Empowering Communities for Better Health

8/8/2019 Empowering Communities for Better Health

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empoweRing Communities oR BetteR HeAltH Bl 11

7TDR BL11 2008 R r

1.1. Context and rationaleMany e ective and simple interventions and toolsare available or the prevention and treatment o in ectious diseases o poverty, such as malaria andNTDs (the most important being leishmaniasis,human A rican trypanosomiasis, Chagas disease,trachoma, leprosy, buruli ulcer and the helminthin ections including hookworm, ascariasis,trichuriasis, lymphatic lariasis, onchocerciasis,drancunculiasis and schistosomiasis). However,these interventions do not reach the a ectedpoor rural and urban populations that need themmost, particularly in A rica. The promising newinterventions that do get to communities o ten havea limited impact because they are not deliveredin an e cient and sustainable manner to poorpopulations. Largely as a result o this, in ectiousdiseases remain a major cause o morbidity andmortality in developing countries and especially in

A rica, where they are responsible or 60% o alldeaths.

In many developing countries, especially A rica,e ective and sustainable delivery o promisinginterventions is di cult due to the weakness o public health systems. At the same time, many

simple interventions do not require trained healthpro essionals or delivery and can be administeredat the community level by community memberswho have received basic training. Disease controlprogrammes are there ore increasingly settingup community-based delivery strategies andinterventions that utilize these groups o trained,community-based volunteers when clinical/ hospital sta and/or acilities are not available.However, approaches used vary signi cantly interms o community involvement, e ectiveness and

sustainability, and there has been very little researchto evaluate and compare these strategies to determine

how they could be optimized. There is, there ore, anurgent need or research into integrated community-based interventions that build on e ective models,such as home management o malaria andcommunity-directed treatment o onchocerciasis, in

which communities are empowered to manage theprocess themselves.

Over the past ten years, a strategy o community-directed treatment with one annual dose o ivermectin (CDTi) has been developed andtested. This intervention was designed, set up andmanaged by each community itsel , with the helpand participation o the national health systemand/or international level partners. In cooperationwith the A rican Programme or OnchocerciasisControl (APOC), this original model now reachesover 40 million A ricans annually, distributing thedrug that can prevent the debilitating symptomso skin dis gurement, itching and blindness.Building upon that experience, a new study oncommunity-directed interventions(CDI) wasdeveloped to test how many other interventions o varying complexity or di erent conditions could bedelivered with this model. The result was the nalreport on the three-year, multi-country study (TDR,2008) that showed dramatically improved accessto a number o interventions, including malariatreatment. Looking orward, uture research on theadvantages and/or disadvantages o CDI or thedelivery o interventions at the community level,and on scaling up CDI or other interventions, willhave a potentially positive impact on the poor andrural populations access to health interventions.

During the past decade, TDR has acquired uniquetechnical and eld experience in the design andimplementation o complex multi-country studies, aswell as in the development o models or community-

based interventions such as CDTi, some practicalaspects o home management o malaria (HMM) and

1. Context, strategicobjectives and framework


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empoweRing Communities oR BetteR HeAltHl 11

CDI as strategies or e ective delivery o integratedinterventions. More generally, TDR is a globalleader in implementation research on access andcommunity-based delivery strategies against malaria,neglected tropical diseases and other in ectious

diseases o poverty, and thus is well placed to pursuethis work.

Additionally, the community-directed models t wellwith WHOs recently articulated goals and strategies

or strengthening primary health care systems atthe community level and promoting integratedapproaches to service delivery. Finally, the currentcommitment among global research partners and

unders to helping communities play a pivotal role inmanaging their own research priorities and servicesprovides signi cant support to this e ort.

1.2. Strategic objectivesIn line with the overall goal o developinginnovative, e ective and e cient strategies orimplementing community-based interventions(CBI) in poor populations, there are our strategicobjectives:

1. Develop an analytic ramework or integratedcommunity-based interventions.

2. Conduct research on critical actors in thescale-up o community-directed interventions(CDI) (a sub-section o the broader concept o CBI) and explore how to e ciently introduceCDI into new areas.

