In the fight against Neglected Tropical Diseases (NTDs), community engagement and mobilization play a vital role. In Plateau State, a group of dedicated volunteers called Community Directed Distributors (CDDs) have succeeded in eradicating some NTDs while in other north central states, the CDDs have taken up the responsibility of sensitising their communities about NTDs and distributing drugs for their elimination.
Luqman Musa, a 42-year-old resident of Limawa A in Chachanga Local Government Area, Niger State, was once afflicted with schistosomiasis. Unaware of the disease at the time, Luqman experienced rashes on his hands and legs, which persisted for years until he became involved as a community direct distributor (CDD).
Inspired to make a difference in his community, Luqman joined the group of volunteers to combat neglected tropical diseases (NTDs) and became a community mobilizer a s well as a CDD. Through his efforts and those of other CDDs, the prevalence of NTDs, particularly schistosomiasis, has significantly decreased in Limawa A.
Musa said: “I have been a Community Directed Distributor since 2018. I joined the community volunteers because I wanted to help my community.
“When I joined, there were high cases in my community, especially schistosomiasis. But now, most of the cases are cured while some people who were affected have moved away from here.
“We were able to identify the cases because there would be rashes, people would be scratching their skin as it would be itching them.
“They also experience fever and cough, while the non-physical symptom is the passing of bloody urine.
“But now, there are no cases of any NTDs in Limawa here.”
Leading a team of 38 CDDs, Musa covers between 92 and 100 houses during drug distribution campaigns. Dividing themselves into pairs, they cover the 19 wards within the community.
The role of CDDs is crucial, as they bring medicines and vital information to hard-to-reach areas where health workers are insufficient.
“In Limawa A, we have more than 30 CDDs. We are divided into different areas and we do the demarcation of the area and take it piece by piece.
“We have 19 areas to cover and we share two people per area,“ Musa said.
Image Credit: The Nation
CDDs are essential volunteers who facilitate the distribution of medicines and raise awareness about NTDs in hard-to-reach areas. Due to the shortage of health workers, CDDs have become the driving force behind NTDs elimination in Nigeria and across the world. Trained, equipped and supervised, they visit communities and households, carrying drugs and educating people about NTDs.
Their familiarity with the local population and their ability to build trust is crucial in persuading community members to participate in mass drug administration campaigns.
The fight against some of the world’s most devastating, disfiguring, socio-economically damaging and stigmatising NTDs has engendered an unprecedented global response, which is the reason why most states now involve the use of CDDs.
Plateau, Nasarawa and Kaduna states have interrupted the transmission of onchocerciasis while several states have achieved the elimination of trachoma by relying or building programmes predominantly on the work of the CDDs for these achievements.
The NTD Coordinator of Bosso Local Government Area of Niger State, Garba Duba Suleiman, stated the need for more attention and resources to be paid to the Community Directed Distributors if the state wants to succeed in the elimination of NTDs in the shortest possible time.
He said: “The CDDs are the engine room of NTD elimination in Niger State. We train them on how to carry out the implementation, that is, to have the knowledge of the disease, know what the diseases are, and know about the drugs to be administered to people.
“Then during this exercise, we carry out the drug administration by measuring the heights of the people. We use a stick which is called a calibrated stick so that it would be easier for any CDD to measure the height of a person, which determines the number of drugs to give the person.
“But the maximum an individual can take is four tablets. We train them and teach them how to mobilise, sensitise and persuade the people to take it.
“After the training, we give them these drugs at the health facilities and they would carry the drugs to their community, going from house to house.
“They register the names of the people and give them the drugs, telling them the adverse effects or what to do when they observe an adverse effect.
“The CDDs are the real people that carry the drugs to the people that use the drugs. Without them, we cannot go and meet the people in the community because they do not know us and cannot trust us.
“But these people (CDDs) are their people who they relate with daily. So we try to build a network of trust by involving these community volunteers who their people can trust and would take the drugs without any doubt or hesitation.”
According to the Niger State Coordinator for NTDs Elimination, Ummulkha Nauzo, the availability of many effective disease control medicines has had a limited impact on the burden of the diseases and weak delivery systems due to insufficient health workers, adding that this necessitates the harnessing of community human resources, which would help in the administration of the drugs.
Nauzo said: “Community Drug Distributors (CDDs) can help improve healthcare, especially for people living in remote rural areas.
“They are very important to these communities. We often refer to them as foot soldiers in getting rid of Neglected Tropical Diseases (NTDs) in the state.”
She explained that the CDDs are trained, equipped and strictly supervised because they are dealing with drugs, which can either make or mar the lives of people depending on the way it was administered.
“In Niger State, the CDDs also assist in the collection of data for our mapping and analysis.
“Another role the CDDs play is sensitization, that is community mobilization. They know these people and are trusted by the people because they live in the community.
“They know how to mobilise the people for the exercise and how to speak to them in ways that they would accept to take the drugs.
“We rely on them to organise these communities, and they are closely monitored to report any issues, like if people are not taking the medicine they should.
“They work under supervision to ensure they do their job properly, because people’s lives are at stake.”
Overcoming challenges
While CDDs make significant contributions to NTD elimination, they face various challenges. One of the primary obstacles is the hesitancy of some community members to accept the drugs. Urban areas, in particular, exhibit higher rates of rejection compared to rural areas.
CDDs, like Hajara Mohammed of Makera Ward in Chachanga Local Government Area of Niger State, often encounter resistance from those who feel disillusioned by receiving only medicines as the government’s response while their other needs remain unaddressed. To overcome this, CDDs employ persuasive techniques and revisit resistant households, emphasising the importance of taking the medication.
