There are many factors to keep in mind while planning for mass drug administration (MDA) of preventative chemotherapy for neglected tropical diseases (PC-NTDs). Acquiring the drugs is only the first step – or the “first mile” in supply chain lingo. The real challenge comes in getting drugs from the Ministry of Health into the hands of the people who need them. This process can be complex, particularly when the people who need treatment are in remote and hard-to-reach areas. The “final mile” of an MDA relies on the hard work of community volunteers and specifically, community drug distributors (CDDs).
The importance of these volunteers cannot be overstated. They bridge the gap between the NTD programs and the communities they are serving, often times leading by example by taking medicines alongside the communities and ensuring the cultural acceptability of the MDA. They also carry out crucial activities to prepare for the MDA like census activities and community sensitization, as well as deliver drugs during the MDA and sometimes even after the official distribution period is over.
Sustaining the motivation of these volunteers is critical – but how?
This question is at the heart of iChord, the new collaboration between the Bruyère Research Institute (Canada), the African Institute for Health and Development (AIHD) (Kenya), University of Health and Allied Sciences (UHAS) (Ghana), and the Ministries of Health in Côte d’Ivoire and Uganda. Technical assistance to the project is provided by researchers in the Rollins School of Public Health, the Task Force for Global Health and WHO-TDR. iChord – or Improving Community Health Outcomes through Research and Dialogue – works with CDDs, community partners, and government NTD programs to sustain the motivation of CDDs and to improve their performance.
In celebration of their website launch, I spoke with iChord’s founders – Alison Krentel of the Bruyère Research Institute, Margaret Gyapong of the Institute for Health Research in UHAS in Ghana, and Mary Amuyunzu-Nyamongo of the AIHD – about the motivation behind and vision for the collaboration. The following responses reflect the views of all three of the founders.
What was your motivation behind iChord? Was it inspired by any particular studies or experiences in the field?
In November 2014, the Coalition for Operational Research on Neglected Tropical Diseases (COR-NTD) asked us to host a session for program managers that would specifically delve into understanding their needs and concerns. It was an excellent session with plenty of participation. One issue that was deemed crucial for successful operational research (OR) was around understanding and sustaining the motivation of CDDs. Many program managers and people working to support MDA programs felt that they faced challenges keeping these individuals motivated over the course of the elimination programs. Some of the participants felt that low coverage in some of their districts was attributable to low motivation of under remunerated CDDs. We followed up on this initial request for OR with a meeting in Accra Ghana in April 2015 with representatives from Ghana, Kenya, Uganda, the Democratic Republic of Congo (DRC), Côte d’Ivoire, and Cameroon. During this meeting, we brainstormed around the issues that affected CDDs and mounted these issues on index cards and posted them all over the walls of the meeting room so we could study them and plan exploratory research to understand them better.
The Accra meeting was the basis for a project that began in Cote d’Ivoire and Uganda in 2016. The aim of this first phase was to understand what motivates CDDs working in NTD programs. We based our research on a systems approach – meaning that we wanted to understand CDD motivation from the perspectives of the CDDs themselves, the health system, and the communities they serve.
What did you find as a result of this study? Were you surprised by what you found?
We were surprised by some of the results – especially the fact that financial motivation was not the main concern of CDDs. Rather, they needed recognition, appreciation and feedback on the work they were doing. Our results showed that CDDs were in fact highly motivated individuals who work under challenging circumstances at times.
Another surprising finding was the different profiles of urban CDDs compared to their rural counterparts, specific to the research sites in Côte d’Ivoire. They are younger, more educated and come from wealthier households. However, we found that the rural CDDs were more efficient in their work, had more experience and spent more time with the community when they were distributing drugs.
Did you find any marked differences in the results between the two countries, Côte d’Ivoire and Uganda?
It was interesting that there were differences between the two countries in terms of how CDDs felt based on the stories they told us. These differences underline the importance of understanding the context. The area in Uganda, where the research was carried out, is an area where there has been a history of social displacement resulting in a more fragmented society with internally displaced people and refugees from neighboring countries. We heard many stories of drunk people harassing CDDs during MDAs as well as other social challenges for the CDDs. Through the use of micro-narratives in our surveys we have been able to catch a glimpse of the real life experiences of the CDDs while in the field. These micro-narratives can be a powerful tool to know how to plan interventions to improve working conditions for the CDDs.
You are now in the process of the next phase of this work in Côte d’Ivoire and Uganda. How have the results of your earlier study impacted the study design of this next phase?
The results of the first study were the main drivers for the design of the second study. The project was designed using an implementation research design with a 3-phase approach. The pre-intervention phase consisted of a baseline and needs assessment. In Phase 2, the results from the baseline study were fed back to the community and the program managers at country level to ascertain their opinions and analysis. Presently, we are carrying out the interventions and recommendations derived from the baseline study.
One of the important considerations for this current phase is that all the interventions that we are trialing to improve and sustain the motivation of the CDDs are based on a model that will not cost the NTD programs any additional money. The first phase of our research suggested that financial payments were not the primary drivers to motivate CDDs; rather feedback, active supervision and community support were seen to be more important. As such, each of our interventions is based on non-financial incentives.
Following the intervention, we will measure the perceptions of the intervention as well as any impact for CDDs and communities in post-MDA mixed methods research.
How do you see iChord and the results from your research affecting programmatic decisions?
The study is already influencing program decisions regarding selecting of CDDs engaging better with communities, the approach to training of CDDs before MDA begins and providing feedback to CDD. Specific elements of this project have already been presented to countries considering Triple Drug Therapy with ivermectin, diethylcarbamazine, and albendazole (IDA). Because we have proposed interventions that can be incorporated into existing programmatic activities, we expect that NTD programs should be able to adapt and implement them in their countries without additional resources. Because achieving high coverage is required for IDA rollout, enhancing the support of CDDs is going to be paramount to reaching our elimination goals. See our website: www.ichord.org for more information on the project and to see some of the interventions we are testing in Cote d’Ivoire.
Is there anything else from your work with CDDs that you would like to highlight?
As a NTD community, we sometimes forget that the weight of our success in achieving good coverage is borne largely by a volunteer workforce. We tend to simplify their involvement as being only financially motivated. When no additional funds are available, we are challenged to find other ways to support and motivate these individuals. Our research shows that these people are willing volunteers; in fact they are professional volunteers, working across many different health programs and hoping for better connections with their communities and with the primary health care centers in their villages. They need much more than money to do their jobs – they need feedback on their work, better training and supervision in their work. The Supervisor’s Coverage Tool is an example of a simple tool that can be useful to both CDDs and supervisors during MDA.
We also found some surprising results around urban CDDs. We believe that programs need to rethink their approach to selecting CDDs in urban areas to ensure that they select individuals who are known to their communities. Young and inexperienced CDDs may be able to carry out urban MDA but they require more support and training to ensure that they maximize efficiency and effectiveness in their distribution.
Lastly, we have experimented with a digital guidebook for CDDs with simple dosing information and photos to download onto their phones. We had great success with CDDs downloading it in the urban areas of the study. We are anxious to see how it was used and appreciated by both the CDDs and the community members themselves. Stay tuned!