3. Develop and test alternative community-basedintervention strategies targeting underservedpopulations.

4. Develop strategies that enhance communitiescapacity to demand and implement community-based interventions.

Crosscutting objectives: researchto promote gender equality andempowermentGender equality is a critical actor in the delivery

and uptake o interventions at the communitylevel. The research activities o this business linewill systematically assess the speci c role o genderin the planning and implementation process atthe community level, evaluating gender-speci ccoverage o the interventions. CDI models employtraditional consultation and decision processes,which are male-dominated in most DECs. Thisresearch will include a detailed analysis o theroles o gender in the decision process, and towhat extent rein orcement o the roles o women

within the context o the prevailing socio-culturalenvironment would strengthen interventiondelivery and its sustainability. Both qualitative andquantitative research methods will be employedto document the role o gender and to identi ygender-related opportunities to strengthen equitabledelivery o these interventions o the business line.


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Improvedaccess of communitiesto e cient,sustainablee ective anda ordablehealthinterventions

Develop an analyticframework for

integrated commu-nity-basedintervention

Policy briefs onintegrated CBI and

tool box for designof integrated CBI2009

Policy used by national

health service2009

Conduct researchon critical factorsin the scale-up of the CBI strategyexploring itse cient introduc-tion in new areas

Strategy for CDI inareas where CDTi hasnot been installed2010-12

New policies & strategiesdeveloped based on therecommendations(NTD and Malaria)2010

Develop strategiesthat enhancecommunitiescapacity to demandfor and implementcommunity -basedinterventions

Strategies that enhancecommunities capacityto demand for andimplement CBI2010-12

New policies & strategiesdeveloped based onthe recommendations2011

Develop and testalternativecommunity-basedinterventionstrategies targeting

underservedpopulations

Alternate CBI strategiestargeting urban areas& underservedpopulations (post-con ict, nomadic &

transitory populations)2011-12

New policies & strategiesdeveloped based on therecommendations(underserved populations)

2010

BL11impact

BL11outcomes

BL11objectives

BL11end-products

(by 2013)

BLbusiness plan

approved(JCB 07)

Fig. 1. i ra d c y-ba d rv ra c a r ach

1.3. Strategic frameworkThe strategic plan o this business line takesadvantage o the statistical power o large multi-disciplinary, multi-country studies. It is beingundertaken in close collaboration with national,regional and global disease control programs,including the A rican Programme or OnchocerciasisControl (APOC) and WHOs NTD and malariaprogrammes. Preparation o these studies involvesextensive consultation with disease controlprogrammes and ministries o health to care ullyde ne the research needs and research questions.This is ollowed by exploratory studies to identi ypotential solutions that also take into accountcritical social actors, such as gender and economicstatus. The business line ocuses on A rica, and

the research is conducted through the extensivenetwork o A rican public health and social science

researchers that has been established in the contexto previous TDR research.

The intervention strategies to be tested willbe implemented through the national healthprogrammes such as the national ivermectintreatment cycle, rather than as a parallel activity.

The main research activities are to be carried outby DEC researchers selected through a competitiveprocess involving responses to TDR Calls or letterso intent open to all developing countries in A rica.Proposal development workshops with prospectiveresearch teams and research leaders will precedeselection o teams that will execute the studies.Studies are being coordinated, acilitated, supervisedand managed by the TDR secretariat or BL11and evaluated by the SAC, including through sitevisits by committee and TDR secretariat members

and other external scientists. Fig. 1 illustrates thestrategic approach o this BL.


