Collaborative Campaign Planning of Vitamin A Supplementation and Elimination of Lymphatic Filariasis in Nepal: Prospects and Challenges of Integration

Abstract

This pilot study examined collaborative planning for integration of the lymphatic filariasis (LF) elimination and vitamin A supplementation (VAS) campaigns in Rainas municipality, Lamjung district in Nepal.

Female community health volunteers (FCHVs) used the complementary monitoring and supervision approach (CMS) during home visits to support the partial integration of the campaign interventions in the following steps: 

• Share information on both health interventions with households. Offer vitamin A capsules during household visits.
• Verify if family members received mass drug administration (MDA) during the LF campaign that was conducted a week prior to the vitamin A campaign.
• Reinforce the importance of taking LF medications that were missed.
• Refer individuals to a nearby health facility for LF medication.
• Record and report those who haven’t accepted LF MDA and refer  to the local health facility, and/or Ward Committee members.

Applying the CMS approach during the vitamin A campaign enabled FCHVs to identify people who missed MDA in the preceding LF campaign who could be referred to nearby health facilities. 

Stakeholder perspectives were explored during the collaborative planning of campaign integration. In the final project stage, stakeholders reported that collaborative planning was related to the effective use of limited resources. 

The following challenges were encountered during the collaborative planning process and implementation of campaign activities:

• Competing priorities due to COVID-19 response
• Challenges in scheduling officials for collaborative planning meetings
• Lack of policy directives and guidelines for integration
• Difficulties with integrated logistics management
• Lack of budget for awareness activities
• FHCVs experienced some confusion about target ages and reporting structures
• Drug hesitancy
• Difficulty swallowing albendazole for children and people with disabilities

However, through collaborative planning, solutions were identified. These included:

• Staying the course on project plan development and submission, ethical clearances
• Utilizing the collaborative planning process to identify solutions (e.g., logistics, IEC budgets)
• Continued communication with officials
• Rescheduled LF campaign enabled use of the CMS approach
• Local, culturally sensitive IEC materials                               
• Crushing albendazole tablets to ease swallowing for children and people with disabilities, per WHO guidelines

The study team recommends working with the targeted divisions of the Ministry of Health of Nepal to assess the feasibility of collaborative planning in more depth, and conducting a representative study of LF and VAS campaigns to generate evidence that could be generalized to the whole country.

The following promising practices were identified throughout this case study: 

1. Form a campaign integration working group to provide technical support and guidance during all phases of campaign integration, including pre-planning and planning. 
2. Sensitize local health workers to the key aspects of the two campaigns, and engage their views on integration. 
3. Conduct observations during campaign integration to identify challenges in field implementation. 
4. Interact with communities to understand viewpoints, opportunities, and barriers. 
5. Develop a complementary monitoring and supervision approach and train health workers and female community health volunteers.
6. Devise a plan to outreach to migrant/mobile populations for catch-up campaigns.
7. Develop IEC materials that are tailored to the needs and concerns of the community.

Background

Problem

Nepal has a population of 29 million people settled in ecologically diverse settings (1). Neglected tropical diseases (NTDs), including lymphatic filariasis (LF), persist as public health problems.

Despite efforts over the past 17 years, mass drug administration (MDA) coverage of the eligible population in some urban areas and communities has remained low. As a consequence, eleven districts remained LF-endemic. In contrast, vitamin A supplementation (VAS) campaigns conducted since 1993 have achieved consistently high coverage (2). Since 2010, Nepal’s VAS campaigns have integrated deworming treatment of soil-transmitted helminthiasis (STH) through co-distribution of albendazole and VAS.

There is a need to develop and implement effective health intervention models for LF elimination in Nepal. An integrated approach to both LF MDA and VAS was considered suitable in Nepal, enabling a more effective utilization of resources to provide services to populations living in remote areas, as well as highly mobile populations, which are reflected in those ten  districts where LF remains endemic (1). 

