1. 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

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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?

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

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

10. 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

11. 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

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

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

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

15. Community Involvement in …
Well Construction

16. Participation in Water Supply Project
Multiplier effect on immunization participation

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

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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. Involving Local Resource People
TBA in Nigeria volunteers as a CDD

28. 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?

29. Community Resource People like TBAs Can Aid Malaria/Disease Prevention
TBAs in in several Nigeria communities volunteer to distribute LLINs and provide IPTp

30. 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

31. 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?