Article Type : Research Article
Authors : Kooma EH, Masaninga F, Lungu C, Kafula S, Zinyengere D, Sande S, Chirwa B, Iwuchuku N, Chilumba S, Lwando E and Zulu R
Keywords : CB-IRS delivery model; Community empowerment; Community action cycle; Community mobilization; PHC
We recommend that
Indoor Residual
Spraying (IRS) has been an effective strategy to control malaria and ultimately
eliminating the disease. The move from morbidity control to interruption of
transmission and achievement of malaria elimination requires novel advanced
innovative technologies aimed at reducing the infection reservoir or reducing
the rate at which infections spread. This must be done by an innovative
research portfolio that has to be expanded such as Community-Based IRS Delivery
Model. The concept of Community-Based Indoor Residual Spraying is to shift
accountability, management and operations of IRS activities closer toward and
within communities targeted for IRS activities. It involves the hiring or using
community members to spray their own communities. The spray operators are
identified within the community, recruited and trained within their localities.
The IRS intervention has been the most effective tool in preventing
transmission of malaria after mosquito feeding [1]. This underscores the
critical need for IRS coverage at community level for individual protection
from mosquito bites. An effective IRS campaign on the average, regardless of
the size of the operation requires 30-35 days and takes place once or twice in
one year based on the transmission of malaria season and the efficacy of the
insecticide used at that particular time [2]. IRS has been found to be a
complex operation that requires a good number of human resources and
approaches: technical and support staff, short term employees and strong
community engagement and subsequently existence of community empowerment
through Primary Health Care structures [3].
Principles
of primary health care (PPHC) and indoor residual spraying campaign
In order to
successfully implement Community –Based IRS Delivery Model, it has to be known
that many communities have similar patterns of social economic problems. These
problems in one way or another promote failure or success of the planned
intervention [4]. It has been also found useful to understand primary health
care core principles and the variable set of basic actions in relation to IRS
tasks of significance in promoting PHC for the success of indoor residual spraying
campaign models. Community–Based IRS Delivery Model must follow the principles
of universal coverage (UHC) through increasing the number of households
receiving IRS as close as possible and ensuring 80% and above of each community
population has been protected. This has to be achieved through the way
implementers explore their experience and their passage through the local
community health system. The approach has to be achieved through total
community participation and empowerment. Commitment to health equity and
quality assurance for IRS must be part of development oriented to social
justice. The advantages of community approach in implementing primary health
care (PHC) have been: a) community participation approach that leads to a cost
effective way that extends a health care system to the geographical and social
periphery of a country b) communities that begin to understand their health
status in an objective manner rather than fatalistically c) communities that
invest labour, time, money, and materials in health promoting activities and
are more committed to the use and maintenance of their products such as food,
water supplies and human resources and own environment d) health education and
has been effective in the context of village activities; and all community
health workers, if are well chosen, have the confidence of the people and are
able to change their lifestyles [5]. CB-IRS Delivery Model is about Intersect
oral action oriented. The ministries of health have been requested by WHO to
engage in Intersect oral action for community health in order to improve health
equity [6]. The objective of CB-IRS Delivery Model is to reach every HHs
wherever people live in eligible structures. In the 21st century, new however,
fresh opportunities have been gradually emerging. New initiatives are trickling
in as health stands high on the international agenda to extend health-enabling
environment and quality of care for universal coverage of populations. However,
this literature review explores how the values and practices of PHC have
adapted to realities of today`s complex community health landscape that might
provide a basis for the improvement of the Community-Based IRS Delivery Model
campaign for high disease burdened communities. It reviewed basic ideas about Community-Based
IRS Delivery Model and classified the concept of the development of community
health empowerment systems that must typically be based on primary health care
concepts and principles. In addition, the implementation of Community –Based
IRS Delivery Model has to be piloted and continuously evaluated [7]. The
implementers must continue to strive for performance quality improvement and
ensure strong universal coverage by the community itself through its own human
and material resources under close support supervision.
Community
based work force for the implementation of the community-Based IRS delivery
model
Importantly, meeting
urgent community health challenges while laying stronger foundations for model
systems requires strong leadership and supervision from the District Health
Offices (DHO) or Rural Health Centre (RHC). This facilitates the improvement of
the CBVs workforce in terms of training levels and skill categories. To achieve
the goals associated with the health systems driven by PHC, new options for the
community education and capacity building are required so as to ensure that
CBVs are more closely tuned to community malaria elimination needs by every
country [8]. To sustain the CBVs or other alternative community care providers
has been found difficult [9]. There have been strategies found to be effective
and successful. The training of more CBVs requires that the current CBVs are
valued for their distinctive contribution rather than treated as second class
health providers [10].
District
stewardship, community involvement, participation and empowerment towards the
model
Admittedly, responsible
District Health Management Teams must provide oversight and pro-equity
commitment to the District, RHCs and the community they serve. The community
leadership has been essential to building and maintaining CB IRS Delivery Model
based on primary health care concepts and principles. However, health
authorities must engage with and respond to RHCs Advisory Committees in two
ways if they are to perform their stewardship role effectively. Community
involvement together with dimensions of participation, ownership and
empowerment have been found to be key demand side components of the
community-based health system. This has been found necessary to promote
effectiveness and accountability to initiatives for quality performance of
community programs like the Community Based IRS Delivery Model [11]. Therefore,
the importance of community consultation, involvement, participation,
collaboration and empowerment were acknowledged by the Alma-Ata Declaration
that affirmed that people have a duty and right to individually and
collectively participate in the planning and implementation of interventions
for their health care. The concept of community participation, however has not
been easy to practice. Community health interventions become successful when
the right structures are in place, effective governance and vigorous community
involvement and support of each other [12].
