Empowering the NTD Workforce – Highlighting Community Drug Distributors

By Pamela Bongkiyung & Prof. Sally Theobald

Mass Drug Administration (MDA) remains a fundamental part of approaches to address several Neglected Tropical Diseases. However, the people who make this process happen at the community level – Community Drug Distributors (CDDs),  are sometimes not given enough attention or  sufficient acknowledgement  for their contributions and how best to motivate with some form of remuneration and reward this critical cadre is subject to much debate

Most CDDs come from the communities in which they work, and are chosen through community processes. Training and supervision is varied and often not given enough resources or attention. Their selection, supervision and training remain a community effort. For a very long time, they have not been sufficiently considered as an essential part of the health system around the world. This in turn has meant that in some contexts they are considered by governments as voluntary workers who don’t always need formal payment. Though there have been promises to include some payments for CDDs in national budgets, this frequently doesn’t materialise in practice. The issue of paying CDDs is embedded in controversy – who should pay?

The idea to start using CDDs was created during the Bamako Initiative in 1987 and then enacted in the Community Directed Treatment with Ivermectin (CDTi), rolled out by APOC (African Programme for Onchocerciasis Control). This process was designed from the onset to be owned by the community but challenges such as support, sustainability and remuneration remain.

Given that these communities were too poor to pay for drug distribution themselves, CDD work was viewed as serving one’s community and therefore a reward in itself. It was not envisaged that serving your village or clan should be met with monetary rewards. There remains a great difficulty in putting monetary value to the high esteem given to these individuals within communities.

The work of CDDs is also relevant in the detection of diseases, but they are often not mobilised to fulfil a monitoring role. The situation is further complicated when gender is inserted into the mix.  In the analysis of Community health worker programmes, men are more likely to be paid then women; and also more likely to be in senior roles. Little is known about how gender shapes the experience of being a CDD; the relationships that are built at community level and the implications for equitable and gender transformative processes.

Although CDDs have been central for over three decades, there is very little recent literature making an appraisal of their inputs and how best to support them. . It is imperative that their work is better acknowledged as a key interface for NTD elimination. So, we ask, how can we help sustain CDDs in health systems?
This is why COUNTDOWN has taken the initiative to bring the issues and experiences of CDDs to the limelight in the Coalition for Operational Research of Neglected Tropical Diseases (COR-NTD) from 10 – 11 November 2016. We will host a specific-session exploring evidence and evidence gaps. Panellists from Ghana, Nigeria and Cameroon will discuss the experience of CDDs in different contexts, how gender, poverty and relationships shape this and priorities for action.

COUNTDOWN will also be well represented at the Health Systems Global (#HSG2016) Conference in Vancouver, Canada from 14 – 18 November 2016. The Liberia COUNTDOWN Country Director – Karsor Kollie is presenting on the experience of Community Health Workers in the Ebola response in Liberia; and we have a panel on intersectionality which explores the interplay between different axes of inequalities.


COUNTDOWN Launched at 9th Mano River Union Meeting on Neglected Tropical Diseases

19th-21st October 2016, Monrovia, Liberia

Prof. Russ Stothard

Originally created in 1973, the Manu River Union (MRU) is an intergovernmental institution comprising of Sierra Leone, Liberia, Guinea and Cote d’Ivoire. Primarily, the MRU was formed to promote local trade and economic development. Since 2006 its scope has expanded. Today this includes issues related to health policies and practices, specifically in the harmonization of ongoing interventions against neglected tropical diseases (NTDs) as several NTDs cross-borders. A very pertinent example of when cross-border collaboration was crucial was evidenced by management of the Ebola Virus Disease (EVD) epidemic. Without a cross-country response in Liberia, Sierra Leone and Guinea the epidemic would not have been curtailed. Nonetheless, the EVD crisis severely shocked the health system and suspended many ongoing interventions against NTDs. Thus for Liberia to host the 9th MRU on NTDs is a testimony to reinstatement of routine activities.

In Liberia, the COUNTDOWN team is a collaboration between the Ministry of Health and University of Liberia-Pacific Institute of Research and Evaluation (UL-PIRE). Each partner was very busy this week in preparations to host the 9th MRU meeting. This brought together just over 90 Anglophone and Francophone delegates, inclusive of the MRU secretariat and many representatives of those practicing NTD control in West Africa and elsewhere beyond. We were delighted to represent COUNTDOWN as part of the international partners and were well-placed to assist the Liberian team. In addition to the standing MRU agenda, this 9th MRU meeting was especially significant for it marked the formal launches of the Liberian COUNTDOWN programme and the Integrated NTDs Case Management Programme as well as the inauguration of the first Liberian NTD Ambassador Dr Everlyn Kandakai.


Prof. Russell Stothard – COUNTDOWN Director & Dr Evelyn Kandakai – Liberia NTD Ambassador

The strategic plan for integrated case management of NTDs is the first of its kind in sub-Saharan Africa. Clearly Liberia is forging ahead and should be much congratulated in its efforts. Alongside patient management of Buruli ulcer, leprosy and yaws, detection and surgical-interventions against hydrocele, a complication of lymphatic filariasis, were reported. Over the years the LSTM-FPSU, as supported by DFID-UK, has played a major role in assisting Liberia to develop an action plan for management of hydrocele. This was reported at the meeting by Brent Thomas.

At the start of the MRU meeting we were all very touched by a personal testimony given to us by Annie Toweh, a young girl who had had a very extensive Buruli ulcer lesion. She much benefited from the closer attention to this condition and had undergone treatment with skin-grafting; we were happy to see that she was well on the road to recovery and gaining a normal life.