This case study addressed the existing knowledge gap and gauged potential interest in collaborative planning and integration of LF and VAS campaigns. The study was piloted in the Rainas Municipality of the Lamjung district, located at 3,800-5,800 feet above sea level and representative of the districts affected by LF. Rainas Municipality has an estimated population of 18,527 of mixed ethnicity. LF is concentrated in its river basin settlements. There have been over 11 rounds of MDA for LF, in contrast to the recommended six rounds, because pre-transmission assessments failed to attain less than 1% prevalence of LF (2, 4).

Rationale for integration

The rationale behind considering these campaigns’ integration is multifold.

First, campaign integration has the potential to more effectively utilize resources and increase coverage in the context of health service decentralization. Nepal adopted the three-level Federal Governance System: federal, province, and local. Each level has the power to enact laws, plan, budget, and mobilize resources, unlike in the past Unitary System. The 2019 National Health Policy (NHP) is the main policy document for directing the health sector in Nepal (3). The NHP mandated attaining universal health ccoverage by integration of promotional, preventative, curative, rehabilitative, and palliative programs. In the new decentralized health system, local governance bodies are responsible for implementing health programs, including campaigns (3). However, this is a new system that needs guidance for collaborative health campaign planning.  

Second, vitamin A supplementation and LF elimination campaigns apply some common strategies. Both campaigns involve mobilizing a large number of female community health volunteers (FCHVs) for service delivery, monitoring campaign activities, and early reporting of potential cases. FCHVs are the backbone of Nepal’s health system, working as a bridge to increase community access to health services. FCHVs advocate for healthy behaviors amongst mothers and community members to promote safe motherhood, child health, family planning, and other community-based health promotion and service delivery.

Finally, integrating these two campaign interventions could serve as a more efficient way to administer albendazole. Both campaigns are nationally organized mass drug/supplement administration campaigns (vitamin A capsules to prevent vitamin A deficiency-related disorders combined with albendazole for deworming, and diethylcarbamazine (DEC) plus albendazole in the LF elimination campaign). Albendazole is used both for children 24-59 months of age in LF MDAs (historically scheduled about two months prior to VAS), and for deworming via co-administration in vitamin A campaigns to children ages 12-59 months. In effect, integration would ‘save’ a dose of albendazole. 

Enablers to integration

The main advocates of campaign integration at the federal level were the Directors of the Epidemiology & Disease Control Division (EDCD) and Family Welfare Divisions (FWD). At the local level, the municipality is the main implementing body of development work, including health services. Officials believed that integrating the campaign was essential for effective use of limited resources in the health workforce, medicines, logistics, and time. Since campaign integration is a new initiative, collaborative planning is crucial to identify prospects, challenges, and a way forward. In this case study, stakeholders identified these pertinent aspects for collaborative planning for these two campaigns by engaging in a series of activities under four key stages (pre-planning, planning, implementation, and post-implementation.)

Several factors led to collaborative campaign planning in 2021, including conducive policy, leadership, willful relationships, and awareness of the existing resources and standard government processes. Promotion of the programmatic need and policy mandate for the integration process was mainly facilitated by Directors of the concerned Divisions of the Ministry of the Health & Population (MoHP). Additionally, project experts (i.e., the technical lead and advisor) had served as public health professionals in the MoHP and worked with the technical working groups through official processes. These cordial relationships proved to be especially important during the pre-planning phase to ‘break the ice’ for discussions on campaign integration.

Objectives

As guided by the National Health Policy (NHP), the overall goal of campaign integration was to increase coverage of LF MDA and VAS. Through integration, the aim was to accelerate the effectiveness of both campaigns.   

The overall objective of this case study was to identify, support, and document the collaborative planning approach to health campaign integration.