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Strategicobjective

End-products(2013)

Indicators orend-products

Expectedoutcomes

Indicatorsor expectedoutcomes

1. Developan analytic

ramework orintegrated com-munity-basedinterventions

Policy briefs fromy a c r v

ra dc y-ba d

rv (CBi)

Tool box on howto locally designand implement

ra d CBi

Number of policybriefs produced

Tool box developed

Policy briefs usedby national health

rv c (Q4 2009)

Number of nationalservices using policybrief in year

2. Conductresearch oncritical actorsin the scale-upo community-directedinterventions(CDI)

Strategy for CDI inar a h r h r

ch c rc aa d ha hav v rhad c y-d r c d r a

h v r c(CDTi) installed

n b r a dpercentage of com -

c v r dwith CDI (neglectedtropical diseases[NTD] and malaria)

New policies andstrategies devel -

d ba d r c da(NTD and malaria)(2010)

Number of newpolicies and strate -gies developedba d h r c -

da (ntDand malaria)

Number andpercentage of com -

c v r dh CDi (ntD a d

malaria)

3. Develop andtest alternativecommunity-basedinterventionstrategiestargetingunderservedpopulations

Alternative deliverystudies for:

Community-basedrv

rba ar a

Community-basedrv -c f c ar a ,

ad c a d ra -tory populations

n b r a d r-centage of commu -

c v r d hh r arch d

CDi ( d r rv dpopulations)


d ba d hr c da( d r rv d -lations) (2011-2012)

Number of newpolicies and strate -gies developedba d hr c da( d r rv dpopulations)

Number andpercentage of com -

c v r dwith CDI regular

r ra

4. Developstrategiesthat enhancecommunitiescapacity todemand andimplementcommunity-based

interventions

s ra haha c c -

ca ac y demand and imple -

c y-ba d rv

n b r a d r-centage of commu -

r dto in uence imple -

a ra ya d a a cto reinforce theirdemands for sup -

port and supplies forrv


d ba d hr c da(2011)

Number of new poli -c a d radeveloped based on

h r c da- ( c v

volunteers)

Table 1. InDICaTORS fOR enD-PRODuCTS anD OuTCOmeS fOR bl11 ,COmmunITy-baSeD InTeRvenTIOnS


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2. Key stakeholders, rolesand responsibilities

Key partners at the international level includeglobal or regional disease-control initiatives,including ormal partnerships where these exist(such as Roll Back Malaria, the Global Alliance orthe Elimination o Lymphatic Filariasis and the

International Trachoma Initiative). The businessline interacts on a regular basis with the technicaladvisory bodies o such programmes. The businessline also draws rom the experience o otherpartners working in knowledge translation at thecommunity, national and global levels, such as the

Alliance or Health System and Health ResearchPolicy and the Regional East Community HealthPolicy Initiative. Members o the communitieswhere the research activities take place also areactive shareholders and partners. Funding of the BLs

activities, like all implementation research in TDR,is mainly supported by TDR. The key stakeholdersroles and responsibilities are set out in Table 2 .


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Key stakeholders Responsibilities RolesMinistries of health (MoH),national disease control

r ra (nDCp ), d r chealth management teams(DHmt )

De ne research needs and obstaclesto control

Postulate and test possible solutions

Implementers of research

Use research ndings and convertto policy

Scientists for DEC institution u d r ak r arch Implementers

Non-governmentalr a za

De ne needs and undertake someof the research

Users, implementers andr r

Leading international scientists Ensure that the research is of higha dard

Capitalize on the latest scienti cadva c

Advisers and facilitators

Global/regional disease controlinitiatives: Roll Back MalariaProgram (RBM), Global Alliancefor the Elimination of LymphaticFilariasis (GAELF), International trach a i a v (iti)

Technical programmes interactregularly with research leaders/teams

Adv r

WHO/AFRO

Actively involved in all activities of thebusiness line, especially in the interpre -tation of research ndings and assess -ment of their relevance for regionalhealth policy

Support, provision of policy briefs

WHO/country o ces

Facilitate e ective interaction withministries of health, especially withrespect to needs analysis and transla -tion of research ndings into nationalpolicy

Facilitators

African Programme forOnchocerciasis Control (APOC)

Leverages CDT experience interest incontinued BL research for improvedcontrol strategies

Facilitators, supporters

WHO/HQ (GMP, NTD) Close interaction with the techni -cal units for di erent diseases at theglobal level of WHO

Advisers, facilitators andr r

Potential unding agencies/partners

African Programme for Onchocerciasis Control (APOC)

Bill and Melinda Gates Foundation

United States Agency for International Development (USAID)

