1. CDI Module 5: Community-Directed Interventions to Deliver Malaria Plus Packages (MPPs)
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

2. Overview
Our training uses malaria as a foundation for integrated community case management (iCCM) and community-directed intervention (CDI), but in other countries/areas other combinations of package components may be more appropriate for starting out

3. Module 5 Objectives By the end of this module, learners will:
Name components of a Malaria Plus Package (MPP)
Describe key household and community practices that impact child growth promotion and development
List steps and activities for disease prevention at the home/community level to reduce illnesses and deaths
Explain home management of malaria-related diseases (e.g., diarrhea, chest infection, malnutrition, anemia)
List activities to promote care seeking and compliance with healthy practices

4. A Malaria Plus Package …
… starts with preventing and treating malaria services, but then:
Strengthens the health system to improve delivery of a variety of community interventions
Expands the capacity of the Ministry of Health (MOH) and the local government authorities in the target states/municipalities, to deliver an integrated package to the community
Provides appropriately tailored support to the states/municipalities to help them improve their planning, implementation, coordination and supervision capacities for the integrated package

5. Malaria Plus Includes …
Increasing access to, and utilization of, preventive measures
Expanding access to, and utilization of, effective diagnostic and treatment services
Strengthening community mobilization and communication for behavior change
Improving state-/municipality-specific monitoring and evaluation (M&E) for evidence-based management
Strengthening partnerships for resource mobilization and implementation
Enhancing capacity of the states/municipalities for oversight and project coordination

6. Three MPP Delivery Channels/Links
Family-oriented, community: Home management of childhood illness; health-promoting activities like exclusive breastfeeding, long-lasting insecticide-treated net (LLIN) use, intermittent preventive treatment in pregnancy (IPTp)
Population-oriented outreach and schedulable services: Delivery of health services (e.g., through a Child Health Week in collaboration with partners)
Individual-oriented clinical services: Facility-based care available on a 24-hour basis to deliver routine services and manage severe illness

7. Our Focus in CDI
We are focusing on the family/community channel for CDI
Key household and community practices are a set of practices that—when combined—have the greatest impact on child survival, growth and development
These key practices can prevent a variety of health problems, not just malaria
Families play a very significant role in the growth and development of their children as well as in the well-being of mothers

8. Role of Families and Communities
Caregivers need knowledge and skills in key household and community practices that have the greatest impact on the well-being of mothers and children
The purpose of this module is to outline contents for training community-directed distributors (CDDs)/community-oriented resource persons (CORPs) to promote the key household and community practices

9. Why Malaria Plus Packages?
The majority of children die at home in spite of the availability of health services
Many children die from other malaria-related diseases (e.g., diarrhea, chest infection, malnutrition, anemia)
Initial care (whether using orthodox or traditional medicine) takes place in the family
Formally trained health workers are usually either inaccessible or unavailable
Feasible interventions that can significantly reduce illness and death exist, and can be practiced at home/in the community

10. Examples of Good Practices
Appropriate breastfeeding can reduce childhood illness by 10%
Good hygiene practices can reduce childhood illness by 10%
Improved complementary feeding can prevent death from malnutrition, diarrhea, measles, etc.

11. Household Practices
The key household practices can be grouped into four broad clusters:
Growth promotion and development
Disease prevention
Home management
Care seeking and compliance
Can you name these practices and the services the community can provide to foster these practices?

12. Growth Promotion and Development
Exclusive breastfeeding: Feeding a baby with only breast milk, not even water, from birth until six months of age
Complementary feeding: Feeding children with freshly prepared energy- and nutrient-rich complementary foods, beginning at six months of age, while continuing to breastfeed up to two years or longer

13. Growth Promotion and Development (continued)
Micronutrients and diet supplementation: Ensuring that children receive adequate amounts of micronutrients (vitamin A, iron, iodine and zinc in particular), either in their diet or through supplementation
Growth monitoring: A process of weighing a child at intervals, charting the weight on a child health card and showing the mother whether the child is doing well or not

14. Growth Promotion and Development (continued)
Promoting mental and psychosocial development: Providing children with a stimulating environment to achieve optimal development later in life
Birth registration: The official recording of the birth of a child with the National Population Commission

15. Disease Prevention
Proper feces disposal and handwashing: Disposing of feces, including children’s feces, safely; and washing hands with soap after defecation, before preparing meals and before feeding children
Protecting children and pregnant women in malaria-endemic areas, by ensuring that they sleep under insecticide-treated nets
Preventing HIV and caring for people living with HIV/AIDS (PLWHA): Providing appropriate care for HIV/AIDS-affected people, especially orphans, and taking action to prevent further HIV infections