In that case, realizing
genuine community involvement, participation, collaboration and empowerment
requires overcoming numerous community obstacles. There have been two
constraining issues. Firstly, communities such as the rural poor have been
found to be unaware of the mechanisms of community involvement. Secondly, those
who are relatively wealthy and more influential social groups have been found
to dominate political processes at community level more specifically in rural
areas of the developing world [9]. When the better-off have been allowed to
“represent” the whole community in planning for situational analysis and
implementation discussions, relatively affluent groups have been found to
absorb benefits at the expense of poor groups in the community. Undoubtedly,
the affluent patterns restrict the capacity of poor people to participate fully
in the designed process to foster community involvement in CB IRS
implementation systems. Implementation of local policies and use of Memorandum
of Understanding (MOU) are key aspects to overcoming the obstacles of local
leadership stewardship in community health activities. The resolute to CB IRS
Delivery Model values of equity, universal coverage to care, community
engagement, consultation, participation, collaboration, empowerment and
Intersect oral action have been found to be more of value than ever before. The
sociology of the community has to be fully understood.
What
is a community in the context of the CB- IRS delivery model?
In particular, like all
social institutions around the world, the community cannot be regarded as human
beings, it cannot eat, think, indulge or play golf and therefore we must
anthropomorphize it if we want to be accurate in understanding it, and through
predicting its actions [13]. A community has in contrast been a scientific
model and sometimes people anthropomorphize the community (think of it and talk
about it as if it was human being). As the Community–Based IRS is being
introduced in any community and people mobilize the community, facilitators
have to be careful to consider communities as if a community has been an
individual and human beings thinking. No one must slip into that kind of
thinking [14].
The
concept of community-based indoor residual spraying delivery model
Indeed, Community-Based
IRS Delivery Model has been a new model organized within mini operational sites
established as a “downstream intervention” in a district more especially in
malicious areas described as “hot spots”. The Community Health Workers (CHWs
and CHAs) serve as IRS team leaders and assume responsibility for managing
store rooms, wash rooms, Spray Operators, and data collection and reporting
process for the communities they serve. The spray operators are hired from the
same communities they serve and do not require transport and camping facilities.
Instead they go home at end of each spray day. The model lies upon capacity
building, a key ingredient in redressing social exclusion, inequality and
vulnerability in the community including spray quality assurance by SOPs.
Good planning by the implementing
urgency helps communities to shape and exercise control over their social,
physical, economic and cultural environment. The implementer must begin with
community action cycle for the community mobilization. This helps communities
to shape and exercise control over their social, physical, economic and
cultural environment. It has been about the community members taking the lead
and deciding how they want their community to be and how to make it a better
place to live. CB-IRS –Delivery Model is the most appropriate model regards the
desired outcome to intervene to IRS community challenges. Unquestionably,
countries are implementing the model as a paradigm shift from the expensive
traditional model to less expensive delivery model with concepts of universal
coverage of HHs in the communities. The approach involves incorporating
planning, capacity building and execution of the operation into primary health
care system. There have been main reasons for the paradigm shift such as: a)
Increase in spray coverage b) Increase in community participation and ownership
of the program; and c) Reduced running costs (camping, transportation, meals
and other needs) and makes IRS more sustainable. Where IRS is integrated into
the health systems, community health workers fulfil the complete role and
responsibilities of the team leader. The CHWs manage all IRS processes at the
village level which usually lasts for 1-2 months each year in some communities.
With CB-IRS-Delivery Model, the period of camping reduces to almost half or
less 10 days of implementation making it very cost-effective exercise. The
number of selected SOPs remain bigger than the technically required number of
staff so that after ratification by technical health workers from the district
and RHC, the number comes to the original number required. For example, if 10
SOPs are technically required ask the community to choose 20 then the number of
SOPs after screening through interviews must come back to the 10 required
(Quality assurance at selection). The community Health Workers select spray
operators together with the NHCs to train and conduct the spraying with
approval of the Community Executive Committee. CHWs assume the responsibility
for mobilizing the community: managing store rooms and insecticide stocks,
washers and operators: and overseeing the data collection and reporting
processes for their team into the data system. The CHWs in each village are
trained on IRS techniques and management and operate in own villages. However,
in order to avoid any disruption with routine health system activities, only
one (1) CHW per village leads the spray team during the spray operation while
the other CHWs carry routine health system duties. In the CB IRS Delivery
Model, SOPs and Team leaders are hired from resident communities in which they
operate. There has been no need for transport for SOPs camping facilities as
required for traditional District-Based Indoor Residual Spraying. However, it
has been found imperative for DHMTs to strategically continue planning for CB
IRS Delivery Model activities and give oversight leadership to Model approach,
allocate resources and supervise the spraying operations and members of the
spray teams. Countries like Ethiopia and Tanzania that have used the model in
Africa have never systematically evaluated it and recommend for its
implementation. Zambia has piloted the model at a small scale in Sinazongwe
district but no date has yet been released though remote perspective gives good
results and outcome of the approach of the model.
