E-drug: Community-Directed Treatment
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Source: tdr-scientists@who.ch
Herewith an other item of the new issue of TDR Newsletter which will
be available in October 97.
Stepping beyond with Community-Directed Treatment
based on an interview with Professor O.O. Kale*
'Radical'; 'a kind of mini-revolution'; Professor Oladele Kale is ex-
cited by the prospects for Community-Directed Treatment. 'Its not so
much a brand new approach to primary health care, but more a logical
extension of the concept. It is primary health care at a more basic
and practical level - not only is it health of the people, and for
the people, but it is also by the people.'
Dissatisfaction with the old primary health care (PHC) system, with
its inefficiencies and diversions, led a group of scientists and re-
searchers in Bamako in June 1994 to the idea of Community-Directed
Treatment (ComDT). ComDT goes a step beyond most community involve-
ment. It goes beyond merely asking the community about its wants and
needs, beyond mere partnership between the client and the care pro-
vider, to ownership by, and empowerment of, the community. Not only
is the community consulted about its wants and needs, as in commu-
nity-based treatment, but afterwards the community designs and imple-
ments the delivery of treatment too (whereas in community-based
treatment the control programme designs and implements the delivery
of treatment; in other words, the control programme tells the commu-
nity what to do). In 1994, it was not known whether the concept of
ComDT was at all practical; there was only a lack of satisfaction
with community-based treatment as it was then practised and some an-
ecdotal evidence (from Mali in particular) that community-directed
treatment might be better. Many people felt that communities would
not be able to handle the responsibility for drug distribution; and
even the communities were sceptical.
The mass distribution of ivermectin to populations at risk from on-
chocerciasis was used to test the concept of ComDT in a study which
was completed in 1996. Although ivermectin had been donated to the
countries, the PHC systems were not efficient at delivering it in the
right quantities to the right people, and so a multicountry study was
conceived in which ivermectin-delivery systems designed and imple-
mented by communities themselves were compared with those designed
and implemented by control programmes. The study involved eight sites
in five countries in Africa, which together covered a total popula-
tion of some 1.5-2 million people. Findings of the study showed that,
in all respects (effectiveness, acceptance, coverage), community-
designed systems were better than programme-designed systems. Commu-
nity-directed distributors adhered well to treatment procedures and
were able to differentiate between those who should and should not
receive the drug; they gave the correct dose, to within half a tab-
let, in over 90% of cases; and they were able to identify severe ad-
verse reactions and refer such cases to the nearest health facility.
The study was successful to the extent that ComDT has now been
adopted as strategy by APOC, and 19 countries are committed to making
it work.
What are the reasons for the success of ComDT? Primarily, success
rests in the philosophy of ownership and empowerment. During the
study, and as the communities became more confident, the part played
by 'ownership' became quite clear. Giving communities the freedom to
design their own system, to select the distributors they want, and to
change the system when necessary, means that the system is flexible.
Programme-designed systems, in contrast, are relatively inflexible.
Benefits that can be expected from ComDT include less diversion of
drugs (the possibilities for diversion are less when the people are
in charge themselves); better indicators for sustainability (less de-
pendance on health care from outside); and least distraction of vil-
lage life (having a distributor in the village means that drugs can
be distributed at night, when it is convenient to the villagers, and
not in the daytime, when it is convenient to the health workers).
The main difficulties encountered during the study were poor report-
ing (a problem which was actually more apparent in programme-designed
systems) and failure in supply (which depends on support from the
health system). Less of a problem was the resistance of some health
workers, who felt apprehensive about ComDT, that they were being dis-
placed and their status threatened.
What remains to be done therefore is to fine-tune ComDT, in particu-
lar to define more clearly how ComDT fits into the orthodox health
service. The two main points of contact between ComDT and the health
services are the taking care of cases of adverse reaction and the
supply of ivermectin to communities. Consequently, one of the next
steps will be to look at what information is needed - by both control
programmes and communities. The communities will not only be asked
what information they want, but also how they are going to go about
getting it - thus taking the concept of ComDT a step further (usu-
ally the health service tells the community what information it wants
and then gets it). Other points of contact between the health serv-
ice and ComDT include supervision and training. In the multicountry
study, some basic supervision by local health service staff was asso-
ciated with better performance in terms of treatment coverage than no
supervision at all; and the 'open' training (when the community could
look on) not only reinforced acceptance by the community but also re-
sulted in indirect monitoring of the performance of trainees by the
communities themselves. Involving health workers at the interface
right from the start, in meetings with the community, in the training
of distributors and in supervision, helped overcome resistance. An-
other issue is that of cost sharing and cost recovery.
In the multicountry study, ivermectin was mostly provided free of
charge. But in Cameroon, where a programme of cost recovery was in
place, coverage was less. We need to know therefore how paying for a
drug affects performance, since drugs are not always free of charge
and ComDT is applicable only in mass treatment programmes, where lots
of people without signs and symptoms of the disease, who may not per-
ceive the need for treatment, have to be reached. These are some of
the issues which will be looked at in the next multicountry study
planned for ten onchocerciasis sites in Africa. The challenge now is
to see if ComDT works in 'real life', as opposed to the experimental
conditions of the multicountry study. The challenge is to persuade
governments and control programmes to accept the philosophy - to ac-
cept that people can be empowered and that they have the intelli-
gence, willingness and ability to look after themselves.
But can the concept of ComDT be extended any further? ComDT is only
suitable for mass treatment, where a single drug is to be given in a
single distribution (no more than two times per year). It must be
easy to determine who should and who should not receive treatment.
And, preferably, there should be no need for laboratory diagnosis.
Some obvious candidates for ComDT therefore might be lymphatic fila-
riasis, schistosomiasis, and intestinal parasites; a study of ComDT
in lymphatic filariasis is already planned for eight sites in Asia
and Africa. With time, communities may be able to take on responsi-
bilities of a different nature, such as disease surveillance. The
guineaworm programme has shown that villagers can be used as village-
based health workers for control programmes and this approach has not
been fully exploited. And what about EPI? The health care system
must be persuaded to think of programmes other than drugs which could
benefit from the ComDT approach.
All in all, ComDT could be a technically important means of health
delivery. At the very least, it promises to be the most cost-
effective and sustainable variant of community-based mass deliv-
ery/distribution systems for chemotherapy-based disease control pro-
grammes.
--
* Professor O.O. Kale is Professor of Preventive and Social Medicine,
University of Ibadan, Nigeria; Chairman, (ex-) Task Force on Oncho-
cerciasis Operational Research, TDR;
Chairman, TDR Steering Committee on Applied Field Research;
Senior Consultant, Global 2000 Guineaworm Eradication Programme, Ni-
geria.
--
Jocelyne Bruyere
TDR Communications
WHO Geneva
mailto:bruyerej@who.ch
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