Targeting Hard to Reach Populations for NTD Control: The Sierra Leone Example

April 30th, 2013

There are many reasons why certain communities in a country may be hard to reach for public health programs: remote geographical locations, poor road infrastructure, mistrust or lack of interest in healthcare, to name a few. Such programs are faced with the task of evaluating the pros and cons of reaching–or not reaching—them all.

Treating Elephantiasis in a Remote Area in Sierra Leone

Treating Elephantiasis in a remote area of Sierra Leone
Credit: Helen Keller International

While some public health programs may have the luxury of achieving only partial program coverage, such is not true in the case of national neglected tropical diseases (NTD) control, where disease elimination is the goal for most of the NTDs targeted. As such, effort is needed to reach and treat all communities and districts at risk for the various NTDs, no matter how hard to reach (HTR). The principal barriers to NTD services identified by the Sierra Leone national NTD control program are common in many countries: bad roads, travel by sea, mountainous terrain and inadequate attention to the problem. The interventions used to reach HTR communities included finding appropriate modes of transportation; improving sensitization and social mobilization in HTR communities  and simply prioritizing HTR communities during program planning and implementation. The strategy requires more funding and commitment from all stakeholders, especially district health workers, but the reward is that NTD program outcomes will continue to be good and control efforts will reach the desired goal at the expected time.



Santigie Sesay1, Joseph B. Koroma2*, Bolivar Pou3, Katherine Sanchez3, Mary H. Hodges4, Mustapha Sonnie4


There are many reasons why certain communities in a country may be hard to reach for public health programs: remote geographical locations, poor road infrastructure, mistrust or lack of interest in healthcare, and so on. Such programs are faced with the task of evaluating the pros (complete coverage, better program success, better disease control, more equitable healthcare) and cons (costs, time, staffing, logistics, etc.) of reaching–or not reaching—them all. While some public health programs may have the luxury of achieving only partial program coverage, such is not true in the case of national neglected tropical diseases (NTD) control, where disease elimination is the goal for most of the NTDs targeted. For NTD control programs (NTDCPs), success relies on reducing pockets of disease transmission nation-wide. As such these programs need to make an effort to reach and treat all communities at risk of the various NTDs in every district, no matter how hard to reach (HTR). However, this need to reach every last eligible community can be a daunting task for national NTDCPs  (1, 2, 3).


The national NTDCP in Sierra Leone has faced numerous implementation challenges in its attempts to reach diverse population segments, particularly those living in remote areas. Some communities are considered HTR because of poor accessibility due to bad roads or remote locations, such as on islands or in hilly, mountainous or otherwise remote areas of the country.

Districts such as Koinadugu, Bombali, Tonkolili and Kono in the northern and eastern provinces are HTR even in good weather, due to their very bad roads and the locations of some communities in hilly or mountainous areas. Reaching them is even more difficult during the rainy season (May-October) and the immediate post rainy season period (November-December). These are usually the months when mass drug distribution campaigns are conducted for the control and elimination of the various NTDs. Since some of these communities have no ‘roads’ at all, vehicles attempting to access them to provide the necessary NTD control drugs run the risk of breaking down ‘in the middle of nowhere.’ Other communities in Koinadugu and Tonkolili are located in very high mountains, where commercial vehicles generally refuse to go (4).

Sierra Leone is also home to a number of island-dwelling communities that are also relatively HTR. For example, the fishing community of Yeliboya in the Kambia district is located on an island very close to Guinea that is accessible only by crossing the Atlantic Ocean by boat.  Also, the Bonthe district has many small islands, some with populations as small as 50 people. Many of these islands are inhabited by just one or two families. Reaching these island communities with NTD drugs is both time-consuming and financially costly (4).

Other communities are considered HTR due to socioeconomic conditions driven by poverty.  For example, people living in densely populated urban slums areas such as the Kroo Bay in Freetown are HTR because they give little priority to health care. In addition, concerns regarding drug and equipment theft or safety and personal security for healthcare workers may limit access to people living in slums and other urban areas (4).

Health care providers face a dilemma in selecting the most effective intervention strategy to address the problem posed by HTR communities. However, it is worth noting that nobody is impossible to reach; it just depends on the approach taken as some communities are more expensive to reach than others (5).


