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Stepping beyond with community-directed treatment.


 In Nigeria, the concept of primary health care has reached a new level with the development of Community-Directed Treatment (ComDT) that extends beyond mere community partnerships to community ownership and empowerment as communities, rather than the control program, design and implement the actual delivery of treatment. In a study completed in 1996 that involved the mass distribution of ivermectin to control onchocerciasis at eight sites in five African countries, the more flexible ComDT systems outperformed program-designed systems in effectiveness, acceptance, and coverage. ComDT should result in less diversion of drugs, better indications for sustainability, and less distraction of village life. The difficulties encountered in the program included poor reporting (more of a problem in the program-designed than in the community-designed delivery system) and supply failure (which depends upon the support of the health system). ComDT must now be fine-tuned, especially at points of intersection with the health system such as treatment of cases of adverse reactions and ivermectin supply. ComDT communities will be asked (not told) what information they need to achieve these goals and how they are going to get the information. Further issues that must be addressed during the next multi-country study include identifying the involvement of health workers, cost sharing, cost recovery, and whether ComDT will be successful in a "real life" setting. ComDT use can be expanded to efforts to prevent other parasitic diseases or deliver vaccines, and communities may be able to take on other responsibilities, such as surveillance.
