF implementation such as staffing, door-to-door drug administration, vector management, and technical support by laboratory technicians.
| Staff members maintained under NFCP proved to be a great asset throughout the implementation of the ELF program. Amravati leveraged these staff members to address human resource shortages during the MDA program, especially for door-to-door drug administration. In Wardha health assistants, who were part of NFCP’s administrative structure, were trained to carry out door-to-door supervision in coordination with the MDA teams. Laboratory technicians under NFCP also provided additional capacity for blood slide diagnosis and vector-control activities. |
Maharashtra used input from NFCP’s vector management and monitoring activities to assess the IU microfilaria rate to indicate the success of MDA programs. NFCP staff conducted field surveys to identify pockets of high endemicity and addressed them through the introduction of night clinics. Staff at these clinics notified hospitals and doctors about new cases and provided treatment with DEC tablets. NFCP field workers and laboratory technicians also conducted microfilaria surveys in four sentinel and four random sites in each IU to track the microfilaria rate to determine whether it was eligible to perform a transmission assessment survey. Sentinel sites were selected based on the number of lymphedema cases reported in a tracking database, whereas random sites were chosen without consideration of the presence of clinical cases from the study locations.
Other health programs implemented by the state for malaria and polio also informed and enabled ELF in Maharashtra. Integrated vector management activities, though important in the ELF program, were funded entirely through the malaria program and brought additional cost efficiencies. These activities enhanced the technical knowledge of ELF staff members as an added bonus. The state mitigated any lack of trust on the safety of the drugs among communities, as observed in previous health interventions such as polio, by working with organizations trusted by the community. Maharashtra worked closely with community-based organizations to extend their reach and ensure community support. In Wardha, the ELF program team partnered with a medical college to support community-level activities in urban settings to increase adoption of MDA. In Amravati, program staff members raised funds to supplement outreach for communication and social mobilization activities, which ensured high adoption of the program within the communities.