Global Fund to Fight AIDS, TB and Malaria (GFATM) Drug-donating pharmaceutical companies, possible bilateral donors

Potential funders

Table 2. Key STaKeHOlDeRS, ROleS anD ReSPOnSIbIlITIeS


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3.1. Plan, progress and key milestones

Key highlights

The frst Scientifc Advisory Committee (SAC)meeting was held in May 2008

The SAC made a thorough review o the basedocument or BL11 and re ashioned the speci cobjectives. Timelines were also rede ned to makethem more realizable. The revised plan reorganizedpriority areas o research as:

CDI in non-onchocerciasis-endemic areas andurban areas;

Incentives and social science research; Community interventions in post-con ict and

nomadic populations.

Strategic objective 1. Develop ananalytic framework of integratedcommunity-based interventions

End-product: Policy brie s rom systematic reviewo integrated community-based interventions andtoolbox on how to locally design and implement

integrated community-based interventions. A systematic review on the cost, e ectiveness andmanagement o community-based interventionshas begun, identi ying key actors infuencingcommunity participation in the ght againstin ectious diseases o poverty. The nal baseproducts are expected in the later hal o 2009.This area o work will be an ongoing activity toinclude new research developments as evidence isgenerated.

Strategic objective 2. Conduct researchon critical factors in the scale-up of community-directed interventions

End-product: Research strategy o CDI in areas

where there is no onchocerciasis and the populationhas never been exposed to CDTi.

Research activities in this area ocus on the criticalactors that infuence the scale up o CDI or NTDs

and malaria, including the inter ace between thehealth system and the communities.

A three-year, multi-country CDI study involved4 countries 40 health districts in 8 study sites

rom 2004 through 2007 and examined some o the critical actors that infuence the scale-up o CDI. The study covered around 2.4 million peoplewith an average o 380 000 530 000 people livingin the area de ned by each study site. In all, veinterventions (including the ongoing ivermectintreatment) were delivered through the CDI process.

The nal project report, Community-directedinterventions for major health problems in Africa: amulti-country study, was published in April 2008(Fig. 3). The study ndings indicate that CDIis a more e ective strategy to deliver additionalhealth interventions in a community-based setting

than traditional methods o delivery in the caseo Vitamin A supplementation, the distribution o insecticide-treated nets (ITNs), home managemento malaria (even surpassing Roll Back Malariatargets), but not or treatment o tuberculosis.Moreover, it was ound that at least our to veinterventions can sa ely be incorporated into theintegrated delivery package. The CDI processachieves higher coverage or di erent interventionswith no increase in implementation costs at thehealth district and rst-line health acility level,

and is there ore more cost-e ective. Based on these

3. Implementation plan for20082013 and progress


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ndings, the study developed criteria to evaluatetypes o interventions or which the CDI process isappropriate and guidelines or the implementationo integrated CDI against major health problemsin A rica. Extensive stakeholder consultation and

consensus-building were critical actors ensuringsuccess o the study at the community level aswell as synthesis o study results or the nal CDIpublication. For instance, SPSS training was held orthe economists o the eight teams. This has enabledthe development o standard algorithms or analysiso the costing data.

Findings were presented publicly at theInternational Con erence on PHC and HealthSystems in A rica in April 2008 at Ouagadougou,Burkina Faso, and to the news media. The

Joint Action Forum o the A rican Programmeor Onchocerciasis Control (APOC), in its

meeting o December 2007, endorsed the mainrecommendations o the study group. These urgethat: CDI be used or the integrated community-level delivery o appropriate interventions whereit is already established or onchocerciasis control;CDI packages be developed on the basis o localconsiderations and criteria rom this study;special e orts be made to ensure reliable supplies,supportive policies and guidelines; priorities or

uture research include research on the use o CDIin non-onchocerciasis areas; and health systemsresearch be conducted on supply systems. Findingsand recommendations rom the study have beenwidely reported at high-level meetings, as well as invarious media in print and lm. Research ndingshave thus already exerted very signi cant leverageon health policy at multiple levels (global, regional,country) as well as on practice at country level(Section 4.1).