HTR communities are of concern for the NTDCP in Sierra Leone because they may be sources of persistent infection that can continue to delay the country’s control/elimination efforts (1, 2). As such, the country’s NTDCP, with financial support from USAID and technical support from Helen Keller International (HKI), strives to improve NTD treatment coverage in HTR communities. As part of the country’s primary health care system, the NTDCP aims to address health inequalities and engage everyone, including the marginalized and socially excluded sectors of society (1, 2). With that goal in mind, the first challenge that the NTDCP and its partners had to overcome was identifying barriers and other factors that restricted access to program services. The second was finding acceptable solutions (6).

The program identified the following principal barriers or restricting factors:   bad roads, numerous island-dwelling communities accessible only via travel by sea, mountainous terrain and inadequate attention to these problems. Following this assessment, the program began implementing additional interventions to reach HTR communities and improve program coverage. Among its strategies are: utilizing appropriate modes of transportation to reach and treat these areas; ensuring that sensitization and outreach messages reach these communities to improve community acceptance and participation; and prioritizing HTR communities by including them in all phases of planning and implementation (4).

Utilizing appropriate modes of transportation meant renting boats to access all riverine areas and motorcycles (instead of cars) to traverse difficult terrain. To improve the community’s receptivity to the visiting health workers, specifically tailored messages were also developed and disseminated to target community leaders; and the leaders were then asked to collaborate in disseminating information on the campaign to the entire community. Sensitization campaigns were intensified in HTR communities and community meetings were conducted using previously designed information, education and communication (IEC) materials (4). During the community meetings, local community drug distributors (CDDs) were selected to distribute the relevant medications to their friends and neighbors within their own communities. Joint collaboration between community leaders, local CDDs and the visiting district health workers was important for establishing trust and improving community participation and ownership in the program (7, 8). Another very important intervention has been to prioritize efforts to reach HTR communities and to consider the challenges of so doing in program planning, implementation and reporting.


These interventions have ensured that the populations in Sierra Leone’s HTR communities are not missed, thanks to the NTDCP’s decision to implement creative strategies aimed at reducing the treatment gap between HTR communities and the general population. Studies need to be undertaken to produce data showing how effective these interventions have been in reducing NTD transmission and how they contribute to program control efforts. Such studies would inform the NTDCP and its partners, enabling them to continue to adapt the strategies to better serve HTR communities, as well as improve their ability to secure the additional funding and commitments from all the stakeholders (especially district health workers) that are needed to continue implementing the interventions. We expect that NTD programs will reap many rewards for making these interventions, most importantly good disease control and the ability to reach the desired goal at the expected time. In fact, these extra efforts to reach HTRs may make the difference between simply reducing NTD transmission and outright elimination of NTDs as a public health concern within a country.


  1. Brackertz N (2007) Who is hard to reach and why? ISR Working Paper. Online:
  2. Flanagan SM and Hancock B (2010) Reaching the hard to reach – lessons learned from the VCS (voluntary and community Sector). A qualitative study. BMC Health Services Research, 10:92. Http://
  3. Pfeil M and Howe A (2004) Health care for hard-to-reach groups. Primary Health Care 14 (7): 23-26.
  4. FHI360 (2012) End Neglected Tropical Diseases in Africa (END in Africa) Annual Work Plan Oct. 2012 – Sept. 2013.
  5. Pitt C, Roberts B and Checchi F (2012) Treating childhood pneumonia in hard-to-reach areas: A model-based comparison of mobile clinics and community-based care. BMC Health Services Research, 12:9. Http://
  6. Dowrick C, Gask L, Edwards S, Aseem S, Bower P, Burroughs H, Catlin A et al. (2009) Researching the mental health needs of hard-to-reach groups: managing multiple sources of evidence.  BMC Health Services Research, 9:226. Http://
  7. Boatin BA, Richards FO, Jr. (2006) Control of onchocerciasis. Adv Parasitol 61: 349-394.
  8. WHO (2010) African Programme for Onchocerciasis Control – report of the sixth meeting of national task forces, October 2009. Wkly Epidemiol Rec 85: 23-28.


  1. National Neglected Tropical Diseases Control Programme, Ministry of Health and Sanitation, Freetown, Sierra Leone
  2. FHI360, END in Africa Project, Ghana Country Office, Accra, Ghana
  3. FHI360, END Project, Washington DC, USA
  4. Helen Keller International, PO Box 369, Freetown, Sierra Leone