When my friends Karen and Ian did my KAI inventory, they told me I often would find myself outside the cognitive climate of many people I worked with. That analysis really helped me understand myself far better, but it hasn’t stopped me occasionally ranting about things that seem so obvious to me – but not, apparently, to others.
Here’s an example. Five years ago, I discovered the African Programme for Onchocerciasis Control (APOC). Onchocerciasis, more commonly known as river blindness, affects or could potentially affect 200 million Africans. APOC has been a huge success in addressing it, using a community-driven approach, since 1995. I’ll give you the potted version of what I learned, so you understand why I rant occasionally about distribution of bed nets in Africa.
In the 1980s, the WHO’s Tropical Diseases Institute was worried about tropical illnesses such as river blindness that weren’t receiving much attention. They decided on a long term strategy, which was to train African scientists and also to work with pharmaceutical companies to develop treatments for these illnesses. They did a brilliant job of both.
One of those scientists was Dr. Uche Amazigo, who used to visit small villages on weekends to help local women. One weekend, a nurse pointed out a woman with disfigured skin, and said she thought it was related to the parasite that caused river blindness. Dr. Amazigo analyzed a snip of skin and found that the nurse was right. That discovery, along with the discovery of a new drug, helped inspire a radical change in treating river blindness. Initially, control programs focused on spraying blackfly-infested areas where blindness was a huge problem. But the research showed that the secondary effects were actually a much bigger problem, over a much wider area of Africa. Students couldn’t concentrate because they were always scratching, and many women were living in social isolation because their husbands left them.
Local distribution works
The drug controlled the side-effects during the parasite’s 14-year life span, if taken once a year for all those years. So then the question was – how to distribute this drug, once a year for 14 years or more, and over such a large area, at reasonable cost? A study done by TDI’s African research team in 1995-6 found that using local distributors chosen by the community would be very effective. And so it proved to be.
Since 1997, local volunteer distributors have collected the drug from distribution centres, handed it out annually in their villages, and kept records. They called this Community-Directed Treatment with Ivermectin (CDTI), and it has been one of the most effective public health interventions ever carried out in Africa. In 2006, 42.6 million people were treated by the volunteer drug distributors; in 2009, 70 million people were treated – 75% of the target population. More than 1.3 billion tablets have been delivered locally, and Merck’s donation of this drug is the world’s longest-running drug donation program.
After a few years, APOC looked at whether this same method could be used to deal with some other common public health interventions, including distributing bed nets, and found it could. Their report noted that CDTI was not just empowering communities to control disease – it also was building local health system capacity in remote areas where governments couldn’t afford to do so. Such capacity is, of course, crucial to achieving the Millennium Development Goals.
The key lies in community ownership of the program. The communities choose the distributors, and provide support; that means a lot of preparatory work by APOC, with communities. (Some other NGOs tried to use local distributors but chose these people themselves, rather than asking the community to do so, and that didn’t work.) Those 146,000 communities also were working in partnership with a unique public-private collaboration – 23 countries, 20 donors, research institutes, 15 non-governmental development organizations**, and the private sector. To adapt that old real estate saying about the importance of location, success lay in “collaboration, collaboration, collaboration.”
What I don’t understand
So here is what I don’t understand. When you have this amazing success story, and a model that works and is building systemic capacity, why isn’t every NGO that is working on these health-related issues, also coordinating their work with CDTI and APOC? Periodically I get messages from various charities urging me to help support the distribution of bed nets and it sounds like some are setting up their own distribution systems – that’s part of why they need funds.
And this is what often leads me to rant, most often via email. Please understand I am not against bed nets. What I do get frustrated about is how NGOs choose to distribute them. We talk a great deal about capacity building. Here, local capacity has been built and has proven itself able to deliver one vital health care intervention sustainably in the remotest areas and sometimes, even when fighting is going on. Why then are NGOs not working with that system?
My rant usually takes the form of an email, telling the organization about APOC and giving them the report references. I urge them to approach APOC, so that as well as improving health, they improve the primary health care system. I don’t recall ever getting a reply. I encourage you to read the documents, and if you agree with me, then next time someone asks you to help with their particular health intervention in Africa, ask them if they are working with CDTI and APOC. If we all do it, maybe the message will get across.
Here are the links:
- Community-Directed Treatment with Ivermectin
- Revitalising health care delivery in sub-Saharan Africa. The potential of community-directed treatment to strengthen health systems. (2007). Authors: APOC/WHO
- 15 years of APOC 1995-2010, African Programme for Onchocerciasis Control, Unique Global Public-Private Partnership. (2011). WHO/APOC.
- Dr Uche Amazigo, retired Director of the African Programme for Onchocerciasis Control – APOC. (2005-2011)
** Partners in CDTI include Charitable Society for Social Welfare, ChristoffelBlindenmission, Helen Keller International, IMA World Health, International Eye Foundation, Light for the World, Lions Club International Foundation, Mectizan Donation Program, Mission to Save the Helpless, Organisation pour la Prévention de la Cécité, Schistosomiasis Control Initiative, Sight Savers, The Carter Center, United Front Against River Blindness, and US Fund for UNICEF