Transcript Mr Simon Bush_Onchocerciasis and Community

Demonstration Models
Onchocerciasis and communitydirected distribution
Simon Bush,
Director Neglected Topical Diseases
Sightsavers
Summary
Origins of the ‘issue’
Evolution of the approach
Scale-up
Future prospects
What was the Challenge?
(Map from APOC Programme Overview 2009 www.who.int/apoc)
•
Ivermectin: Cleared for human
use in 1987. Safe and effective –
generously donated by Merck
and Co Inc., via the Mectizan
Donation Programme: “wherever
it is needed for as long as it
needed.”
•
Challenge: How to distribute the
drug to the population in need in
hard to reach rural communities
and locations in view of a weak,
under-resourced health system.
•
Solution: Empower communities
to distribute the drugs
themselves through Community
Directed Distributors
•Spectrum of activities leading to CDTI
Treatment strategy
Decision
making
Pure mobile
team
approach
Outreach
using mobile
team
OCP informs
chief
OCP-team
based in a
hospital and
“fans out” to
villages
Process
Delivery to
village
Record
keeping
Chronology
Description
NGO / nurse
informs chief
Community
based
treatment
Community
based
treatment
Nurses
(Volunteers for
absentees)
Volunteers
selected by
the Chief
Volunteers
(CBD)
OCP
Nurse / CHW
CHW
CBD
1990
Used by OCP
and some
NGOs when
they started
treating with
ivermectin
CBD
CDD
NGO / District
1989
used by the
(OCP) from
1989 (when the
drug became
available
through the
Mectizan
Donation
Programme)
Community
Directed
Treatment
CDD
(from health center)
CHW / CBD
District
Community
Directed
treatment
Community
Nurses
OCP
Community
based
treatment
National
program
Nurses / CHW
Distribution
Supervision
NGO
supported
Outreach
Nurse on a
motor bike or
mobylette went
to villages from
a Health centre
1991
Volunteer
carried out the
treatments but
timing of
treatment, drug
delivery to
village decided
by the
program, and
volunteer
chosen by chief
or program
1995
Community
consulted about
when and how
to distribute the
drugs
Community now
asked to
decide when
and how to do
the drug
distribution and
to choose the
CBD
Community
chose CDD,
timing and
method of
treatment,
records kept by
CDD and CDD
goes to pick up
drugs from
health centre .
•Involvment & ownership by community
•External
direction
• mixed
• Community
directed
•ownership shift through CDTI
•CDTI: Community Directed Treatment with Ivermectin | OCP: Onchocerciasis Control Programme | CBD: Community Based Distributor | CHW: Community Health worker
Community
chose CDD,
timing and
method of
treatment,
records kept by
CDD and CDD
goes to pick up
drugs from
health centre
History of NGDO Coordination & Evolution of CDTI
•Preliminary results on CDTI
presented to TCC (June)
•TDR Implementation of multicountry study of CDTI
•study of socio-economic
importance of skin disease
•Research
•evolution
•Scientific evidence
to expand control
beyond OCP areas
•Ongoing operational
research
within OCP
74
75
76
77
78
•Multi-country study
protocol development
workshop in Bamako, Mali
•Height/weight study
for MEC
•TDR multi-country study showing
importance of skin disease
79
80
81
82
83
84
85
•APOC adoption of
CDTI strategy
86
87
88
89
90
91
92
93
94
95
96
97
98
•CDTI strategy in
country programs
•Prevention of blindness
•Group established at WHO
•IAPB Establishment
•Country
•programme
•evolution
•The consultative group
of NGOs working
•with PBD/WHO
•Prevention of blindness
•NGOs in official
relations with WHO
•NGO Coordination
Group established
•with coordinator
in Geneva
•Ivermectin (IVM)
•became available
•NGOs + OCP began
ivermectin distribution
•early NGO supported IVM treatment
•programmes established
Mali, Nigeria,
Uganda, Malawi, Cameroon
•NGOs supported country
•programs pilot community based
•approaches to IVM distribution
•Creation of NGO
Country Coalitions
•NGOs developing
•strategic, coordinated
sustainable approach
•River Blindness Foundation
Funding IVM distribution
•Outside OCP
•Country NOTFs
•established
•NGOs supported
country programs
using CBTI
•Launch of APOC
(December)
What are community-directed
interventions?
•A health intervention that is undertaken at the community level under the
direction of the community itself.
•The concept of Community-Direction is introduced by the health services
and its partners (NGDOs) in a participatory manner, highlighting community
ownership from the onset.
•From then on, the community takes charge of the process, usually through
a series of community meetings combined with implementation by selected
community members.
•The community, the health services and other partners have specific roles
in the community-directed intervention (CDI)
Community-directed interventions
• Community-directed interventions are a process built on the
experience of community members and thus enhances
decision making and problem solving capacity. Activities are
both in and of the community.
• Community exercises authority over decisions.
• The community plans the distribution, decides on the
method of distribution acceptable to them (e.g. central place,
house-to-house) and when to distribute.
• Ensures sensitivity to community decision-making structures
and social life.
Community-directed interventions
• Community is informed about the detailed tasks of
distribution, but they decide who should distribute and
whether or not such persons are strictly volunteers or should
receive some compensation.
• The community is the lead stakeholder in the provision of
services, creating a sense of ownership, and thus enhancing
the likelihood that the activities will be integrated into the
community’s health agenda.
• There is room for innovation by the community.
