Lessons from CouNTDown: Implementation Research Supporting the WHO NTD Roadmap

CouNTDown Director Dr Rachael Thomson formally welcomed attendees to the session and gave an overview of the 7-year programme, including its theory of change and core values of; promoting equity, rights and responsiveness to gender and disability, participatory approaches, reaching marginalized and vulnerable groups to ensure no-one is left behind, promoting community and health system responsiveness and resilience and capacity strengthening.

Dirk Mueller spoke on behalf of the Foreign, Commonwealth and Development Office (FCDO) to thank all of the programme partners and countries and acknowledge CouNTDown’s achievements. He noted that CouNTDown’s research and impact will serve well within the NTD space in addition to health systems building and fighting infectious diseases.

 Pillar 1: Accelerating programmatic action

Anthony Bettee and Dr Akinola Oluwole presented on CouNTDown’s study ‘Strengthening the health system for the management of Female Genital Schistosomiasis (FGS) at the primary care level in Liberia and Nigeria’

Previous CouNTDown work on stigma and treatment barriers surrounding FGS in Ghana led to work on FGS services being embedded into primary care in Nigeria and Liberia. As well as developing and testing an integrated package of care for FGS, this study put referral systems in place for FGS at all levels of the health system. The intervention improved knowledge and capacity of frontline health workers to be able to manage cases of FGS at the primary care level, and reduced inequality in access to healthcare and treatment for FGS. As a consequence, there was reduced stigmatisation of girls and women affected by FGS, and researchers developed extensive evidence for policy on the management of cases.

The FGS Training guide for Nigeria can be found here, the FGS trainer manual here and the associated presentation here. The Liberia FGS Intervention manual can be found here.

 Pillar 2: Intensifying cross-cutting approaches

Dr Luret Lar spoke about how ‘Development of an integrated training package for community-based case detection and referral for NTDs affecting the skin: a pilot study in Kaduna and Ogun states, Nigeria’ addressed knowledge gaps, through the use of integrated approaches at community levels.

After a literature review and stakeholder meetings, the research team developed an integrated algorithm and tools for detection, referral and management of NTDs- the intervention manual can be found here. Following piloting of the training cascade, the intervention was evaluated. Learning and knowledge gained was found to be sustained and enhanced over time and there was increased awareness at community level on identification and referral of skin NTDs- a participatory approach has resulted in local ownership of the intervention, and stakeholders are enthusiastic about scaling up the training intervention. Integrated approaches can bring strength and opportunity to NTD programmes. In this study there has been an increase in integration and shared learning between state NTD units and the state Tuberculosis, Buruli Ulcer and Leprosy Control programmes.

The next study was presented by lead Dr Oluwatosin Adekeye, ‘Establishing a community-based support system to improve health and wellbeing of people affected by stigmatising skin NTDs in Kaduna and Kwara states’. After a scoping review and photovoice activities, with photographs taken by persons affected by NTDs and their caregivers, photos were grouped into themes and included in booklets- the Kwara booklet can be found here and the Kaduna booklet here. After dissemination and intervention planning meetings, and the setting up of support groups, an evaluation of the impact of the support groups was carried out. A Support group photo booklet and Support Group guide were developed, and it was found that the support groups improved social connection and led to a reduction in stigma.

Anthony Bettee’s presentation illustrated how on the development of the Liberia Communication Strategy stemmed from CouNTDown’s implementation research findings, showing weaknesses in social mobilization processes and lack of awareness of NTDs in communities. The communication strategy was developed by the NTDs Unit, Ministry of Health and implementing partners, with a purpose to increase awareness of NTDs, increase acceptance of NTD interventions, raise the profile of the NTD programme, increase the knowledge of health workers and make use of traditional communication techniques and local knowledge. It was highlighted that multi-sectoral expertise facilitated the development of appropriate messaging and that through shared learning there was a contribution to new mechanisms of governance that support the addressing of health challenges.

Pillar 3: Changing operating models and culture to facilitate country ownership

Previous CouNTDown work in Ghana and Cameroon had highlighted the need for inclusion and participation in the planning of mass drug administration (MDA) activities. The use of seasonal calendars and expanded access to MDA highlighted the crucial role of including communities and Community Drug Distributors (CDDs) in planning. Increased participation led to increased acceptability and has been shown to be core to more equitable coverage of MDA and increased case detection.

‘Participatory planning for equity in MDA: Community advocacy for meaningful partnerships, communication and engagement of those left behind’ was presented by Georgina Zawolo, who explained how CouNTDown research sought to develop solutions to existing challenges in NTD programmes and used visual methods to explore intervention ideas to address health system challenges. A case study on this research can be found here. Solutions generated included community-led intervention design and the establishment of community-based social mobilisation teams. The use of visual methods resonated at all levels for knowledge translation, and helped to flatten hierarchies, enabling the creation of solutions at different levels of the health system.

Noela Gwani spoke about ‘Scale up of a bottom-up participatory planning approach for Mass Administration of Medicines in Nigeria’ which applied a multi-disciplinary participatory action research cycle approach. Participatory approaches such as community mapping and transect walks engaged communities, and various intervention evaluation methods were used such as ethography, activity-based costing and community feedback. Tools developed included the Paticipatory Guide for Planning Mass Administration of Medicines (PGP) and accompanying videos which can be found on the CouNTDown YouTube Channel.  Learning packs and an advocacy costing toolkit, plus other resources such as the Standard Operating Procedures, can be downloaded from the CouNTDown Tools and Booklets page here.

