On February 10, 2015, India’s first National Deworming Day, 89 million children received treatment at schools and preschools for parasitic worms. Our small organization, Evidence Action, worked with India’s national and state governments and a host of other stakeholders to accomplish this task—the largest one-day deworming program to date.
How did we achieve that kind of reach with just 50 full-time employees and a handful of short-term workers in India? Our success is based on a three-prong strategy: a sustainable program structure, skilled advocacy, and targeted technical assistance. A bit of background might help explain how we came to do this work in India.
As our name implies, Evidence Action’s mission is to scale up rigorously evaluated programs, filling the gap between knowing what works and achieving large-scale impact. When Evidence Action launched in 2013, we took over the management of the Deworm the World Initiative, which works with governments to develop and implement national school-based deworming programs. Deworm the World grew out of research in Kenya and was incubated by Innovations for Poverty Action, a nonprofit research network that designs and evaluates solutions to global poverty. We continue that work in Kenya and recently added Ethiopia, but the program in India is our largest.
Parasitic worms are endemic in India, where an estimated 241 million children are at risk. The highest rates of infection tend to be among children between ages 5 and 15. If untreated, worm infections interfere with nutrient uptake and can result in anemia, malnourishment, and impaired mental and physical development. They pose a serious threat to children’s health, education, productivity, and even lifelong earning potential. Yet research shows that deworming is safe, easy, and effective.
The Abdul Latif Jameel Poverty Action Lab considers school-based deworming a “best buy” in global health because it reduces school absenteeism, improves cognition and nutrition, and boosts future earnings—all for about 10 cents per child annually. Although mass treatment has some detractors, most experts and organizations, including the World Health Organization (WHO), endorse it over screening, which costs four to ten times as much as the treatment itself.
Capitalize on Existing Infrastructure
Deworming through schools—as opposed to health centers or home-based visits—reaches a large number of children at risk while minimizing costs. Teachers dispense the chewable pills once or twice a year, depending on how prevalent worms are in the area. Treatment decisions are based on the best available current guidelines by the WHO. School-based deworming programs aim to treat at least 75 percent of children at risk. And experience in other countries shows that school-based programs work. The annual national deworming program in Kenya, for example, reduced the prevalence of parasitic worm infections among schoolchildren from 33 percent to 18 percent from 2013 to 2014 alone. Prevalence rates—the percentage of children found with worms when tested—right after the 2014 deworming round fell to as low as 6 percent.
Identify Champion Government Officials
Succeeding in India required skilled advocacy. Parasites are a disease of poverty, and those most affected lack a strong political voice. In a country of about 1.3 billion people with 29 states and seven union territories—each with its own government—establishing a national deworming program is a logistical and political achievement of some magnitude. India faces many public health problems that need attention, such as malnutrition, anemia, and widespread open defecation. As government agencies and NGOs prioritize public health issues, deworming easily gets lost among competing priorities.
Although deworming programs are not new to India, large-scale school-based programs are. We are one of the few groups giving concentrated attention to the issue. To begin, we focused on reaching decision makers, first in India’s national government, which sets policy, develops program guidance, and provides funding to state governments. We worked closely with the Ministry of Health and Family Welfare and met frequently with officials there to discuss the problem and then worked with them to create a plan for a scalable program.
To advocate effectively, we described the gains made already in a number of Indian states and other countries. We also shared information on the prevalence of soil-transmitted parasites in different regions of India. Officials asked for detailed additional information, including effective methods for rolling out large-scale deworming programs.
We understand that government agencies are often understaffed and have to deal with any number of priorities. So we try to make it easy to support a deworming program.
Securing support at a national level was helped by the fact that we had already been working in several states with the local Health, Education, and Women and Child Development departments. We had learned there to tailor our communications and emphasize our work’s connection to priority issues. For example, when we talked with education officials we focused on cognitive and educational benefits. When we spoke with staff in the Department of Health, we focused on the health impacts of deworming.
We understand that government agencies are often understaffed and have to deal with any number of priorities. So we try to make it easy to support a deworming program. Before speaking with state officials, for example, we look at available data on worm loads and proxy indicators such as open defecation, anemia, and malnutrition rates, in addition to budgets and policies. If the state has a vitamin A supplement program for children, but not a deworming program, we advocate robust deworming as well, because evidence shows that vitamin supplementation is not as effective if a child has worms. This kind of background research helps to make an effective case for mass deworming.
Provide Targeted Technical Assistance
We also offer two levels of technical assistance to state ministries of health and education as needed: light and comprehensive. Light technical assistance works best for a state that already has the infrastructure for a robust deworming program and the resources to train teachers and pre-school workers. These states might need help in specific areas, such as mobilizing communities, and look to us to design a public awareness campaign.
Our comprehensive package of technical assistance, which runs from three to five years, assists governments in building a program from the ground up. Teachers and health care workers, for example, must be trained to administer medicine and educate children and communities about sanitation, hygiene, and preventing worm infections. In addition, we conduct surveys to determine worm prevalence, develop detailed operational plans, assist with procurement of drugs through donation programs, and monitor the quality of the program as it is implemented. We essentially provide all of the elements needed to create a good program and localize it for the community. And we do all the organizational legwork, such as getting the critical people together and helping them get the trained staff needed to run the program.
We currently work in six Indian states, providing comprehensive technical assistance to five. Engaging to this degree of depth requires our staff to be diligent. In addition, we use short-term workers for specific tasks, such as calling schools and collecting monitoring data during the deworming program so that we can assess how well it is implemented. Regardless of the level of support we provide, Evidence Action creates a customized plan that delivers what governments need. For example, a state government may ask us to assist with determining the extent of program coverage and the reliability of reporting on implementation.
In every case, a central component of our technical assistance is gathering and sharing evidence that governments can use to build best practices. For example, we are building a database that shares detailed costing for each state we work with. Those models help states assess what it costs to run a mass deworming program. In addition, we monitor the quality of deworming programs, enabling our partners to make better management decisions and create more effective programs.
In India, some states have been deworming school children for several years, but because they may not measure results, they may not know how effective their programs are. We help them measure the prevalence of worms before deworming, as well as their reach and coverage. In one instance, a large state treated 21 million children twice a year. This year, we did a prevalence survey and determined that it needed to do only one high-coverage round of deworming per year, saving resources that the government could use for other priorities.
Delivering deworming medicine to 89 million children on India’s first National Deworming Day represents a significant victory in the global fight against soiltransmitted diseases and other parasitic worms. The government of India has demonstrated a strong commitment towards tackling the public health threat of worms. We at Evidence Action are focused on continued advocacy and technical assistance for school-based mass deworming in India and elsewhere. Perhaps our strategy can help other organizations have the same sort of outsized impact delivering proven interventions.