The specific objectives of the collaborative planning process were to:

• Explore potential benefits or challenges of integrating campaigns
• Initiate collaboration across program and logistics divisions involved in LF and vitamin A campaigns
• Develop and model an effective collaborative plan, implement, and assess outcomes

Methods

The case study team reviewed secondary data (i.e., annual reports, literature, existing guidelines, and online databases) to develop a project proposal, project plan, and interaction guideline. These documents were shared with government division officials, and a newly formed Campaign Integration Working Group (CIWG) (described in Results – Planning Phases) once the project was officially initiated. Documents generated during implementation of the project, including minutes, exercise sheets, discussion notes, and checklists, were thematically reviewed. 

Primary data were collected according to the study protocol approved by the Nepal Health Research Council. Focus group discussions with FCHVs were conducted in two health facilities of the sentinel sites (n=8 participants). In-depth interviews were conducted with two individuals in the community identified by FCHVs as not having taken part in the MDA. Key informant interviews were conducted with officials of the municipality (n=7), provincial health directorate (n=4), divisions (n=7), and MoHP leadership (n=2). A total of 30 respondents participated in the primary data collection phase of the study.

Interview and focus group discussions were recorded and transcribed. During the analysis phase, emergent findings were organized by prospects, challenges, and next steps. Themes were organized by policy, program planning, implementation, and potential solutions.

Results

Enablers of collaborative planning

The collaborative pre-planning process fostered open communication that highlighted stakeholders’ perceptions of integration. Four factors facilitated the collaborative planning process. 

• Leadership: Promotion of the programmatic need and policy mandate for integration was facilitated by directors of the concerned division of the MoHP; relationships with the HEAL Group and recommendations of technical experts and advisors supported integration advocacy.
• Collaborative approach: Joint planning sessions involved health coordinators and were approved in meetings chaired by the Mayor.
• Involving health workers and local representatives: Four project staff visited the site to orient health workers (n=41) and FCHVs (n=66). Three new dignitaries (director, section chief, and focal person) were invited to join the concluding CIWG meeting, and participated in key informant interviews. 
• Identifying underlying problems and potential solutions: One of the underlying issues was a misconception in the community that taking LF drugs along with medication for hypertension and diabetes could be risky, so culturally sensitive IEC material was developed to address this point.

The prospect for collaborative planning and the integrated campaign were well perceived and received by stakeholders. 

Phased approach

All stakeholders of both the LF elimination and VAS programs were involved in collaborative planning, and this convening was novel and well received. Four levels of stakeholders were involved in the process: health sector federal program divisions, local governing bodies, local health service providers, and the community. A series of meetings were conducted over the project period, in which directors and the focal person of the program divisions’ and municipality officials provided directives. 

The phased approach to collaborative planning is described below.

Pre-planning phase

In this project, the first meeting of the concerned division directors was to discuss the project objectives, modality, and expected outcomes, to set the momentum for campaign integration, and to establish the commitment of division directors. However, a larger meeting with officials did not materialize due to COVID-19 related restrictions and precautions. Communication continued through in-person and virtual meetings. During a meeting with the  LF focal person attending from the field, consensus was reached on proceeding for Department of Health Services (DoHS) approval, and subsequently a formal application was submitted to DoHS.

Planning phase

The DoHS approval letter endorsed the establishment of the CIWG, composed of EDCD and FWD directors, focal persons from EDCD, FWD, and the Management division (Logistics section), and the HEAL Group. The CIWG approved a project work plan and guidelines, and issued directives for completing implementation activities before the LF campaign date scheduled for April 2-13, 2021.

Implementation phase

HEAL presented the identified issues and discussed them with the municipality. In coordination with Rainas municipality health officials, the study team prepared interactive sessions for local health service providers, worked on microplanning with the municipality health officials in interactive sessions, and facilitated sessions for local health service providers, including FCHVs. 

