1. CDI Module 2: The CDI Process ©Jhpiego Corporation The Johns Hopkins University A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

2. Module 2 Objectives By the end of this module, learners will:  Define the community-directed intervention (CDI) approach  Describe program coverage benefits from using CDI  Outline the steps to establish CDI  List key approaches in gaining community commitment for a CDI program  Describe the steps in selecting and training community distributors  Explain how CDI can be adapted for use in controlling malaria 2

3. What Is CDI? For many years:  Health services and nongovernmental organizations (NGOs) have been distributing health commodities to communities We now know that:  Communities can carry out this distribution very well themselves  CDI happens when communities take charge of distributing health commodities themselves with guidance from the health service 3

4. CDI and Onchocerciasis  CDI was first tested for use for the African Program for Onchocerciasis (APOC) Control by the Special Program for Research and Training in Tropical Diseases (TDR) as “community-directed treatment with ivermectin” (CDTI)  Research was conducted to learn if communities could deliver the drug ivermectin more effectively than agency outreach had done in the past  When CDI proved successful, it was adopted as APOC’s official strategy  Now over 100,000 villages throughout Africa are benefiting from annual onchocerciasis (river blindness) control through CDI 4

5. Benefits of CDI  When communities are in charge, coverage is often better than it is when distribution is centrally organized by a health agency  The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution 5

6. Expanding Beyond Ivermectin  Recently, APOC observed that the CDI approach is being used for other issues  Studies have documented that CDI has been used to promote numerous interventions, including:  Guinea worm control  Immunization programs  Vitamin A distribution  Water and sanitation projects  Schistosomiasis control 6

7. A Multicountry Study  TDR has specifically tested CDI for malaria control through a seven-site study:  In selected districts in Uganda, Nigeria, Cameroon  With continued ivermectin distribution plus four additional interventions: –Vitamin A –Home management of malaria (HMM) with artemisinin-based combination therapy (ACT) –Insecticide-treated nets (ITNs) –TB case detection and follow-up for case completion 7

8. Multicountry Study: Intervention Plan  Stakeholder support gained to combine the five health interventions in selected districts  Two implementation arms (comparison districts versus CDI districts)  Three-year implementation  CDI districts –Year 1: two interventions delivered through CDI (ivermectin plus one additional intervention) –Year 2: three interventions delivered through CDI (one more intervention added) –Year 3: All five interventions delivered through CDI (remaining two interventions added)  Comparison districts use conventional delivery of all five interventions for all three years Source: The CDI Study Group 2010 8

9. Children Sleeping under ITNs 9 RBM Target 2005 RBM = Roll Back Malaria Partnership Source: The CDI Study Group 2010

10. Pregnant Women Sleeping under ITNs 10 RBM Target 2005 Source: The CDI Study Group 2010

11. Children Receiving Appropriate Malaria Treatment 11 RBM Target 2005 Source: The CDI Study Group 2010

12. Basic Ivermectin Coverage Improves Even When More Tasks Are Added 12 Annual ivermectin coverage of 65% is needed to control the disease Extra interventions enhance community interest APOC target

13. Lessons Learned CDI works when:  The disease is perceived as an important health problem that affects all sections of the community  An intervention is available that is relatively simple to implement  The intervention has a clearly perceived benefit  Implementation of the intervention is under the full control of community implementers  The intervention materials are made accessible to the community in adequate quantities 13

14. Key Lessons The most critical factors are:  An empowered community  Supplies delivered regularly, in adequate amounts and on time 14

15. Start-Up Components of CDI  Approaching the health service includes:  Involving stakeholders from all component programs of integrated community case management (iCCM)— child health, maternal health, disease control  Building a partnership between an affected community and the nearest health facility  Approaching the community includes:  Gaining support for CDI  Mapping and learning about the community  Training distributors selected by the community 15

16. MOH Village Leaders NGO USAID VHT Others SMOH LGA PHC NGO CDDs CBOs Religious Groups Organizational Partners Community Partners Other WHO UNICEF Each partner has a well-defined role 16

17. CDI for iCCM Can Build on Existing Programs 17 In Nigeria, for example:  Ivermectin for river blindness control had been delivered through CDT since 1995  In states with active ivermectin CDT programs, it was possible to add the iCCM package of interventions to existing community efforts  In districts that did not have CDT previously, state ministry of health staff used their experience in river blindness endemic districts to start the CDI/iCCM program in new districts

18. Approaching the Health Service Health Service Roles 18

19. Starting with Comprehensive or Integrated Facilities These facilities offer:  Antenatal care (ANC)  Safe delivery and postnatal care  Family planning services  Appropriate management of childhood illnesses  Immunization, vitamin A distribution  Prevention services such as ITNs Other facilities may be updated over time 19

20. Roles for the Health Service  Mapping facility catchment areas  Organizing community meetings to mobilize support and commitment for CDI  Training community-directed distributors (CDDs) selected by and accountable to the community  Maintaining stocks of basic health commodities for CDI  Guiding conduct of village census  Reviewing census results for estimating needed commodities, supplies 20

