Applied Research and Evaluation The Potential for Community-Directed Interventions: Reaching Underserved Populations in Africa International Quarterly of Community Health Education 2015, Vol. 35(4) 295–316 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X15592757 qch.sagepub.com William R. Brieger1, Johannes U. Sommerfeld2, Uche V. Amazigo3, and CDI Network4 Abstract Community-directed interventions (CDIs) have the potential for fulfilling the promise of primary health care by reaching underserved populations in various settings. CDI has been successfully tested by expanding access to additional health services like malaria case management through local effort in communities where ivermectin distribution is ongoing. The question remains whether the CDI approach has potential in communities that do not have a foundation of community-directed treatment with ivermectin. The UNICEF/UNDP/World Bank/WHO Special Program of Research and Training in Tropical Diseases commissioned three sets of formative studies to explore the potential for introducing CDI among nomads, urban poor, and rural areas with no community-directed treatment with ivermectin. This article reviews their findings. Community and health system respondents identified a set of mainly communicable diseases that could be adapted to CDI as well as participatory mechanisms like community-based organizations and leaders that could form a foundation for local organizing and participation. It is hoped that the results of these 1 Department of International Health, Health System Program, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2 UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland 3 African Program for Onchocerciasis Control, World Health Organization, Ouagadougou, Burkina Faso 4 Principal Investigators and their institutions listed in Appendix Corresponding Author: William R. Brieger, Department of International Health, Health System Program, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA. Email: wbriege1@jhu.edu 296 International Quarterly of Community Health Education 35(4) formative studies will spur further research on CDI among peoples with poor health-care access. Keywords access, infectious diseases prevention and control, community-directed interventions, nomads, urban and rural health systems, Africa Introduction While development strategies to achieve the Millennium Development Goals,1 the Roll Back Malaria targets,2 and now Universal Health Coverage3 recognize that access issues are key barriers to health services, there is yet to be full agreement on how to expand access and coverage of basic primary health care (PHC) commodities and services. The promise of accessible PHC enshrined in the 1978 Alma Ata Declaration has rarely been fulfilled in a systematic way, especially that form of PHC in which communities take responsibility for delivering basic services themselves.4 Soon after Alma Ata PHC broke down into selective PHC wherein frontline health services attempted to provide a few essential child survival services that were expected to have high impact and scattered comprehensive community PHC efforts by nongovernmental organizations (NGOs) and university researchers.5 Once separated at birth, neither approach to PHC had the strength to achieve widespread coverage, of what is now being termed universal access. Selective PHC lacked the reach into physically and socially remote communities, and comprehensive efforts lacked access to adequate supply systems for essential commodities. Reaching the Hard-to-Reach Through Community Participation Nearly 20 years later, the African Programme for Onchocerciasis Control (APOC) in collaboration with the UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases (TDR) designed intervention research that tested the relative effectiveness of ivermectin distribution through a community-based approach involving outreach by health agencies compared with a community-directed version where communities, with training and support from health agencies, planned, organized, and supervised their own ivermectin distributions. This first study in 1995 found that community-directed treatment with ivermectin (CDTi) achieved higher coverage than health system-oriented community-based distribution (CBD).6 Thus, when Brieger et al. 297 APOC started awarding grants to country programs in 1996–1997, it required that program design be based on CDTi.7 The distinction between CBD and community-directed intervention (CDI) rests on the level of agency exercised by communities themselves.8 CBD focuses on selecting local agents, volunteers, or low-paid cadres or on outreach through mobile clinics of various levels of sophistication, to deliver a set of commodities and services provided by the health service. Community-directed distribution also focuses on a basic package of commodities and services but differs in that it puts the responsibility of the design and implementation of distribution on the communities themselves. Thus, communities conduct their own censuses to estimate need, select as many volunteer community-directed distributors (CDDs) as they think they will need to get the job done, support these CDDs to get training, help collect supplies and commodities from the closest health services, maintain a community register and records of any distributions, and overall ensure that any volunteers are held accountable to community expectations and norms. So while both approaches appear to take place in the community, CBD is organized fully by the health system, while CDI is organized by communities with support from the health system. The latter approach grew out of the CDTi program of APOC and has sustained ivermectin distribution in over 200,000 villages for over 15 years. In contrast, the CBD approach is always bemoaning drop out of their selected distributors or lack of petrol for their outreach vehicles. With CDI, the community takes charge and does not rely on any one volunteer. The CDTi concept as a form of CDI was refined over the years to find ways to increase sustainability, community ownership, and coverage (population coverage: the proportion of people treated on an annual basis; geographical coverage: the proportion of communities/villages/hamlets reached in an endemic area).9 This has led to the largest single community volunteer program in the world covering 20 African countries. The overall health system did not ignore the success of CDTi. UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases (TDR) documented that local or district health departments had started adding other interventions to CDTi such as immunization duties, deworming, schistosomiasis control, guinea worm elimination, and even agriculture extension duties.10–12 UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases (TDR) and APOC decided to take CDI to the next level in a systematic way. A four-country, eight-site implementation research project tested whether adding a specific set of additional services to CDTi, thus creating a broader CDI, would be handled by communities and the health system, whether CDI would have the same improved effects on these selected services