“There’s many a slip ‘twixt the cup and the lip,” an old proverb says. For the large-scale mass drug administration campaigns delivering pills to prevent or treat neglected tropical diseases (NTDs), this is both literally and figuratively the case.
Despite support from international public health organizations, major public and private donors and pharmaceutical companies, it’s no easy task to move medications from container ships to individuals. And where a person lives at least partly determines whether they’ll receive necessary drugs for lymphatic filariasis (LF), trachoma or other NTDs.
In 2015, about 20 percent of health districts slated for LF and trachoma elimination in 2020 were not meeting coverage targets, according to USAID surveys. During the 2016 COR-NTD conference in Atlanta, program managers came together to discuss strategies for maximizing coverage in rural and urban areas in Africa and Asia.
Mass drug administration campaigns rely heavily on donated drugs and volunteer community drug distributors (CDDs) to reach as many people as possible with little manpower and low budgets.
CDDs are the unsung heroes of these campaigns, participants in the treatment coverage breakout session agreed. These individuals usually work on foot, they are rarely paid, and are indispensable because they deliver drugs and motivate people to take them.
While program managers disagree on the best approach to recruiting and managing these key volunteers, they agree that the NTD community needs to do more to support, supervise and – perhaps most importantly – incentivize their work.
With limited political will and finite funding to fight NTDs, resources need to be managed so that CDDs are trained, equipped and respected, according to program managers. These volunteers also need to stay motivated and proactive as the battle against NTDs advances.
“As we move toward eliminating the NTDs, more work has been added onto the CDDs, and the pressure on the communities to sustain these incentives has also increased,” said Uzoma Nwankwo, senior medical officer in Nigeria’s NTD control and elimination division.
Drug distributors need to be known and trusted in their immediate community, and they need to be bilingual to communicate with both residents and researchers. They gather data essential for tracking treatment coverage and the efficacy of drugs. This is a lot to ask of a person who is paid little or nothing, and program managers rely on individuals committed to improving community wellness, said Nwankwo.
But more than altruism may be needed to meet the WHO 2020 goals for NTDs.
“This has put the question of incentives back on the agenda for discussion by all stakeholders as an issue of renewed importance,” said Nwankwo, emphasizing that the overall welfare of the drug distributors needs to be a concern across the NTD community.
Training and supervision are also needed to make sure that accurate coverage data are recorded and reported up the chain. But a supervisor cannot do the job of a community liaison, especially in fragmented or conflict-zone communities.
Women CDDs and the organizations they work for face extra challenges, especially in conflict areas, says Dhekra Annuzaili, a physician working with the Schistosomiasis Control Initiative in Cairo.
Women CDDs in war-torn areas run the risk of physical harm, including sexual assault, in addition to traditional demands of homecare and children. Many lack the resources to feed, clothe and educate their children, and Annuzaili believes they should be provided with resources for their children as well as paid for their hours on the job.
Women CDDs are more effective at enrolling disadvantaged women and girls in MDA programs than their male counterparts, according to a report by Uniting to Combat Neglected Tropical Diseases. But if they work for free, they may unintentionally foster the idea that women should work without pay.
Better compensation and more incentives for these workers can improve MDA coverage, said Annuzaili. “If you lose women, you lose CDDs, you lose coverage and lose your [treatment] targets.”