“RADICAL”, “a kind of mini revolution”; Professor Oladele Kale* is excited by the prospects for Community-Directed Treatment (ComDT). “It’s not so much a new approach to primary health care, more a logical extension of the concept It is primary health care at a more and practical level - not only is it of the people, and for the people, but it also by the people.”

* Professor Oladele Kale is Professor of Preventive and Social Medicine, University of Ibadan, College of Medicine, Department of Preventive and Social Medicine, PMB 5116, Ibadan, Oyo State, Nigeria. Tel. and fax: + 234 2 8103563, e-mail: sysop@nga.healthnet.org (mark message for the attention of Professor Kale). This article is based on an interview with Professor Kale, which was first published in TDR Newsletter, No. 54, October 1997.

Dissatisfaction with the old primary health care system, with its inefficiencies and diversions, led a group of scientists and researchers in Bamako, Mali, in 1994 to the idea of Community-Directed Treatment, which goes a step beyond most community involvement. It goes beyond merely asking the community about its wants and needs, beyond mere partnership between the client and the care provider, to ownership by, and empowerment of, the community. Not only is the community consulted about its wants and needs, as in community-based treatment, but afterwards the community designs and implements 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 community what to do). In 1994 it was not known whether the concept was at all practical; there was only a lack of satisfaction with community-based treatment as it was then practised and some anecdotal 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.

Community-Directed Treatment with ivermectin, near Kita in Mali. The house-to-house distributor fills in the paperwork, while his colleague holds the measuring stick used to determine dosage by height

Photo: WHO/TDR/A. Crump

Ivermectin study shows the benefits

The mass distribution of ivermectin to populations at risk from onchocerciasis was used to test the concept of Community-Directed Treatment in a study which was completed in 1996¹. Although ivermectin had been donated to the countries, the primary health care systems were not efficient at delivering it in the right quantities to the right people. Therefore a multicountry study was conceived in which ivermectin-delivery systems designed and implemented by communities themselves were compared with those designed and implemented by control programmes. The study involved eight sites in five African countries, which together covered a total population of some 1.5 - 2 million. Study findings showed that, in all respects (effectiveness, acceptance, coverage), community-designed systems were better than programme-designed systems. Community-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 tablet, in over 90% of cases; and they were able to identify severe adverse reactions and refer such cases to the nearest health facility. The study was successful to the extent that Community-Directed Treatment has now been adopted by the African Programme on Onchocerciasis Control and 19 countries are committed to making it work.

¹ WHO. Community directed treatment with ivermectin. Geneva: World Health Organization; 1996.

The value of “ownership”

What are the reasons for the success of Community-Directed Treatment? 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 flexibility. Programme-designed systems, in contrast, are relatively inflexible.

Benefits that can be expected from Community-Directed Treatment include less diversion of drugs (the possibilities for diversion are less when the people are in charge themselves); better indicators for sustainability (less dependence on health care from outside); and least distraction of village 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 reporting (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 Community-Directed Treatment - that they were being displaced and their status threatened.

Assessing information needs

What remains to be done, therefore, is to fine-tune Community-Directed Treatment, in particular to define more clearly how it fits into the orthodox health service. The main points of contact between the two occur when dealing with cases of adverse reaction and with ivermectin supply 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 Community-Directed Treatment a step further (usually the health service tells the community what information it wants and then gets it). Other points of contact between the health service and Community-Directed Treatment include supervision and training. In the multicountry study, some basic supervision by local health service staff was associated 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 resulted in indirect monitoring of the trainees’ performance 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.

Another issue to be addressed concerns 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 Community-Directed Treatment is applicable only in mass treatment programmes. Here lots of people without signs and symptoms of the disease, who may not perceive the need for treatment, have to be reached.

The next phase

These are some of the issues that will be looked at in the next multicountry study planned for 10 onchocerciasis sites in Africa. The challenge now is to see if Community-Directed Treatment 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 accept that people can be empowered and that they have the intelligence, willingness and ability to look after themselves.

But can the concept of Community-Directed Treatment be extended any further? It is only suitable for mass treatment, where a single drug is to be given in a single distribution (no more than twice 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, therefore, might be lymphatic filariasis, schistosomiasis and intestinal parasites. A study of Community-Directed Treatment in lymphatic filariasis is already planned for eight sites in Africa and Asia. With time, communities may be able to take on responsibilities of a different nature, such as disease surveillance. The guinea worm 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 the Expanded Programme on Immunization? The health care system must be persuaded to think of programmes other than drugs that could benefit from the Community-Directed Treatment approach.

All in all, Community-Directed Treatment 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 delivery/distribution systems for chemotherapy-based disease control programmes.