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Case study: Onchocerciasis treatment

Two of the three lectures of the fourth week reflect on various attempts to combat Onchocerciasis – the so-called river blindness (see explanations below). This parasitic disease can be treated with the drug Ivermectin, which has to be applied long-term (for about 15 years) to be effective. This means, that any really successful treatment programme has to be sustained for 15 years (with one dose of the drug given per year and person) even in remote villages in sub-Saharan Africa. Against the background of this problem, Prof. Brieger examines the differences between a community-based and a community-directed treatment programme.

Community-based programmes: A community-based health programme follows the social policy planning approach discussed during the second week of this course. An outside NGO (such as the APOC – the African Programme for Onchocerciasis Control) basically plans the intervention from the outside and then comes into the community to carry it out. The members of the community are therefore simply recipients of an outside service, but have no “ownership” of the programme. This reduces the commitment to and the interest in the programme and therefore its effectiveness. It is also noteworthy, that outside health workers are usually under some pressure to present positive statistics to their superiors and are thus inclined to “push” measures on community members.

Community-directed programmes: A community-directed programme is initiated from outside the community by a NGO or government organization, but is then – sooner or later – gradually passed over to the community itself. Such community ownership means e.g. that the members of the respective community can decide among themselves, which community members shall receive health worker training by the NGO, who shall be responsible for the distribution of the drugs and when and how the drugs shall be passed out to the community members. The outside agency is simply acting as a facilitator to this process, providing the drugs itself as well as advice and outside resources needed for a successful project. Such community ownership practically guarantees that local issues and sensitivities are respected and that the programme is better accepted. Additionally, running a community-directed programme builds up skills and organizational structures within the community, that can prove to be very useful for future health- and non-health-related projects.

About Onchocerciasis / river blindness

The lectures of the fourth week center around efforts to combat Oncochericiasis in sub-Saharan Africa. Oncochericiasis – or river blindness – is a severe parasitic disease caused by a roundworm (Onchocerca volvulus). This specific parasites spreads to humans via the bite of the black fly and can cause severe infection in the eyes, leading – at least in some cases – to permanent blindness. The WHO estimates that about 18 million people worldwide are currently suffering from river blindness – with about 270.000 cases of actual permanent blindness caused by the disease:

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Prof. Brieger blogs under and can be found on twitter as @bbbrieger.

Levels of community involvement

Prof. Brieger differentiates between five levels of community involvement in (health) programs:

(1) Acceptance: Acceptance merely means passive cooperation, such as the use of health services provided by an outside agency. This level of involvement includes no active participation on the side of community members (e.g. putting up a mosquito net offered for free by an NGO).

(2) Mobilization: At the mobilization stage, the program is still run from the outside, but valuable input and ideas are provided by community members (e.g. obstacles with mosquito net use are actively discussed with the outside agency).

(3) Participation: Participation implies, that community members carry out parts of the program themselves and voluntarily contribute to it (e.g. community members with authority make the public case for mosquito net usage and see that nets are distributed within the community).

(4) Involvement/planing: At this stage, the program is not longer run completely from the outside. Community members plan and evaluate measures themselves, the community is given a high level of autonomy (e.g. a community health center is up that actively promotes distributes mosquito nets and has people regularly going from door to door to see if the nets are actually being used).

(5) Control/ownership: At this stage, the program is not longer run from the outside but is in total control of the community. Community members decide not only on the goals, which they are trying to reach, but also on the methods by which these goals should be accomplished. Outside agencies at this point only provided needed resources and outside contacts (e.g. a mosquito net program that is completely run within the community, whith local businesses buying and selling the nets with some help by outside agencies and local health centers advocating and controlling net usage).

When success and failure of a program are not seen as the success and failure of the outside NGO or agency by the community, but as success and failure of the community itself, an optimal level of involvement has been reached. Reaching that goal requires outside agencies to give up control over the program and accept local decisions, even if they are based on beliefs and customs that might not be shared by the respective agency.

These lecture notes were taken during 2012 installment of the MOOC “Community Change in Public Health” taught by Prof. Dr. William R. Brieger of the Johns Hopkins Bloomberg School of Public Health at Prof. Brieger blogs under and can be found on twitter as @bbbrieger.
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