Maharashtra and other states throughout India launched the first National Filaria Control Program (NFCP) in 1955. Most other states discontinued the program in 1960, but Maharashtra continued implementing it under the state health budget. In 2004, as part of India’s revitalization of its commitment to eliminate LF, the country designed the Elimination of Lymphatic Filariasis (ELF) program and launched it in all endemic states with funding from the National Health Mission. Maharashtra started the implementation of the ELF, while continuing with the efforts of the previous program, the NFCP. The activities undertaken by both NFCP and ELF created synergies across both programs that contributed to Maharashtra’s success toward eliminating lymphatic filariasis (LF).
Figure 1. Comparison between the National Filaria Control Program and the Elimination of Lymphatic Filariasis Program
Launched in 1955 with the objective of undertaking control measures in endemic areas, NFCP has continued to be an important component of Maharashtra’s LF response to date. These control measures, carried out through survey units, control units, and night clinics, included mass diethylcarbamazine (DEC) administration, antilarval measures in urban areas, and indoor residual spraying in rural areas. Maharashtra benefited from control measures such as studying the endemicity across its implementation units (IUs), identifying hotspots, identifying cases and treating them at hospitals, and conducting vector management activities like spraying insecticides and clearing stagnant water. Findings from NFCP informed Maharashtra on the progress of the ELF program and provided significant input to assess district endemicity.
Launched in 2004, the ELF program aimed to accelerate the path to LF elimination through two main pillars: preventive chemotherapy via mass drug administration (MDA) and alleviation of chronic illness through morbidity management and disability prevention (MMDP). While MDA focuses on interrupting community transmission through supervised administration of drugs, MMDP focuses on alleviating the suffering of affected populations through surgery and home-based treatment. In this section we describe key activities that Maharashtra undertook as part of MDA.
Until 2010, Maharashtra used a single-drug therapy with DEC as part of MDA. Over time, the double-drug therapy of DEC and albendazole proved to be more effective in eliminating LF and therefore the IUs adopted it. In 2018, the state introduced triple-drug therapy using ivermectin, DEC, and albendazole, the impact of which has yet to be documented.
Key Stakeholders in the ELF Program
Since 2004, Maharashtra has conducted MDA through collaboration with multiple stakeholders at the national, state, division, district, block, and community levels, as represented in Figures 2 and 3.
Figure 2. Stakeholders at Central, State, Division, District, Block and Community levels
The state and IUs established clear roles and responsibilities for each stakeholder to ensure the implementation of MDA as planned, as shown in Figure 3. The sections below describe the key steps that these stakeholders implemented throughout the MDA campaign cycle.
Figure 3. Roles and responsibilities of stakeholders
Mass Drug Administration Program Overview
MDA is a six-step process with activities that fall broadly in three stages:
- Pre-MDA—planning, drug procurement, training, and social mobilization. Preparation for the actual MDA campaign and the most critical stage for building momentum across stakeholders to ensure successful program implementation.
- MDA administration—drug administration, the annual administration of drugs to the entire population as well as the supervision and reporting of drug administration.
- Post-MDA—monitoring and evaluation after MDA surveys and reporting to the state along with along with third-party MDA assessments for tracking drug coverage and addressing gaps of the campaign.
Figure 4: Drug and staff estimates calculated at a PHC level were used to inform state and district level planning and ensure smooth MDA implementation
Pre-MDA Activities
Planning was the first activity of the MDA cycle and was important to ensure that all resources were properly estimated and procured. This stage laid the groundwork for an effective MDA program (Figure 5).
Figure 5: The planning phase laid the groundwork for an effective MDA program
The planning began six to eight months before the MDA rounds. Planning started at the block level where medical officers estimated requirements and created a block action plan based on funding and drug estimates from the previous year’s MDA. They then submitted the block action plan to the district where input across blocks was consolidated into a district action plan. The district action plan was subsequently submitted to the state where it was consolidated and incorporated into the state’s Program Implementation Plan. The executive committee of the State Health Society made the state’s Program Implementation Plan and the state government or governing board approved it. The plan outlined the strategies to be deployed, budgetary requirements, and health outcomes.
The National Health Mission then disbursed the state funds in April or May, based on the Program Implementation Plan, and the money for the ELF program was appropriated based on the estimates shared. The central government also initiated drug procurement based on the estimates shared in the plan.