“I am from this community, but I often face challenges in convincing the people to accept being administered the drug. Like some of the people, if we take the medicine to them, they refuse to take it, and they don’t cooperate with us. They say that they want more than drugs from the government.
“However, sometimes we take our time to persuade them. At other times, when they are hesitant, we would go and come back maybe the next day or another day within the distribution period.
“However, some accept, while others do not.”
The NTDs Coordinator of Bosso Local Government Area also corroborated that some residents reject the administration of drugs, especially residents in the urban parts of the local government areas.
He said: “We often face rejection by people in the urban areas where we have the elites.
“Sometimes when we are having the programmes, the elites reject taking the drugs while often in the rural areas, we do not face many of such rejection challenges.
“Most times, when the programme is late in being implemented, we receive calls from the leaders in the rural areas on why there is a delay.
“We don’t have many cases of rejection in rural places, unlike the urban area where the rejection rate is high.” Plateau, Nasarawa involve teachers as CDDs
In Plateau and Nasarawa states, The Carter Center—a nongovernmental organisation that helps to improve lives by resolving conflicts, advancing democracy and preventing diseases—was able to use Community-Based Distribution (CBD) when its intervention transitioned from a mobile delivery system to community-based distribution (CBD). The Center leveraged village-based personnel to hasten the transition and eradication process.
In these two states, the volunteers were also recommended by their community leaders. But unlike Niger state where anyone can be called upon to participate, most of the eligible volunteers in Plateau and Nasarawa states were school teachers, and this was due to their communication and arithmetic expertise.
“The community-based distributors (CBDs) were required to be available for five to ten work days just before and during the treatment period,” the Carter Center explained.
Insufficient resources, motivation
Image Credit: The Nation
Another challenge faced by CDDs in Niger State is the need for more financial incentives. With an allowance of only N1,000 (approximately $2.50) after each mass drug administration, many CDDs feel undervalued.
This inadequate stipend has led to a high turnover rate among CDDs. The low motivation resulting from financial constraints jeopardises the success of NTDs’ elimination efforts.
Musa said that most often, several of his team members no longer come out for the distribution because the work they do is not commensurate with the stipends they receive, and the state is not ready to increase the stipends.
“But to be honest, N1,000 is too small. A team can cover over 100 houses and in each house, you will administer drugs to at least three to four people.
“That money is too small. We have pleaded with them to increase it but they have not.”
Mohammed opined that sometimes when she is called for the exercise, she is tempted not to go because she does not feel encouraged by the stipends paid. But she goes because she believes it is part of her responsibility to the well-being of her community.
The Bosso NTDs Coordinator, while corroborating the allowances given to the CDDs, said that the stipends were being paid by Mitosath, an organisation involved in the elimination of NTDs in the state, as transportation allowances to the CDDs.
According to him, the allowances are nothing to write home about, emphasising the need for the government to look into them.
He said: “The CDDs are the engine room in the elimination of NTDs in Niger State. There is need for their allowances to be looked into and reviewed.
“I promise you that within the shortest possible time, NTDs will become a thing of the past in Niger State.
“In the past in Bosso Local Government Area, we had over 400 CDDs. But now, due to lack of motivation in terms of allowances, they are dropping.
If you go to some communities, you will see the traditional leader looking for someone else, because when you call on a CDD, they refuse to come.
“These days, some of them reluctantly partake in the exercise. But they carry out the distribution in the evenings after they are back from their farms.”
Additionally, the absence of identifiable uniforms or badges hampers CDDs’ credibility, especially when dealing with skeptical elites in urban areas, as Suleiman also pointed out that no T-shirt or jacket is given to the CDDs to make them easily identifiable in the community when they embark on the implementation.
The case is, however, different in Plateau and Nasarawa states, where communities are no longer endemic to Onchocerciasis.
Assessing the services of the Community-Based Distributors for the transmission process, the CBDs were provided with monetary incentives ranging from ₦100 to ₦200 (approximately $8-16 in 1992), but a report seen by the Reporter revealed that some of these CBDs were underpaid while others were not paid at all.
Also, favoritism affected the selection of competent CBDs in these communities, as community leaders often selected their relatives or friends for the roles. At the end of 1994, over 1000 CBDs were trained in Plateau State.
Recognising the Importance of CDDs
Despite the challenges, the NTDs coordinators at the local and state levels acknowledge the indispensable role of CDDs in NTDs elimination. Efforts are being made to address the issues faced by CDDs, including an increase in their allowances and providing them with additional training, according to the Niger State Coordinator on NTDs elimination, as she added that measures such as providing identification apparel for CDDs are being considered to enhance their credibility and effectiveness.
Nauzo said that before the next mass administration of drugs, they would be given additional training as they are very helpful in reaching the hard-to-reach communities and have helped in communities where insecurity is present in ensuring that the people in those communities are not left out, “We acknowledge their efforts and we want them to know that we are working on increasing the stipends being given to them. It is because of the paucity of funds but with hope, there would be an increase in their stipends.”
The dedicated efforts of Community Directed Distributors in Niger State exemplify the power of community engagement in combating Neglected Tropical Diseases. Community Directed Distributors like Luqman Musa play a crucial role in eliminating NTDs in Niger State while in Plateau and Nasarawa states, they were responsible for the elimination of Onchocerciasis. Their commitment and efforts have resulted in significant progress.
However, greater support, including increased stipends and visible identification, is necessary to motivate and empower these volunteers in states yet to eliminate the NTDs. By recognising the invaluable contributions of CDDs and investing in their training and welfare, states can accelerate the elimination of NTDs, ultimately improving the health and well-being of its communities.
**This article was originally published by The Nation