The
organization of the community-based IRS delivery model
For the most part, the CHWs are usually assigned at the RHC and Health Post and the CBVs from the two institutions lead the spray team. If they are more than one, they must share a lot of responsibilities; one for IRS and one for routine activities. The demonstration in the organogram below; one CHW acting as a team lead for the four spray operators and one porter selected from the community have been responsible for planning and implementing IRS in the community. The District Malaria Focal Point and the DEHO of each district must closely supervise the operation and provide technical back-up when need arises. The District Health Information Officer (DHIO) or any one must work as a Clerk for daily data entry and reporting together with Environmental Health Technologist (EHT) at the facility or zone EHT (Figure 1-3).
Figure 1: Organogram for community Based–IRS delivery model (Ethiopia).
Figure 2: Organization of CB-IRS-delivery model (Zambia).
Figure 3: Primary health care community organization structure.
Capacity
building of district staff and lower levels (Cascade Training)
Therefore, during the Training of Trainers (TOT) for
District IRS, DEHOs and other EHTs are oriented on how to train CHWs to serve
as leaders of spray teams and assist communities with selection of spray
operators from targeted communities, messaging and communication skills, data
recording and reporting. The District Malaria FPPs and other staff have to
mentor the CHWs/Community Health Assistants (CHAs) on their role as team
leaders on their responsibilities and training of the spray operators chosen
from the community by the community to implement and manage IRS in their
respective communities. In Ethiopia, where CB-IRS Delivery Model has been
piloted and fully implemented since 2010, and in 20 targeted communities, CHWs
recruited 100 spray operators with full engagement of the community leadership
and NHCs(five from each community) and taught them for a period of six days on
IRS operation in their communities with less support from the district. The
issue of community participation, involvement and ownership subsequently
empowerment have been described as vital for the generation of support to the
community and stimulating the community capacity ownership for activities that
are preventable in nature. Therefore, community actions have to be strengthened
and communities must have concrete and effective involvement in the decision
making and implementation of their community affairs. It has been strongly
emphasized that only through this approach people are able to control their own
health. The health institution must draw on existing human and material
resources in the community to support the community and individuals in strengthening
public participation in the direction of health matters [15]. Through capacity
building of the providers of CB-IRS Delivery Model and community empowerment,
targeted investments are made to allow the community and providers reflect,
scale up and build efficient CB-IRS Delivery Model systems as well as growing
inspiring and accountable structural culture [16,17]. Every community has been
endorsed with various resources and talents that can feed into its overall
development to eliminate any disease such as malaria. Environmental and
personal safety have been borne in mind by the implementing urgency.
Environmental
compliance for community-based IRS delivery model campaign
Absolutely, it has been a trend that soak pits are
built at a health facility and for CB IRS Delivery Model, the soak pits have to
be built at a health post prior to the campaign season where no health post
then at the RHC. All sites must have soak pits to manage effluent waste and
storeroom to keep PPEs, IRS equipment and insecticide stocks. Storeroom/base
(10km apart from each base) must be sited away from homes and have double
locking system to ensure safety of the community. All left over chemicals in
the pumps from the field must be disposed of at the operations site in the drums
provided. PPEs and pumps must be cleaned daily and must not be carried home. A
builder has to be contracted to build two-meter soak pits with one-meter depth
within the communities. The District MEOs closely supervises the whole process
with technical guidance from the District Environmental Health Officer and any
representative from the Environmental Management Sector. The environmental
compliance has been meant to further protect soil from chemical contamination
and wash areas have to be covered with polyethylene sheets. Bathrooms for both
sexes have to be constructed as well and water supply has to be adequate enough
for the operation including sanitation of the toilets. Obviously, it has been
proven a successful approach to provide new spray pumps that do not require
maintenance at all. It was also found imperative for future CB-IRS Delivery
Model to enhance the knowledge of SOPs and provide them better skills to manage
and repair used spray pumps. However, CB-IRS Delivery Model remains with its
own particular problems in its implementation.
Problems
with implementation of community-based IRS delivery model
As a consequence, the
general implementation of CB-IRS Delivery Model has many problems. Firstly,
Indoor Residual Spraying itself has been complex in operation involving
hundreds of personnel. The CB-IRS Delivery Model needs a big number of SOPs as
well as team leaders of the five SOPs within a short time of the campaign being
observed. The model requires strong community involvement, engagement, participation,
consultations, collaborative leadership and ultimately community empowerment
through social-cultural structures and the PHC system structures. Another
disadvantage of this approach is that district-level spray teams often are
transported from other parts of the district and only available within a
particular community for 1 or 2 days, in order to efficiently move through
pre-determined, sequentially-planned, district-managed, spray operation
schedule. If households have not been properly sensitized and mobilized for
that scheduled stop, many households will be missed for spray operations for
that campaign. This is often the case as community mobilization efforts are not
always adequately planned and because people go for farming in the morning and
are only available in the afternoon for many of the same periods when IRS
operations occur. This results in low coverage as well. Furthermore, if quality
is not strictly followed, implementation of the model becomes a loss of
resources such as chemicals and finances and increases environmental pollution
detrimental to human life. It is quite difficult to implement the model with
limited budgets. In the face of fiscal pressures improving the efficiency of
delivery of IRS is a means of increasing coverage without increasing resources
needed. The purpose of the study was to discover the important factors; best
practices and approach methods for CB-IRS Delivery Model and assist individual
institutions that would like to implement the model with information for their
planning, operations, environmental compliance, monitoring of “vector density”
and logistical planning for later year planning. The comparison between the
DB-IRS Delivery Model and CB-IRS Delivery Model approach performance remains
critical to the future users to make a decision on the type of the model to
use. The aim of the review study was to assess whether using CHWs and SOPs
right at the ground level would reduce costs and increase community acceptance
of IRS and promote sustainability of the operation with high maintenance of
quality and compliance to environmental standards and safety at large.