Health workers were sensitized using an ‘exercise sheet’ that compared the key aspects of both campaigns. The exercise sheet used in this study was adapted from the Health Campaign Effectiveness decision tool (6). Health workers and FCHVs were also oriented to the CMS approach to integration during a half-day long orientation which took place on the same day as an orientation for child immunization. The CMS approach was comprised of the following steps:

• Share information on both health interventions with households
• Verify if family members received MDA during the LF campaign that was conducted a week prior to the vitamin A campaign
• Reinforce the importance of taking LF medications if they were missed
• Refer individuals to a nearby health facility for LF medication (FCHVs could only offer vitamin A capsules during household visits)
• Record and report LF MDA non-compliance to the local health facility, for reporting up through levels to the EDCD  

These sessions emphasized that by applying the CMS approach during the Vitamin A campaign, people who missed medication in the preceding LF campaign could be identified. The LF campaign was monitored using pre-developed checklists utilized at booths where beneficiaries received LF MDA. The checklist administered to the individuals who came to the booths included a recording of the number of family members, whether people had taken LF MDA, and notes relevant to the providing of LF medication and VAS. Observations included whether local health service providers gave counseling and correct dosing.

IEC materials were updated to include short messages and add pictures to make them more self-explanatory. These materials were developed to raise awareness by addressing prevalent rumors and misconceptions surrounding LF MDA, specifically targeting individuals taking hypertension and diabetes medications. At the municipal level, draft IEC material was pre-tested with four groups: health staff, FCHCVs, students, and community members. Pre-testing showed that the IEC messages and pictures were relevant and understandable. Subsequently, EDCD gave the directive to print and distribute the IEC chart. In the next field visit, the chart was posted at the health facilities, ward offices, and schools. 

Coverage results

A municipality team collected outcomes of the integrated campaign on post-LF campaign medication administration at nine health facilities. There was an increase in LF medication coverage to 90% in 2021 (16,260 out of 18,090) vs. 85% in 2020 (14,609 out of 17,141).  In total, 69 individuals received LF medication by visiting health facilities in the month of Baisakha (mid-April to early May) following the completion of the LF campaign, including migrant construction workers in the area. VAS coverage decreased to 80% in 2021 (1,296 of 1,611) from 85% in 2020 (1,259 of 2,076). This was reported to be due to children being away from the study areas with their families. 

It was noted that health workers at three booths observed that children aged 2-4 years had difficulty swallowing tablets; in one booth, health workers observed an elderly individual with a physical disability needed assistance to swallow the tablets.

Post-implementation phase

Findings of the field implementation were shared with the CIWG and suggestions made for improvement. Local health service providers suggested scheduling the next LF campaign in October, one week before the VAS campaign, in order to increase coverage.

Challenges and mitigation

Several challenges were reported in this pilot of the integrated campaign.

• Competing priorities due to COVID-19 response: Some officials were not available for meetings due to COVID-19 response. 
• Challenges in scheduling officials for collaborative planning meetings: Convening, scheduling, and advocating across many busy officials is difficult and time-consuming.
• Lack of policy directives and guidelines for integration of the health campaigns..
• Difficulties with integrated logistics management: This affected the VAS campaign’s human resources and incentive planning.
• Lack of budget for conducting awareness-raising activities: There was a need for outreach to people who had been absent from the community during MDA due to festival travel.
• FHCVs experienced some confusion in sharing both campaigns’ information about differences in target ages: The VAS campaign targeted children aged 6 months to 5 years, whereas LF MDA targeted children aged 2 and above. 
• Drug hesitancy: There was misconception in the community that people taking hypertension and diabetes medication would have ill effects from combining these medications with LF drugs.
• Difficulty swallowing albendazole: Young children and people with disabilities needed special assistance.

