What Did Odisha Do?

The first activity of the MDA cycle is planning––critical for ensuring successful MDA campaigns across geographies. Detailed planning ensures that all resources––drugs, staff, and information, education, and communication (IEC) activities––are properly estimated for, procured, and mobilized. Planning gives direction to and streamlines all levels of MDA implementation.

Planning for the MDA campaign typically begins six to eight months before the MDA rounds and follows a bottom-up process; this timeline of activities was maintained in Odisha. In Odisha, as per operational guidelines, planning began at the village level, where health workers––using data from the previous years’ MDA––estimated and reported funding and drug requirements to the block level. At the block level, this data was compiled into a block action plan and submitted to district-level authorities, who in turn aggregated all block action plans into a district action plan and submitted the same to the state health society. The state health society known as the Odisha State Health and Family Welfare Society then aggregated the district/city health action plans into a state’s Program Implementation Plan, which detailed and outlined the strategic guidelines, budgetary requirements, training materials, health priorities, and outcomes for the MDA campaign.

In December, the Program Implementation Plan is shared with the Directorate of the National Vector Borne Disease Control Programme, located in Delhi, for approval. After approval (typically by February), the National Health Mission disburses funds to the Odisha State Health and Family Welfare Society in April/May, which further enables its downward flow to all levels. The reception of funds at all levels in turn spurs the mobilization of necessary resources required for the actual implementation of MDA.

At the central level, a monitoring committee is created in December to oversee the actual implementation of the MDA campaign. Created under the stewardship of the Ministry of Health and Family Welfare, this committee includes representation from all levels––national, regional, and district—of the health system. Committee members are responsible for preparing an operational manual for MDA implementation; mobilizing human and financial resources; preparing, reviewing, adapting, and updating guidelines and training materials; and preparing for the monitoring and evaluation of MDA and transmission assessment survey activities. Successful preparation for MDA implementation at the central level strengthens and streamlines the planning process at lower levels.

Similarly, at the state level, coordination committees, such as the State Task Force and State Technical Advisory committees, meet to discuss preparatory activities for MDA implementation. Preparatory activities include conducting intersectoral meetings, microplanning, selecting and training drug administrators, preparing social mobilization strategies, and projecting the flow of drugs. These committees in Odisha also launched training at the state headquarters for district-level officers and ensured the timely release of funds by the Odisha State Health and Family Welfare Society.

At the district and subdistrict levels, Odisha organized the district coordination committees (DCCs) to oversee MDA implementation and ensure timely drug distribution. All three study districts––Jajpur, Kendrapara, and Koraput––reported that they followed national guidelines by conducting two DCC meetings.

During the first DCC meeting, typically held two months before the beginning of MDA implementation, DCC members are informed about the purpose of MDA, dates for the MDA campaign, and the detailed action plan for MDA. These meetings are conducted under the chairmanship of the district magistrate or district collector, who asks members to ensure maximum participation from relevant teams to support activities like human resource mobilization, training needs, mobilizing funds, and enabling maximum IEC outreach. The district’s teams in Odisha were proactive in using the DCC platform to preempt challenges and develop mitigation strategies in consultation with the teams.

Key areas of reviews in the second DCC meeting, typically conducted 7 to 15 days before MDA rounds, include the district’s demographic, human resources/workforce assessment, logistical assessment, supervision mechanisms, and preparedness for launching MDA rounds. The steps involved in planning of the MDA campaign are depicted in Figure 6 below.

Figure 6: Formation of the coordination committees and drawing up of the microplan laid the groundwork for an effective MDA program

Drug Procurement and Distribution: The procurement of drugs was done by the Odisha State Medical Corporation Limited based on estimates detailed in the Program Implementation Plan. In 2013, it was incorporated under the Odisha State Health and Family Welfare Society to act as an independent agency for the timely procurement of quality medicines through a fair, transparent, and competitive bidding process.² The Odisha State Medical Corporation Limited performed the additional step of checking the quality of drugs before distributing them for MDA rounds. These drugs were further supplied downward to the district and community health center levels, in line with requirements, in addition to a 10 percent buffer stock.