that CDTi originally showed with ivermectin coverage, and whether in the process ivermectin coverage would remain at target levels. The results of this expanded CDI research, reported in 2008, examined the addition of malaria case management, insecticide-treated net promotion, and 298 International Quarterly of Community Health Education 35(4) Vitamin A distribution in communities where ivermectin was already being provided.13,14 All three additional interventions were available at the local health facilities in control and intervention arms, but the CDI arms of the study enabled the communities to deliver these services themselves, with health agency supervision. Not only did the CDI arms achieve better service coverage of the new interventions, but their ivermectin distribution coverage also improved. In short, villagers expressed great satisfaction in the increased access to a greater variety of services at their doorsteps. Factors contributing to the success of the expanded CDI intervention included “. . . stakeholder identification and consultation at all levels of the health system,” throughout the 3 years of intervention. This ensured that CDI was an integral part of the local PHC system. Success from the community perspective rested on their engagement in all aspects of program decision making. In addition, the community appreciated that they could have access to both preventive and treatment interventions through CDI.15 CDI was not without challenges. Not all countries look favorably on community health workers (CHWs). During the study period Cameroon set forth a new malaria treatment policy stipulating that CoartemÕ be prescribed only after a patient had been positively diagnosed with malaria. This made it impossible to incorporate the home management of malaria into the CDI process in Cameroon. (WHO, 2008) Fortunately, work is being done to validate the ability of CHWs to perform malaria rapid diagnostic tests.16 In addition, the nation-wide CHW program in Rwanda actually requires CHWs to perform malaria rapid diagnostic tests as part of their malaria case management duties.17 Clearly, CDI requires a supportive policy environment and strong procurement and supply system to function. At the end of the expanded CDI study in 2008, dissemination meetings were held in Uganda, Nigeria, Cameroon, and Tanzania, the CDI study countries with ministries of health and other stakeholders. The key question was whether this expanded CDI approach would work in settings that were not endemic for onchocerciasis and thus did not have a CDTi base on which to build. This led UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases (TDR) to embark on a series of three multicountry formative studies to learn whether there was potential for using CDI among (a) nomadic populations, (b) communities with no history of onchocerciasis/CDTi, and (c) urban settings. The findings from these formative research efforts are summarized herein. Nomadic Populations Nomadic populations constitute a significant proportion of the population in many sub-Saharan African countries. Sixty percent of the world’s estimated Brieger et al. 299 50 to 100 million nomads and seminomads live in Africa. Here, nomadic populations also have the least access to health services when compared with the general population. Access barriers include financial constraints and cultural and political differences between nomadic and settled populations, including health workers. These populations are also disproportionately vulnerable to infectious diseases such as malaria, tuberculosis, guinea worm, leishmaniasis, onchocerciasis, intestinal parasites and helminthes, brucellosis, and trachoma.18 Access barriers include financial constraints and cultural and political differences between nomadic and settled populations, including the health workers themselves.19 It is not uncommon for disease control programs to miss nomads because they often appear invisible to the local health department staff who are members of the majority indigenous population in an area.20,21 Not surprisingly, nomads often prefer seeking services from private health providers.22 Chabasse et al.23 argued that improvements in the health of nomads in Africa would depend on better access to health services. Opinions differ as to how to achieve access given nomads’ mobility and the frequent friction between nomads and the sedentary populations. Some suggest that nomads will have to wait until all villages in the region are covered by PHC services so that nomads can reach static services at all times of their movement cycle.24 Others recommend mass campaigns through mobile units as a temporary measure.25 Ailou26 argued that it is possible to organize mobile PHC services for nomads based on their seasonal circuits. Similarly, Omar,27 on the other hand, emphasized the for PHC programs based on with their full involvement in the planning and implementation. When given the chance to participate in CDTi, nomadic groups were able to achieve high ivermectin coverage28 and adapted this approach to surpass Roll Back Malaria goals for antimalarial treatment.29 Urban Health In 2008, for the first time in history, the majority of the global population lived in urban areas and by 2050, 86% of the global population will live in developing countries.30 The density and diversity of the population in urban areas, characterized by very high concentrations in the most underserved, impoverished communities, offers formidable challenges for health-care delivery.31–34 There is evidence that both morbidity and mortality due to infectious diseases such as malaria, TB, HIV/AIDs, neglected tropical diseases (NTDs), and more disproportionally effects the urban poor and underserved communities.35 The current approaches and systems in urban areas have thus far been unable to reach agreed-upon health goals and targets, such as the MDGs, and bridge existing gaps in care. Without improved delivery of health services, the present obstacles—accessibility, affordability, and utilization of the health systems—will perpetuate disparities and likely increase the risk factors, incidence, and 300 International Quarterly of Community Health Education 35(4) prevalence of treatable and manageable health conditions as the size of vulnerable and marginalized urban populations grows.36–42 WHO is concerned that, “The urban setting as we know it today is a complex and dynamic environment that has a profound impact on the health of the human community.” This dynamic consists of rapid growth, an upsurge of poverty and a proliferation of slums. It is within this context that WHO is advocating for more inclusive and participatory urban planning leading to more resilient cities.43 In urban areas, governance is often met with different opinions and opposition from various groups because of the diversity of knowledge and cultures that abound. These often lead to more robust contributions that have enabled urbanoriented arrangements and social networks to be translated to development opportunities in different parts of the world.44 Diffuseness of the urban setting has necessitated a new arrangement of formal organizations