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Societal Influences on NTD Programme Success: Reflections of a Four-Country Panel

News article 16 Apr 2019

By Dr Theresa Hoke

The COUNTDOWN Consortium recently convened in Monrovia, Liberia for our Annual Partners Meeting.  One highlight of the meeting was a panel discussion moderated by Karsor Kollie, Country Director for COUNTDOWN, Liberia and Director of Liberia’s National NTD Programme.  Research colleagues from the COUNTDOWN teams in Cameroon, Ghana, Nigeria, Liberia, and Liverpool served as panel participants. The aim was to examine the relevance of key findings produced by COUNTDOWN Liberia’s social science research portfolio to NTD programmes in other COUNTDOWN countries.  

L-R:Dr Michèle Ndonou, Vida Kukula, Dr Theobald Nji, Noela Gwani, Professor Sally Theobald, Alice Perkins, Karsor Kollie

Below are some key take-aways from panellists’ remarks.

Q. Liberia has found traditional beliefs can impact low acceptability and therefore low awareness which has led to challenges for delivery of services.  What are the similarities and difference in your own countries?

Dr Theobald Nji, Social Scientist with COUNTDOWN Cameroon, confirmed that traditional beliefs influence the success of NTD programming in his country. For example, it’s not uncommon for people to believe that NTDs are caused by people being “bewitched”. It follows that traditional medicines are sometimes used to treat NTDs. Traditional beliefs about the causes of ill-health and the effectiveness of health services strongly influence how communities respond to NTD services. 

Alice Siakeh, COUNTDOWN Liberia, raised the point that NTDs have the greatest impact on the poorest communities, which often implies those with the least education. The social science research team identified how communication was a major gap in NTD programming. To combat limited awareness of NTDs and the drug distribution programme, COUNTDOWN findings show the need for communications using multiple methods, including interpersonal communication, large-scale community meetings, the use of town criers and engagement of town chiefs and elders.

Q. Since CDDs are a key actor in delivering services, we need to look for ways to support and enable them to function effectively.  How have you done this in your own countries?

Noela Gwani, Social Scientist, COUNTDOWN/Nigeria, confirmed this is a priority concern in her country. Programme managers are seeking the best solutions for providing incentives, either financial or non-financial.  In some cases, a certificate of recognition is a strong source of motivation for CDDs.

Vida Kukula, Social Scientist, COUNTDOWN Ghana, described a notable development in her country. CDD training has recently doubled from 2 days to 4 days in response to a request from CDDs themselves for more extensive instruction.  Another interesting finding emerging from COUNTDOWN’s social science research in Ghana is CDDs’ desire “to belong”.  Specifically, CDDs have made it clear that they want to be identified as part of the health care system. One practical solution suggested by study participants is to have an identification card or badge that affiliates CDDs with the Ministry of Health. 

Another opportunity to recognize CDDs’ contributions is during training. It is worth recalling that CDDs belong to the communities where they distribute drugs.  When national programme leaders come to trainings held at the periphery, their presence brings prestige and attention to the work of CDDs. This, in turn, increases CDDs’ ability to mobilise communities and encourage participation in MDA.

Q. Where, when, and how drugs are distributed has shown to be a key factor in willingness to take them, Delivery models include fixed point and house-to-house. How are different options used in your countries, and what lessons can be learnt from these options?

Panellist Dr Michèle Ndonou, Health Economist, COUNTDOWN Cameroon, explained that the most important lesson is that delivery models must be shaped by community needs and preferences. In some communities, people prefer house-to-house distribution, so they don’t have to spend money on transportation to access MDA. Fixed-point distribution may not work in rural areas where communities are too far apart, requiring people to travel long distances to access drugs.  By contrast, in urban areas house-to-house distribution may not work if many people spend substantial amounts of time away from their homes.  A more effective solution for urban areas may be to rely on places where large number of people convene, like churches and mosques.

Vida Kukula reflected on how delivery models have been adapted to situations in Ghana.  MDA is not nation-wide, but rather focused on districts that are hotspots for NTDs. Substantial effort is focused on reaching hard-to-reach communities. In areas where hamlets are widely dispersed, programme managers have found that it is best to have set distribution points. 

The panel turned to the topic of resource mobilisation for programming. Reflecting on the example of Liberia’s National Communications Strategy, its development was a major step forward, but implementation of that strategy is what really matters now.  Essential to success is investment of resources that flow all the way down to the periphery. Two factors threaten adequate resource allocation, however.  First, as one panellist put it, “Those who manage budgets don’t live with NTDs.”  Stated another way, NTDs are diseases of poverty, and the communities most impacted by NTDs typically lack the power and influence to ensure that NTDs receive adequate attention. A second threat to adequate funding is the way NTD programming is heavily donor-driven. Programmes are dependent on donors prioritizing NTDs and allocating enough resources for roll-out.  One panellist commented, “We have the tools.  It’s implementation that’s the problem.”

Professor Sally Theobald from COUNTDOWN LSTM shared some closing remarks.  She noted Liberia’s great achievement in developing the Communications Strategy, success that can be attributed to formation of an effective partnership across Ministry of Health departments.  She also noted how well-substantiated accounts of how people are affected by NTDs bring into sharp focus why we must get MDA right.  Prof Theobald reminded us how WHO has referred to NTDs serving as a “litmus test” for the Sustainable Development Goals. This means that progress in eliminating NTDs is an important indicator of how essential health services are being extended to the poorest, most vulnerable communities.

A clear conclusion drawn from the panel is that all four countries face similar challenges, and some of the strongest influences on programme success are social rather than technical. The COUNTDOWN Consortium has come to appreciate the invaluable contributions of a multi-disciplinary team. Whilst the technical expertise of parasitologists and epidemiologists is important, social scientists have emerged as an essential partner on the research team. They gather evidence to help tailor NTD services to local contexts, and they serve as a liaison to implementers and community members to ensure their voices is represented in programme design and implementation. Partners in all four COUNTDOWN countries have learned and benefitted from multidisciplinary collaboration.