During collaborative planning, potential solutions were identified, including:

• Utilizing the collaborative planning process to identify how processes for logistics and budgets for IEC could be combined
• Continued communication with officials at all levels
• Rescheduled LF campaign enabled use of the CMS approach by FCHVs
• Local, culturally sensitive IEC materials                               

Stakeholder perceptions

Stakeholders felt that integration would enable better use of resources for communication by developing and delivering communication messages jointly. They also felt that campaign integration would help to mobilize people of different age groups and build community leadership for VAS and LF campaign efforts. In other words, integration can create a ’critical mass’ of people who disseminate messages to families. 

FCHVs were supportive of the CMS approach and reported: “Many people have taken LF medicine in comparison to last year but some are still non-compliant. We informed every person about LF medicine in the home visit, and those who missed LF medications were referred and reported. However, providing both campaign interventions at the same time caused some confusion among health workers and the community, since the vitamin A program focused on children from 6 months to 5 years of age, and the LF program targeted children and adults above 2 years.” FCHVs were not always certain if a child should receive albendazole.

An official in the municipality stated: “This year’s LF campaign is more effective in comparison to the past two years. That is because we worked in collaboration with locally elected representatives. Moreover, the integration of the LF campaign and VAS informs people about both medicines at the same time, asks them whether they intend to take it or not, and educates them that it is effective. It has helped to increase the number of people taking LF medicine this time. So, it should continue….”     

During the KII with municipality officials, the study team asked what could be done to increase awareness among people returning from travel who had been absent during the LF campaign. The municipality’s Women and Children Section, Women’s Co-operative, and Education Section suggested mobilizing school children to ask family members who traveled for the festival season whether they had not taken LF medication, urging those who have not taken the LF medication to visit nearby health facilities. Similarly, the Municipality health section suggested directing health facilities to adequately stock LF medication and administer it to those who were absent during the MDA.

Program divisions expressed the following opinions of the collaborative planning process.

“To initiate a way forward to the collaborative campaigns, both program divisions [FWD and EDCD] should sit together, discuss the findings or evidence generated from this pilot study, review process, results, and outcomes, along with strengths, weaknesses, opportunities related to the vitamin A program and LF campaign integration. So that we can find out the possibility of integration of both campaigns and work together from the planning phase.”

“Even though the National Health Policy mentioned health programs should be integrated, there are some obstacles that exist. We should move forward gradually with the evidence generated by this project. Immediate action could be the development of interim guidelines on the VAS campaign and LF elimination campaign for targeted areas with a predominance of LF cases.”

“There is a need for further study with representative populations and sites for better understanding of the potential component to be integrated with best modality and benefits.”

Promising Practices 

The study team identified the following promising practices that should be consistently applied to collaborative approaches to campaign integration:

1. Form a CIWG to provide technical support and guidance during all phases of campaign integration, including pre-planning and planning. In Nepal, the CIWG included directors and focal persons from the national EDCD and the FWD, the Management division (Logistics section), as well as the HEAL Group. The CIWG approved a project work plan and guidelines, and issued directives for completing implementation activities.
2. Sensitize local health workers with an ‘exercise sheet’ comparing key aspects of the two campaigns. The ‘exercise sheet’ used in this case study was adapted from the Health Campaign Effectiveness decision tool. Health workers should also be engaged to get their views on integration.
3. Conduct observations during campaigns to understand challenges in field implementation (such as difficulty in swallowing albendazole).
4. Interact with communities to understand viewpoints, opportunities, and barriers to implementation, and mobilize local community groups (e.g., women, school children) to participate in public information campaigns.
5. Develop a CMS approach and train health workers and female community health volunteers in CMS when they promote and deliver the integrated campaign.  The approach comprised six steps: giving both campaigns’ information to community members, asking community members whether they had taken LF medication when FCHVs went to homes for the vitamin A campaign a week later, identifying and educating community members who had been missed by the LF campaign, referring people who had been missed by the LF campaign to a nearby health facility to take the LF medication, and reporting information to the respective health facility. 
6. Devise a plan to do outreach to migrants and mobile populations and to conduct catch-up campaigns. In Nepal, there is a need for a supplementary program to reach people missed in the scheduled campaigns in sites where travel is high, especially for populations traveling during festival seasons and migrant workers.
7. Develop IEC materials that are tailored to the needs and concerns of the community. In Nepal, one of the underlying issues was a misconception in the community that taking LF medication along with medication for hypertension and diabetes could be risky, so culturally sensitive IEC material was developed to reassure people that LF MDA is safe and eligible people should take it.