Closer to the MDA rounds, Maharashtra set up coordination committees at all levels of implementation, including the State Task Force, the State Technical Advisory Committee, and the District Coordination Committees, chaired by the State’s Minister of Public Health and Family Welfare, the Director General of Health Services, and the district collector, respectively.
District coordination committees were established typically 30 to 45 days before the program began. To ensure the effectiveness of district coordination committee meetings, the state first set up a divisional meeting to brief key district officials—such as the district health officer, civil surgeon, and medical officer—on MDA dates, activities, and monitoring measures as communicated by the central committee of the Ministry of Health. Key stakeholders attended subsequent district coordination committee meetings. Key stakeholders included the district malaria officer, district account manager, Zilla Parishad (district council) CEO, members of Panchayati Raj Institutions (a system of local rural self-government), education officers, Ministry of Women and Child Development CEO, nongovernmental organization representatives, civil society, members of municipal corporations (local governing bodies), superintendent and commissioner of police, chief irrigation engineer, chief engineer, forest officer, head of other departments, zoologist, university heads, and local bodies.
The ELF guidelines recommend three district coordination committee meetings in each IU. In Maharashtra, the city of Amravati organized two district coordination committee meetings and Wardha organized three meetings. During the first meeting, held 30 to 45 days before the program began, participants were informed about the purpose of MDA and asked to ensure that the teams they were responsible for participated fully in the program. The second meeting was held roughly 15 days before MDA implementation and the third district coordination committee meeting was conducted after implementation to review operations and strategize how to mitigate or resolve any challenges.
The district coordination committee reviewed and finalized a microplan, which documents information on the district’s demographic, human resource and training, communications, and social mobilization activities and estimates staffing, funding, and drugs required. The microplan is drawn up to document changes in requirements since the previous MDA and to ensure accuracy of implementation. Maharashtra, in accordance with the national guidelines, used a bottom-up approach to draft the plan, with the blocks preparing population and infrastructure estimates based on data from annual family surveys. The finalized microplan was ready at the primary health centers (PHCs) 30 days before MDA implementation.
Drug procurement and distribution: The state began procurement of drugs according to the Program Implementation Plan estimates based on the previous year’s requirements including an additional 10 percent for buffer stock. Closer to MDA implementation, the medical officers and health assistants at PHCs calculated drug requirements and included the details in the microplan, which was used as the basis for distributing drugs procured by the state.
Staffing: At the PHC level, medical officers and health assistants determined the number of workers that were required for door-to-door drug distribution or the number of booths to be established based on the size of the population to be served. The person-days were estimated based on the assumption that one health worker would cover about 50 families during the MDA rounds. At the district level, the district malaria officer submitted the plan to the state.
Funding: Based on the Program Implementation Plan, the National Health Mission distributed funding to the State Health Society, which passed it on to the districts. At the district level, the district health officer, district malaria officer, and Zilla Parishad CEO were co-signatories for fund distribution. On the approval of two signatory authorities, the district account manager transferred the funds to the blocks where the Taluka (block-level) health officer was in charge of fund distribution. From the Taluka health officer, the block account manager channeled the money to the medical officers at the PHCs.
Figure 6: Distribution of funding for MDA campaign
Maharashtra undertook drug procurement activities after the National Vector Borne Disease Control Program (NVBDCP) approved the Program Implementation Plan, in accordance with the previous year’s estimates. These drugs were typically distributed to the Government Medical Store Depots, 120 days in advance of MDA. The NVBDCP established the price for these drugs centrally, but the procurement of DEC was decentralized—states were responsible for procurement and suppliers were directed to deliver the drugs directly to the district consignees. Albendazole was donated by WHO and was therefore distributed via the NVBDCP to the states.
Drug distribution and storage processes had to be kept flexible to accommodate potential delays, especially in the case of albendazole.
Drug distribution: In Maharashtra, the state procured DEC and delivered it directly to the district consignees. WHO donated albendazole, however, which resulted in a longer and more complex supply chain. WHO delivered albendazole to the NVBDCP headquarters in Delhi, and then they were delivered to Mumbai. The state then transferred the albendazole drugs to the state headquarters of health services at Pune and ultimately to the respective IUs. The procurement of albendazole involved multiple stakeholders, resulting in an extensive process for approvals and procurement that in some cases could have resulted in delays (refer to the section on challenges).