CDI or delivery o praziquantel

The Kenyan arm o a multi-country studyevaluating the use o a CDI strategy or treatmento schistosomiasis with praziquantel ound that theCDI approach could increase both treatment accessand coverage. Completion o the study in two othercountries, Mali and Ghana, was delayed somewhatdue to delays in national drug treatment cycles, butwas nonetheless nalized by the end o 2008.

Ten research teams have been selected rom a totalo 67 that sent in letters o intent or the researchstudies. These 10 participated in a proposal/protocoldevelopment workshop to develop a core protocol

or the studies. Six teams have been selected basedon their nal proposals to undertake both the

ormative and intervention phases.

Strategic objective 3. Develop andtest alternative community-basedintervention strategies targeting theunderserved population

End-product: Evidence-based alternative deliverymethods, including community-based interventionsin urban areas and community-based interventionsin post-confict areas, nomadic and transitory

populations.

A peer reviewed selection was made rom a numbero letters o intent. Ten teams were selected andparticipated in a protocol/proposal developmentworkshop to develop their core protocol orthe multicounty study. One o these ve teamswill be selected to conduct research addressinginterventions in urban poor areas.


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Strategic objective 4. Develop strategiesthat enhance communities capacity todemand and implement community-based interventions

End-product: Evidence or strategies that enhancecommunities capacity to demand and implementcommunity-based interventions.

This research area includes the systematic reviewo evidence on the e ects o incentive mechanismson the per ormance o community implementers.

A study in Mali has ound 14 di erent healthprograms that use community volunteers, all withdi erent incentive policies ranging rom no external

nancial incentives to payment per person covered. A multi-country study has been unded by APOCin several A rican countries to conduct a situationanalysis like the Mali study. A second interventionphase will be managed by Business Line 11 todevelop and test possible solutions. The ull review

or this objective is being planned.

Table 3 describes the complete list o plannedactivities or the BL against milestones reached/ progress made and revised timetable dates.

3.2. Implications of progress/delays and global contextchanges on 20082013There have been delays in the initiation o protocoland proposal development workshops, which are toprecede each o the multi-country activities planned

or 20082013. This has been due to unsatis actoryresponse to calls or letters o intent, includingvirtually no applicants rom the Francophone/ Lusophone countries. Repeat calls weresubsequently issued. The rst protocol developmentworkshop was success ully completed in October2008 or one o the studies planned under StrategicObjective 2 (conduct research on critical actors inthe scale-up o community-directed interventionsstrategy, and explore how to e ciently introduceit into new areas). These delays will a ect the setmilestones and also the delivery time o the nalend products, moving them 812 months later thanthe milestones originally de ned.


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3.3. Specific activitiesfor 2009In 2009, the BL will undertake the ollowingactivities:

A protocol development workshop for tenresearch teams, with a view to selecting thebest ve teams to undertake research on theintroduction o CDI into urban areas.

Initiate studies on the introduction of CDI intourban areas.

Formative phase of study on strengtheningprimary health care in rural A rica using thecommunity-directed intervention approach.

Proposal development workshop for the

intervention phase o the multi-country studyon strengthening primary health care in rural

A rica using the community-directed interventionapproach.

Protocol development workshop on proposals forCDI in nomadic and post-confict areas.

Studies on the impact of incentives on communityimplementers, including:- systematic review o evidence on the e ects o

incentive mechanisms on the per ormance o

community implementers;- innovative solutions or incentives andmotivation o community implementers;

- mechanisms through which communities areempowered to better ght in ectious diseases o poverty.

Other research areas to be pursued within thisbusiness line will be in the speci c areas o publichealth ethics, equity e ectiveness and the use o schools settings or interventions.

School-health programmes such as preventivechemotherapy against schistosomiasis andintestinal helminths are attractive or the deliveryo interventions among school-age children, buttheir use or neglected diseases has been limited in

A rica. BL11 plans to explore in the next year whatthe main obstacles are to enlarging the outreacho these programs, and once the reasons are betterunderstood, to experiment with possible solutions.


