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AFRO-NETS> Multi-country study: Community-Directed Delivery of Health Interventions in Africa

Multi-country study: Community-Directed Delivery of Health Interventions in 
Invitation for letters of interest



A major challenge for onchocerciasis control is to deliver annual iv-
ermectin treatment to all target communities and to sustain a high 
treatment coverage over a very long period. So far, Community-
directed Treatment (ComDT) with ivermectin has been very effective. 
Ivermectin treatment is popular and communities have responded enthu-
siastically to the concept of community directed intervention in 
which they are themselves in charge of planning and implementation. A 
recent external evaluation of APOC concluded that "ComDT has been a 
timely and innovative strategy...and communities have been deeply in-
volved in their own health care on a massive scale. .... ComDT is a 
strategy which could be used as a model in developing other community 
based health programmes and is also a potential entry point in the 
fight against other diseases".

As a result of the success of ComDT in onchocerciasis control, there 
is a growing interest at the national and international level to use 
the approach of ComDT for interventions against other diseases. This 
development provides an important opportunity to integrate ivermectin 
treatment with other disease control activities, and to contribute to 
health care development for some of the poorest populations in Af-
rica. But to ensure that this opportunity is properly exploited, 
there is an urgent need for good scientific basis for multi-disease 
applications of ComDT.

The Joint Action Forum of APOC recommended during its meeting in De-
cember 2002 that TDR undertakes, in collaboration with APOC, a multi-
centre study on the use of the community-directed treatment approach 
for other diseases. TDR and APOC have responded positively to this 
request, and have started to prepare for a multi-country study.

Preliminary consultations on research questions

Because of the complexity of the issues involved, it was decided to 
start with consultative meetings with key partners concerned with a 
multi-disease approach to ComDT, in order to identify the principal 
research questions to be addressed in the study. An important finding 
of these consultations was that the attitudes towards ComDT vary 
widely, ranging from the very positive attitudes of those with ex-
perience of ComDT in onchocerciasis control to the doubts of experts 
in other diseases who were not always convinced about the potential 
of the ComDT approach for the diseases they are concerned with. It 
became very clear that a scientific comparison of community-directed 
and alternative approaches for delivery of interventions against en-
demic diseases, including onchocerciasis, is very much needed to pro-
vide objective evidence on the advantages and disadvantages of Commu-
nity-directed Delivery (ComDD) as compared to other approaches to de-
livery of health interventions at the community level in Africa.

Other major research questions that were identified during the con-
sultations included:

What are the diseases and interventions (including prevention and 
health promotion) for which ComDD would be appropriate, what adapta-
tions would be needed, and is the concept of ComDD relevant if the 
intervention is not free of charge? What are the advantages and dis-
advantages of integrated delivery of health interventions at the com-
munity level? When would a community become 'overloaded'; is there a 
threshold for the number of interventions to be included in ComDD? 
How to handle different combinations of diseases between communities 
and different disease specific partnerships? How to deal with the is-
sue of incentives? Is the approach of leaving this to the community 
to decide also appropriate for other interventions? Community empow-
erment takes time and effort, but many health programmes want quick 
results. Do the advantages of ComDD justify the extra efforts and in-

Letters of interest 

To address those questions, TDR intends to undertake a multi-centre 
study in Africa, with research teams from different centres studying 
different combinations of interventions but according to a standard 
research protocol. Letters of interest are invited from multi-
disciplinary research groups in Africa that are interested in joining 
the study and who are in a position to undertake a comparative study 
of alternative approaches to the delivery of health interventions, 
including ComDD, for selected diseases of public health importance in 
their area. To qualify, a research group should have strong expertise 
in public health and social sciences, and have direct links to the 
Ministry of Health and the relevant disease control programmes. Ex-
pertise in health economics would be an advantage.

The letters of interest will be reviewed by the TDR Steering Commit-
tee on Implementation Research which will select the research teams 
to participate in the study. Selected research teams will be invited 
to a workshop where a standard research protocol will be developed.

The following content is suggested for the letter of interest:

Outline of a proposed research design, including the diseases, inter-
ventions and delivery mechanisms to be studied; a description of the 
study area and population; the current status and plans for control 
of the selected diseases and main challenges for delivery of the cor-
responding interventions; description of research team and institu-
tions to be involved and evidence of links to Ministry of Health or 
the disease control programmes concerned; one page summary curriculum 
vitae of the principal investigator, the social scientist and other 
major co-investigators 

How to apply

Letters of interest should be sent, preferably by e-mail to:
<>, under subject title <Letter of Interest>, or if e-
mail is not possible by mail to:

Dr J.H.F. Remme
Onchocerciasis Research Coordinator, TDR
World Health Organization
1211 Geneva 27
Tel: +41-22-791-3815
Fax: +41-22-791-4774

Letters of interest should be no longer than 4 pages maximum (exclud-
ing CVs). The deadline for letters of interest is 30 August 2002. 
Please note that letters of interest arriving after this date can no 
longer be included in the review.

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