Community-Directed Interventions For Priority Health Problems Inafrica: Results Of A Multicountry Study

Abstract

Objective To deterrnine the extent to which ihe cornrnunity-directed approach used in onchocerciasis control inAfrica could effectively and efficiently provide integrated delivery of other health interventions. Methods Athree-year experirnental study was undertaken in 35 health districts frorn 2005 to 2007 inseven research sites inCarneroon, Nigeria and Uganda. Four trial districts and one cornparison district were randornly selected in each site. All districts had established iverrnectin treatrnent prograrnrnes, and in the trial districts four other established interventions - vitarnin A supplernentation, use of insecticide-treated nets, horne rnanagernent of malaria and short-course, directly-observed treatment for tuberculosis patients - were progressively incorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations of intervention coverage and provider costs, as well as qualitative assessments of the CDIprocess. Findings With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for Short-course, directly-observed treatment. Tile 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. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problerns with the supply of intervention ~aterials were a major constraint to implementation; (iii) the communities and cornmunity implementers were deeply committed to the CDI process; (iv) community irnplementers were more motivated by intangible incentives than by external financial incentives. Conclusion 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 inAfrica.