News
28 September 2010
Dear Colleague in the fight against Neglected Tropical Diseases,
We are pleased to introduce to you a joint initiative by the Liverpool School of Tropical Medicine—Centre for Neglected Tropical Diseases and Helen Keller International entitled "NTD News for Africa". Over the past few years there has been growing commitment from national Governments, technical partners and donors to move NTDs from being marginalized to becoming a health and development priority. There is an increasing volume of scientific literature being produced related to NTDs. However the richness of this literature itself poses its own challenges, as those of you in the frontlines of controlling these diseases often do not have the access and the time to cull out what is most immediately relevant for your programs.
"NTD News for Africa" is a monthly electronic newsletter whose aim is to disseminate state-of-the-art research and policy papers to scientists, program planners, policy makers, and opinion leaders working in the field of NTD control in Africa. Students and faculty members of the Centre for Neglected Tropical Diseases and staff members of Helen Keller International identify and will summarize relevant articles and policy statements from the scientific literature and international agency publications. We also encourage members of this network to suggest possible documents of interest and to provide feedback on the articles selected. "NTD News for Africa" will be published in English, French and Portuguese.
Please forward "NTD News for Africa" to any of your colleagues who may be interested, and encourage them to subscribe by sending an e-mail request to NTDNews@hki.org.
Helen Keller said "Although the world is full of suffering, it is full also of the overcoming of it." We are poised to make major strides in overcoming the suffering of millions in Africa caused by NTDs – we hope that this newsletter can contribute to the cause.
Yours in control of Neglected Tropical Diseases,
Moses Bockarie |
Shawn K. Baker |
28 September 2010
Community-directed interventions for priority health problems in Africa: results of a multicountry study
The CDI Study Group, Bull World Health Organ 2010;88:509-518
Introduction
Despite the proliferation of health initiatives, impact on the poorest in remote communities, is still not adequate. Community-directed intervention (CDI), whereby the communities themselves plan and direct implementation, adopted by the African Programme for Onchocerciasis Control (APOC), has led to successful annual distribution of ivermectin to millions of people in sub-Saharan Africa. The success of the strategy prompted APOC to solicit the Special Programme for Research and Training in Tropical Diseases (TDR) to investigate the extent to which the CDI strategy can be used to carry out multiple health interventions.
Methods
A 3-year multicenter experimental study of health intervention delivery was conducted in 7 study sites in Cameroon, Nigeria, and Uganda. Each site included 5 health districts of which 4 were randomly designated trial districts where 5 health interventions were phased in and the fifth was randomly assigned as a comparison district where the 5 interventions were delivered conventionally. The 5 interventions of different complexity were CDI where community-directed treatment with ivermectin had been well established, vitamin A supplement (vit A), distribution and retreatment of insecticide-treated nets (ITNs), detection and referral of tuberculosis cases and short-course, directly-observed treatment (DOT), and home management of malaria (HMM). Quantitative and qualitative indicators were established to assess the intervention effectiveness using a standard questionnaire for a representative sample of households and costs were estimated at district, first-line health facility and community levels. In total, 584 interviews with community implementers, 371 interviews with health workers, 278 interviews with community focus groups, 147 interviews with key informants of the non-governmental organization (NGO) partners, and 445 focused discussions during stakeholder briefings and structured observations using checklists were conducted.
Results
Complete coverage evaluation was conducted only in years 2 and 3. The coverage for vit A, ITN and HMM was significantly higher when delivered through CDI. The coverage even doubled for antimalaria interventions in trial districts. In contrast, DOT could only be fully implemented in 1 district due to the resistance of health workers, and did not show any difference. The integrated interventions also benefited ivermectin treatment coverage with a 10% increase.
The calculated median cost per district for CDI was US $15,000 and US $30,000 for non-CDI districts (P=0.007). Allocations of the cost were similar with staff salaries constituting half of the total. At the first-line facility level, differences in the cost were not statistically significant (P=0.51), median costs were US $1,025 for the CDI districts and US $1,170 for comparison districts. At community level, the median opportunity cost for community implementers was slightly higher for trial communities at US $65 than for non-CDI communities, at US $44; however the difference was not statistically significant (P=0.24).
