Optimising the performance of frontline implementers engaged in the NTD programme in Nigeria: lessons for strengthening community health systems for universal health coverage

Background The control and elimination of Neglected Tropical Diseases (NTDs) is dependent on mass administration of medicines (MAM) in communities and schools by community drug distributers (CDDs) who are supported and supervised by health facility staff (FLHF) and teachers. Understanding how to motivate, retain and optimise their performance is essential to ensure communities accept medicines. This study aimed to capture and translate knowledge, problems and solutions, identified by implementers, to enhance NTD programme delivery at the community level in Nigeria. Methods Qualitative data was collected through participatory stakeholder workshops organised around two themes: (i) identification of problems and (ii) finding solutions. Eighteen problem-focused workshops and 20 solution-focussed workshops were held with FLHF, CDDs and teachers in 12 purposively selected local government areas (LGA) across two states in Nigeria, Ogun and Kaduna States. Result The problems and solutions identified by frontline implementers were organised into three broad themes: technical support, social support and incentives. Areas identified for technical support included training, supervision, human resource management and workload, equipment and resources and timing of MAM implementation. Social support needs were for more equitable drug distributor selection processes, effective community sensitisation mechanisms and being associated with the health system. Incentives identified were both non-financial and financial including receiving positive community feedback and recognition and monetary remuneration. The results led to the development of the ‘NTD frontline implementer’s framework’ which was adapted from the Community Health Worker (CHW) Generic Logic Model by Naimoli et al. (Hum Resour Health 12:56, 2014). Conclusion Maximising performance of frontline implementers is key to successful attainment of NTD goals and other health interventions. As NTDs are viewed as a ‘litmus test’ for universal health coverage, the lessons shared here could cut across programmes aiming to achieve equitable coverage. It is critical to strengthen the collaboration between health systems and communities so that together they can jointly provide the necessary support for frontline implementers to deliver health for all. This research presents additional evidence that involving frontline implementers in the planning and implementation of health interventions through regular feedback before, during and after implementation has the potential to strengthen health outcomes.


Disease Definition
Lymphatic Filariasis (LF) is caused by a thread-like parasitic worm Wuchereria bancrofti in Nigeria. The disease is spread from infected person to uninfected person through mosquito bites. The adult worm lives in human lymph vessels and has a life span of 4-6 years. The microfilaria (immature worm) circulates in the peripheral blood with a marked nocturnal periodicity. Major chronic stages of LF are elephantiasis and hydrocoele.
Onchocerciasis is caused by a filarial worm known as Onchocerca volvulus. The disease only infects humans and is transmitted through the bite of an infected black fly of the Simulium genus, predominantly found around fast flowing rivers and streams. These flies transmit immature larval forms of the parasite from person to person. The parasites on maturing into adult female worms, can live up to 14 years and produce thousands of microfilariae.
Schistosomiasis, also known as bilharziasis or snail fever, is a primarily tropical parasitic disease caused by the larvae of one or more of five types of flatworms or blood flukes known as schistosomes.
There are five types of schistosome:Schistosoma mansoni, S. mekongi, S. japonicum, S. intercalatum, S. iaematobium, Eggs are excreted in human urine or faeces and, in areas with poor sanitation, contaminate freshwater sources. The eggs break open to release a form of the parasite called miracidia. Freshwater snails become infested with the miracidium, which multiply inside the snail and after about a month mature into new larvae (cercariae) that the snail ejects into the water. The cercariae, which survive outside a host for 48 hours, quickly penetrate unbroken skin, and travel Soil-transmitted helminths refer to the intestinal worms infecting humans that are transmitted through contaminated soil ("helminth" means worm): Ascaris lumbricoides (sometimes called just "Ascaris"), whipworm (Trichuristrichiura), and hookworm (Ancilostoma duodenale and Necator americanus) are the major STH.
Trachoma is a potentially blinding infectious eye disease caused by a microorganism called Chlamydia trachomatis spread by a direct or indirect contact with infected individuals.

Schistosomiasis (SCH) Soil-transmitted Helminths (STH)
Trachoma to the liver where they grow and sexually mature. Mature male and female worms pair and migrate either to the intestines or the bladder where egg production occurs.