21. Staff at Local Clinic Train and Supervise Community-directed Distributors (CDDs) 21

22. Mapping Catchment Areas  CDI training, supervision, commodity storage and recordkeeping are coordinated by frontline health facilities  These facilities ensure that all communities in their service catchment areas participate in the program 22

23. Clinics Should Also Have Community Maps 23

24. More Health Department Roles  Conduct supportive supervisory visits to communities  Provide retraining  To refresh CDDs  To replace dropouts  Coordinate data collection  Ensure communities and CDDs submit data in a timely manner  Incorporate village data with facility data to ensure that: –All data are captured and forwarded, as appropriate –The facility recognizes that catchment community data also belong to the facility and form part of the facility service delivery output(s) 24

25. Reaching Out to the Community Make contact with community leaders to:  Define the problem jointly  Inform leaders about available services  Identify community roles in accessing the available services 25

26. Reach the Entire Community  Meet the entire community to:  Define the problem jointly  Inform about available services  Identify community roles in accessing the available services  Remember that visitors, farm workers and others are also part of the community  Ask the community to meet and discuss the community implementation plan—CDD selection, census, distribution of commodities 26

27. Ensure Participation  Return to the community for feedback from the community meeting  Document the community implementation plan  Reiterate the importance of the community playing its roles  Inform communities that they can select more than one CDD  Collect the list of selected CDDs  Provide information on CDD training (timing, venue, requirements) 27

28. Train Health Workers for Their Roles  Help health service staff members understand their importance as facilitators  Highlight the benefits of CDI to the health system, for example:  Reduced workload for health workers  Increased contact with the community  Transfer skills for training adults and semi- literate CDDs, using:  Role play, demonstration, illustrations, motivation 28

29. Trained Frontline Health Workers Ensure That the Program Reaches the Community Frontline health workers should be prepared to:  Transfer skills for monitoring and supervision as well as for evaluation  Clearly define targets before setting out to supervise  Use checklists  Appreciate the information from the field  Provide immediate feedback  Support the supervisee to use the feedback, and then evaluate immediately 29

30. Trained Frontline Health Workers Are Essential for Planning and Monitoring  Planning and documentation  Addressing the initial objectives after the job is done  Defining the goal  Setting the timeline  Reporting  Passing information top- down-top  Assessing how it was documented and transmitted 30

31. Approaching the Community Gaining Support for CDI 31

32. First Meeting Begin by:  Sending word to the community that health staff would like to meet with leaders to introduce the program  Including key leaders in this initial meeting (perhaps four to five leaders) whose support is needed to proceed  Explaining CDI to the leaders and answering their questions  Obtaining a clear sense of commitment  Arranging a larger community meeting 32

33. First Meeting with Community Leaders 33

34. Second Meeting  Ask the leaders to assemble all villagers—men, women, youth and even “visitors” (e.g., life farm laborers— farmers who live on their farms during the farming season and return to the village when the season is over)  This meeting is intended to engage everyone in the CDI process  The slides that follow outline activities that take place at community meetings  It may not be possible to do everything at one meeting  The community should hold follow-up planning meetings 34

35. Second Meeting with Community Members 35

36. Discuss and Gain Commitment to Community Roles, Including …  Decide convenient days, times and means for distribution of health commodities  Map the community (see earlier slides on community mapping and module on community structure, networks and organization)  Select CDDs  Develop criteria to define the types of residents best suited to the work  Select the number of CDDs needed  Sponsor CDDs to attend a short training activity  Make it clear that CDDs work for/with the community, not instead of the community 36

37. Roles for the Community The community should:  Conduct a village census to aid in estimating commodity needs  Collect health commodities at the nearest health facility, based on estimates from the census  Maintain a village distribution register  Monitor the implementation process  Referrals  Compliance  CDD performance (adherence to treatment procedures, treatment of ALL eligible persons) 37

38. More Roles for the Community The community should also:  Summarize information from the register to report back to the health facility  Provide drug boxes so CDDs can store commodities safely  Buy supplementary medicines for the community (e.g., analgesics)  Make advocacy visits to facilities and local government headquarters to ensure adequate and timely supply of commodities  Support their own CDDs with appropriate recognition and rewards  Monitor implementation  Community self-monitoring is critical 38

39. 39 Training Community-Directed Distributors Recruitment, Commitment, Responsibilities

40. Basic Principles for CDD Training  Training should be based on knowledge and skills CDDs will actually use  Training methods should involve local communication processes (e.g., storytelling, songs and proverbs)  As adult learners, CDDs should be asked to contribute their own ideas and experiences throughout the training  Training evaluation and rewards (e.g., certificates) are crucial 40

41. Make a Training Plan for CDDs  The venue should be open and convenient (i.e., it should be within the community) to create community awareness  Involve the community leaders in the training (e.g., these leaders can officiate at training session openings and closings)  Emphasize the limits of the skills CDDs will acquire  CDD skills will not go beyond their job descriptions 41

