Community Directed Interventions for Malaria

Last year we reported on the second year results of the UNICEF/UNDP/World Bank/WHO Tropical Disease Research (TDR) Program’s Community Directed Intervention (CDI) Multi-Country study. CDI was originally developed for annual distribution of ivermectin as part of the African Program for Onchocerciasis Control. The current study tested whether the community and the volunteer distributors selected by the community could manage additional health interventions. Included in the trial were ITNs for children and pregnant women, home management of malaria with Coartem, Vitamin A and TB case detection.

At the end of the second year of the study “Malaria home management coverage doubled, Bednet coverage doubled to quadrupled, Vitamin A coverage was significantly higher, and TB case detection rate doubled.” One of the seven research team leaders, Richard Ndyomugyenyi of Uganda, explained that, “… if we involve them (the community) as stakeholders right from the beginning, and they are following up what you are doing, it becomes easy for them to implement, because those results would also be theirs.”

Richard further noted that, “The main reason this works seems to be that this process [CDI] empowers the communities to own the process and the programme. So they actively participate in deciding how these interventions should be delivered – so they take an interest in their own program, and it increases coverage”

According to Elizabeth Elhassan, the team leader from Kaduna, Nigeria, “Once you empower people, and they realise it is for their own benefit, it becomes a priority for the communities.” Of course community participation must be coupled with availability of commodities. “The study went well, particularly in 2006 as we had a reasonable supply of materials: nets, antimalarials, and vitamin A, to both the study and the comparison arms,” Elizabeth told RealHealthNews.

The seven teams from Nigeria, Cameroon and Uganda just completed their third year and final data analysis last week in Douala.  Interventions were added to the existing ivermectin distribution each year to observe how communities could handle the extra responsibilities. In control arms normal ivermectin distribution occurred but the other interventions were provided to the district health authorities to distribute through their ‘normal’ channels. The CDI process used in the research is described on the TDR website where a short video clip from the team that worked in Taraba State, Nigeria can be found.
cdi-preliminary-sm.jpgThe accompanying graphs show that the results have maintained a positive direction.  The study arms that received the malaria interventions by the second year had higher coverage than those in the other two arms in year two and by the third year those who had received the interventions in either year did better than the control districts/arms.  ITN coverage for pregnant women and home management of malaria showed the best results.  The improvements in ITN coverage for children were still below RBM targets, and qualitative results indicated that better follow-up by the volunteer distributors in reminding people to use the nets is needed.

Clearly the community directed participatory approach can help get basic health commodities to people living in remote and rural areas. Qualitative results found that the malaria interventions were particularly successful because communities see malaria as a serious problem that affects everybody.

The research teams are now planning advocacy meetings with policy makers in their countries, while TDR staff are sharing the results internationally to encourage other countries and donors to adopt the CDI approach.

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