Odisha’s continuation of activities under the National Filaria Control Programme (NFCP) and its effective implementation of the Elimination of Lymphatic Filariasis (ELF) program reflects the state’s strong aspiration toward eliminating the disease. By the year 2020, Odisha had successfully implemented mass drug administration (MDA), such that 9 out of 20 endemic districts cleared various levels of transmission assessment surveys.
Odisha’s long history of efforts toward lymphatic filariasis (LF) elimination have enabled it to scale LF elimination programs and sustain outcomes.
Five key approaches enabled Odisha to emerge as an Exemplar State in LF elimination:
- Adherence to national guidelines with local adaptations
- Collaboration across departments
- Effective leadership and human resource management
- Engagement with local influencers and social mobilization campaigns
- Adaptation of learnings from previous public health interventions
This section explores each of these approaches in detail.
The National Vector Borne Disease Control Programme, the governing body for ELF in India, frames and disseminates guidelines for ELF implementation across all states. These guidelines are based on extensive research and observation of LF interventions within and outside of India, and incorporate practices and processes designed for effective program implementation.
Odisha closely adhered to and effectively communicated guidelines across all levels of implementation. Training materials and guidelines were translated into local languages to ensure comprehension, coherence, and alignment on guidelines across all levels of the hierarchy. National Vector Borne Disease Control Programme officers and consultants were actively involved in the training of the assistant director of health services, district malaria officer, and block-level health officers on national guidelines at least a month before MDA rounds began. The guidelines streamlined actions at all levels, and contextual references and translations of guidelines enabled easy reference to ground realities during training. The following examples highlight how Odisha’s adherence and adaptations to guidelines ensured effective program implementation.
Supervised Drug Administration
Odisha closely observed the recommended practice of supervised drug administration during MDA rounds. Unlike other states that distributed drugs to families for self-consumption, drug administrators in Odisha made door-to-door visits and ensured that drugs were ingested in their presence. This helped ensure that each person actually consumed the drugs, increasing compliance alongside coverage among target households.
Mop-Up
Drug administrators returned to households they missed during the first round of MDA in the evenings or over the next two to three days for drug administration. Such an approach helped minimize coverage gaps in endemic districts.| To ensure high compliance, drug administrators ensured that each and every member of the community consumed the drugs in their presence. They often marked the houses that had been left out and needed to be revisited within three days as per guidelines. Drug administrators planned to visit the households after lunch, usually at 2 p.m., to ensure the drugs were not ingested on an empty stomach. Mop-ups were extended in urban areas for a period of five days, and up to a week in more remote areas, such that maximum coverage was achieved. |
Bottom-Up Planning
In Odisha, collaborative planning efforts integrated local perspectives to ensure that microplanning included estimating funding, staffing, and drug requirements for MDA, in accordance with guidelines. The block program manager and the public health extension officers drafted block-level microplans to ensure that plans for MDA implementation accurately accounted for ground realities. Furthermore, all microplans were discussed with village-level supervisors before they were finalized, which ensured MDA acceptance and support from the community.
Contextual Adaptation
Odisha not only effectively adhered to existing guidelines at all levels, but it also adapted and tweaked the guidelines to address context-specific challenges and avoid disruptions in MDA implementation.
For instance, between 2006 and 2009, Jajpur’s district malaria officer went beyond established district action plans and came up with a “feasibility plan,” that addressed the nuances of a particular district with respect to population density, types of workers, and the rhythms of their days. This in turn ensured smooth MDA implementation. Similarly, in remote areas where safety of female drug administrators was a concern, male family members of female drug administrators were inducted as volunteers to represent them in these regions. Likewise, with respect to social mobilization activities in Koraput, a tribal district, training for drug administrators was conducted in local dialects to ensure effective communication with community members of the 52 tribes living in the region.
Multi-stakeholder coordination committees set up by the state were responsible for charting the course of MDA implementation and therefore played an important role in enabling collaboration across departments for planning purposes. At the state and district levels, the state task force, state technical advisory committees, and district coordination committees were set up and held regular meetings, which were attended by the ELF program team along with members of various other government departments and local bodies. These meetings provided stakeholders with the platform to identify and anticipate challenges in the MDA campaign, and consequently come up with strategic solutions to mitigate them.