42. Training Plan  Identify training requirements and materials  Design culturally relevant job aids and information, education and communication (IEC) materials that CDDs can take home and use  Plan the refreshments  Ensure that training and facilitators are lively and supportive 42

43. Choosing Training Content  iCCM  Malaria  Pneumonia  Diarrhea  Prevention of common illnesses, such as:  Malaria  Diarrhea  Other interventions (immunization, vitamin A, etc.) Countries and programs should decide on the package of interventions that best suits local health needs 43

44. Additional Skill Content for CDDs  Health education to community  Target each segment of the community separately, including men, women, youth, migrant workers, etc.  Address drug availability within the community  Identifying eligible persons  Make this activity interactive, starting with CDDs’ knowledge (prompt for issues not mentioned)  Recordkeeping and reporting  Safe commodity supply management 44

45. CDD Skills  Treatment  Drugs available  Treatment modes, regimen, requirements, possible reactions, reaction management  Referral  Conditions for referral  Referral points 45

46. Example of Training Content for Malaria Interventions through CDI  Distribution of ITNs and ensuring “hang-up”  Intermittent preventive treatment in pregnancy (IPTp) and referral to ANC  Prompt diagnosis—rapid diagnostic tests (RDTs)—and appropriate treatment (ACT)  Health education on appropriate use of interventions  Referral of severe malaria  Recordkeeping, monitoring and surveillance All of these topics will be covered in detail in the modules that follow 46

47. Involve CDDs in Generating Content and Ideas  Start with a general discussion about the learners’ experience with malaria  Discuss experience with malaria in children, in pregnant women and others  Discuss management of malaria in the community (note the different modes of management)  Local practices, beliefs  Treatment of different groups, children, pregnant women, others 47

48. Distribution of ITNs There are two possible modes of distribution:  CDD collects medicines and supplies from the nearest facility and distributes them for free  CDD provides an ITN coupon to the pregnant woman and refers her to the nearest facility to collect the ITN  In all cases CDD ensures people hang and use nets 48

49. ITNs Directly through CDI The CDD:  Collects ITNs or coupons from the health service  Starts with small supply  If community responds well, increases supply  Ensures that each household receives enough nets for each sleeping space  Consults with household members on how to hang their nets  Encourages regular nightly use and makes home visits for a reminder 49

50. Medicines Delivered through CDI Train the CDD to:  Collect commodity from agreed point  For malaria—ACT, sulfadoxine-pyrimethamine (SP) for IPTp, RDTs, paracetamol  For diarrhea—oral rehydration solution (ORS) packets, zinc, hand soap  For pneumonia—antibiotics  Inform the community leader and co-villagers about the availability of drugs  Provide health education on the importance of prompt and appropriate treatment 50

51. IPTp through CDI Train the CDD to:  Provide health education to the woman  Issue drug to the woman and ensure that she swallows the full dose  Record the information about giving IPTp in the village register  Refer pregnant woman to ANC for follow-up dose and ITN if she has not already received one 51

52. Train CDD for Health Education on IPTp Explain to the CDD that:  Malaria may be in your blood, even if you don’t feel sick  Malaria makes your blood weak  When the mother has malaria, the newborn is too small and can get sick easily  IPTp prevents malaria in pregnancy 52

53. More Health Education on IPTp Explain to the CDD that:  IPTp should only be given after the mother can feel the baby move inside  This is likely to be 16 to 20 weeks after she becomes pregnant  A second dose of IPTp should be taken a month after the first dose  It is best to get the second dose at the antenatal clinic where trained staff can check and test the mother and baby to ensure that the pregnancy is going well 53

54. Prompt Diagnosis and Appropriate Treatment 54

55. Three Main Steps for Case Management The CDD should: 1.Find out what illness the patient has by:  Asking the patient/caregiver to explain signs and symptoms  Feeling the body to determine fever  Performing RDT for malaria  Checking for other signs (e.g., anemia, cough and difficult breathing)  Deciding whether the patient has malaria or another disease 2.Provide the approved anti-malaria drug supplied by the program for those with positive RDT 3.Counsel the patient on taking the full dose of any medicines provided to ensure full recovery 55

56. Recordkeeping  The village leaders and CDD should create and maintain a village register (the project or community can supply notebooks) in which:  Each household has a page  Children, pregnant women and others are included  All services (case management, provision of LLINs, etc.) are recorded  A monthly summary of services is made from the register and forwarded to the health system 56

57. CDDs Monitor and Refer The CDD:  Refers pregnant women to nearest ANC clinic to get regular examination and other commodities  Ensures that children are up to date on immunizations Health workers should:  Spot check register for beneficiaries to ensure proper documentation during supervision visits  Register should contain enough details for tracing beneficiaries to ensure: –Accountability –That the register is updated to account for new births, deaths, new entrants and those leaving the community 57

58. Summary and Conclusions  CDI was first tested for use for APOC by TDR, and it proved successful  Communities can carry out the task of distributing health commodities very well  CDDs do not replace health workers; rather, CDDs complement health worker services  CDI happens when communities take charge of distributing health commodities themselves with guidance from the health service  CDI guarantees that services reach the grassroots 58