Staffing: At the primary health center 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.

To overcome staff shortages and complete drug distribution in the time stipulated by the national guidelines, district malaria officers recruited volunteers, such as the family members of community health workers (known as accredited social health activist workers or ASHAs in India), nongovernmental organizations (NGOs) working in the public health space, and contractual laboratory technicians, all of whom received incentives and rigorous training in preparation for conducting MDA activities.

Funding: The flow of funding through the state machinery is depicted in Figure 7 below. Based on the Program Implementation Plan, the National Health Mission distributed funding to the Odisha State Health and Family Welfare Society, which in turn disbursed it to district health societies called Zilla Swasthya Samiti. In all three study districts, district and block levels released and received funds without delay. The implementation of direct fund transfers in Odisha since 2009 greatly decreased the delays in the transfer of funds to the district and block levels. In the case of shortfall of funds due to new guidelines or changes in demographics, Odisha drew up an additional budget and was allocated money from the National Vector Borne Disease Control Programme’s “flexifund” (a basket fund with flexibility to be allocated toward activities of health programs under the purview of the National Vector Borne Disease Control Programme).

Figure 7: Flow chart of funding distribution for the mass drug administration campaign

Drug administration activities in Odisha fell broadly under three categories: (1) administration of the drug to the population, (2) supervision and monitoring, and (3) reporting activities. The details of this activity are represented in Figure 11 below.

Figure 11: Drug administrators undertook supervised drug administration and performed mop-ups to increase

Drug administrators conducted supervised drug administration in Odisha, in line with recommendations. The process consisted of drug administrators making door-to-door visits to households to administer drugs to observe the drugs being ingested, for maximum coverage and compliance. On the day assigned to MDA, a drug administrator typically covered approximately 500 to 700 people in densely populated areas and 400 to 500 people in sparsely populated areas. Drug administrators typically visited households during breakfast hours or after lunch so that people would not experience side effects from consuming drugs on an empty stomach. Additionally the drug administrators briefed community members on 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. To ensure maximum coverage, drug administrators also marked the households where people were missed, and returned to these houses in the evening and repeatedly over the following two to three days dedicated to following up with people who were missed.

Stakeholders at all levels were involved in the administration of drugs to the community. The entire process was managed by the additional district public health officer under the guidance of the chief district medical and public health officer and the joint director for vector borne diseases. The administration was implemented via the network of primary health centers in rural areas and via municipal health institutions in urban areas. The on-ground drug administrators consisted of community health workers, Anganwadi workers (women who provide health and nutrition services to children and pregnant women), and auxiliary nurse midwives.

To mitigate the shortage of health care workers available for the MDA campaign, volunteers were brought in to support drug distribution. Typically, these volunteers were community members selected by the Anganwadi workers or community health workers and were often family members of the workers. In Jajpur’s mining district, the district malaria officer recruited non-medical staff as public health officers with corporate social responsibility funding from mining companies operating in the area. These public health officers supported the management of vector borne diseases (i.e., malaria, dengue, and filariasis). Additional volunteers were recruited as drug administrators to support the MDA campaign.

In all three districts, to maximize drug coverage, two to three days of “mop-up” were designated for administering drugs to people who had been missed during MDA rounds. Mop-ups began a day after the MDA round, during which drug administrators made visits to households they had marked to indicate those who were missed.

The standard allotted time of one day for drug administration and two to three days for mop-ups was found to be insufficient in the tribal district of Koraput, given its hilly and remote geography. As a result, drug distribution and mop-ups were conducted for an entire week in Koraput.

In the study districts of Odisha, monitoring and supervision activities were undertaken at three levels: state, district, and block. These activities followed a cascade system, with a special emphasis on community supervision.

