Mass Drug Administration (MDA): Engaging Stakeholders and Volunteers

When preparing to undertake azithromycin mass drug administration (MDA) (as the “A” component of the “SAFE” strategy), it is important to consider who are the key people and groups that need to be informed and involved in planning for the MDA. Successful planning will involve all the relevant stakeholders, including:

• Ministry of Health officials at the national and/or district levels
• Organisations that implement activities to control Neglected Tropical Diseases (NTDs)
• Organisations that implement any other aspect of the SAFE strategy
• District and health centre staff
• Key village representatives, both male and female.

There are key differences between national and local MDA stakeholders:

• National stakeholders focus on planning and training
• Local stakeholders focus on distribution in districts and villages.

Involving all stakeholders promotes trust, transparency and accountability about the MDA. And it helps trachoma programmes achieve success by ensuring good participation in, and excellent coverage of, the MDA campaigns.

Communication with MDA stakeholders

Communication with stakeholders needs to continue through the whole process of planning, implementing and reporting on MDA campaigns. It’s really important to have the attitude that MDA is done together with the people, and not done to the population by the health team!

Communication tools for MDA

At the national level:

• Meetings
• Reports
• Emails

At the district level:

• Discussions with village and household heads
• Media – radio and TV
• SMS text messaging
• Posters
• Community health talks and plays

Community Directed Distributors

Most MDA programmes rely on community volunteers, who are often known as community drug distributors (CDDs). CDDs are the main people involved in actually distributing azithromycin to the people. They can be very important in mobilising communities and building their trust in MDA.

Selection of the CDDs is done by the community. It’s essential to communicate with village leaders and advocate for the MDA campaign to gain support and identify distributors who are well-known and trusted.

CDDs should represent the whole community with regard to gender, language, ethnic and religious make-up. They are likely to have limited health knowledge and, because they are volunteers, they can usually only give short amounts of time to MDA. On average one CDD can manage distribution to 100 to 200 people.

Motivating CDDs to stay involved is an issue and many MDA programmes have found the need to identify a suitable incentive. This might be an in-kind gift such as a T-shirt, or sometimes a cash incentive. The concept of community volunteerism differs between cultures and therefore there is no single approach that should be used for all situations.

CDDs can be a strong force for the success of the programme. How effective they are depends on:

• How well they are accepted by the community
• Their training and supervision
• Suitable motivating factors and incentives

Supervision of CDDs

Supervision ensures that CDDs fulfil their tasks. Good supervision with a suitable incentive has been linked to obtaining the coverage rates (80% or more) needed for successful MDA programmes.

Best practice suggests that a health worker can supervise 5 community directed distributors (CDDs). However, this does depend on local factors such as population density and geography of the area.

Case study: House to house distribution in Niger

Moussa and Issoufou – both respected people in their village – were selected to be disitrbutors for their community’s first round of azithromycin treatment. In addition to treating all the families in their own village, they were assigned 10 other communities to visit.
Because most families were busy with farming during the day, Moussa and Issoufou would wait to finish their meal at dusk and then begin their distribution. Each evening for two weeks, Moussa and Issoufou rode their horses to neighbouring villages carrying azithromycin and tetracycline, register books, measuring sticks and oil lanterns. Working by the light of their oil lanterns, the teams would register households and treat family members.
When questions arose, they took the time to explain the purpose of the drug and the importance of preventing trachoma. Some women seemed nervous about the presence of strangers in their home but Moussa and Issoufou made sure to greet the women’s husbands and explain the nature of the visit. Although large Nigerian families could take up to 30 minutes each to treat, Moussa and Issoufou left the communities with a better understanding of trachoma prevention and community support for future treatments.
Acknowledgement: Case study taken from ‘Women and trachoma. The Carter Center, 2009’

MDA distribution team: Main responsibilities

District level programme manager

• Coordinates the overall distribution of antibiotics
• Trains the community-directed distribution team
• Coordinates the overall logistics and supply for the distribution<
• Liaises with local media to publicize MDA
• Ensures the drug is delivered at the temporary store on time
• Assigns responsibilities to supervisors and the teams to be involved in the distribution
• Investigates all reports of adverse experiences, ensuring onward communication to the country programme manager
• Approves drug quantity before it is given to the CDD team.

Field supervisor

• Monitors the activities of 5–10 CDD teams
• Ensures that the distributors have the right documents (such as the population census), materials and drugs before they leave the central distribution point
• Distributes received drugs to the dispensers
• Ensures that the CDD teams are working in their respective communities as per schedule
• Oversees the fact that all eligible people are taking the drug
• Facilitates the work of the CDD teams by solving problems encountered during the day
• Monitors drug balances prepared by dispensers each day and assists dispensers to calculate coverage of the distribution
• Investigates any reports of adverse experiences
• Checks drug balance at the end of the distribution.

Dispenser (health worker)

• Leads the CDD team at the community level
• Takes the drug from the field supervisor as per the census of the given community population
• Makes sure that they have the proper census list
• Ensures (with the support of community members) that each person has come with the household head and family
• Makes sure that each person is getting treatment as per the census
• Supervises the proper measurement of height
• Observes that everybody swallows the drug
• Checks that everybody on the census has come and has taken the drug
• Reports all adverse experiences to the field supervisor
• At the end of each day, calculates the balance of issued drug from the field supervisor and then signs with the assistant on the balance sheet.

Assistant health agent/women’s group leader

• Informs community 1 week in advance, and 1 day before distribution date about distribution schedule and the drug
• Informs community members to bring drinking water to be used for swallowing drugs
• Ensures that every community member indicated in the census has come to get the drug
• Identifies that the person who comes to take the drug is in the census and is a member of that household
• Makes sure that peace and order are in place in the distribution areas
• Takes the height measurement correctly and directs person and document to the dispenser
• Assists the dispenser in making the drug balance at the end of each day and signs with the dispenser on the balance sheet.

Acknowledgement: MDA distribution team roles taken from ‘Zithromax® in the Elimination of Blinding Trachoma A Program Manager’s Guide. International Trachoma Initiative, 2010