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Table 3. ImPlemenTaTIOn PlanS anD PROgReSS fOR 20082013 aCTIvITIeS

BL objectives Activities(20082013) Milestones andtarget dates Progress made Revised dates(if relevant)

Develop ananalytic ramework

or integratedcommunity-basedinterventions (CBI)

Systematic review of available evidence oncosts, e ectivenessand management of CBi

Identi cation of keyfactors in uencingc y ar-ticipation in the ght

against infectiousdiseases of poverty

Study commissioneda d c d c d (2009)

Draft reports andpolicy briefs on inte -

ra d c y-ba d rv(Q2 2009)

n y c d c d.Initial attempts atcommissioning failedbecause of last-minute decline of theconsultant to under -

ak . A h r a ar c r .

D c b r2009

Conduct researchon critical actorsin the scale-up

o community-directedinterventions(CDI) strategyand explore howto efcientlyintroduce it intonew areas

Research on criticalfactors that in u -ence the scale upof CDI for NTD andmalaria, including theinterface between thehealth system and the

c

Conceptualizingup-scaling CDIprograms identi edwith agreed inclusionof an implementationr arch c(Q1 2009)

Major obstacles toup-scaling CDI identi -

ed. Studies launchedto test possiblesolutions (2009)

Preliminary factorsidenti ed from themajor CDI studycompleted 2008

Yet to be

implemented

napplicable

s d d rhow to most e -ciently introduce CDI

ar a hCDTi for

ch c rc a

Competitive selectionof researchers for amulti-country study

CDi ch c r-ciasis-free areas done,research protocol

nalized, researchteams funded and

d ar d(Q1 2009)

Selection done.Research protocol forformative phase nal -ized for SAC review by1 Ja ary 2009

napplicable


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BL objectives Activities(20082013) Milestones andtarget dates Progress made Revised dates(if relevant)

Develop andtest alternativecommunity-basedinterventionstrategiestargetingunderservedpopulations

Introduction of com -y rv

rba ar a

R arch rselected through ac v r cfor a multi-countrystudy on delivery

ra rbaar a ; r arch afunded and studies

ar d (2009)

Teams selectedfor protocoldevelopment inJa ary 2009

Develop strategiesthat enhancecommunitiescapacity todemand andimplementcommunity-basedinterventions

sy a c r vof evidence on thee ects of incentive

cha hperformance of com -munity implementers

sy a c r vof evidence on thee ects of incentive

cha hperformance of com -munity implementers

ar d (2008)

Preliminary reviewscompleted throughAfrican Programmefor OnchocerciasisControl-funded

d (Q1 2008)

Full reviewv d

early 2009


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4.1. Leverage

Findings and recommendations rom the CDI study(TDR, 2008) have already been widely reported athigh-level meetings, in-country brie ngs and in themedia, including a BBC documentary, EmpoweringCommunities to Fight Disease. Findings also were

eatured in a box in the World Health Report 2008 (p. 109) as well as being included in re erences 1.This represents the rst time a TDR BL reports

ndings were noted in a World Health Report.

Findings and conclusions o the study have thusbegun to exert very signi cant leverage on policiesat various levels (global, regional, country) as well ason public health practice at country level. Leverageis particularly pronounced with respect to countriesworking in partnership with APOC and/or oninterventions related to neglected tropical diseases.

1 - World Health Report 2008, p. 112, re . 19, 27.

High-level policy and country technicalbriefings

Consultation of R&D for malaria eradicationmeeting in Seattle in March 2008;

Round table on CDI at the InternationalCon erence on PHC and Health Systems in A ricain April 2008 at Ouagadougou, Burkina Faso,with o cial launch o report and press release;

Mectizan Expert Committee in Atlanta, Georgia,United States o America;

Technical Consultative Committee,Ouagadougou, Burkina Faso;

Country-speci c post-study brie ngs have beenheld or wide audiences in Nigeria and Uganda;a similar brie ng was held in Cameroon inDecember 2008;

In terms o unding leverage, TDR unding o implementation research helped leverage signi cantinvestment by other agencies, particularly the

A rican Programme or Onchocerciasis Control. Along with co- unding the CDI study, APOC also

unded preliminary studies to ascertain nationalpolicies on incentives or volunteers. Further APOCsupport or planned studies is also anticipated.