Intersectoral Collaboration
During implementation of the MDA campaign, community organizations and local leaders facilitated community buy-in and uptake of drugs. Community organizations such as the Gaon Kalyan Samitis and Rogi Kalyan Samitis spearheaded the effort to mobilize resources for preparing, executing, and monitoring village health plans.
Members of Gaon Kalyan Samitis were actively involved in formulating the microplan and provided input on head counts, drug estimations, and other issues. For effective communication, auxiliary nurse midwives used the Gaon Kalyan Samitis platform to inform the public about MDA rounds. The Gaon Kalyan Samitis and auxiliary nurse midwives also engaged with local leaders and influencers including Sarpanch (elected head of the Gram Panchayat) and ward members to encourage the community to participate in the MDA. Odisha relied on the Rogi Kalyan Samiti to monitor funds and expenditures for training, night blood surveys, and other MDA-related activities. Similarly, when it came to drug storage and warehousing of additional supplies after MDA rounds, the state worked closely with local stakeholders such as the chief executive officer of the Zila Parishad (a district council) to mitigate any challenges surrounding drug storage.
| Gaon Kalyan Samitis members are community volunteers, elected Gram Panchayat members, auxiliary nurse midwives, multipurpose health workers, school teachers, and members of preexisting committees (e.g., school education, water sanitation). There is also representation from service users such as pregnant women, mothers with children under age three, and patients with chronic diseases. |
Stakeholders, operational officers, and leaders at all levels displayed a high degree of motivation and ownership for the MDA program, going above and beyond their predefined duties to ensure success. They were able to avoid disruptions and guarantee smooth MDA implementation by accounting for particularities of their local context, creatively mobilizing staff, and ensuring rigorous training across levels.
The district malaria officer in Jajpur exhibited great inventiveness in anticipating and mitigating challenges during her tenure from 2006 to 2009. Because Jajpur is a conglomerate of industrial, rural, and urban areas, consisting of an equally heterogeneous population, the district medical officer went beyond the established guidelines and district action plans to create a feasibility plan to accommodate the district’s particularities. For instance, recognizing that school children, industrial workers, and cultivators have unique routines, community health workers were advised to visit households at times when most family members were present in the household or to administer drugs in community centers such as the immunization center. Her perceptive insights and actions benefited not only Jajpur but also set a precedent for subsequent MDA rounds.
The district malaria officer was also quick to realize that for drug administration and mop-ups, it was practically impossible for community health workers to cover all people assigned to them in the designated two to three days, as outlined in the guidelines. She therefore recruited volunteers to supplement drug administration and mop-ups activities by (1) encouraging community health workers to recruit family members as volunteers; (2) involving a few NGOs that were already working in public health to work with them; and (3) with support from the District Collectorate, recruiting public health officials from the industrial areas, especially for vector borne disease management. To provide incentives and training to these volunteers, the district malaria officer secured corporate social responsibility funding from the TATA Group of industries.
Across the three study districts, the regional office placed special emphasis on providing thorough institutional and field training on transmission assessment surveys and MDA to volunteers and contractual laboratory technicians. This emphasis on strengthening the capacity of all volunteers may have been an outcome of the fact that leaders such as district malaria officers and vector borne disease consultants themselves underwent and benefited from regular and in-depth training at the national training center in Rajahmundry (formerly known as the Regional Filaria Training and Research Centre) on filariology.
Leadership ensured that laboratory technicians working on other vector borne diseases (e.g., malaria and dengue) had the necessary technical training to work on LF, such as carrying out night blood surveys and transmission assessment surveys. Using state MDA funds, vector borne diseases consultants sent laboratory technicians for multiple rounds of training on night blood collection, slide staining, and reading filaria blood slides. Similarly, leaders ensured that the training of volunteer drug administrators was comprehensive. Their training began with a theoretical deep-dive into LF and LF prevention via preventive chemotherapy, which was followed by practical training sessions in drug dosage, administration, and management of adverse effects. Further, during the MDA rounds, volunteers were supervised and provided on-the-spot training and counseling to ensure they did not deviate from the guidelines.
The leadership also emphasized that role-based training should be differentiated at the district, block, and primary health center levels to ensure effective and efficient division of labor and synchronicity between different levels of the hierarchy. In Odisha, special emphasis was placed on training drug administrators and health workers in interpersonal skills and community sensitization techniques. Such training in soft skills equipped field workers with the requisite knowledge and confidence to adequately respond to community queries. This in turn inspired confidence in the community to participate in MDA.