Critical process factors of the CDI strategy were also evaluated. With regard to the stakeholders' consultation and mobilization, the degree of consensus on the integration of the interventions grew as CDI matured. Positive results reinforced the commitment of the stakeholders. The health systems at the end of the study period had improved their procurement, supply and distribution of the needed intervention materials, although there was a shortage for implementation at the beginning of the study due to the increased demands of multiple interventions. The third critical factor evaluated was the communities' participation. The high perceived value of the interventions and the consensus building process of the CDI approach resulted in strong participation of all the communities which in turn empowered them and enhanced ownership. The community implementers valued more communities' intrinsic incentives than outside incentives. Nevertheless they concomitantly wished for external financial incentives as conventional interventions practice. Other positive systemic effects included enhanced community awareness of public health issues and their related rights and responsibilities; increased women's participation; and enhanced partnership between health workers and communities for delivery of interventions.
Discussion and conclusion
The authors concluded that CDI approach could sustain multiple interventions and remain cost-efficient thus would be a platform for the integration of several health delivery interventions. The major limitations of the approach seemed to reside in the social factors such as acceptability by communities and in the health system factors leading to the shortage of materials and the unwillingness to entrust communities for the administration of DOTs. Integration of multiple health deliveries through CDI strategy proved to be feasible and sustainable when all the interventions materials were available. There was a willingness of all partners to support the CDI approach, since it allowed coverage increase and costs savings. The investigators stressed that CDI builds on the core principles of primary health care. APOC recommended that the approach be adopted for integrated health interventions and confirmed APOC's commitment to the CDI approach to reach all the people at risk of onchocerciasis.
Editor's comments
Community-Directed Treatment with Ivermectin (CDTI) is a well established CDI system for onchocerciasis control in sub-Saharan Africa. Hundreds of thousands of trained community drug distributors have delivered annual treatment to millions of people throughout sub-Saharan Africa. There have been other reports that the CDI platform has been successfully used to distribute insectide-treated nets for malaria and vitamin A supplementation and to provide comprehensive eye care by detecting eye diseases such as cataract and integrated drug delivery for lymphatic filariasis (Haddad et al. 2008). This multicenter study provides further confirmation of the feasibility of using the CDI platform to provide an effective and efficient approach for a number of health intervention deliveries.
In the current integrated control of Neglected Tropical Diseases (NTDs), the CDI system is certainly one of the existing platforms along with Child Health Days that can be used to expand the program coverage for the control of other major NTDs. A good example comes from the NTD control program in Sierra Leone (Hodges et al, submitted for publication). However, as a national NTD control program, the delivery strategy must be carefully thought out and selected according to local situations in each country. There are some cautions with using the CDI platform. Firstly, the CDI should be part of the existing primary health care system as for any other platforms, and should not be treated as a standalone system. Secondly, the existing CDTI is present only in onchocerciasis endemic areas, and the feasibility and cost of establishing and using such a system in non-onchocerciasis endemic areas need to be studied. Thirdly, the CDI system relies on the trained community implementers whose ability and literacy level must be considered. Before integrating any additional health interventions into the CDI system, feasibility studies, such as the ones presented in this article, must be carried out to avoid overburdening the system. Finally, the CDI system has evolved and proven very effective in rural communities. In urban settings, a different system is needed for intervention delivery (Hodges et al, submitted for publication).
Recommended readings
Haddad D, et al. Health care at the end of the road: opportunities from 20 years of partnership in onchocerciasis control. Glob Public Health. 2008;3(2):187-96.
Kabatereine NB, et al. How to (or not to) integrate vertical programmes for the control of major neglected tropical diseases in sub-Saharan Africa. PLoS Negl Trop Dis. 2010;4(6):e755.
12 August 2010
It is with great sadness that the NTD NGDO Network notes the death of Dr. Bernadette Yoda, Coordinator of the National Program for the Prevention of Blindness in Burkina Faso. Dr. Yoda led her country's efforts to eliminate trachoma as a blinding disease and was a valuable presence at the GET 2020 meetings over the past 10 years. Her passing is a great loss for her country and the international trachoma community.
Earlier this year, Dr. Adrian Hopkins, NTD NGDO Network chair, and Dr. Simon Bush, vice-chair, sent a letter to UK Secretary of International Development, the Right Honorable Andrew Mitchell, requesting that NTDs be supported by the European Union within the Millennium Development Goals (MDG) framework. They received the positive response that individual MDG issues will be discussed at the upcoming UN MDG Summit in New York and that the UK's Department for International Development (DFID) will work on strengthening possible references to NTDs at the Summit. In the letter, Secretary Mitchell agreed that addressing NTDs is an important component of achieving the MDGs, particularly MDG 6 - Combat HIV/AIDS, malaria, and other diseases.