Lessons Learned

The following lessons learned were developed as a result of unexpected findings and/or challenges encountered during this study. 

1. Leadership in the concerned division of the MoHP can play an important role in the promotion of the programmatic need and policy mandate for integration. 
2. It is important for collaborative planning to involve stakeholders from both campaigns and across multiple levels. In Nepal, collaborative planning included stakeholders from both the LF elimination and VAS programs at each of the following levels: health sector federal program divisions, local governing bodies, local health service providers, and the community.
3. Use of a complimentary monitoring and supervision approach to identify people who have been missed by campaigns can help identify and reach persons in need of a specific intervention.
4. Collaborative planning may be an opportunity to identify local community groups to mobilize for the campaign. For example, school children can be mobilized to encourage immediate family members returning home from festivals to take LF medicines.
5. Greater health worker capacity building and a stronger system of support for health workers are needed in an integrated campaign to minimize any confusion and promote clear messaging on the integrated campaign in the community.
6. It is important to sensitize communities through the use of culturally appropriate IEC materials that address specific concerns in the local language, with familiar images to clearly communicate concepts.
7. Sufficient time should be allocated to train local health facility staff and health workers in the use of the tools developed for microplanning. This time needed for training may be increased in an integrated campaign.
8. Section chiefs from sectors such as Agriculture, Women and Children, Veterinary, and Ayurveda should be included in collaborative planning meetings at the municipality level. As the implementation body for all development programs, the municipality provides a forum for collaboration across sectors.

Conclusion and Recommendations

This pilot case study indicated the importance of collaborative planning, demonstrated the possibility of integration, and identified challenges and potential actions to take to improve success.

In Nepal, a representative study should be prioritized to reflect national prospects for collaborative planning of campaigns. Such a study would provide a higher level of evidence to promote policy change given the country’s transition to a decentralized health system.     

The CMS approach is viable at the implementation level at the municipality, the local governing body in a decentralized health system. The CMS approach could be introduced and utilized by FCHVs during their home visits on the days following LF campaigns. Training in CMS can be included in the next campaign’s orientation of FCHVs with a short amount of additional planning time. Support structures should be strengthened for FCHVs to ensure their success.

The LF campaign is usually held in February, and the VAS in April and October. The government may choose to approve the collaborative campaign of these two campaigns by scheduling them closer together, as was done in 2021 due to the COVID-19 pandemic. Such integration will save a dose of albendazole among children aged 24 to 59 months in the 11 districts where both campaigns are conducted.

References

1. Central Bureau of Statistics. Population Monograph of Nepal, Volume III, Economic Demography. Kathmandu: Central Bureau of Statistics. Nepal. 2017.
2. Department of Health Services (DoHS), Ministry of Health & Population. Annual Report 2018/2019. Nepal. 2021.
3. Department of Health Services (DoHS), Ministry of Health & Population. Annual Report 2018/2019. Nepal. 2020. Retrieved from:  https://dohs.gov.np/wp-content/uploads/2021/07/DoHS-Annual-Report-FY-2076-77-for-website.pdf
4. Rainas Municipality, Gandaki Province. Rainas Municipality Development Plan. 2020.
5. World Health Organization. Control of lymphatic filariasis: a manual for health personnel. World Health Organization; 4th Edition. Geneva. 1987.
6. Health Campaign Effectiveness Coalition. Decision Guidance Tool for People-Centered. Integration of Health Campaigns. Decatur, GA: The Task Force for Global Health, 2021.