Community-directed primary health care interventions are far more effective than other methods in getting basic treatments to those who need them in remote rural areas of Africa, concludes an unprecedented three-year study done in four African nations. The study covered 2.35 million people, living in seven research sites in Cameroon, Nigeria, Uganda and Tanzania.

The study found that the approach doubled the use of home-adminstered anti-malarial drugs, use of bed nets approached 60% even where nets were scarce; Vitamin A supplement coverage was significantly higher than control sites, reaching an average of 90% of eligible children, while Onchocerciasis (river blindness) annual treatment jumped from 10% to 74% of the populations studied., compared with existing approaches. The health care costs were similar in the CDI and control districts, making CDI more cost-effective in part because of the many volunteer hours spent by local communities.

The 130-page study was presented at the 4th Primary Health Care Conference which opened in Ouagadougou, Burkina Faso, on Monday. It is being attended by more than 30 health ministers and is focusing on innovations.

“The findings indicated that the community-directed approach has potential for far broader applications,” said Dr Hans Remme of the Special Programme for Research and Training in Tropical Disease (TDR) which oversaw the research done by eight multi-disciplinary research teams from both anglophone and francophone West, Central and East Africa. The studies reported on were carried out between 2005 and 2007 in seven research sites comprising a total of 35 health districts in Cameroon, Nigeria, and Uganda, where community-directed treatment with ivermectin for onchocerciasis control had been implemented for several years. The data from Tanzania, still ongoing as the report was being written, will be reported later.

TDR developed the “community-directed” approach a decade ago to deliver the drug ivermectin, being provided free by Merck, the pharmaceutical company that delivered it, to more than 55 million Africans at risk of river blindness (onchocerciasis) living in  remote, rural areas without doctors or health care centres. The drug kills worms that cause onchocerciasis, a debilitating disease that causes severe skin lesions and itching, and eventually blindness. Since that time, CDTi has demonstrated that people living in remote communities can direct distribution, store drugs, and sustain a program that needs to be done annually.

Community participation in CDTi is known as “structural participation”, in which community members play an active and direct role in project development and decision making. This is a different level of participation from “marginal participation”, when communities have very limited influence, or “substantive participation”, where decision-making is externally controlled although community members can identify needs and contribute to activities. The term “structural participation” implies “a shift in power and decisionmaking, which allows for communities to play a more substantive role with support from the health system and other facilitators”.

The CDTi experience, coupled with the larger need to improve overall access for Africa’s poor to other critical health care tools, prompted the Board of the African Programme for Onchocerciasis Control (APOC) to commission the study in 2005 to examine see if an expanded CDI strategy could combat other diseases in communities with prior experience with CDTi. As health ministers of 19 onchocerciasis-endemic countries are represented on the APOC Board, the study was seen as having significant relevance both to national level policy-makers and health professionals in the field.

Preparatory consultations with key partners showed that given the varying attitudes toward CDI within the scientific and expert community, a scientific comparison of community-directed and alternative approaches for delivery of specific health interventions at the community level in Africa, including those used for onchocerciasis control, was needed to provide clear, measurable, and objective evidence about the specific advantages and disadvantages of a community-directed intervention strategy.

When study findings were presented to APOC’s governing board, the Joint Action Forum (JAF), in Brussels in December 2007, the JAF endorsed the recommendation that CDI systems should now be used more broadly for other health treatments. APOC will now work to help expand into countries currently using this approach for river blindness alone, and will work with Ministers of Health and TDR to assess how to implement this approach in areas that have never used the community-based process before 

The Special Programme for Research and Training in Tropical Diseases (TDR) is an independent global programme of scientific collaboration. Established in 1975 and co-sponsored by the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP), the World Bank and the World Health Organization (WHO), it aims to help coordinate, support and influence global efforts to combat a portfolio of major diseases of the poor and disadvantaged. TDR focuses on neglected infectious diseases that disproportionately affect poor and marginalized populations.

This story was prepared from a TDR story entitled Community-directed interventions for major health problems in Africa; information in the study report, an April 29, 2008 Panafrican News Agency story entitled Burkina Faso: Community-directed health works; a story entitled BBC Survivors' Guide series profiles TDR-research; and a RealHealthNews interview entitled Could river blindness lead the way?

 

 

 

 

 

 

 

 

 

 

 

 

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