The Principles of CommunityDirected Treatment with Ivermectin
(CDTI)
• In the CDTI process, it is essential that the MoH and partners (e.g.
NGDOs) be committed to empowering the communities not dominating
but contributing according to their roles and responsibilities.
• BUT health personnel (and programme people) find it difficult to give
communities the freedom to design their own delivery system.
• BUT takes time to produce results, but when it does they are sustained.
• BUT the transition from community-based programmes controlled by
heath staff, to CDTI, is a major challenge to health systems as middle
level health staff (and programme people) often lack the management
skills needed to foster community participation.
Scale up
The programme now treats over 90 million people annually in 19 countries,
protecting an at risk population of 115 million, and preventing over 40,000
cases of blindness every year.
After 15–17 years of ivermectin treatment in two onchocerciasis foci in
Kaduna State, Nigeria, prevalence had fallen to zero level in all
communities and all individuals examined were skin-snip negative (1).
“The onchocerciasis story is a leading example of the contribution of a
group of NGDOs to operational research which led to important changes
in treatment strategies and policies.” (2)
(1)Teckle EH AH, Isiyaku S, Amazigo UV, Bush S, Noma M, Cousens S, Abiose A, Remme JH: Impact of long-term
treatment of onchocerciasis with ivermectin in Kaduna state, Nigeria: first evidence of the potential for
elimination in the operationa area of the African Programme for Onchocerciais Control. Parasite and Vector
2012,5: 28
(2)Stefanie E O Meredith,Catherine Cross, Uche V Amazigo, Empowering communities in combating river blindness and
the role of NGOs: case studies from Cameroon, Mali, Nigeria and Uganda, Health Research Policy and Systems
2012,
Treatments using CDTI 1997-2011
Number of CDDs Trained
What does the Chief Economist of
the World Bank think about
community directed treatment?
• “The success of APOC in controlling river blindness is due to the partnership
approach to organization, in which countries, civil society, the private sector,
donors and UN agencies all play key roles, and to the community approach to
implementation, which places the programme in the hands of its beneficiaries.”
•
“APOC has helped countries create a community-directed treatment strategy
(CDT) involving community-directed distributors, extending and strengthening
health systems and providing an avenue for concomitant management of other
diseases.”
•
“Through this work, 600,000 cases of blindness have been prevented …….and
removing the threat of the disease has reclaimed at least 25 million hectares of
abandoned arable land for settlement and agricultural production, capable of
feeding 17 million people annually.”
(Africa’s Future and the World Bank’s Support to it - World Bank Regional Strategy for Africa. March 2011)
Some Questions
• How did CDTI develop into a vehicle for delivery of health
interventions/treatments in rural communities in Africa?
• What are the factors responsible for onchocerciasis
control’s initial vertical approach and the factors which have
made it possible to initiate an integrated approach:
• How CDTI developed into a vehicle for delivery of health
interventions/treatments in rural communities in Africa
• How is CDTI is different from other community models, such
as DOTS for TB, and how it differs from other community
distribution methods - e.g. delivery of bed nets for malaria?
Some Comments
•
The transformation of outreach treatment strategies to community- based
methodologies was a natural evolution based on programme delivery needs.
•
The transition to community-based treatment and then to Community Directed
Treatment with Ivermectin would not have happened without NGDO involvement
- or if it did it would have been very slow. NGDOs were the driving force- their
strength being in outreach and community engagement. (1)
•
‘Ivermectin may have changed the face of tropical medicine more than any other
drug this century’. The introduction of ivermectin enabled the evolution of new,
effective and sustainable strategies of community- directed health interventions
which are now being adopted for other neglected tropical diseases (NTDs). (2)
(1) Stefanie E O Meredith,Catherine Cross, Uche V Amazigo, Empowering communities in combating river blindness and
the role of NGOs: case studies from Cameroon, Mali, Nigeria and Uganda, Health Research Policy and Systems
2012,
(2) E W Cupp C, TR Unnasch: Importance of ivermectin to human onchocerciasis:past, present and the future.
Research and reports in Tropical medicine 2011, 2:81-92.
Some Questions
• What is CDTI's comparative advantage?
• What are the lessons learnt in the delivery of health
services/interventions at community level including spin offs
- Community Directed Distributors identifying cataract
cases/eye care, delivery of other NTDs, and motivation of
distributors)?
• What is the additional workload as result of integrated
delivery of NTDs and/or delivery of multiple health
interventions?
• What are the lessons learnt for community health systems
strengthening?
Some Comments
•
The success and advantage of CDTI for onchocerciasis control over other community
models comes from its ability to mobilise communities to take on the responsibility for an
activity of a short duration (part-time over a few weeks) once a year.
•
The packages of drugs are not too large and can be easily transported on the back of a
bicycle; calculation of dosage is easy with the height poles; the exclusion criteria are not
too difficult to determine; and the system of recording usage can be handled by people
without high levels of literacy.
•
CDTI is thus suitable for unpaid village volunteers. It does not take them away from their
other responsibilities for too long, and the community can find ways of compensating them
such as by helping them with their farm work or building a house.
•
Compare that to the difficulty of monitoring the combination of drugs necessary for TB
patients over a period of months (DOTS).
Stefanie E O Meredith,Catherine Cross, Uche V Amazigo, Empowering communities in combating river blindness and
the role of NGOs: case studies from Cameroon, Mali, Nigeria and Uganda, Health Research Policy and Systems 2012,
•Elimination of Onchocerciasis Transmission
in Africa
1
•Jan H.F. Remme
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