The role of the NTD ambassador is primarily to promote activities of the NTD programme, especially in supporting the interface between ministries and promoting appropriate communications and messaging to and from disease-endemic communities. Dr Kandakai has had an outstanding career in shaping education in Liberia from tertiary to primary levels and wished to bring her skills to ensure that the education sector fully embraces the activities of the NTD programme.

A key channel of communication is the weekly 45-minutes health promotion slot on national radio. This is broadcast across the nation on 99.9 FM and on Tuesday, I took part in a radio interview with Karsor Kollie (MoH COUNTDOWN) and Miatta Sonkarlay Sonkarley, (Map International). During discussions I was able to highlight Laura Dean’s recent work with UL-PIRE which is now ready to start fieldwork this coming month in Bong and Maryland Counties, respectively and we look forward to their findings.


R-L: Prof. Stothard, Karsor Kollie – COUNTDOWN Liberia Country Director, Miatta Sonkarley – Liberia Programme Manager MAPs International (Medical Assistance Programmes), Talk Show Host – Sabbah

As Kate Hawkins once told us, in COUNTDOWN communications should be everyone’s business. Team Liberia has now established a twitter account @COUNTDOWNLR and was active throughout the MRU meeting tweeting and taking notes. This helped to provide two recap sessions at the start of each day as well as drafting the 12 formal recommendations forthcoming the deliberations from the meeting. With regards to the recommendation of establishing an effective communication strategy to address NTDs implementation programme, it is therefore very fitting that COUNTDOWN is helping Liberia to develop an inclusive strategy. This will also be adopted in due course by other MRU countries so we have a lot to expect from the 10th MRU meeting to be held in Guinea.



Spaces of Evidence: Evidence and Organisations in Development

6 -7th October, University of Edinburgh

By Prof. Russ Stothard

Funded by the Economic & Social Research Council (ESRC), Spaces of Evidence is a global network of scholars, practitioners and activists exploring the intersections of politics, measurement and evidence-based policy in health, development, economics, medicine and beyond. The network organises regular discussion meetings. This symposium took place at Edinburgh University, being the last in its series of events, and focused on five topics: Institutional responses to demand for evidence, neglected tropical data, evidence shaping policy, performing evidence generation and the politics of evidence generation. I thank the organisers Drs Ian Harper and James Smith for hosting such a stimulating meeting.

Being the only biomedical parasitologist there, it was a good forum for me to learn and exchange concepts and ideas in a wider audience. Each topic was assessed across the two days by a combination of presentations and panel-led discussions often responding to questions from the floor. At first-glance, neglected tropical diseases are typically lodged within health-specific silos, so to be given a chance to present their wider socio-political context was important. A key thread throughout was, what evidence is or data are judged to be most appropriate for assessing effective development and (or) poverty-reduction activities? There is no simple answer to this I am afraid, for there is no accepted technique or protocol that can piece together the jigsaw of evidence into a picture that all can understand, or even use generically to evaluate original goals and ambitions.

The controversy behind worm wars was much debated, as it should in an academic venue such as this, including the future use of neglected tropical diseases (NTDs) as tracers of development. I was glad to present my perspective on this with examples taken within COUNTDOWN, and from my recent survey work in Uganda. In so doing, I was able to explore with Professor Tim Allen and Dr Georgina Pearson, from the London School Economics, the common ground needed to support interventions against soil-transmitted helminthiasis and schistosomiasis, highlighting the global importance of NTDs. In the end, we all agreed there is no doubt that infected children need treatment, on equity grounds alone, but the question remains how best to empower the local health system to do so and COUNTDOWN will provide sensible answers to make it happen.

During the meeting, the growing fascination with metrics and results from random controlled trials was debated. Much of the desire to do ‘good’ typically gets lost within numbers and analytical designs. The danger here is to fall victim with the love of numbers to the occlusion of the guiding principles in bioethics, autonomy, justice, beneficence and non-maleficence. The challenge should simply boil down to better measuring these in the most robust way, not forgetting voicing the experiences of those doing and receiving the intervention in a meaningful manner. I was glad to share Prof. Sally Theobald and Dr Ifeoma Anagbogu’s blog in The Lancet Global Health about the importance of Expanded Special Project for Elimination of NTDs (ESPEN), discussing the many facets of evidence we will need in future.

Those of us in COUNTDOWN know that ‘development’ and ‘poverty-reduction’ has many dimensions and location-specific facets. This makes assessing the progress of any specific-intervention, albeit framed as outputs, outcomes and(or) impact, within a broader remit difficult to dovetail. During the spaces of evidence discussions, it brought it home to me the tremendous importance of our COUNTDOWN logframe and theory of change. Critically, these two documents help us be logically consistent and able to measure our progress in a considered and step-wise manner. Without them, complex projects like COUNTDOWN which is navigating across new ground by exploring interdisciplinary methods, would get lost. Put simply, if you have no idea of where you are going then you do not know which direction to take.

All this may sound trivial, but it is easy to get lost in details for it was clear to me from open discussions that considered the list of failed projects, their doom rooted back to a common catalogue of problems: misconceived ideas, inappropriate interventions, unrealistic donor-driven demands, poorly co-ordinated teams and each with members having mismatched skills. Sadly, in the growingly commercialised landscape of implementation research, it is all too easy for large consortia to be formed, or rather malformed, primarily upon greed beset with vague intentions. This is not the case with COUNTDOWN for our long term intention is described best described within the Sustainable Development Goal 3.3 – By 2030, to end the epidemic of AIDS, tuberculosis, malaria and neglected tropical diseases. All we need to do is simply get on with it!