and professional associations.45 In particular, the social networks and organizations focused on urban community development not only help maintain cultural ties and a sense of collective development, these can also bring people of different ethnicities together in urban communities to advocate for social amenities such as electricity, and security of life and property.46 An example participatory of urban health access intervention in Lagos, Nigeria, the community coalition, demonstrated that community social networks and community-based organizations (CBOs) could come together on a neighborhood basis to address child and family health needs.47 Rural Primary Care Makaula et al.48 has observed that over 30 years later, implementation of PHC as defined in the Alma Ata Declaration remains suboptimal in sub-Saharan Africa, and access to health interventions is still a major challenge for a large proportion of the rural population. They have noted that despite serious attempts to revitalize the PHC concept,49–51 these health systems continue to be weak and provide only an inadequate mechanisms for delivering PHC services to individuals and communities in need. The potential of CDTi to bring to the poor some measure of intervention in some other health-care programs, such as those for malaria control, eye care, maternal and child health, nutrition and immunization, has been widely discussed,52 making the point that some remote rural areas would not have received PHC interventions without CDTi as a foundation. The CDI Study Group13 did show that the principles begun with CDTi could improve delivery of basic health commodities by building on ivermectin distribution that was already happening. This occurred because at state/regional and district levels, there were advocates from ivermectin programs who could convince their malaria and child health partners to take part in the CDI approach. Even then, it took a year to get the basic commitment and logistics lined up. Brieger et al. 301 What would be the fate of launching CDI in areas without a strong history of community participation? An example of applying CDI in non-CDTi areas comes from Akwa Ibom State along the southeast coast of Nigeria where onchocerciasis is not endemic.53 Community-selected volunteers, trained by frontline antenatal care staff, were able to increase coverage of malaria in pregnancy interventions including intermittent preventive treatment and insecticide-treated net use compared with health center catchment areas where these services were available only at the health facility. Although the intervention eventually covered 29 facility catchment areas in seven local government areas, there is need to explore how CDI can be introduced and taken to scale in other rural non-CDTi communities. A Formative Approach to Learning About Hard-to-Reach People The three sets of formative studies were designed and funded by the UNDP/ World Bank/UNICEF/WHO Special Program of Research and Training in Tropical Diseases (TDR) and focused on the same basic idea of learning the potential relevance of CDI in new settings. Thus, prior to designing CDI for a specific population or setting, it was necessary to conduct formative study among those communities to learn about the organizational strengths and structures that could facilitate the development of a CDI approach in that setting. Common threads in these studies included efforts to accomplish the following: . Document the delivery process of existing health interventions in poorly served communities . Identify priority health problems that could potentially be addressed through CDI . Determine existing community participation mechanisms and resources that could be adapted to promote the CDI approach, for example, social gatherings, community meetings, workplace, market, and social networks . Suggest approaches and a minimum intervention package that could be delivered through CDI in the particular setting Table 1 details the study sites used in the three sets of investigations. In each setting, the research teams gathered information on at least four defined areas, for example, districts, wards. (Study teams are listed in Appendix.) Common methods, primarily qualitative, were used in all studies using protocols that were designed at three proposal development workshops for team members of each study group. The studies were conducted within a 12-month period. The following instruments were common among the studies: . Key informant interview (KII) guide for health workers/health professionals 302 International Quarterly of Community Health Education 35(4) Table 1. Study Sites. Study group Country Locations Nomads Nomads Nomads Nomads Nomads Nomads Nomads Non-CDTi Non-CDTi Non-CDTi Non-CDTi Non-CDTi Non-CDTi Urban Urban Urban Urban Cameroon Mali Nigeria Nigeria Tanzania Tanzania Uganda Cameroon Kenya Malawi Nigeria Nigeria Uganda DRC Ghana Liberia Nigeria Dschang and Foumban Districts Timbuktu and Gourma Rharous Districts Adamawa State Enugu State Arusha Region Central areas Karamajong areas Centre and Eastern Provinces Southern Nyanza Province Mangochi and Mzimba Districts Cross River State Kaduna State Busoga subregion Kinshasa Bolgatanga and Wa Municipalities Monrovia Ibadan Rural Rural Rural Rural Rural Rural Note. CDTi ¼ community-directed treatment with ivermectin. . KII guides for community leaders and opinion leaders (including NGOs and CHWs) . Participatory rapid appraisal guidelines including community resource mapping . KII guide for traditional healers (practitioners) . Document review guide . Focus group discussions with community members Qualitative data consisted of textual data, mainly notes and transcripts from participatory rapid appraisal meetings, observations, and interviews. All qualitative data were analyzed using the qualitative software package AtlasTi (www.atlasti.com) or other appropriate and convenient equivalent packages. All interviews were tape-recorded (if appropriate) or detailed notes taken simultaneously, including verbal citations. Tape-recorded interviews were transcribed according to standard rules as articulated by MacLean, Meyer, and Estable54 and translated into English (if necessary). Detailed minutes/notes were taken from all stakeholder consultations, and these notes were carefully transcribed soon afterwards. Brieger et al. 303 All textual, visual, and audio data were entered into AtlasTi software, coded according to an established code-list. Memos annotating coded citations will help in building grounded theory on the qualitative data. Citations, citations by code and memos were analyzed according to emerging themes using the network visualization abilities of the AtlasTI software for qualitative analysis. Data analysis was a continuous process, starting from early stages when the data collection began. For instance, through debriefing meetings with the research team after transcription of the field notes and recorded tapes, there were interactive discussions to determine the direction of further data gathering and whether data saturation had been reached.55,56 The teams sought and obtained ethical approval from the appropriate ethical