In the past couple months I have presented information on the community directed intervention (CDI) approach at several meetings. The common question arises, “Can volunteers handle all those different interventions?”Â This made me realize that the CDI approach, though well accepted in the onchocerciasis control community, may not be understood by others.
CDI was developed through field research in 1995 as a way of ensuring that the ‘people beyond the end of the road’ would be able to get annual ivermectin treatments to control onchocerciasis by reducing microfilariae loads and reducing the fertility of the adult female Onchocerca volvulus worms.Â CDI was adopted as the official mechanism for ivermectin (Mectizan) distribution by the African Program for Onchocerciasis Control (APOC) when it was launched in 1996.
CDI means that the community takes responsibility for ivermectin distribution in terms of conducting a village census and maintaining a village register, deciding on distribution days, times and modalities, collecting the ivermectin from the nearest health facility, managing simple side effects and referring adverse events and finally submitting simple records of treatment. In the process the community may select one or more volunteer community directed distributors (CDDs) to handle the different tasks, but at the same time community members like chiefs, opinion leaders, and others such as traders and teachers, may equally help with tasks like mobilization to take the medicine, collecting the ivermectin from the health center and returning the tally sheets after distribution.
In short CDI is not specifically a ‘volunteer’ program. It is a program where the community takes responsibility and divides up the tasks. The community can decide to change its approach, select new CDDs, ask other community members to help, try new distribution mechanisms – e.g. change from a house-to-house format to a central place distribution event.Â In short, the process is not and should not be dependent on an individual volunteer.
Recently APOC and the UNICEF/UNDP/World Bank/WHO Tropical Disease Research Program (TDR) have documented that other health and development programs have taken advantage of the existence of CDI to promote activities ranging from immunization coverage to agriculture extension. Subsequently APOC/TDR have intentionally tested the addition of specific tasks to the CDI process and found that not only does the community approach guarantee better coverage of these additional services (home management of malaria, bed net use and vitamin A consumption), but those communities that add these services to their ivermectin CDI activities actually achieve better ivermectin coverage than communities without the additional interventions.
The project did find that not every task is appropriate for CDI. For example, efforts to carry out Directly Observed Therapy Short-course for Tuberculosis were not possible in five of the seven research sites because of health worker resistance and community perceptions of stigma.Â Alternatively recent study has found that CDI can be used to provide intermittent preventive treatment for malaria in pregnancy because the CDDs and the community can be effectively linked to the nearest health center for ogistical and technical support.Â Additionally a new report from APOC documents how the CDI approach can strengthen health systems.
APOCâ€™s strategy of community-directed treatment has brought continent-wide success for onchocerciasis control in Africa while other health initiatives have floundered. This report explores how community-directed treatment is helping to supplement and reinforce health systems, while empowering communities to control disease.
Finally CDI works best when it is introduced at the most basic unit of community.Â A town may be too large. In southeastern Nigeria, for example, towns are composed of several villages and each village contains several kin groups or clans (extended families of 100-200 people). These kin groups are the best level to implement CDI because even when volunteers are selected, they are accountable to close friends and relatives whom they would be helping anyway.
So to borrow from a former US President – don’t ask what community volunteers can do for you, ask what you and your whole community can do for each other.