The Tropical Disease Research (TDR) program of UNDP/World Bank/WHO/UNICEF piloted Community Directed Intervention (CDI) for ivermectin distribution for onchocerciasis (river blindness) control in 1995, and found that it provided greater coverage than distribution efforts organized by only the health authority. With CDI communities made decisions when and how to collect their annual ivermectin supplies, about the preferred mode of distribution (house-to-house, central), and days when distribution would occur, and who would be their volunteer Community Directed Distributors (CDDs). This model was adopted by the African Program for Onchocerciasis Control (APOC) and has become possibly the largest community participatory disease control mechanism in Africa, and possibly the world, reaching millions residents in isolated villages who often rarely see the formal health service. While the health system provides training, supervision and commodities, it is the villagers themselves that organize their own ivermectin distribution.
Two years ago, TDR embarked on new research that tested whether other health interventions could be integrated within the CDI model. Thus, in selected districts in Cameroon, Nigeria, Tanzania and Uganda CDDs are also promoting home management of fever with antimalarials drugs, distributing insecticide treated nets, undertaking case detection for TB, and giving Vitamin A, in addition to annual ivermectin doses. One new intervention was introduced at each site in each of four trial districts, while the fifth serviced as control (offering only ivermectin as usual). A second intervention was added in year two. In the third and final year, all five interventions will be taking place in the four study districts at each site. Effort was made to ensure that the district health departments had supplies of all commodities, but only in the intervention districts were the commodities made available through the CDI approach.
The research teams recently completed a data analysis workshop on progress made by year two. ITN ownership, net use and timely and appropriate home management of malaria episodes in children under five years of age showed significant progress over baseline and compared with the control areas where only ivermectin distribution was provided through the CDI approach.
The key lesson is that even though malaria commodities are supplied to district health services, they do not always reach people unless the community is involved. Some countries are including community volunteers in their malaria strategy, such as Role Model Mothers in Nigeria. We hope that with the preliminary results of TDRâ€™s CDI study, more countries will take seriously the need to get communities actively involved in their own malaria control efforts.