Odisha’s experience in engaging and mobilizing the community demonstrates the value of robust communication and social mobilization strategies. The outcome of any public health program is contingent on positive community engagement and response. The goal of social mobilization is to raise community awareness and change community perceptions and behavior.
Odisha customized its communication efforts to the local context to facilitate absorption of the information by all communities. For instance, all posters, handbills, billboards, and advertisements were translated into local languages and tribal dialects, and visual elements were used with people who could not read. Odisha used innovative channels to influence health-seeking behavior among the general public, including the use of the swasthya kantha, also known as the health wall. The swasthya kantha was introduced in Odisha in 2009 as part of a month-long communication campaign, with the target of promoting health-related programs. The majority of district and block officials reported using the swasthya kantha to disseminate information about the dates and timing of MDA rounds. This multifaceted media strategy ensured increased awareness about LF and MDA in the community.
Communication efforts were intensified closer to MDA rounds to ensure that no one remained unaware of the program. The state leveraged community organizations, such as the Gaon Kalyan Samitis and Rogi Kalyan Samiti, who took the lead in mobilizing resources. Gaon Kalyan Samitis used strategies such as providing 10,000 Indian rupees (approximately $US138) to be used for attending to the health and sanitation needs of the community.
| The Gaon Kalyan Samitis are vibrant, well-established village health and sanitation committees that have increased the ability of communities to take ownership for improving the health status of the community and organize health promotion and prevention activities at the village level. Odisha’s swasthya kantha (“health wall”) initiative supported the dissemination of health-related messages and worked toward further empowering Gaon Kalyan Samitis and their mission across the state. |
Odisha health officials were able to leverage local influencers to generate momentum for the MDA campaign. They engaged political leaders such as members of Panchayati Raj Institutions (a system of self-government at the village level) and respected community members including religious leaders, district-level authorities, family physicians, and school teachers to further expand their reach through these trusted individuals.
Local influencers also addressed the extensive spread of misinformation and resultant fear of side effects during the initial years of MDA implementation. District officials and key community leaders consumed diethylcarbamazine and albendazole tablets at inauguration ceremonies, in front of the media, and at village-level meetings to assure the community of their safety. Health officials also leveraged the media, sensitizing them about MDA and asking them to broadcast complete information about the MDA program.
Community health workers and auxiliary nurse midwives also played a vital role in easing fears among community members by describing commonly occurring side effects of the MDA drugs. They also educated the community by explaining that side effects indicated that the drugs were working and were killing the microfilaria in the body, which further eased apprehensions. In addition, they equipped the community with the knowledge necessary to manage these side effects, thereby increasing confidence and maximizing compliance.
| Community mobilization activities for MDA rounds were primarily the responsibility of auxiliary nurse midwives, community health workers, and other health workers. Community health workers went door-to-door to counsel and inform the community members about the benefits of consumption of diethylcarbamazine and albendazole tablets. Volunteers told them about the dates of drug distribution and advised them to be available at home during that time. |
Lessons, assets, and resources from previous programs accelerated MDA planning and provided the experience needed to anticipate and mitigate implementation challenges in Odisha.
Experienced staff from other public health programs were closely involved in the planning, implementation, and monitoring of the ELF, bringing a wealth of experience to increase the effectiveness of the MDA program. For example, laboratory technicians working on other vector borne diseases were trained to read filaria blood slides and conduct night blood surveys and transmission assessment surveys, which supported various implementation activities and facilitated the effective launch of ELF activities.
The implementation team for MDA rounds anticipated and mitigated challenges in MDA implementation based on their experience with other health programs. For example, they used existing health infrastructures to manage adverse events in remote areas by using mobile health unit networks as rapid response teams in the tribal blocks, since there were already at least two mobile health units per block.
Similarly, with respect to social mobilization and training, the majority of block officials made use of historic data from other outreach programs to ascertain geographies that required aggressive information, education, and communication activities. The auxiliary nurse midwives belonging to these identified areas received additional interpersonal and behavior change communication skills, as specified in the guidelines, to effectively convince community members to participate in MDA.