body/council in the country. The teams also sought and obtained introduction letters from the relevant local authority. Researchers sought and obtained individual informed consent from all participants in the study. This was applicable to any research-related activity, including photography and videotaping. Learning to Improve Access Each team submitted a project report. These were reviewed, and major common findings and lessons learned are summarized below. Health Intervention Delivery Processes in Poorly Served Communities All studies among nomadic groups identified both curative and preventive services. While most mention a mix of public, private, NGO, and indigenous health services, two countries in particular stress a strong preference for the private sector. Some use of mobile and outreach services was reported. A common theme was weaknesses of the public sector—lack of supplies, lack of or poor quality of staff, negative staff attitudes toward nomads, and poor accessibility. There was frequent resort to indigenous healers or self-medication with local herbs. Ultimately, respondents did not state a preference for indigenous over orthodox but implied that both forms of care were acceptable, if available. Preventive services were described as outreach and occasional. Nomads did not expect to have these provided on a regular basis. Immunization services were most commonly mentioned. Other commodities provided during outreach included insecticide-treated nets, deworming medicines, and vitamin A, often integrated into immunization outreach campaigns. NGOs were key partners mentioned in such efforts. In a couple instances, the issues of community participation in outreach or community-based service delivery were mentioned. A major concern was that it was difficult to recruit nomads for such efforts. There was little hope that they could be found and rallied. 304 International Quarterly of Community Health Education 35(4) Existing health interventions in the context of urban health system were usually a mix of private and public health centers. However, surrounding communities often perceived the services as “really insufficient and barely operational.” High service cost was a common complaint. Because of access to a mix of services, urban populations practice a pragmatic coutilization of primary, secondary, and tertiary orthodox care, traditional medical practitioners, and church-based healing services. Urban areas are characterized by specialized centers such as those for TB treatment and orthopedic services. Concerning basic primary care, Ghana was the exception with a relatively well-organized government-run service delivery system. Generally, serious access barriers for curative products and services were in evidence. A few slum areas had no PHC government services or private clinics. This mix of urban services can be expensive, and complaints of cost were common. Out-of-pocket expenditure was the norm in all urban settings except Ghana, which has some coverage by a national health insurance scheme. Very rarely do staff in the urban health facilities reach out to communities to provide health care. Respondents commonly felt that urban health facilities do not offer adequate care for most of the diseases prevalent in the community. A key rural finding was that National political commitment to PHC usually exists but was characterized by suboptimal implementation in existing health programs. These rural services were primarily public in nature. Poor implementation is attributable in part to access constrained by poor road networks in rural areas. Human resources also contribute to the problem either because some structures were not staffed, were staffed with only one person, or were covered by less comprehensively trained personnel. Various types of community health extension workers were identified, but due to resource problems, they rarely extended themselves beyond the clinics. Ironically, where trained personnel exist, they either are unwilling to work in more remote facilities or are unemployed due to hiring embargoes. Another form of health-care extension, the mobile clinic, was only rarely mentioned and not seen as a solution to reaching underserved areas at the level needed. Although many rural programs were driven by donors, such as malaria treatment and prevention, noncompliance with strategic plans and policies for these programs was commonly observed. Program guidelines were rarely distributed beyond the district health office. Basic equipment and infrastructure existed in some rural clinics but was often not replaced when needed nor well maintained. Stock-outs of drugs and other medical commodities were common. Actual resources for maintaining equipment and medicine supplies were poor despite moves some years ago to create revolving funds through the Bamako Initiative because rural clinics often have little access to cash buy what they need when they need it. Brieger et al. 305 Priority Health Problems That Could Be Addressed Through CDI Among nomads, the challenge in developing a focus was that the respondents suggested “an inexhaustible list of health problems.” A plethora of diseases of poverty were mentioned, but uniquely they were acutely aware of seasonal health patterns. Affected populations mentioned both communicable and noncommunicable diseases, including injury and snake bite among the latter. Malaria was the most common communicable health concern expressed across all countries. One of the most pressing conditions mentioned by nomads was shortage of water for human consumption and hygiene leading to communicable diseases including skin diseases, diarrheal illnesses, dysentery, and typhoid. Urban populations mentioned a wide variety of mostly communicable disease priorities with malaria topping the list. Respondents across the board recognized problems associated with poor water supply and sanitation including typhoid and diarrheal diseases. Although more of an urban problem in most countries, HIV/AIDS was mentioned in only two settings. Again, while noncommunicable diseases are another more urban type of health issue, these were mentioned in only three settings and included hypertension, diabetes, and asthma. Among the priority interventions that could be handled through community participation and distribution, urban respondents identified their desire for ivermectin for lymphatic filariasis, distribution of insecticide-treated nets, and home/ community management of malaria. Rural communities commonly mentioned communicable diseases such as malaria and diarrheal diseases as priorities that could be addressed through CDI. Respondents often noted that rural health problems derive from poverty and gave malnutrition as an example. These health issues were couched in problems of access due to poorly staffed facilities or long distances. Community Participation and Service Mechanisms That Could Promote the CDI Among the nomad study group, the basic social unit above the family is the camp which may be located for longer or shorter periods. The men who herd the cattle go out from the camp for days at a time, but this unit is a place to consider for