Implementing community-directed treatment with ivermectin for the control of onchocerciasis in Uganda (1997-2000): an evaluation.

Over the period 1997-2000, an evaluation was made, in 10 districts of Uganda, of the onchocerciasis-control programme based on community-directed treatment with ivermectin (CDTI). This programme is supported by the Ministry of Health, the African Progamme for Onchocerciasis Control (APOC) and The Carter Center Global 2000 River Blindness Programme. The data analysed came from: (1) monthly and annual reports; (2) annual interviews, in randomly-selected communities in selected districts, with heads of household, community leaders and ivermectin distributors; (3) participatory evaluation meetings (PEM); (4) participant observation studies; and (5) key informants. The percentage of treated communities in the 10 study districts achieving satisfactory treatment coverage [i.e. > or = 90% of the annual treatment objective (ATO)] rose from 46.0 in 1997 to 86.8 in 2000. This improvement was largely attributable to the adoption of collective CDTI decision-making by community members, avoidance of paving monetary incentives to the ivermectin distributors, and the satisfaction with the programme of those who had been treated. Coverage improved as the numbers of community members who were involved in choosing the method of distribution and in selecting their own community-directed health workers (CDHW) increased. Health education was also critical in improving individual members' involvement in decision-making, and in mobilizing other community members to take part in CDTI. Involvement of kinship groups, as well as educated community members as supervisors of CDHW, also helped to increase coverage. In a regression model, satisfaction with the programme was revealed as a significant predictor of the achievement of the target coverage (P<0.001). Cost per person, as an indicator for sustainability, varied with the size of the population under treatment, from at least U.S. $0.40 when the district ATO was <15,000 people, to U.S. $0.26 with an ATO of 15,000-40,000 and less than U.S. $0.10 when the district ATO exceeded 40,000 people. These results cast doubt on the validity of the current APOC indicator for sustainability, of a cost of no more than U.S. $0.20/person for all CDTI projects, whatever the size of the population to be treated. Although some women were involved in decision-making, their current involvement as supervisors or CDHW was minimal. Most of the present data were obtained through monitoring and operational-research activities that have been carried out, in an integrated fashion, within the Ugandan CDTI programme since its launch. It is recommended that assessment, monitoring and evaluation be widely used within all CDTI efforts. Operational research should remain focused and appropriate and directly involve the personnel who are executing the programme.