Community Directed Distributors serving to save lives in Akwa Ibom State, Nigeria
by Bright C. Orji, Jhpiego, Nigeria
In 2011 when Jhpiego expanded its malaria program in Nigeria to include integrated community case management (iCCM) of malaria, diarrhea and pneumonia using community directed intervention (CDI) approach, the aim of the program was to encourage community participation through community selected volunteers in mobilizing community for better access to life-saving interventions. This iCCM intervention successfully built on existing CDI activities including distribution of insecticide treated nets and intermittent preventive treatment (IPTp) using sulphadoxine-pyrimethamine (SP) as well as an increased ante natal care attendance through community referral.
The communities in the CDI program were required to select as volunteers members of the community whom they trust and who were able to read and write, reside in the community and more importantly be willing to volunteer their time. The volunteers at the end of their training and under the supervision of the health facility lifesaving interventions such as conducting parasitological diagnosis of malaria using Rapid Diagnosis test (RDTs) and provision of anti-malarial drugs (ACTs) to the door steps of those at risk. They treated the three conditions according to the national guidelines.
Not only did communities select their own volunteers, but over time engaged in self-monitoring of the program and oversight of the volunteers, ensuring that community members volunteered actually carried out the tasks they agreed to take on. Communities also designed their own reward systems for the volunteers.
Ekpuk Essien and Ekpuk Itiat are kindreds (clans) in rural Ndon Eyo and Ikot Annang communities in the Niger Delta region of Southern Nigeria. Ekpuk Essien has a total of 29 households with 294 population compared to Ekpuk Itiat with 33 households and total population of 381. Both communities base their livelihoods on farming.
Ekpuk Essien selected Mrs. Comfort John while Ekpuk Itiat selected Mrs. Aniefiok Udofat and Uduakobong Aniedi Ikpe as volunteers. All the volunteers were trained at the same time on iCCM. On returning from the training Comfort went from one house to another treating children with fever and encouraging mothers and care-givers to ensure their wards slept under insecticide treated nets.
Last December, Ekpuk Essien recognized and rewarded Comfort with cash and promised to give her some seedlings for the forth-coming farming season. These are efforts to encourage Comfort to continue with her resourcefulness to the community.
However, this cannot be said of the Ekpuk Itiat. When Uduakobong and Aniefiok returned from the training. Uduakobong travelled to Uyo the capital city, her colleague Aniefiok was waiting for her return before providing services. Uduakobong failed to return at the agreed time. Itiat community has waited for almost a month without the volunteers providing services and meanwhile the volunteers had collected monthly stipend, a monthly token the community agreed to contribute to support the volunteers.
Therefore, the community summoned them and imposed a fine of one goat for failing to provide services. With current challenges in the management and control of malaria funding, the emergence of community self-monitoring gives the hope of Sustaining Gains, Saving Lives that would lead to more Investment in Malaria.
Both of these villages demonstrated the importance of community self-monitoring of health programs. Health workers can provide technical supervision for CDI and iCCM efforts, but only the community can hold its members accountable for delivering the life saving services.