Reaching the Last Mile: Expanding Deworming to Migrating Populations in India
By Aparna Ananthakrishnan, Knowledge Management Associate, Evidence Action
Guddi is a 25-year-old mother of three and a migrant laborer working at a brick kiln in the north eastern state of Tripura, India. She is not conversant in the local language, lacks a formal education, and her daughters do not attend school regularly. Life at the kiln is physically demanding and low-paying; this has limited her health-seeking behaviors for herself and her family. She is further alienated from accessing health services due to illiteracy and until recently, was completely unaware that her children could live a life free from intestinal worms.
Neglected tropical diseases disproportionately affect people living in poverty, especially those who are difficult to reach via traditional mass drug administration channels. The treatment of these diseases should constitute an important building block of universal health coverage (UHC) efforts across the global south. India faces the highest burden of soil-transmitted helminths (STH) globally, with over 225 million children at risk of parasitic worm infections. The implications for those affected are severe, with long-term impacts on nutrition levels, economic potential and overall quality of life. India’s National Deworming Day (NDD), initiated in 2015, is the world’s largest single-day public health intervention, providing children between the ages of 1–19 with free deworming tablets. Most treatments are delivered by teachers in schools and workers at anganwadi centers (preschools), where out-of-school children are also welcomed and encouraged to come for treatment. Since STH infections are especially common in poorer populations that lack basic services, such as safe water and sanitation, governments implement strategies to include high-need but hard-to-reach groups such as out-of-school children, migrant populations and children living in geographically remote areas. As part of Evidence Action’s technical assistance to the Government of India and select state governments for NDD, we are collaborating on several tailored strategies to target hard-to-reach children, including migrant workers in Tripura.
Prior to NDD, Guddi had no knowledge of the health implications of intestinal worms or that the government offered free deworming. After learning about NDD through the program’s community mobilization efforts, she recognized its importance for her daughters’ short and long term well-being, and brought them for treatment. She continued to spread the news about the program to other mothers at the kiln who could have their own children treated on mop-up day, which happens a few days after the NDD to capture those missed.
Tripura’s pioneering efforts to conduct deworming at brick kilns began in February 2017, in response to the presence of child laborers and out-of-school children whose parents work at the kilns. The strategy centered around community-level mapping of kilns and ensuring that frontline health workers who manage local primary health sub-centers in each region, such as auxiliary nurse midwives and multi-purpose workers, communicated closely with kiln managers to set up temporary treatment booths at these locations. At these booths, multi-purpose workers explained the benefits of deworming before administering the drugs to the children. The booths displayed sensitization materials to inform children, families, and workers about NDD and the benefits of deworming as well as messages supporting good health and hygiene practices.
In the January 2018 treatment round, the government of Tripura reported deworming 1.09 million children. In the state’s concerted outreach efforts to migrant communities near brick kiln sites, 7,400 children were targeted with about 6,500 ultimately treated (nearly 88% of the target). Although this effort was successful and has been replicated since, there remains opportunities for larger expansion into more treatment geographies as well as at-risk populations.
Most of the deworming programs that Evidence Action supports face some degree of challenge in reaching out-of-school or other hard-to-reach children. While some countries or states devise strategies to reach island communities or pastoralist groups, in Tripura, health worker teams must identify the migrant communities, such as tea plantation workers, laborers, and brick kiln workers, who move across state boundaries every four to five months, and encourage these populations to come for deworming. On top of logistical difficulties, migrant workers are often selective about the health services they seek and may be harder to mobilize.
To ensure that the benefits of UHC enable societies to reach their full potential, there is an active need to prioritize initiatives that facilitate greater inclusion of vulnerable populations. Neglected tropical diseases, from their very name, suggest that they face the dual burden of inadequate focus within health systems, as a subset of infectious diseases and in terms of the disproportionate prevalence in sub-groups of marginalized populations. Prioritizing these cost-effective treatments, which protect at-risk children like Guddi and allow them to realize their productive potential in the future, must be central to our UHC efforts if we truly are to leave no one behind.