Signs and Symptoms
The signs and symptoms of LF are mainly elephantiasis (leg, arm, vulva or breast) and hydrocoele (swollen scrotum). Others may include: fever, headache, pain and chyluria (milky urine).
The adult worms are found in nodules located in the subcutaneous tissue under the skin. Migration of the microfilaria through the skin and eyes is responsible for the major symptoms experienced by infected persons. The conditions include skin lesions (scaly or leopard skin), skin rashes accompanied by intense itching and resultant scratching (causing a condition commonly known as craw-craw), hanging groin, and ultimately, blindness.
Many individuals do not experience symptoms. If present, it usually takes four to six weeks for symptoms to appear. The first symptom of the disease may be a general ill feeling. Within twelve hours of infection, an individual may complain of a tingling sensation or light rash, commonly referred to as "swimmer's itch", due to irritation at the point of entrance. The rash that may develop can mimic scabies and other types of rashes. The disease can also start with blood in urine or stool, anaemia, or problem with growth and development of children, and eventually become life threatening due to health effects such as bladder cancer, kidney and liver problems. Other symptoms can occur two to ten weeks later and can include fever, aching, cough, diarrhoea, or gland enlargement.
People with light soiltransmitted helminth infections usually have no symptoms. Heavy infections can cause a range of health problems, including abdominal pain, diarrhoea, blood and protein loss, rectal prolapse, and physical and cognitive growth retardation. Soil-transmitted helminth infections are preventable and treatable with medication prescribed by health care provider.
Discharge from the eyes, reddening of the eyes, and deformity of the eyelids, inability to see properly, and eventually blindness.

Intervention Measures
The Local Government Area (LGA) is LF endemic when a selected community of the LGA has at least one (1) positive person in 100 recruits with immunochromatographic test (ICT). The intervention Endemicity is determined using nodular palpation or skin snipping methods. Currently prevalence of 10% and above of an area identified using REMO principles calls for LGA is schistosomiasis endemic when the average prevalence of the five selected communities in the LGA is at least one percent (1%) positive using standard diagnostic procedures (Heamastix/microscopy). The LGA is STH endemic when the average prevalence of the five selected community in the LGA has at least twenty percent (20%) positive using standard diagnostic procedures (Kato- The target is to treat the entire population.

Trachoma of Medicines (MAM)
Population Commission (NPC) figure of the LGA is the at-risk population for LF.
an endemic community. The population at risk is the whole population in identified groups of villages or communities and not necessarily an entire LGA.
of the annual projected National Population Commission (NPC) figure of the LGA is the at-risk population for school age children in low and medium risk LGAs while the entire population is the at-risk population in high risk communities.

School Age Children (SAC) and Women of Child Bearing Age (WCBA)] in endemic
LGAs. 28% of the annual projected National Population Commission (NPC) figure of the LGA is the at-risk population for STH.

Eligibility
People who can take the LF medicines (Ivermectin and Albendazole tablets) are those that are ≥ 90cm in height or ≥ 5 years of age living in endemic LGA. Those people that cannot take the medicines include those that are <90cm in height or <5years of age, pregnant women, lactating mothers within the first 7 days and seriously sick people.
All persons > 5years in an endemic community is required to use an annual dose of ivermectin with the exception of children below 5 years or less than 90cm in height, pregnant women, lactating mothers within the first 7 days of delivery and severely ill persons.
People who can take the Schistosomiasis medicines (Praziquantel tablets) are those that are between 5 and 15 years of age and not less than 110cm, include adult in high risk LGAs. Those people that cannot take the medicines include pregnant women and children who are ill on the treatment day. This is not because of any danger of side effects, but to prevent the potential misperception that the deworming drug(s) have caused the illness. These children can be given the drug(s) later when they are well again.  A parasitic disease that is spread by the bite of sand flies infected with the protozoa Leishmania.

Innovative Disease Management (IDM) NTDs
There are several forms of leishmaniasis, the most common being cutaneous and visceral leishmaniasis (known as kala-azar). The cutaneous form of the disease causes skin sores and is usually named for a geographic place (for example, Jericho boil, Baghdad button, Delhi sore). Visceral leishmaniasis affects the internal organs of the body and can be fatal.
Leprosy is a slowly progr essing bacterial infection that affects the skin, peripheral nerves in the ha nds and feet, and mucous membranesof the n ose, throat, and eyes. De struction of the nerve en dings causes the the affected areas to lose sensation. Occasionally, because ofthe loss of feeling, the fingers and toes become mutilated and f all off, causing the deformities that are typically associated with the disease.
An acute, infectious, usually fatal viral disease of the central n ervous system that is transmitted by the saliva and bite of infected a nimals and occurs in many mam mals, including dogs, cats, raccoons, and b ats causing madness and convulsions.
Yaws: contagious disease, caused by a bacterium that enters skin abrasions and gives rise to small crusted lesions which may develop into deep ulcers.