In order to meet the aims of the study, the
following research questions were formulated for investigation:
·
What is Community-Based
Indoor Residual Spraying Delivery Model campaign?
· What barriers and
unique challenges exist that impede successful community empowerment for
Community-Based IRS Delivery Model?
·
What options are
available for improving CB-IRS Delivery Model methods?
·
What community
empowerment strategies and approach methods can make CB-IRS Delivery Model
succeed?
This was a descriptive and analytical study using
documents that reviewed Community-Based IRS Delivery Models of countries that
piloted it (Ethiopia, Tanzania and Zambia during responsive IRS in nine
facility areas of Sinazongwe district with high incidence of malaria. The
sources of data for the study topics were organized around community action
cycle for community mobilization, community development, collaborative
leadership, community empowerment, integration of primary health care system
into the model approach, spray coverage status, quality of spraying, time spent
period of spraying, environmental compliance comparative analysis of the two
different models, compliance with standards, gender disparities, community
structures, lessons learned, best practices, approach methods, cost analysis
and efficiency of the two models. The review of the topics focused on community
health needs, “bottom-up” or “grass roots” practice, strengths-based approach,
inclusive practices, and investment in the community capacity and
sustainability of the model.
The findings for the successful implementation of
the Community-Based IRS Delivery Model are presented in the comparative
analysis. Clearly, learning from Ethiopia, the District Health Office and AIRS
project closely monitored the preparations of the pilot program for CB-IRS
Delivery Model campaign in one of their communities. They also kept accurate
records of all the financial resources provided to support the piloted CB-IRS
delivery model. The resource tracking was meant to analyse actual expenses to
compare them with similar efforts required to implement traditional District
Based IRS model and project the potential cost savings in the future IRS
campaign activities.
Cost:
The overall total cost for CB IRS
Delivery Model was found to be slightly less than a similar sized activity
implemented through the DB IRS Delivery Model. Some costs were however higher
in the CB IRS Delivery Model, the reason being the operation year and certain
capital investments were made for each community. The mentioned investment
included construction of new soak pits, the supply of IRS logistics such as
pumps, some spare parts, PPEs increased number of SOPs and training cost and
other needs. These are not recurrent costs and did not appear during the next 2
to 3 years of IRS operations according to the study (Table 1).
Therefore, it has to be known that CB IRS Delivery
Model requires approximately 15-20 SOPs the whole district on the average. The
training cost has been found to be higher with CB IRS Delivery Model because
the number of providers to be trained become higher. The wage payment to the
SOPs provider becomes slightly lower in the CB IRS than the DB IRS Delivery
Model. Even the number of actors becomes higher in CB IRS delivery model. The
picture becomes so because CB IRS Delivery Model operation takes short time to
complete compared to DB model (Table 2).
Time: In the study conducted in Ethiopia, when compared on time spent on DB-IRS Delivery Model and CB-IRS Delivery Model, spray quality assessment showed that spray operation in the CB IRS Delivery Model in pilot districts took an average of 22 working days compared to 31 days used to complete an average traditional DB-IRS hired SOPs for each community and their total number often been twice larger than that which normally has been recruited for CB-IRS Delivery Model. The approach was found to be shorter (Benjamin J etal, 2016). The parameters used in the make spray time has been targeted structures for catchment area (Total structures to be sprayed per operation per day). Distance from the IRS base and time needed to reach the catchment area including clustering of structures for the catchment areas where spray teams must not just crowd are one catchment even when structures available only needed one team [18].
Table 1: Cost of IRS campaign in US dollars, by community delivery model in selected districts of Ethiopia, 2012-2014.
Average per District |
|||||
Coverage Measure |
2012 |
2013 |
2014 |
Difference (2013-2012) |
Difference(2014-2013) |
CB IRS districts (N=5) |
DB IRS |
CB IRS |
|||
Total amortized costs |
47163 |
52609 |
52930 |
5446(11.5%) |
321(0.6%) |
cost per structure sprayed |
2.52 |
2.27 |
1.98 |
-0.25(-0.98%) |
-0.29(-13.0%) |
cost per person protected |
0.88 |
0.87 |
0.86 |
-0.01(-1.3%) |
-0.01(-1.0%) |
DB IRS districts (N=5) |
DB IRS |
||||
Total amortized costs |
N/A |
48990 |
49665 |
N/A |
675(1.3%) |
cost per structure sprayed |
2.47 |
2.47 |
0 |
||
cost per person protected |
1 |
1.03 |
0.04(3.3%) |
||
Abbreviations: CB IRS,
community-based indoor residual spraying; DB IRS, district-based indoor
residual spraying; IRS, indoor residual spraying |
Table 2: Indoor Residual spraying coverage by delivery models in selected districts of Ethiopia, 2012-2014.