intervention and community participation purposes.19,28 Study reports revealed two schools of thought concerning community participation mechanisms. First, it was suggested that nomads might contribute money or labor to extend existing health service in outreach campaigns. The second view better used the rich data on the social structure of the population and indigenous resources as a foundation including indigenous healers, weekly market networks/visits, and local leadership structures. Examples of 306 International Quarterly of Community Health Education 35(4) the former were cited such as contributions toward building a health center and paying for transportation to bring health workers to nomad camps. Newly created structures and mechanisms were also mentioned including volunteering to be trained as a CHW and participating community health or development committees, which was a norm in the settled communities in the study areas. Reports observed a low level of participation in these mechanisms by nomads, but there was still conjecture from respondents that these mechanisms could be applied to mobile populations. Indigenous mechanisms among the nomads that might be tapped for health service delivery included their own healers. Over the years, the involvement of indigenous healers and community birth attendants as CHWs has been common, and this approach would likely be acceptable to nomadic populations. In several locations, respondents identified indigenous associations and leaders among the nomads who could be vital in helping establish CDI. These included women groups and livestock cooperatives. More work is needed in defining and understanding roles for CBOs among mobile populations. Urban community participation mechanisms and resources were much more evident and robust. Groups identified at the community level included Community Development Associations or Community Development Committees, Landlord/Landlady Associations, youth and women social groups, and economic groups like market women associations. The landlord associations and Community Development Committees are gatekeepers in the community and are relevant for decision making.46 The role of churches, mosques, and faith-based social groups to mobilize community participation was recognized in all urban settings. Schools and pharmacy/medicine shops were other important urban social resources. Rural communities and health services were in theory served by a variety of auxiliary cadres such as community health extension workers as mentioned. These are often people who come from the communities within a catchment area or district and thus in some cases can build on their ties to mobilize communities. There were several sociopolitical groups actively involved in the delivery of various PHC activities within their communities as exemplified in Malawi.48 The ones structured by the health system were village health committees that dealt with health issues and village development committees that focused on overall developmental including health. Indigenous CBOs existed with some focusing on specific needs like homebased care for people living with HIV and AIDS. Rural primary schools (with their parent–teacher associations) and women’s social groups were additional community resources identified. Although volunteer CHW programs exist in the countries studied, these were either inadequate in number or not mentioned by rural respondents. Likewise, rural communities had been mobilized in the past to help the health department Brieger et al. 307 with programs like immunization campaigns but were not given responsibilities for managing programs and volunteers as is the case with CDI. The Way Forward With CDI This review of formative studies that examined the feasibility of introducing CDIs in new areas of underserved peoples should help address what is unique and what is generalizable to promoting access to the health services. CDI is a process of community involvement, not a volunteer CHW program. The key lessons therefore revolve around identifying those community mechanisms and resources that could form the basis of participation in health-care delivery. Connections With the Health Service Although CDI in theory is spatially flexible, there still need for some known points of contact between communities/populations and the health services where supplies can be acquired, records submitted, and training or retraining can occur. The value of understanding seasonal migratory routes is necessary to make this principle work among nomadic populations.29 Also, because nomadic populations sometimes trust private health providers more than the public services run by members of the settled communities,22 CDI needs to be flexible in the type of contact points it uses for nomads. While both urban and rural communities, being settled, would in theory have access to a health facility where CDI supplies could be obtained, they differ in type. The urban setting, as found, is characterized by a mix of public and private services, though in some cases, there are neighborhoods without available clinics of either kind. The decision to involve the private sector in the provisioning of CDI activities is an important urban decision, and such facilities proved to be the focal point of community health coalitions in Lagos.47 The rural public sector plagued by staff shortages may present problems in terms of health facilities being able to serve as focal points for managing commodity supplies for a CDI package as well as reaching out to involve communities and to supervise volunteers. Communities are often willing to manage their health programs, but health services with minimal staff and stock-out problems may diminish CDI capacity. Clearly, health system strengthening must go hand-in-hand with community strengthening. Alternatively, communities have been able to collectively manage their medicine supplies on a small-scale basis,57 so research on scaling this up would beneficial. Also, the role of nonformal providers like patent medicine sellers could be considered.58 In reviewing the illnesses and problems presented in the country reports, one can discern commonly mentioned issues that have the characteristic of possibly being tackled by a simple, low-cost commodity or behavior change, and thus 308 International Quarterly of Community Health Education 35(4) amenable to CDI. Examples of these relatively simple interventions are malaria medicines, deworming tablets, and oral rehydration salts. This idea of relative simplicity was what undergirded the 2008 CDI Study by WHO/Tropical Disease Research Program.13 The noncommunicable group including high blood pressure, back ache, rheumatism, diabetes, and snake bite have not yet been incorporated into CDI, but community interest in these topics implies a need to test their inclusion in future CDI studies. The biggest health system challenge mentioned in the formative studies was the common experience of stock-outs. Frontline health facilities will not be enthusiastic about providing medicines and supplies for community distribution when they themselves are lacking the basics. Again, this highlights the