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

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

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

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 for Health 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

Larger and Smaller Arrangements of 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?

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

What Constitutes Participation? (continued) The community determines collective needs and priorities, and assumes responsibility for these decisions

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

Village Health Workers (VHWs) Promoting Filters Product, price, place and promotion organized by VHWs

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

Community Involvement in … Water Supply Improvements Raising money Helping dig Dedicating the well Supervising use and maintenance Community involvement

Community Involvement in … Well Construction

Participation in Water Supply Project Multiplier effect on immunization participation

Community-Managed Essential Drugs VHWs, selected by the community, buy and maintain village drug stocks In the graph above, LGA = local government area.

Community Problem-Solving Above: Community Action Cycle: Save the Children Discuss community involvement efforts you have seen

Participatory Approach for Improving MCH Save the Children worked in Bolivia to help women’s groups plan their own program On the slide above: MCH = maternal and child health TT = tetanus toxoid ANC – antenatal care BF = breastfeeding

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 areas

Community Involvement Addresses the 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

Who Are 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)

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

Malaria Is Often Managed in 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

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

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

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?

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

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?