Average per District |
||||||
Coverage Measure |
2012 |
2013 |
2014 |
Difference (2013-2012) |
Difference(2014-2013) |
Difference(2014-2012) |
CB IRS districts (N=5) |
DB IRS |
CB IRS |
||||
Number of eligible structures found
by SOPs |
19,085 |
22843 |
26568 |
3,758* (19.6%) |
3,725 (14.0%) |
7,483* (39.2%) |
Number of eligible structures sprayed |
18,958 |
22,809 |
26,365 |
3,851 * (20.3%) |
3,556 (13.5%) |
7,407* * (39.1%) |
Spray coverage rate |
99.30% |
99.90% |
99.20% |
0.60% |
—0.70% |
—0.10% |
Total population protected |
54,902 |
59,551 |
60,765 |
4,649 (8.5%) |
1,214 (2.0%) |
5,863 (10.7%) |
DB IRS districts (N=5) |
DB IRS |
|||||
Number of eligible by SOPs structures
found |
18,797 |
20,322 |
20,396 |
1,525 (8.1%) |
74555 (0.4%) |
1,599" (8.5%) |
Number of eligible structures sprayed |
N/A |
20,245 |
20,347 |
N/A |
10255(0.5%) |
N/A |
Spray coverage rate |
99.60% |
99.80% |
0.20% |
N/A |
||
Total population protected |
51,871 |
50,326 |
—1,545 (-3.0%) |
N/A |
||
Abbreviations: CB IRS,
community-based indoor residual spraying; DB IRS, district-based indoor
residual spraying; IRS, indoor residual spraying; SOP, spray operator. The 5
CB IRS districts transitioned from DB IRS in 201 3; 2012 numbers refer to DB
IRS coverage before CB IRS was implemented. * k.05 comparing 2013 with 2012;
**k.01 comparing 2014 with 2012. + k.01 for difference in change between DB
IRS and CB IRS comparing 2014 with 2012. " Pc .01 for difference in
change between DB IRS and CB IRS comparing 2014 with 2013. P<.001 for
difference in change between DB IRS and CB IRS comparing 2014 with 2013 |
Quality:
The piloted spray assessment showed that
the spray operators learned well and that their spraying techniques and
spraying quality were adequate. The wall Bioassay tests conducted 1-3 days
after spraying showed mosquito mortality of 100%. These results were found to
be the same with CD-IRS Delivery Quality Model Assessment test in other nearby
areas. A strong feedback was reviewed from SOPs, communities and district
health workers that the overall quality of spraying in the piloted area was
most likely even better than from CB –IRS Delivery Model areas.
Table 3: IRS quality control test results by CB-IRS delivery model and type of wall surface, selected districts of Ethiopia 2014.
Percent Mortality of Susceptible and
Wild Mosquitoes |
||||
IRS model |
Dung (n=2 houses;
180 mosquitoes) |
Mud (n=2 houses;
420 mosquitoes) |
Painted (n=2
houses; 300 mosquitoes) |
Total (N=6 houses;
900 mosquitoes) |
CB IRS (2
districts) |
100% |
93.60% |
100% |
96.30% |
DB IRS (2
districts) |
100% |
92.40% |
100% |
95.90% |
Abbreviations: CB
IRS, community-based indoor residual spraying; DB IRS, district based indoor
residual spraying; IRS, indoor residual spraying. |
Table 4: Compliance to environmental health and safety standards by IRS delivery model in selected districts of Ethiopia 2013 & 2014.
Year |
Overall |
CB IRS sites |
DB IRS Sites |
Difference in Performance (DB IRS —
CB IRS) |
2013 |
84.10% |
80.80% |
91.60% |
10.8 percentage
points |
2014 |
99.20% |
98.50% |
100% |
1.5 percentage
point |
Abbreviations:
AIRS, Africa Indoor Residual Spraying; CB IRS, community based indoor residual
spraying; DB IRS; district based indoor residual spraying; IRS, indoor
residual spraying. °Average compliance scores on a 13•item checklist. B Data
are from 6 CB IRS districts and 30 DB IRS districts. Five operational sites
(villages) from each of the 6 CB IRS districts (30 operational sites total)
and 1 operational site from each of the 30 DB IRS districts (30 operational
sites total) were selected for the compliance assessment. *** P<001. |
However, storage for insecticides and IRS equipment
were found to be a problem at the village level. Health Posts/HCs were used to
store insecticides and equipment during the operation period. In many cases,
such space could not be used to store the items in between the spraying
campaigns. Items were transported back to the district stores. In this
situation, it has been important to build mini-storage structures and IRS bases
10 km apart from each base in the communities selected for CB-IRS Delivery
Model. When collaboration with the community has been well handled, it is
another way of trying to solve the storage space problem [20].