interconnected partnership that is needed between health facilities and their surrounding communities to make CDI work. A study by McCord et al.59 is one of the few that directly address the issue of planning for stocks of commodities for CHWs, and more focus on this enabling factor for CDI is needed. Community Participation Mechanisms Local health staff would benefit from more socially and culturally appropriate approach to their communities and clients. Health workers need to identify and work through existing social structures to gain community commitment to the participatory CDI process where they themselves take responsibility for service delivery. Understanding and accepting local leadership structures, including religious leaders and indigenous healers, will enable health staff to initiate CDI on a foundation of existing local organizational mechanisms. One of the achievements of an earlier CDI sustainability implementation research project was improved relationships between communities and health workers when the research team facilitated more organized contacts between them in the form of community forums. Health workers not only came to enjoy these interactions but improved their attitudes toward community participation when the community members responded in a more friendly and welcoming manner.60 As mentioned previously, CDI differs from other community health programs in that the focus in not on individual community volunteers, but on enhancing the agency of the community itself in planning and managing its own health services and programs. In the process, communities will select volunteers to distribute the package of commodities determined in conjunction with health system partners, but these CDDs are always accountable first and foremost to their own communities. Technical supervision and guidance is certainly needed from the health facility, but the CDDs are decidedly not mere extensions of the health system. The voluntary role does not have to be played by individuals alone. Earlier description of the community coalition intervention in Lagos, Nigeria demonstrated the importance of local CBOs in mobilizing for community action and service. Respondents in both rural and urban communities explained that there Brieger et al. 309 are committees created by the health department or the local council for health and development matters. These too should be used to generate the participation needed for CDI, but with the caution that such committees can become politicized or even ignored when people are too busy with their existing family and CBO commitments.61 Conclusions In conclusion, these three sets of formative studies that explored CDI potentials in different settings found common health needs with relatively straightforward technical interventions that could be handled by communities. Some variations were noted such as a greater emphasis on noncommunicable diseases in urban settings, but overall basic expressed needs could be incorporated into the CDI model. Also, all settings were replete with local social and cultural organizations that could form the basis for community participation in CDI. Because these study sites did not have the benefit of a CDTi foundation, it is incumbent on the health worker to reach out, learn about, and mobilize the existing community involvement mechanisms to build on community strengths. Next steps involve addressing some knowledge gaps. Major international attention is focused in integrated community care management of child illnesses. While the CDI studies have shown that community case management can be handled under CDI, there does need to be a thorough examination of the key elements of the two approaches to learn how they can be complimentary. Dating from the original CDTi work the question remains of finding a balance between agency-directed and community-directed approaches. Another gap in knowledge is greater understanding of the commodity needs and procedures for best delivering community interventions. Now it remains to design and fund the next round of CDI efforts to ensure that the goals of PHC reach these different types of underserved populations. Acknowledgments Participating research study teams who carried out formative research on the potential of CDI for health care in nomadic, urban, and rural health systems in Africa (2008–2011) are listed in Appendix. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research work carried out between 1995 and 310 International Quarterly of Community Health Education 35(4) 2011 on community-directed interventions for onchocerciasis control and for major health problems in Africa was supported by the UNICEF/UNDP/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland, in collaboration with the African Programme for Onchocerciasis Control. Appendix: Study Teams Study group Country Nomads Nomads Cameroon Mali Nomads Nomads Nigeria (Adamawa) Nigeria (Enugu) Nomads Nomads Nomads Non-CDTi Rural Tanzania (Arusha) Tanzania (Central) Uganda Cameroon Non-CDTi Rural Kenya Non-CDTi Rural Malawi Non-CDTi Rural Nigeria (Cross River) Non-CDTi Rural Non-CDTi Rural Urban Nigeria (Kaduna) Uganda DRC Urban Ghana Urban Liberia Urban Nigeria Team members (PI listed first) J. C. Taptue Fotso, C. Kouambeng Y. I. Coulibaly, S. Doumbia, S. Diop, A. Gologo, M. Sangare O. B. Akogun, A. Adesina, A. Njobdi, E. Apake J. C. Okeibunor, N. G. Onyeneho, O. C. Nwaorgu K. Massa, G. Mubyazi, A. Mwita, E. Nnko G. M. Kaatano, J. R. Mwanga J. Nsungwa-Sabiiti, W. Aryaija I. Takougang, L. Tchuikam, D. Tandzon, F. Tanneken P. N. M. Mwinzi, J. Alaii, J. Ayisi, L. Ogange, G. Odhiambo, E. Muok, D. M. S. Karanja, V. Atuncha P. Makaula, H. T. Banda, G. B. Mbera, C. Mangani, E. Nkhono, S. Jemu, A. S. Muula H. A. Adie, T. U. Igbang, E. Braide, O. E. Okon, E. Edet, A. Otu, C. Joseph S. Sanda, O. Adekeye, F. Enwezor, S. lsiyaku R. Ndyomugyenyi, A. T. Kabali V. Maketa, S. Lubanza, P. Lutumba, M. Boelaert, T. Maketa, S. Baloji, M. Vuna, R. Magundu P. B. Adongo, P. Akweongo, K. AwoonorWilliams, A. Nang-Fobeih, M. Dalaba, S. Chatio, D. Anaseba, G. Nyaaba, A. Hodgson S. B. Kennedy, R. A. Nisbett, F. Q. Shannon II, C. B. Soko I. O. Ajayi, A. S. Jegede, C. O. Falade Note. CDTi ¼ community-directed treatment with ivermectin. Brieger et al. 311 References 1. United Nations. (2013). The millennium development goals report. New York: United Nations, 2013. 2. Roll Back Malaria Partnership (RBM). (2008). The Global Malaria Action Plan for a malaria free world. Geneva: World Health Organization, 2008. 3. World Health Organization. (2013). The world health report 2013, research for universal health coverage. Geneva: World Health Organization, 2013. 4. World Health Organization and UNICEF. Declaration of Alma-Ata International conference on primary health care. Alma-Ata, USSR, 1978. http://www.who.int/publications/ almaata_declaration_en.pdf. 5. Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008; 372: 950–961. 6. World Health Organization. (1996). Community directed treatment with ivermectin: report of a multi-country study. Document TDR/AFRIRP/96.1. Geneva: WHO, 1996. 