Figure 7: Drug procurement and distribution process in Maharashtra
Drug storage: Blocks received the drugs, along with the additional 10 percent buffer stock, usually 8 to 15 days before MDA implementation. The buffer stock and unused drugs were stored in district stores, which were used in MDA rounds of subsequent years. PHCs received the drugs three to four days before MDA implementation. At the PHC level, drugs were stored at PHC stores.
The NVBDCP provided role-based training to stakeholders for planning, implementation, communication, administration, and response across the three levels: district, block, and PHC (Figure 8).
NVBDCP consultants conducted the training for state-level leadership staff members such as the assistant director of health services, district malaria officer, and Taluka health officer one month before MDA implementation. These officials were trained on technical and programmatic aspects of MDA such as microplanning, communications, logistics estimation, and morbidity management in alignment with their roles in program management. Medical staff members at the district level were trained two to three weeks before MDA implementation.
Figure 8: Training across District, Block and Primary Health Center Levels in Maharashtra
At the block level, Taluka health officers trained paramedical staff members such as multipurpose health workers and auxiliary nurse midwives two weeks before MDA implementation. At the PHC level, multipurpose health workers trained drug administrators one week before implementation to ensure the content was fresh. Field staff, paramedical staff, and drug administrators were trained on consumer-facing skills such as communication, management of side effects, rapid response, and supervision of drug administrations. Volunteers who assisted with drug administration in case of staff shortage also received relevant training for drug administrators before MDA implementation.
Maharashtra leveraged several channels for social mobilization to ensure maximum reach and wide adoption of the MDA program. Maharashtra rolled out the social mobilization campaign in three stages as seen in Figure 9. Communication and social mobilization activities were also developed according to the timeline and intensified as the campaign progressed.
Across the stages, Maharashtra used three major vehicles for social mobilization and community engagement: media and public service announcements, local influencers, and events.
Figure 9: Three Stages of Social Mobilization in Maharashtra
The first stage of the campaign used media, both print and broadcast, to disseminate information and raise awareness in the community. Posters, handbills, and billboards on LF and MDA were distributed in the local language. Announcements and advertisements informing the community about the MDA campaign ran in local newspapers, radio, television, and even in movie theaters. For those who did not rely on governmental information provided via the media, counseling was made available through meetings with family doctors.
The press ran regular case studies and press releases to generate awareness and seek maximum participation. District officials briefed the press on temporary side effects of the drugs to sensitize them and ensure their media coverage did not induce fear within the community. District-level health authorities and doctors also participated in panel discussions that were aired on local television channels to disseminate information about the program.
The second stage of the campaign consisted of community activities, meetings, and other events. Community health workers (CHWs) (also called accredited social health activists), engaged the community by visiting them and providing counseling about the program. CHWs also used cultural events such as “Dwandi”, “Haldi Kumkum”, and “Dohale Jevan” to spread awareness and organized events such as rallies and street plays to draw attention to the program. In Amravati, a competition to create rangoli (an art form consisting of colorful patterns) was organized to raise awareness. Village-level programs, such as Village Health and Nutrition Day, circulated key messages on MDA.
| Staff deployed for LF routine surveillance activities also sensitized the community on MDA rounds. One of the health assistants in the Deoli block of Wardha was confident that showing a picture of affected organs helped convince people to consume drugs for disease prevention. He had many pictures of different types of clinical manifestations of filarial infection (e.g., lymphedema of arms, legs, and hydrocele) on his smartphone that he used as a behavior change communication aid while visiting the households for collecting blood sample. |
Local influencers 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 were encouraged to engage the community and promote MDA. Community-based organizations also took part in information dissemination.
In the third and final stage, CHWs made door-to-door visits to ensure the community was aware of the dates of MDA and other critical information. Ambulances were used to make announcements on loudspeakers in the community regarding the campaign, and religious places such as mosques and temples made announcements regarding the MDA round.
MDA Implementation Activities
Drug administration activities in Maharashtra fell broadly into three categories: (1) administration of the drug to the population, (2) supervision and monitoring, and (3) reporting activities.