This research promoted partnerships and trust. Impacts include increased accessibility and acceptability of the NTD programme, and increased resource mobilisation for NTD implementation at local level, as well as increased involvement of community and religious leaders, and engagement of community structures. Capacity was strengthened considerably in areas such as cascade of training and facilitation of stakeholder meetings, and increased collaboration between State NTD teams and Local Government Area (LGA) NTD teams.

 Panel discussion

In the final part of the webinar, Dr Sunday Isiyaku chaired the panel discussion ‘Collective Capacities: Reflecting on the last seven years to move forward together to eliminate NTDs’. The panel looked back over some of the key learnings of NTD research and programming over the life of CouNTDown, as well as some of its key successes. The panel discussion can be viewed at around 1:26:40 within the webinar recording.

Panellists discussed a wide range of CouNTDown key successes, including the development of various tools and products, and the use of these within NTD programmes and communities, such as the aforementioned PGP in Nigeria, which, as James Yashiyi explained, is one of many tools which can increase the capacity of programme implementers and also increase contact and therapeutic coverage. Kafil Emiola stated, during the panel session, that overall, therapeutic coverage has increased by 35% across Ogun State following CouNTDown interventions.

Kim Ozano spoke about CouNTDown research approaches and frameworks- namely Participatory Action Research (PAR), QI (Quality Improvement) cycles and Community Based Participatory Research (CBPR), and how these help to challenge power dynamics whilst focusing on participation and bringing implementers closer to communities. Gartee Nallo highlighted the importance of engaging with people affected by NTDs and with stakeholders at all levels of the health system in implementation processes in the acceleration towards disease elimination.

The topic of FGS was also discussed during the panel session- Abednego Wright indicated that the main achievement of CouNTDown in Nimba county, Liberia, has been the introduction of the piloting of an FGS integrated package of care and referral systems. He explained that due to lack of knowledge surrounding the condition, many women and girls had been previously misdiagnosed with other conditions such as Sexually Transmitted Infections (STIs).

Dr Sunday Isiyaku led the panel in considering the key learnings to take forward, and how these will be implemented. Hauwa Usman emphasised the importance of involving stakeholders in key activities and the use of IEC materials, as well as the close monitoring and supervision of activities. On the subject of country ownership, which is a key aspect of the WHO NTD roadmap 2030, Karsor Kollie said the following about working with CouNTDown:

“CouNTDown gave us the leverage to drive…we DROVE the agenda in terms of implementation research. So, there was not people from Liverpool coming and giving us questions as to what it is we need to do- we said ‘these are the challenges we are having, can we do research in this [area]’”

(Karsor Kollie)

Uduak Gideon Ntuen of Federal Ministry of Health Nigeria mentioned that CouNTDown work has been timely, as the programme’s findings and recommendations will be used when reviewing the Nigeria NTD Masterplan. He added that the tools produced by CouNTDown will be used practically to push the programme forward- evidence from CouNTDown has revealed that a bottom-top (aso known as bottom-up) approach gives better results when it comes to NTD programming, and this approach will be practicalised for implementation.

Dr Sunday Isiyaku concluded the panel discussion with a reminder of the importance of CouNTDown work, including the following quote:

“I always tell the CouNTDown team in Nigeria…you are the silent achievers, struggling, doing the most fantastic work that will change the lives of millions and millions of people, not just across the Kwara and Kaduna states but across Nigeria and the whole of Africa, if we can take this forward”

(Dr Sunday Isiyaku)

Summation

To conclude the session, Dr Rachael Thomson unveiled the visual minutes poster (as shown below) which illustrates many of CouNTDown’s cross-cutting themes, collaborations and achievements. She also highlighted that CouNTDown has placed those affected by NTDs at the centre of its research and that the programme has worked with NTD policy makers, implementers, NGOs and academics to help tackle challenges faced by NTD services.

 

Speakers

Dr Rachael Thomson, CouNTDown Director, Liverpool School of Tropical Medicine
Mr Dirk Mueller, Foreign, Commonwealth and Development Office
Mr Anthony Bettee, Ministry of Health Liberia
Dr Akinola Oluwole, Sightsavers Nigeria
Dr Luret Lar, Sightsavers Nigeria
Dr Oluwatosin Adekeye, Sightsavers Nigeria
Ms Georgina Zawolo, University of Liberia-Pacific Institute for Research and Evaluation
Ms Noela Gwani, Sightsavers Nigeria

Panel

Dr Sunday Isiyaku, Country Director Sightsavers Nigeria (chair)
Mr Karsor Kollie, NTD Programme Director, Ministry of Health Liberia
Ms Hauwa Usman- State NTD implementer, Kaduna
Mrs Kafil Emiola- State NTD Coordinator, Ogun
Mr Uduak Gideon Ntuen, Federal Ministry of Health Nigeria
Ms Gartee Nallo, University of Liberia-Pacific Institute for Research and Evaluation
Mr James Yashiyi, Sightsavers Nigeria
Dr Kim Ozano, Liverpool School of Tropical Medicine
Mr Abednego Wright, NTD focus person, Nimba County, Liberia