16. Disease Prevention (continued)
Preventing child abuse and neglect, and taking appropriate action:
Taking action to prevent child abuse
Recognizing child abuse when it has occurred and taking appropriate action

17. Home Management
Preventing and managing child injuries by taking appropriate action:
Keeping the home environment tidy and free of objects that may cause accidents among children
Preventing and providing appropriate treatment for child injuries

18. Home Management (continued)
Giving appropriate home treatment for infection:
Beginning appropriate home management of diarrhea immediately to prevent dehydration
Giving salt sugar solution or drinking water in addition to breast milk if the child is still exclusively breastfed
Continuing to feed and offering more food and fluid when the child is sick, including breast milk
Taking the child to a health facility immediately if the child has any of the following signs:
Is not able to drink
Develops a fever
Is getting worse
Passes blood in stool

19. Home Management (continued)
Taking all children with a cough to a health facility where the cough will be properly assessed and treated Also, taking all children to a health facility for assessment if they develop any of these signs:
Breathing is fast
Breathing becomes difficult
Child is not able to drink
Child is getting worse

20. Care Seeking and Compliance
Immunization: Ensuring that every child completes the full course of routine immunization five times before the child’s first birthday
Also, ensuring that, from the age of six months, a child receives vitamin A supplementation and deworming tablets every six months until the child reaches five years of age

21. Care Seeking and Compliance (continued)
Recognizing when a child needs treatment outside the home, and seeking care from appropriate providers:
Taking the child with severe illness to the health facility immediately to save the child’s life
Following the health worker’s advice on treatment, follow-up and referral

22. Care Seeking and Compliance (continued)
Birth preparedness and complication readiness: Getting ready for a baby’s birth and possible problems/dangers that may arise during labor, and taking care of emergencies when they arise
If a woman is well prepared for normal childbirth and possible complications, she is more likely to receive the skilled and timely care she needs to protect her overall health and the health of her baby

23. Care Seeking Family planning using appropriate methods
Families that plan and space their children ensure that the pregnant woman:
Regains her strength between pregnancies
Avoids frequent exposure to health risks
Gives birth to children who are strong and healthy

24. Avoiding Delays
Three ways of wasting time (delays) may lead to complications and death of a woman and her child:
Delay in seeking care
Delay in reaching care
Delay in receiving care

25. Care Seeking and Compliance (continued)
Essential community newborn care:
Identifying danger signs in newborns and advising to take baby immediately to nearest health facility
Ensuring that mother and baby go back to the health facility within the first week and at six weeks of delivery— and if she delivered at home, ensuring that mother and baby go to the health facility within 24 hours
Active participation of men in child care and reproductive health: Ensuring that men actively participate in the provision of child care and are involved in reproductive health

26. MPP-Driven Commodities
Examples of commodities that will drive the MPP implementation strategy are:
Folic acid
Ferrous sulfate
Anti-helminthics
Oral rehydration salts
Antibiotics that are already in the work plan/procurement plan of the participating states/municipalities
LLINs for mop-up phase
Vaccines
Not all commodities will be available through the community channel

27. In Your Country
What is the package of services and health promotion activities that are provided at the community level through community efforts?
How were the components of this package decided?
Are there other services that could be added?
We have discussed many services (20); so, how do we decide:
Which ones to start delivering first?
Which ones to train CDDs on first?

28. Planning for Malaria Plus
Key practices
Resources needed
Source of assistance
Growth promotion and development
Disease prevention
Home management
Care seeking and compliance
As a group exercise, fill out this chart—you may substitute a different set of services relevant to your country

29. Integration Challenges
How can we integrate these additional areas into the training and work of the CDDs/CORPs?
What are the cost implications for CDD training and CDD kits?
How can we provide integrated supportive supervision for CDDs to implement MPP?
What other concerns do you have?

30. Summary and Conclusion
Key household and community practices have a potential impact on child survival, growth and development
The key household and community practices are deployed as part of an integrated maternal, neonatal and child health strategy
Improving knowledge about key household and community practices will:
Promote survival, growth and development of newborns, children under five years of age and their mothers
Strengthen the community management of malaria and related illnesses
Reduce maternal and child deaths
Each MPP must be decided by the country and district concerned