TDR Study featured by WHO Shows Effectiveness Of Community-Directed Interventions in Delivering Health Care In Africa


One of the greatest challenges in achieving the Millennium Development Goals to cut infant and maternal mortality and reduce the disease burden lies in ensuring that available health interventions reach the people who most need them.

One of the greatest challenges in achieving the Millennium Development Goals to cut infant and maternal mortality and reduce the disease burden lies in ensuring that available health interventions reach the people who most need them.


Lucy Vulley completing her home management of malaria training. Photograph World Health Organization (WHO) What is home management of malaria? Home management of malaria (HMM) is a deceptively simple plan -- train local mothers and other community members to recognize fevers, provide pre-packaged medications, and keep the medicines properly stored and recorded. HMM was developed to increase access to medicines in areas where there is no nearby health facility or provider, so that medicines can be provided quickly to children with malaria, preventing the risks of serious illness and death. Source: WHO Ghana Press Release, 11 June 2007.

Many simple, affordable and effective disease control measures have had only limited impact due to their inadequate distribution in poor and remote communities, wrote the CDI Study Group in the paper published in the June 2010 issue of the Bulletin of the World Health Organization.

Although several global health initiatives have improved the delivery of selected health interventions, many priority interventions, such as those directed against malaria, still have unacceptably low coverage, especially in Africa. Thus, there is an urgent need for more effective strategies to improve access.

The proliferation of health initiatives has led to further fragmentation of the overall health effort and there are calls for more integration in primary health care. Greater integration is particularly relevant for the delivery of community-level interventions in which the community itself participates.

Onchocerciasis control

The study set out to determine the extent to which the community-directed approach used in onchocerciasis (river blindness) control in Africa could effectively and efficiently provide integrated delivery of other health interventions.

The study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Four trial districts and one comparison district were randomly selected in each site.

All districts had established ivermectin treatment programmes for onchocerciasis. In the trial districts four other established interventions – vitamin A supplementation, use of insecticide-treated nets, home management of malaria and short-course, directly-observed treatment for tuberculosis patients – were progressively incorporated into a community-directed intervention (CDI) process.

Higher health coverage

The findings showed that with the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course, directly-observed treatment. The coverage of malaria interventions more than doubled.

The district-level costs of delivering all five interventions were lower in the CDI districts, but no cost difference was found at the first-line health facility level.

"The CDI strategy, which builds upon the core principles of primary health care, is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa," wrote the CDI Study Group

Process evaluation showed that:

 (i) participatory processes were important;

 (ii) recurrent problems with the supply of intervention materials were a major constraint to implementation;

 (iii) the communities and community implementers were deeply committed to the CDI process;

 (iv) community implementers were more motivated by intangible incentives than by external financial incentives."


This news is from TDR, 14 July 2010


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