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 CommunityDirected Intervention (CDI) to Improve
Access to Essential Health Services
Module 3 Objectives
By the end of this module, learners will:
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
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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
3
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
4
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)
5
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
6
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?
7
What Constitutes Participation?
Active involvement of the local population in the
decision-making for—and implementation of—
development projects
8
What Constitutes Participation?
(continued)
The community
determines collective
needs and priorities,
and assumes
responsibility for these
decisions
9
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
10
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
11
Village Health Workers (VHWs)
Promoting Filters
Product, price, place and promotion organized by VHWs
12
Effects of Participation
 Guinea worm filter sales are better where villageselected health workers take part
 Communities select their VHWs and usually respect them
45
40
35
30
25
20
15
10
5
0
VHW sold
VHW advised
No VHW
13
Community Involvement in …
Water Supply Improvements



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Raising money
Helping dig
Dedicating the well
Supervising use and
maintenance
Community involvement
14
Community Involvement in …
Well Construction
15
Participation in Water Supply Project
Multiplier effect on immunization participation
70
60
50
40
Indonesia
Togo
30
20
10
0
Participatory
Nonparticipatory
No project
16
Community-Managed Essential Drugs
VHWs, selected by the community, buy and maintain village drug stocks
70
64
60
50
40
35
30
20
7
10
1
0
% buy stock
Community Controlled
Mean times buy
LGA Controlled
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Community Problem-Solving
Above: Community Action Cycle: Save the Children
Discuss community involvement efforts you have seen
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Participatory Approach for Improving MCH
Save the Children worked in Bolivia to help women’s
groups plan their own program
140
120
100
80
60
40
20
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Baseline
Follow-up
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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
20
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
21
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)
22
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
23
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
24
Factors That Affect Malaria Treatment
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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
25
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
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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
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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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