4. BL leverage, contributionto empowerment andstewardship, and synergies

with TDR business lines


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4.2. Contributions tooverall empowerment andstewardship objectivesTDR has demonstrated global stewardship in

acilitating needs analysis and priority-setting orcurrent and uture implementation research oncommunity-directed interventions. The presentbusiness line collaborates with the TDR StewardshipFunction to obtain and to provide up-to-dateand comprehensive in ormation on an analytic

ramework or integrated community-basedinterventions.

In terms o empowerment, the BL activities haveplayed a power ul role in empowering communitiesand health systems o cers at the grassroots todetermine their own health needs and infuenceresearch accordingly. Extensive stakeholder consulta-tion and consensus-building at the communitylevel have been critical actors in all aspects o CDIresearch, as well as in the synthesis o study results.The BLs multi-country studies have contributed verysigni cantly to the training and capacity-buildingo a pool o available trained scientists in A ricanDECs quali ed to engage in community-basedimplementation research rom the biomedical eldsas well as rom economics and the social sciences.This has included speci c activities, such as training

or economists engaged in the 20042008 CDImulti-country study and the new series o protocoldevelopment workshops. Such workshops equipprincipal investigators with skills to lead complexresearch teams. BL11 contributes directly to the TDREmpowerment business line by providing space andsupport or part o the training o ered to traineeswithin the Empowerment plans.

4.3. Elements enhancingsustainability of BL outcomesThe premise o the research in BL11 is that both thehealth systems and targeted communities o DECsplay a central role in planning and execution o research and implementation o results. Researchobjectives are established primarily on the basiso elt needs as articulated by health systempolicy-makers themselves. This builds con denceand helps ensure that the outcome o the research(their product) will not only be welcomed by theministries o health, but will also be sustainable.

4.4. Synergies with workof other TDR BLsThis BL has cross-cutting associations andcollaboration with most o the other businesslines. It is closely associated with those on drugdevelopment and evaluation or helminths andother neglected tropical diseases (BL3 and BL6).It will collaborate with BL5 to investigate thee ects o climatic and environmental changes on

major vectors o disease and is investigating a jointprogram with BL7 on diagnostics, especially inthe area o community acceptance and utilizationo diagnostics. BL11 is working with BL9 to helpdevelop evidence or antimalarial policy; strategiesand models or integrated drug delivery, as well asincentives or community implementers/volunteers,are among the common issues being addressed.

A joint research activity in the speci c area o incentives or community volunteers is beingplanned by BL9 and BL11.


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5.1. Research capacity indisease-endemic countriesFor reasons o relevance and credibility o theresearch, it is essential that study design andresearch implementation is undertaken byscientists rom disease-endemic countries. Not allDECs have the necessary capacity or this type o multidisciplinary research. There is a risk that theresearch teams could be predominantly selected

rom more advanced countries rather than romdeveloping countries, thus limiting the relevance o the research ndings. Special e orts will there orebe undertaken through targeted selection to includecountries with limited research capacity andexperience in the studies. The BL will collaboratewith the TDR Empowerment business line toprovide additional capacity-building support orthose countries and ensure that they can ully ande ectively participate in research activities.

Currently the BL is aced with the challenge o attracting new but experienced scientists andresearchers, especially rom the Francophoneand Lusophone countries, to participate in theresearch e ort. Attempts have been made to targetresearchers rom the non-English countries through

calls speci cally put out or them, but withminimum success.

Another way to encourage resh researchers toparticipate in this endeavour would be to approachthe relevant institutions to support their researchersto submit proposals or consideration or unding.

5.2. Prevailing localconditionsGovernance in DECs has its own challenges, andin certain countries or regions this may be raughtwith unstable and ragile political conditions. Thesecan result in requent changes o administration,especially among ministry o health leadership.Such changes may disrupt the smooth running o research agendas and cause delays in reaching theobjectives o the business line. It will be crucial toinvolve the technical personnel in the countriesconcerned with the research very early in theplanning stage to ensure sustainability in case o leadership change. To do this, it is a requirementthat each research team includes personnel rom thecontrol department o the ministry o health.