The
relationships of the four thematic areas in relation to the model
The relationships of the four thematic areas
presented herein community action cycle for community mobilization, community-
based development and community based service provision remain distinct
community empowerment strategies for the model. Collaboration has been based on
the concept of “Community practice”. Community engagement must be conducted in
a manner that has to be respectful of all partners and being mindful of their
need to benefit from collaboration for the successful implementation of the
model. Importantly, collaborative leadership for CB-IRS Delivery Model brings
the community together through their traditional and political structures in a
constructive way with good information about the model. The community
leadership itself must create authentic strategies and visions for addressing
the shared concerns of the health system and the community. The community must
be brought together and the collaboration must remain inclusive and in a
constructive-design of the processes that deal with different understanding of
different community views, with varying degrees. This allows the health system
process to encourage the community to work together towards a better outcome of
the CB-IRS Delivery Model. Definitely, community empowerment increases the
degree of community autonomy and self-determination in people and the community
at large, in order to enable them to represent their interests in a responsible
and self-determined way, acting on their own authority [21]. Community
empowerment concepts have been widely examined in various disciplines and
different professional fields and have been found to produce good results if
well adhered to by implementers [22]. In this study, the review highlights the
major definitions and conceptual issues regarding community empowerment within
the context of CB-IRS Delivery Model. It also discusses the relationship of
these issues to IRS practices and community empowerment for the successful
implementation of Indoor Residual Spraying. Empowerment has been referred to as
the ability of people to gain understanding and control over the
social-economic development, personal and political forces in order to improve
and take action for their own life situation [23]. Empowerment has been defined
at various levels of analysis and practice; individuals, organization and the
communities. Whereas, the individual empowerment combines efforts that the
CB-IRS Delivery Model approach requires in terms of commitment for the
long-time of financial and personal experience of resources [24]. There have
been collection and analysis of extensive amounts of both quantitative and
qualitative data used for its action in the evaluation purposes [25]. Just
focusing on the community in the 21st century may not be effective in the long
time in the context of today`s modern global world [26]. Given these points,
everyone has to acknowledge that community engagement is a complex process that
has to be accomplished over short term or has been panacea that once
implemented will resolve long standing community inequalities and conflicts.
There has been a need to recognize that the change process as development
involve time and resources to enhance community empowerment and linking the
community together for mutually beneficial community collaboration for a more
local healthy community through malaria interventions like Indoor Residual
Spraying. The concept of organization as both empowered and empowering has
helped to provide the link between organization, community and individual
levels of empowerment for the success of CB-IRS Delivery Model. For a community
to be empowered must have individuals and organization technical skills,
resources and efforts that are being applied collectively to meet their
respective community. The individuals and implementing organization participation
within an empowered community has been found to provide enhanced support for
each other to address conflicts within the community. On the whole, empowerment
at community level must be connected with individuals and the health system.
Researchers still argue whether the three levels of empowerment and one level
leads to the other. It is possible to develop a CB-IRS Delivery Model aimed at
individual empowerment and this does not consider the context in which the
individual has been embedded; such as the community or the organization with
less likelihood to information. Equally important, a community empowerment
model emphasizes on participation, sharing, caring for the mother
responsibility to others and consents power as an expand commodity [27]. It has
to be known that the process of empowering communities has been usually dynamic
and of changing value for the community and its constituent individuals and PHC
health systems. The community has to be empowered in some domains but not at
others as indicated in some literature. It has to be known that community
engagement cannot be achieved in a short period of time but has to take
commitment to a process that is of long term [28]. In short, there have been
wide evidence of stress and development of diverse psychological, physical and
behavioural disorders of the community that incorporate factors such as control
of poverty, stress and its health status. These factors guide health promotion
approaches to community empowerment that facilitates successful CB-IRS Delivery
Model as vector control interventions. However, evidence from research has
indicated that stress has been related to physiological, psychological and
behavioural outcomes. Psychological factors such as control have also been
found to play an important role in modifying the levels of stress and the way
implications are designed; stress, health or the relationship between health
and stress [29]. In addition, the stress process has been found to posit five
major elements such as strenuous or psychological-environmental conditions that
are conducive to individual community stress such as the death of a senior
community citizen, problems with the health system approach to issues, bad
health worker, powerlessness of some individuals, social economic status, bad
nutrition, natural disasters and exposure to harmful environment. Individuals
and communities enduring long term outcomes that stem from short term responses
and perceptions such uprising alcoholism, poor harvest, community forced relocation
and poor supportive relationships in the community, weak community problem
solving abilities, community control and social economic status that negatively
affect the implementation of CB-IRS Delivery Model [30]. In affront approach,
individuals and communities must meet stress needs and enhance control of the
community interventions, objectiveness and increase understanding of
empowerment and the effects of interventions such as evaluation and research
objectives. Subsequently, communities need Participatory Action Research (PAR)
that involve cyclical problem solving diagnosing process, action planning and
taking through evaluating and specifying the learning process [31]. The
approach has characteristic of being a participatory approach, cooperative and co-learning
process, reflective process, that involves conscientization and empowering
process. It achieves a balance between action and research goals and
objectives. The community based activities need to balance the efforts spent on
the action with critical reflection that has been aimed at conscientization of
the community in “hot spots” and “hard-to- reach” areas and areas of high
refusal rate areas and areas of high absenteeism by the HHs owners [32].