7. World Health Organization. (1998). Community-directed treatment with ivermectin (CDTi): a practical guide for trainers of community-directed distributors. Document WHO/APOC/MG/98.5. Ouagadougou: African Programme for Onchocerciasis Control, 1998. 8. Meredith SE, Cross C and Amazigo UV. Empowering communities in combating river blindness and the role of NGOs: case studies from Cameroon, Mali, Nigeria, and Uganda. Health Res Policy Syst 2012; 10: 16. 9. World Health Organization/TDR. (2000). Report of a multi-country study on implementation and sustainability of community-directed treatment of onchocerciasis with ivermectin. Document TDR/IDE/RP/CDTi/00.1. Geneva, Switzerland: UNDP/World Bank/ WHO Special Programme for Research & Training in Tropical Disease (TDR), 2000. 10. Ndyomugyenyi R and Kabatereine N. Integrated community-directed treatment for the control of onchocerciasis, schistosomiasis and intestinal helminthes infections in Uganda: advantages and disadvantages. Trop Med Int Health 2003; 8: 997–1004. 11. Okeibunor JC, Ogungbemi MK, Sama M, et al. Additional health and development activities for community directed distributors of ivermectin: threat or opportunity for onchocerciasis control? Trop Med Int Health 2004; 9: 887–896. 12. Mwinzi PNM, Montgomery SP, Owaga CO, et al. Integrated community-directed intervention for schistosomiasis and soil transmitted helminths in western Kenya – a pilot study. Parasit Vectors 2012; 5: 182. 13. CDI Study Group. (2010). Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ 2010; 88: 509–518. 14. Kisinza WN, Kisoka WJ, Mutalemwa PP, et al. Community directed interventions for malaria, tuberculosis and vitamin A in onchocerciasis endemic districts of Tanzania. Tanzan J Health Res 2008; 10: 232–239. 15. World Health Organization. (2008). Community-directed interventions for major health problems in Africa: a multi-country study: final report. Special Programme for Research and Training in Tropical Diseases. Geneva: World Health Organization, 2008. 16. Counihan H, Harvey SA, Sekeseke-Chinyama M, et al. Community health workers use malaria rapid diagnostic tests (RDTs) safely and accurately: results of a longitudinal study in Zambia. Am J Trop Med Hyg 2012; 87: 57–63. 312 International Quarterly of Community Health Education 35(4) 17. Mugeni C, Levine AC, Munyaneza RM, et al. Nationwide implementation of integrated community case management of childhood illness in Rwanda. Glob Health Sci Pract 2014; 2: 328–341. (www.ghspjournal.org (accessed 13 June 2015). 18. Sheik-Mohamed A and Velema JP. Where health care has no access: the nomadic populations of sub-Saharan Africa. Trop Med Int Health 1999; 4: 695–707. 19. Okeibunor JC, Onyeneho NG, Nwaorgu OC, et al. Prospects of using community directed intervention strategy in delivering health services among Fulani Nomads in Enugu State, Nigeria. Int J Equity Health 2013; 12: 24. 20. Dao MYJ and Brieger WR. Immunization for the migrant Fulani: identifying an underserved population in southwestern Nigeria. Int Q Community Health Educ 1994–1995; 15: 21–32. 21. Brieger WR, Oke GA, Otusanya S, et al. Ethnic diversity and disease surveillance: guinea worm among the Fulani in a predominantly Yoruba district of Nigeria. Trop Med Int Health 1997; 2: 99–103. 22. Otusanya SA, Brieger WR, Titiloye B, et al. Ethnic variations in health seeking behaviours and attitudes between Fulani Herders and Yoruba Farmers in Southwestern Nigeria. Trop Doct 2007; 37: 184–185. 23. Chabasse D, Roure C, Rhaly A, et al. The health of nomads and semi-nomads of the Malian Gourma: an epidemiological approach. In: Hill AG (ed.) Population, health and nutrition in the Sahil. London: Routledge and Kegan Paul, 1985, pp.319–339. 24. Bentley C. Primary health care in Northwestern Somalia: a case study. Soc Sci Med 1989; 28: 1019–1030. 25. Imperato PJ. Problems in providing health services to desert nomads in West Africa. Trop Doct 1975; 5: 116–123. 26. Ailou S. What health system for nomadic populations? World Health Forum 2010; 13: 311–314. 27. Omar MA. Health care for nomads too, please. World Health Forum 1992; 13: 307–310. 28. Brieger WR, Otusanya SA, Oke GA, et al. Factors associated with coverage in community directed treatment with ivermectin for onchocerciasis control in Oyo State, Nigeria. Trop Med Int Health 2002; 7: 11–18. 29. Akogun OB, Adesina AO, Njobdi S, et al. Nomadic Fulani communities manage malaria on the move. Int Health 2012; 4: 10–19. 30. Population Reference Bureau. World population data sheet, http://www.prb.org/ Publications/Datasheets/2008/2008wpds.aspx (2008, accessed 13 June 2015). 31. Atkinson S. Urban health in the Third World. Environ Urban 1993; 5: 146–152. 32. Harpham T and Tanner M (eds). Urban health in developing countries: progress and prospects. London: Earthscan, 1995. 33. Lorenz N and Garner P. Organizing and managing urban health services. In: Harpham T and Tanner M (eds) Urban health in developing countries: progress and prospects. London: Earthscan, 1995, pp.48–63. 34. Atkinson S, Macwan’gi M, Ngenda L, et al. Quality of urban health services, Lusaka, Zambia. Bamako Initiative Operations Research Programme, Research Paper No. 2. New York: UNICEF, 1996. 35. Harpham T and Molyneux C. Urban health in developing countries: a review. Prog Dev Stud 2001; 1: 113–137. Brieger et al. 313 36. Alirol E, Getaz L, Stoll B, et al. Urbanisation and infectious diseases in a globalised world. Lancet Infect Dis 2011; 11: 131–141. 37. Harpham T. Health of the urban-poor in developing-countries. Parasitol Today 1986; 2: 320–323. 38. Harpham T. Urban health in developing countries: what do we know and where do we go? Health Place 2009; 15: 107–116. 39. Harpham T and Blue I. Linking health policy and social policy in urban settings: the new development agenda. Trans R Soc Trop Med Hyg 1997; 91: 497–498. 40. Harpham T and Werna E. Sustainable urban health in developing countries. Habitat Int 1996; 20: 421–429. 41. Phillips DR. Urbanization and human health. Parasitology 1993; 106: S93–S107. 42. Utzinger J and Keiser J. Urbanization and tropical health – then and now. Ann Trop Med Parasitol 2006; 100: 517–533. 43. WHO Kobe Centre, Japan. A Billion Voices: Listening and Responding to the Health Needs of Slum Dwellers and Informal Settlers in New Urban Settings. Knowledge Network on Urban Settings, WHO Commission on Social Determinants of Health. 25 August 2005. http://www.who.int/social_determinants/publications/urbanization/en/ 44. Ogbuozobe JE. Community based organizations (CBOs) in the provision of social services in the Ibadan metropolitan area. NISER Monograph Series, No.1. Ibadan: NISER, 2000. 45. Omobowale AO. Social capital and “Ajo” system among working class traders in Ibadan, Nigeria: working USA. J Labour Soc 2011; 14: 333–346. 46. Ajayi IO, Jegede AS, Falade CO, et al. Assessing resources for implementing a community directed intervention (CDI) strategy in delivering multiple health interventions in urban poor communities in Southwestern Nigeria: a qualitative study. Infect Dis Poverty 2013; 2: 25. 47. Brieger WR, Orisasona SA, Ogunlade PB, et al. Community partners for health: urban health coalitions in Lagos, Nigeria. Int Q Community Health Educ 2000– 2001; 20: 59–81. 