CDI Module 3: The Value of Community Involvement

… and its role in community and home management of malaria

©Jhpiego Corporation

The Johns Hopkins University

A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

Module 3 Objectives

By the end of this module, learners will: Identify and define community structures Define community participation Explain the value and benefit of community

participation and involvement in health programs Identify the various volunteer community health

agents and their roles Describe the community social and economic factors

that affect health List community resource people who can be

involved in malaria control

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Home and Community Management

Although this module uses malaria as an example, we can apply the principles to management of other health problems common in the home and community

Please suggest other common problems that are amenable to home management

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Why Community Involvement?

Health is produced at home and in the community.Health depends upon:– What people do or fail to do

In many countries the National Malaria Control Program (NMCP) strategic plan is directed at improving case management of malaria at the home and community levels

Home management of malaria (HMM) is an important strategy because it provides access to pre-packed, quality, anti-malarial medicines within 24 hours of the onset of fever

This strategy is designed to use a network of community resource persons

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What Is a Community?

A group of people living in the same defined area—sharing basic values, organization and interests (Rifkin et al. 1988)

An informally organized social entity, which is characterized by a sense of identity (White 1982)

A population, which is geographically focused, but which also exists as a discrete social entity, with a local collective identity and corporate purpose (Manderson et al. 1992)

Why Is Community Valuable forHealth Service Delivery?

A community is: An operational area

for delivering a minimum health care package

Designed to mobilize political commitment to health service delivery as a requisite for social development

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Larger and Smaller Arrangementsof Community

Sometimes the health service may group smaller communities to make it easier to deliver services

For example, a ward or sub-district may be the catchment area of a health center and serve many communities

Communities themselves may be composed of smaller units (like blocks, neighborhoods and kindreds/clans)

We need to learn from the communities how they are divided and subdivided, and use this information to foster maximum involvement

How are communities organized in your area?

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What Constitutes Participation?

Active involvement of the local population in the decision-making for—and implementation of—development projects

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What Constitutes Participation? (continued)

The community determines collective needs and priorities, and assumes responsibility for these decisions

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Role in Participation

The community’s role includes:

Formulating a health program

Enabling its residents to understand and make informed choices

Reconciling outside objectives with community priorities

Why Participation?

Participation (assumptions): Increases program acceptance and ownership Ensures that programs meet local needs May reduce costs using local resources Uses local/familiar organizations and problem-solving

mechanisms—and is more efficient Some examples follow

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Village Health Workers (VHWs) Promoting Filters

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Product, price, place and promotion organized by VHWs

Effects of Participation

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VHW sold VHW advised No VHW13

Guinea worm filter sales are better where village-selected health workers take part Communities select their VHWs and usually respect them

Community Involvement in …

Raising money Helping dig Dedicating the well Supervising use and

maintenance

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Community involvement

Water Supply Improvements

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Community Involvement in …

Well Construction

Participation in Water Supply Project

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Participatory Non-participatory

No project

IndonesiaTogo

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Multiplier effect on immunization participation

Community-Managed Essential Drugs

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% buy stock Mean times buy

Community Controlled LGA Controlled

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VHWs, selected by the community, buy and maintain village drug stocks

Community Problem-Solving

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Above: Community Action Cycle: Save the ChildrenDiscuss community involvement efforts you have seen

Participatory Approach for Improving MCH

020406080

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BaselineFollow-up

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Save the Children worked in Bolivia to help women’s groups plan their own program

Rationale and Scientific Basis for HMM

It is widely acknowledged that access to appropriate and effective treatment of malaria should be provided within 24 hours of onset of symptoms

Any strategy to accomplish this should take into account: The rural population Inadequate coverage of the population by the health

system Poor terrain and road networks in malaria-endemic

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Community Involvement Addressesthe Access Gap

HMM is designed to address the access gap

HMM: Is designed to enable communities and homes to

serve as the first “hospital” Relies upon the community and the services offered

by the formal and informal private health sectors Is an integral part of malaria case management within

the overall Roll Back Malaria (RBM) strategy

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Who Are Community Agents?

Community agents: Are volunteers selected by their own communities to

perform basic health and educational duties May be called by many names, but the concept is the

same Community-directed distributors (CDDs) Role model caregivers (RMCGs) Community-integrated managers of childhood illness

(CIMCI) Community health workers (CHWs)/village health workers

(VHWs) Community-oriented resource persons (CORPs)

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Community Management

Community agents promote HMM The HMM strategy has the potential to ensure

effective case management for non-immune people at risk of malaria (such as children under five years of age in high malaria transmission areas)

HMM may also be applicable to adults in low and moderate malaria transmission areas. In this population, the disease could advance rapidly to severe malaria, especially during epidemics

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Malaria Is Often Managedin the Home and Community

In many countries self-treatment is often the most common form of treatment, though it is often not appropriate

In communities, first-line malaria treatment medicines are bought from patent medicine vendors

Usually diagnosis and treatment of malaria is done at home by family members

Such treatment is frequently done on a “wait and see” basis, which leads to delays in care and possible complications

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Factors That Affect Malaria Treatment

Non-affordability of anti-malaria drugs Inappropriate health-seeking behavior Inadequate health care infrastructures Unapproved malaria drugs found in clinics and

shops Non-compliance with drug regimens Poor communication between clients and providers

Trained community agents can address these factors

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Communities Can Also Prevent

Trained community-based workers and community leaders can: Mobilize/sensitize the communities on the value of

antenatal care (ANC), the risk of malaria in pregnancy, the concept and rationale for intermittent preventive treatment in pregnancy (IPTp)

Promote other control measures, especially use of long-lasting insecticide-treated nets (LLINs)/insecticide-treated nets (ITNs)

Refer pregnant women promptly to the appropriate level of care

Encourage the community to accept and use IPTp

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Involving Local Resource People

TBA in Nigeria volunteers as a CDD

Local Resource People

Local resource people understand the cultural, social and economic realities of their own communities

These people can serve as volunteers and opinion leaders to promote malaria control. They include: Traditional birth attendants (TBAs) Religious leaders Teachers Local chiefs

Can you name others?

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Community Resource People like TBAs Can Aid Malaria/Disease Prevention

TBAs in in several Nigeria communities volunteer to distribute LLINs and provide IPTp

With Community Participation, What Might Your Country Be Like without Malaria?

Decreased morbidity, leading to fewer clinic visits and fewer hospital admissions

Increased health resources for other diseases Decreased infant, childhood and maternal

mortality (deaths) Increased life expectancy Reduced absenteeism from school and work Increased work productivity and more food for

everyone Improved national economy

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Summary and Conclusions

Community represents a vital missing link in malaria control efforts

Communities can mobilize members and resources for effective malaria control efforts

Community involvement can strengthen facility and community linkages

Community agents can address and reduce the factors that impede malaria control efforts

Comments and Questions?

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