Barriers
to community empowerment for the successful implementation of CB-IRS delivery
model
Conversely, there have been barriers observed to
community engagement such as situations where community members` historical
experience and other beliefs result in particular feelings that they have no
influence with the health system such as quiescence and powerless and feel
getting involved with IRS interventions would not be worthwhile. Just as
important, there have been usually role-related community conflicts, tensions
and differences that surface between community health promoters and community
members around the issues of interests, values, skills, resources, political
situations and control including cost within the community and individual
research [33]. It has also been found difficult to measure or assess community
empowerment and the ability to show the occurrence of change towards a newly
introduced IRS different approach. There are also situations where health
promoters do more widely understand the value of community approach. In the
same way, provision of good information about the model has been found critical
for evidence-based decision making through involvement of community leadership
experts in the process, to inform the general community about it (http://www.tamarock.community.ca/).
The traditional concept on general leadership has been that of heroic leader
who has a vision, who asserts and personates the community and gain followers.
When collaboration works, it builds and reproduces the characteristics of civil
community allowing the community to deal with future issues in constructive
arrays [34].
Essentials
of collaboration for the successful implementation of CB-IRS delivery model
To summarize, collaboration has been found to demand
engagement and dialogue instead of debate, inclusion and not excluding their
need for shared power than instead of domination and control. There has been a
need for mutual learning instead of rigid adherence to positions that are
mutually exclusive. Collaborative efforts have been found to gain credibility
and influence by insuring community inclusiveness, managing a constructive
community learning engagement, by providing the necessary information for
public health evidence-based decisions, building the coherence of the group and
in helping to negotiate for agreements that lead to successful community health
action [35]. In order for collaboration to work, each community member must
have an opportunity to speak and must be heard and be able to shape decisions
and more groups must dominate in the decisions. The health system must
facilitate the management of community meetings that allow community groups to
constructively work together. The system must work with stakeholders while
remaining neutral about the content of its work. The community capacity must be
built for the proposed CB-IRS Delivery Model and the principles and goals must
be well understood by the health facilitator about the model.
Community
empowerment in community-based indoor residual spraying delivery model
To begin with, before starting, community engagement
towards community empowerment for the CB-IRS Delivery Model, the community
capacity must be built. The health workers or facilitators must be clear about
the purposes or goals of the engagement effort for the populations or the
communities they want to engage. The facilitators must become knowledgeable
about the community`s culture, economic conditions, social networks, political
power structure norms, values, demographic and malaria disease trends. The
history of each area and experience must be well known with efforts by outside
groups to engage the community in Indoor Residual Spraying. In the first place,
the facilitators must learn the community perceptions of those initiating the
community engagement activities. There must be a need to establish
relationships, work with formal and informal leadership, build trust and seek
commitment from organizations within the community and community leadership for
the creation of community mobilization that lead to community empowerment. The
literature review strongly supports the idea that problems and potential
solutions must be defined by the community itself and this applies to
CB-IRS-Delivery Model. Therefore, the communities and individuals need to “own”
the health issues (malaria problems), community to name the problem, identify
the action areas, and implement the strategies. The community must be able to
evaluate the outcomes. There must be an atmosphere of partnering with the
community in order to create behaviour change and improve the model outcomes.
Community engagement must be based on improving the health of the community and
respond to social, economic and political trends that have been found to
negatively affect health and disparities within the community [36]. Also the
community collaboration has been found to require long-term commitment by
engaging the health system and its partners on the ground [37]. Everyone must
remember that community engagement in relation to the CB-IRS Delivery Model has
been a continues and its specifics have to be determined in response to the
nature of one`s endeavour and the health system and community context in which
it has been found to occur. Above all, the involvement of the community and the
collaboration for its members have remained the cornerstone of the efforts to
improve public health interventions in the community and levelling up the
health status of the whole population. Community engagement and its
mobilization and empowerment are essential in public health programs that have
among others addressed the problems of conditions/diseases like smoking
sensation, cancer, obesity, heart diseases and other diseases of public health
concern [38]. The challenges faced by the health system in the 20th century are
not too much different from those of the 21st century.
Mobilization
cycle and community mobilization for CB-IRS-Delivery model
The process of community mobilization has been
participatory and sustainable in order to improve the health status through prevention,
elimination of malaria and improvement of capacity levels. There has been a
need to enhance the overall standard of the community from suffering from
malaria [39]. Indeed, community mobilization has been a strategy that has been
found to organize the community across-sectors for long term change
particularly in seeing the success of the model. It has been one way
communities provide support for the community to make health choices.
Preliminary research on community mobilization initiatives has been found to
demonstrate success in a variety and critical pedagogy [40]. However, in 1970s,
community mobilization emerged as a theory of community change from the
literature of organizing the community, civil sociology and critical pedagogy
[41]. The 1990s have seen the application of community mobilization in a more
targeted context of public health interventions and with reasons of shifting
from individual to community level approaches. Community mobilization has
contended that individuals are more likely to make decisions that are healthful
and accessible by all. Community level change must be supported by targeting
interventions at the community by enabling long term, sustainable systems that
promote shifts in social norm as key elements [42].