At the state level, National Vector Borne Disease Control Programme officers and consultants were responsible for monitoring MDA implementation through spot checks. On these visits, they reviewed the challenges faced by drug administrators and took account of the number of people who faced adverse reactions and hospitalization. Further, for cross-verification of the MDA implementation process, they interacted with community members at multiple levels: at the district headquarters, at two primary health centers, at two subcenters of each primary health center/community health centers, and at two villages of a subcenter. Based on these interactions they filled out a supervisory checklist, which they submitted to the joint director of the National Vector Borne Disease Control Programme in Bhubaneshwar, Odisha.

At the district level, the additional district public health officer for vector borne diseases was responsible for supervision and monitoring activities. Along with other critical officers including the vector borne diseases consultant, the additional district public health officer made visits to the blocks to supervise implementation. The team selected a few villages and reviewed and verified key MDA activities such as program implementation, types of challenges, and how these challenges were mitigated and addressed. The additional district public health officer’s team collected this information through in-depth discussions with block-level supervisors; field functionaries, such as community health workers, other volunteers, and multipurpose health workers; and people from select villages. Following their field visit, the team shared programmatic improvement inputs with the block-level officials.

There were different layers of supervision at the community level. The MDA tasks undertaken by drug administrators were first monitored by the auxiliary nurse midwife, followed by male health workers (multi-purpose workers). Each health worker supervised a designated group of drug administrator teams, ranging from six to ten in number. Using random assessments and surveys in ten percent of all households covered (approximately ten households), health workers verified coverage and compliance by checking their findings against the daily records. The supervisor visited these households and conducted interviews with the families about drug administration in their local language.

Mop-up activities were supervised by auxiliary nurse midwives in a similar manner to drug administration.

Reporting, like supervision and monitoring, was undertaken at all levels and followed a cascading model.

At the village level, drug administrators closely recorded which households were covered, which were missed, the number of tablets distributed, and the number of surplus tablets, which were compiled in a daily report. The drug administrators shared these reports with auxiliary nurse midwives, who in turn collated them in the form of a summary report, which they submitted to the sector supervisor. The sector supervisor then shared it with the block program manager.

At the block level, a standard reporting checklist was used, which detailed key MDA activities and personnel responsible for those tasks. The checklist was filled out and submitted by the medical officer in-charge of the community health center to the vector borne disease technical supervisors at the district level, after completing the MDA program. Three to four weeks after MDA rounds ended, block-level reports were submitted, compiled, and shared with district functionaries, who conducted in-depth meetings to review them.

The key monitoring and evaluation activity to assess the success of a given MDA program is the post-MDA survey. In line with guidelines, a post-MDA survey in Odisha was conducted 30 to 45 days after MDA rounds. The survey was carried out by independent third-party organizations––medical colleges and research institutions––that were appointed by the government of India. In Jajpur and Kendrapara, Srirama Chandra Bhanja Medical College and Hospital conducted post-MDA surveys under supervision of the head of the department of community medicine. Figure 12 below illustrates the activities involved in the process of monitoring and evaluation.

Figure 12: Monitoring and evaluation

To assess the success of the MDA program, the post-MDA survey was conducted by randomly selecting community members belonging to each of the following categories: community members in villages with low, medium, and high MDA coverage, and one urban area with medium coverage. Third-party organizations then visited sample households to conduct in-person interviews using questionnaires. This methodology of structured interviews yielded rich insights about numerous thematic areas of relevance to the MDA program (e.g., community’s perception, reasons for non-adherence). These findings were then compiled, analyzed, and reviewed. The results from the post-MDA Survey in Odisha shown in Figure 13 show an improvement in the drug consumption of the population.

Figure 13: Results from post-MDA surveys in Odisha

Apart from the MDA, community health workers supported LF elimination efforts by creating lists of cases of lymphedema and hydrocele through annual household visits. Based on the number of hydrocele cases and availability of surgeons, medical camps (temporary units with surgical and other specialized services) were held throughout the year to conduct surgeries and treat hydrocele patients. As part of morbidity management and disability prevention, people with lymphedema were trained in self-care––antiseptics and ointments were given to patients to help them manage their symptoms.