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Why Is Maharashtra an Exemplar?

Lymphatic filariasis (LF) was first recorded in India as early as the sixth century BC.1 Since then, India has worked consistently to build its knowledge on the cause, symptoms, and treatment of the disease. Today, India bears 40 percent of the global LF burden,2 with an at-risk population of 630 million across 16 states and 5 union territories.3

Over the years, India has implemented many programs that have contributed to its steady progress toward eliminating LF by 2021.3 India began its LF interventions in 1949, with a pilot project in Odisha aimed at controlling LF through single-drug therapy along with antilarval and adult mosquito management. The pilot, though discontinued, paved the way for the National Filaria Control Program—the first national program aimed at tackling LF. The program had limited success due to community noncooperation and ineffectiveness of the insecticidal indoor spray, but lessons from the program were integral to the development and rollout of the multipronged Elimination of Lymphatic Filariasis (ELF) program in 2004. ELF is based on a twin pillar strategy of chemotherapy via mass drug administration (MDA) and morbidity management and disability prevention for alleviation of chronic illness. The objective of the program is to cover all eligible populations living in endemic districts through annual MDA campaigns to reduce the infection level in the community below a threshold at which the spread of the infection can no longer be sustained and transmission stops.

The World Health Organization (WHO) recommends using transmission assessment surveys to determine when the rate of microfilaria infection has been reduced below 1 percent and MDA can stop. Once MDA has stopped, transmission assessment surveys are used as a surveillance tool to assess the infection levels within the community. An implementation unit (IU) , usually an endemic district, is the smallest administrative unit used as the basis for deciding to implement MDA. IUs carry out transmission surveys after at least five rounds of MDA, with a coverage of more than 65 percent of the population. The survey is administered three times, every two years, to confirm the microfilaria rates in the population remain below the threshold value. When the IU has successfully cleared transmission assessment surveys 1, 2, and 3, it is considered free of LF.

Figure 1. Endemic population vs. TAS cleared districts in 2021

Since the launch of the ELF program in 2004, 143 endemic districts in the country started implementing MDA annually. Many states have demonstrated progress in reducing their LF burden since the ELF program began, but Maharashtra’s case has emerged as noteworthy. Between 2004 and 2005, 17 IUs were enrolled for MDA in Maharashtra. Since 2014, and despite the large number of IUs in the state, Maharashtra consistently recorded an average MDA coverage of 88 percent or higher, with each IU having an MDA coverage of 75 percent or higher, which was higher than the eligibility criteria of 65 percent.3

Although the state had an endemic population of a whopping 31.7 million, it was able to show consistent improvement and by 2020, 8 of 17 MDA IUs had cleared transmission assessment surveys 2 and/or 3 following numerous rounds of MDA consistently achieving high coverage, as highlighted in Figure 1.

Figure 2. Endemic states in India in 2004

While other states with large endemic populations such as Kerala, Tamil Nadu, and Andhra Pradesh also made significant progress in clearing the transmission assessment surveys, Maharashtra bore a close resemblance with other large states that are lagging behind in the elimination of LF such as Bihar, Madhya Pradesh, Jharkhand, Uttar Pradesh and Chhattisgarh on indicators such as child mortality, literacy, immunization of children, anemia among women, and state gross domestic product per capita, as highlighted in Figure 3. This makes the lessons from Maharashtra’s ELF program particularly relevant for these states.

Figure 3. Health and socioeconomic factors in Maharashra compared with other high-burden states

Data from: National Family Health Survey; Census 2011 ; Reserve Bank of India (2014) ; and Maharashtra Economic Survey 2019-20.

Amravati and Wardha were selected as IUs for the study because of their size and high initial microfilaria rates. While many IUs in Maharashtra demonstrated a strong performance in reducing the LF burden over the years, Amravati and Wardha achieved a consistent decrease in the microfilaria prevalence rate—from a high initial rate to a low rate at the end of the implementation period. The larger the population in those two IUs, between 1.3 million and 2.8 million, make the findings more relevant for other IUs.

Figure 4: Status of transmission assessment surveys in Maharashtra

NVBDC Data

To identify the States that were suitable for the Exemplars program we followed a process that incorporated epidemiological, programmatic and contextual indicators:

  • First, we focused on the States that had cleared TAS 2 and/or 3 in more than one third of their IUs. This allowed to avoid the uncertainty around self-reported performance indicators such as MDA coverage, and ensured the IUs had consistently kept transmission below the elimination threshold beyond the first TAS.
  • Next, we focused on States that had an endemic population above 20 million people at the start of the ELF program in 2004. Figure 1 shows the States that fulfilled both criteria.
  • Finally, we used a set of proxy indicators to compare the shortlisted States to the ones that still have a high LF burden. The objective was to ensure the lessons learned from high-performing States would be replicable in similar contexts. Figure 3 shows the comparison of Maharashtra to high-burden States.

The ELF program in Amravati and Wardha adopted key strategies that enabled it to reduce the microfilaria rate to less than 1 percent. These included:

  • Adaptation of all national ELF guidelines to the local context to ensure effective implementation of MDA in communities. Maharashtra was also effective in adopting changes in the guidelines, such as the introduction of the Taluka health offer post.
  • Effective collaboration between government departments and the community enabled proactive planning and responsive stakeholder actions when faced with operational challenges. For example, the Zilla Parishad CEO and representatives from the education department played a key role in the planning and smooth implementation of the MDA campaigns.
  • Strong, capable, and driven leaders who made effective decisions and addressed challenges related to planning, staffing, training, community engagement, and implementation. In both districts, key district officers leading the campaign served during various years, providing leadership continuity and knowledge management.
  • Addressing community fears and increasing acceptance of MDA through local influencers and multiplatform awareness campaigns. Community health workers and other opinion leaders used community events to explain temporary side effects and ensure the press coverage of such events did not induce fear among community members.
  • Learnings and assets from past public health interventions such as the National Filaria Control Program, the malaria program and the polio elimination program, were leveraged to increase the effectiveness of the MDA program.

Maharashtra’s experience offers relevant lessons to inform decision making across other states to enable cost, time, and effort savings. States that are currently implementing MDA and facing challenges with lack of awareness can draw lessons from Maharashtra’s rigorous information, education, and communications activities and multichannel social mobilization strategies. In case of resource constraints, states can leverage Maharashtra’s partnership approach to bring in community-based organizations to reduce time, cost, and effort. Lastly, states that are focused on improving the knowledge and skill of their staff members can use the learnings from Maharashtra’s dynamic training and capacity-strengthening efforts to customize and improve training outcomes.

  1. 1
    National Vector Borne Disease Control Programme (NVBDCP). Guidelines on Elimination of Lymphatic Filariasis India. New Delhi: Ministry of Health and Family Welfare. Accessed September 25, 2020. https://nvbdcp.gov.in/WriteReadData/l892s/43461824631532409675.pdf
  2. 2
    Bagcchi S. India tackles lymphatic filariasis. Lancet Infect Dis. 2015;15(4):380. Accessed October 20, 2020. http://doi.org/10.1016/S1473-3099(15)70116-7 
  3. 3
    World Health Organization (WHO). Lymphatic Filariasis: Monitoring and Epidemiological Assessment of Mass Drug Administration—Drug Administration—A Manual for National Elimination Programmes. Geneva, Switzerland: WHO; 2011. Accessed September 25, 2020. https://www.who.int/lymphatic_filariasis/resources/9789241501484/en/