Abstract
BackgroundCommunity-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level.MethodsThis was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components.ResultsImplementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation.ConclusionThe CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts.Trial registrationThe study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921.
Highlights
Community-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level
3,272 children under 5 years of age and 5,615 women of child bearing age living in the study villages, 47.4 and 44.8% respectively were in the intervention arm of the study
This study has demonstrated that implementation of the CDI approach in rural areas of Mangochi District is feasible, acceptable and effective
Summary
Community-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. PHC was endorsed in 1978 at the Alma Ata, Kazakhstan PHC Conference as a key strategy for attaining equitable access to basic health care, including treatment and prevention of endemic diseases [2] It is an integral part of health systems in many countries and the first level of contact of individuals, family and community with the public health system. The third goal of the United Nations’ Sustainable Development Goals (SDG) advocates for healthy lives and promotion of well-being for all with the Universal Health Coverage (UHC) being central to it [6] Both the SDG and UHC are inherently broad, but the PHC approach has the potential to deliver essential health services provided that the existing challenges and gaps [7, 8] are addressed
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