48. Makaula P, Bloch P, Banda HT, et al. Primary health care in rural Malawi – a qualitative assessment exploring the relevance of the community-directed interventions approach. BMC Health Serv Res 2012; 12: 328. 49. World Health Organization. (2008). Primary health care now more than ever. Geneva, Switzerland: The World Health Report, 2008. 50. World Health Organization. (2010). The Ouagadougou declaration on primary health care and health systems in Africa: achieving better health for Africa in the new millennium. Brazzaville: WHO Regional Office for Africa, 2010. 51. Frenk J. Reinventing primary health care: the needs for systems integration. Lancet 2009; 374: 170–173. 52. Homeida M, Braide E, Elhassan E, et al. APOC’s strategy of communitydirected treatment with ivermectin (CDTi) and its potential for providing additional health services to the poorest populations. Ann Trop Med Parasitol 2002; 96: 93–104. 53. Okeibunor JC, Orji BC, Brieger W, et al. Preventing malaria in pregnancy through community-directed interventions: evidence from AkwaIbom State, Nigeria. Malaria J 2011; 10: 227. 314 International Quarterly of Community Health Education 35(4) 54. MacLean LM, Meyer M and Estable A. Improving accuracy of transcripts in qualitative research. Qual Health Res 2004; 14: 113–123. 55. Morrow SL and Smith ML. Qualitative research for counseling psychology. In: Brown SD and Lent RW (eds) Handbook of counseling psychology, (3rd ed., New York: Wiley, 2000, pp.199–230. 56. Robson C. Real world research: a resource for social scientists and practitioner researchers, (2nd ed.). Oxford: Blackwell Publishing, 2002. 57. Brieger WR, Oshiname FO and Oke GA. The role of community health workers in the management of essential drugs. Int Q Community Health Educ 1994–1995; 15: 379–394. 58. Goodman C, Brieger W, Unwin A, et al. Medicine sellers and malaria treatment in sub-Saharan Africa: what do they do and how can their practice be improved? Am J Trop Med Hyg 2007; 77(Suppl): 203–218. 59. McCord GC, Liu A and Singh P. Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions. Bull World Health Organ 2013; 91: 244–253B. 60. World Health Organization. (2000). Final report on the sustainability of community directed treatment of onchocerciasis with ivermectin. Document WHO/APOC/CS/00.1. Geneva: WHO, 2000. 61. Brieger WR and Adeniyi JD. Urban community health education in Africa. Int Q Community Health Educ 1981–1982; 2: 109–121. Author Biographies William Brieger is a certified health education specialist and has a doctorate in Public Health (DrPH) in International Health from the Johns Hopkins University (JHU) and a Masters in Public Health (MPH) in Health Behavior and Health Education from the University of North Carolina, Chapel Hill. He is a professor in both the Health Systems and the Social and Behavioral Interventions Programs of the Department of International Health at The Johns Hopkins Bloomberg School of Public Health and also serves as JHPIEGO’s Senior Malaria Specialist. Bill taught at the African Regional Health Education Center at the University of Ibadan, Nigeria, from 1976 to 2002. He is internationally renowned for his expertise in the social and behavioral aspects of disease control and prevention, with special emphasis formative research and behavior change program design and evaluation. His particular focus has been on training peer educators, community volunteers and other community resource persons to take an active role in health education and health service delivery. Johannes Sommerfeld is a health social scientist and research manager with the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO), Geneva, Switzerland. Over the past 20 years, Dr. Sommerfeld has conducted research, taught, published and coordinated applied social science Brieger et al. 315 for public health research on a number of social issues in infectious diseases of poverty and their control including access, equity, globalization, conflict, risk and vulnerability, human rights and gender. From 2000–2007, he was managing the TDR Steering Committee for Social, Economic and Behavioral Research. Between 2004–2007 he coordinated research and data analysis in the WHOTDR multi-country study on Community-Directed Interventions for Major Health Problems in Africa and managed, from 2008 to 2011 the portfolio on CDI in nomadic, urban and rural areas presented in this article. He is currently working as scientist and research manager in TDR’s unit for research on Vectors, Environment and Society and is managing major inter-disciplinary research initiatives on vector-borne and other infectious diseases of poverty. Prior to joining TDR in 2000, he held research associate appointments with Heidelberg University Medical School, Heidelberg, Germany and the Harvard Institute for International Development, Cambridge, MA, USA. He holds Master of Arts (MA) and PhD (DrPhil) degrees in cultural and medical anthropology (minors: sociology and economics) from the University of Hamburg and a Master of Public Health degree (MPH) with a focus on epidemiology and biostatistics from the University of South Florida, Tampa, USA. His main fields of expertise and professional interest are the health social sciences applied to public health, community research, and research design and management. Uche V. Amazigo holds a PhD from the University of Vienna (Austria) and was a Takemi fellow at the Harvard School of Public Health (USA). She is a public health specialist and one of the few female Africans to head a UN Agency. She has devoted most of her academic, public and international career to the control of neglected tropical diseases and community participation in governance and health system strengthening. While teaching at the University of Nigeria, Nsukka, her pioneering discovery of the suffering of adolescent girls, disability and social isolation caused by River blindness skin disease contributed to the creation of the World Health Organization African Programme for Onchocerciasis Control (WHO/APOC) in 1995. Professor Amazigo retired as the WHO/APOC director in 2011. She is a trustee of Sightsavers, UK and The TY Danjuma Foundation, and serves as advisor to several global Boards. She is honorary fellow of the Royal Society of Tropical Medicine and Hygiene. She has numerous publications in international peerreviewed journals. In 2013, she received honorary Doctor of Science degree from the University of KwaZulu-Natal, South Africa and won the Prince Mahidol Award 2012 in 316 International Quarterly of Community Health Education 35(4) Public Health. In 2015, she was elected a fellow of the Nigerian Academy of Science. The CDI Network consists of 17 research teams from African universities and institutions in Cameroon, Mali, Tanzania, Uganda, Nigeria, Democratic Republic of the Congo (DRC), Kenya, Malawi, Ghana and Liberia. The team members are listed in the Appendix of this article. They worked together in three groups focusing on rural communities, urban communities and nomads to develop joint research protocols that examined how community directed intervention could be applied to broader primary health care issues.