Drug administrators in Maharashtra conducted house-to-house, supervised drug administration to cover the maximum number of people through MDA. Before the start of the MDA round, drug administrators informed community members about the MDA dates and the expected date of their visit. Multipurpose health workers, insect collectors, Anganwadi workers, and CHWs from the local community were responsible for drug administration. In urban areas, volunteers were mobilized to assist with drug administration due to staff shortages. Each drug administrator was allotted 50 households covering 250 people per day for three days in rural areas and roughly 60 to 70 households per day for five days in urban areas. Each drug administrator carried a flash card, an identity card, and an information collection form and visited households from 8:00 a.m. to 6:00 p.m. for five days in urban areas and three days in rural areas.
The drug administrators ensured the drugs were ingested while they were present, according to the recommended practice of supervised drug administration. They informed community members of the consequences of not consuming the drugs by demonstrating the pictures of patients with lymphedema on the flash cards. Drug administrators also briefed them on the minor side effects of the MDA drugs and asked them to report symptoms such as nausea, vomiting, and dizziness to the nearest health care facility or health care officer. Drug administrators encouraged the use of vector-control strategies like mosquito nets and promoted hygiene practices and self care for those with lymphedema. Drug administrators marked the households where drugs had been administered. The marking indicated the number of members in the family who received drugs in the morning round and those who had been left out. Those left out were given drugs in the evening hours when drug administrators revisited the households.
Figure 10: Drug administrators in Maharashtra undertook supervised drug administration and quick follow-ups to increase coverage
Visits for each house were recorded and reported to closely track houses that were still to be covered. Reports detailed the total number of family members, those who were eligible, and any unwilling or missing members. Drug administrators shared these reports with their supervisors on a daily basis who sent the reports to a medical officer at the PHC.
Mop-ups to ensure all community members were covered started a day after the drug administration in Wardha and Amravati. The standard allotted time of two days was found to be insufficient for mop-up activities in both IUs. In urban areas, mop-ups typically lasted five to six days, whereas in rural areas they lasted three to four days. It was observed that urban community members, especially belonging to the higher socioeconomic strata, were difficult to convince.
Supervision and monitoring activities were undertaken at multiple levels by health assistants, the district malaria officer, and the district filaria officer to ensure minimum deviation from guidelines. At the district level, either the district malaria officer and district filaria officer were the nodal person responsible for carrying out supervision and monitoring activities. At the block level, the medical officer supervised the health assistant and supervisor who in turn supervised and monitored the drug administrators. Each medical officer was responsible for five supervisors and each supervisor managed a team of five drug administrators in urban areas and ten in rural areas. Supervisors conducted random assessments to cross-verify drug administrations in 10 percent of all households covered (approximately ten households). The supervisor visited these households and conducted interviews with the families about drug administration in their local language. Drug administrators also shared daily updates with their supervisors.
Supervisors collected village-level data from the interviews, including coverage data reported by drug administrators, and submitted a consolidated report to the medical officer daily. The Taluka health officer then collected these reports from medical officers and passed them on to the district malaria officer. The consolidated report on drug coverage was shared with district officials after MDA and mopping-up activities were completed. The report was then shared with the joint director of health services at the state level who further submitted the final report to the NVBDCP within 30 days of MDA and mop-ups.
Post-MDA Activities
Monitoring was undertaken at multiple levels by health assistants, the district malaria officer, and the district filaria officer to ensure minimum deviation from guidelines.
Reporting activities continued after the MDA campaign up to 30 days after the mop-ups. During this time, the district malaria officer shared the consolidated report of the MDA with the joint director of health services.
Figure 11: Monitoring and evaluation
The key monitoring and evaluation activity in Maharashtra was a post-MDA survey, which was conducted 30 to 45 days after MDA. Post-MDA surveys were done by third-party organizations to collect data on MDA coverage and assess the success of the program. A post-MDA survey was conducted from a random sample of community members across villages with low, medium, and high MDA coverage, and one urban area with medium coverage. From each category, one site was chosen to conduct the survey. This survey was conducted almost 30 to 45 days after each MDA round in accordance with the national guidelines. Compliance was found to be lower than coverage, but the gap reduced with successive MDA rounds. Results from the post-MDA survey in Wardha and Amravati are presented in Figure 12.
Apart from the MDA, CHWs listed the cases of lymphedema and hydrocele through the annual house-to-house visits. Regular medical camps for surgeries were conducted throughout the year to treat patients with hydrocele, based on the number of cases and availability of surgeons. Lymphedema cases were trained in self-care and antiseptics and ointments were given to patients to help them manage their symptoms as part of MMDP.
Figure 12: Results from Post-MDA surveys in Amravati and Wardha