Prevailing local climatic changes, such as foods anddrought that o ten alternate rom year to year, andthe di culty o securing ood could also derail theactivities envisaged or this business line, given thevery heavy involvement o the community in theresearch activities. These vagaries o the weathershould be anticipated and actored into a possibleextension o the projects so as to be able to completethem satis actorily.

5. Critical issues andsuggested solutions


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There is an urgent need to make available to a ectedpoor and rural populations the many e ective andsimple interventions and tools to prevent and treatin ectious diseases o poverty. However, promisingnew interventions have a limited impact due to

ailures to deliver them in an e cient and sustainablemanner. It is there ore important to nd innovativeways that can build on previous e cacious strategiesto get these tools to the affected people. TDRsprevious experience in implementation research givesit a unique advantage in undertaking the researchneeded to improve the delivery o some interventionsand tools.

The results o the TDR multi-country study showthat CDI is a more e ective strategy to deliver healthinterventions in a community-based setting thantraditional methods o delivery. The BL11 SAC, inits nal meeting report, recommended that utureresearch on CDI ocus on 1) non-onchocerciasisareas, 2) urban areas and 3) post-confict andnomadic populations. Incentives and other socialscience aspects o community-directed interventionswere also named as priority research areas or BL11.SAC made substantive changes in the core BL11business plan so as to make the objectives and theperiod o realizing the end-products more realisticand relevant. While much work remains to beaccomplished, progress made during the rst yearof TDRs new strategy is nonetheless signi cant,helping within this BL to establish evidence-basedstrategies o community-based models o healthservices delivery.

6. Conclusion


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7.1. List of publicationsCommunity-directed interventions for major health problems in Africa: a multi-country study . Geneva,UNICEF/UNDEP/World Bank/WHO Special Programme or Research and Training in Tropical Diseases, 2008.(TDR, 2008)

7. Annexes

7.2. BL11 SAC membershipGender Nationality Chair-person Member Observer Discipline

Dr MaryAMUYUNZU-NYAMONGO

F Kenyan x Anthropology

Pro essorSharon FONN F South A rican x

Health systems genderequity

Dr MargaretGYAPONG F Ghanaian x Social science

Pro . MamounM.A. HOMEIDA M Sudanese x

Internal medicine,community health

Dr CharlesHONGORO

M South A rican x Public health policy

Dr DeborahMCFARLAND

F American x Health economics

Dr KopanoMUKELABAI

M Zambian x Health systems,child health

Dr Pierre

ONGOLO ZOGOM Cameroon x Public. health

Dr FredWABIRE-MANGEN M Kenyan x

Public health,epidemiology,biostatistics

Dr Susan ZIMICKI F American x Social and behaviouralScience

Dr Adrian HOPKINS M British x Ophthalmology,public health


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7.3. Details of revision of business plansRevised BL11 document by SAC members (May 2008) attached.

7.4. Responses to Joint Coordinating Board / Scientific and

Technical Advisory Committee requestsThe Scienti c and Technical Advisory Committee (STAC) recommended in 2008 that:

The development of the science to enhance this line of enquiry needs to underpin this business line. It is a uniqueopportunity for TDR to synthesize data across lessons learnt to generalize what may be possible in other contexts.

BL strategic objective 1 Develop an analytic ramework or integrated community-based interventions is designed to respond to this STAC recommendation. The end product is expected in the last quarter o 2009.


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TDR/World Health Organization20, Avenue Appia1211 Geneva 27

SwitzerlandFax: (+41) 22 [email protected]/tdr

The Special Programme for Research and Training in Tropical Diseases(TDR) is a global programme of scientific collaboration established in1975. Its focus is research into neglected diseases of the poor, withthe goal of improving existing approaches and developing new ways to

prevent, diagnose, treat and control these diseases. TDR is sponsoredby the following organizations:

For research ondiseases of poverty

Empowering Communities for Better Health

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