Benefits
of community mobilization in implementing CB-IRS Delivery model
Strangely enough, community mobilization has offered
numerous community benefits such as cohesion, systematic support and improved
sustainability to community activities. It has been found to promote community
cohesion by establishing new relationships and coalition where perhaps
non-existed before. It infuses new problem-solving energy into community
through helping to overcome denial to the model and apathy by the community and
gain both buy in and support [42]. Community mobilization creates opportunities
for new relationships and continue to generate initiatives and new ideas
overtime for the model.
In this case, community mobilization ideally results
in shifting in community social norms that allow the community to approach
community-based IRS Delivery Model differently over long-term period. Community
mobilization changes made remain in place overtime without being dependent on
outside sources of funds [43]. Especially, the health system in terms of the
Community-Based IRS Delivery Model has to provide the necessary resources
(human, finances, machinery/equipment, staff-training) and networking
opportunities helping each community where the model must be implemented and
the community to be more involved through a structured community mobilization
process.
Health
stewardship structure for the implementation of CB-IRS delivery model
Above all, the District
Health Leadership must offer stewardship to facility EHTs, and community CHAs,
CBOs, CBVs and the community at large. The local leadership team must have
local influence, capacity to recommend SOPs and CHWs and come up with wide
implantable community-wide policy and practice change. Communities must be
well-connected with deep and broad networks in the community. They must be
willing to make commitments to the efforts by dedicating sufficient resources
and time and have public health evidence-based decision of the Community-Based
IRS Delivery Model. As a matter of fact, the model implementing committee must
structure rules for its functioning and communication across the community. A
common vision has to be agreed and endorsed, a road map has to be drawn up by
the community as a strategic action plan, implement planned tools and design an
evaluation of the model with the common set of measures to monitor its
implementation including tracking performance. A transition and sustainability
plan has to be drawn based on the results of the community-wide assessments
that reflect on any risk protective factors. Similarly, the health workers must
promote community ownership of the model by drawing on community expertise and
networks of community members. One writer pointed out that; “The entire concept
of a format of integrating the community into policy development and
environmental change is a key takeaway”. “I may think I know the issues, but I
can`t solve them; I need to facilitate, activate, educate, and motivate the
community to be the solution in order to create sustainable change”. Whereas,
another staff member shared, “The community voice matters more than the model
initiative”. “Any initiative will be effective if you include precious prays”.
It has been found important to recognize that trust building is a
time-intensive and essential part of the process. The health worker or
facilitator must be transparent, open and honest in order to promote trust
building with the community. There has been an emphasis on the importance of
authenticity in each work openly disclosing the initiating of the project and
grant from community members [44]. In any case, it has been found also
important to establish street and open communication and be fine to follow
them. A vision statement must be drafted with the community to allow community
members with diverse philosophical perspectives on the model and find common
ground yet also create strategies that reflect research and science. There are
some questions that need exploration for community mobilization:
· What specific factors have been found to support effective community mobilization?What works in forming and sustaining community coalitions and community collaborations?
·
What
is the role of leadership in building and sustaining community wide efforts?
·
What
strategies will ensure that community leaders and residents remain engaged and
active?
·
What
can we learn from research on health system capacity, leadership development,
collaborative partnerships, and constituent participation in decision making,
community coalition building and the evaluation of collaborative efforts [45].
These questions provide
answers that will help CB-IRS Delivery Model and implementers at all levels to
further refine their strategies and approaches to ensure the community has the
skills, resources and opportunities to reduce or eliminate malaria and reach
full potential with positive health outcomes.
Community
mapping for CB-IRS delivery model
Meanwhile, the
intervention mapping protocol describes the interactive path from problem
identification to problem solving or mitigation. The malaria problem has to be
assessed of its related behaviours and social perspectives of an at risk group
or community and its problem and an effort to get to know or begin to
understand the character of the community, its members and its strengths. In
fact, community mapping as a Public Participatory Geographic Information System
(PPGS) has been a tool that tells a story about what has been happening in the
communities to allow the CB-IRS Delivery Model fit in well. During community
mapping events, community members come together and collect field data.
Community mobilization research has demonstrated success in a variety of public
contexts [46]. In the 21st century there has been uprising and increasing
interest in community mobilization. Community mobilization research has been
described as community level efforts that address issues through actions that
are organized [47]. Furthermore, it facilitates structural and social change in
any community. It focuses on uniting communities around single health issues in
order to create systematic and social change. Community mobilization contends
that individuals have been found to be more likely to make healthful decisions
supported by individual communities and resources that make decisions that are
healthful. Moreover, community mobilization provides numerous benefits for the
community such as cohesion, systematic support and improves sustainability. It
promotes community relationships and establishing new coalitions where non
perhaps existed before [48,49].
This report brings
together all known records of community action cycle for community mobilization
in the thematic areas of successful Community -Based Indoor Residual Spraying
model through: adequate preparations, good and adequate organization,
exploration, adequate planning, acting and evaluating together with the
community and finally adequate preparation to scale –up. The table below shows
the mobilization cycle that leads to successful community empowerment for
successful implementation of the model (Figure 4).
Prepare to mobilize for successful CB-IRS delivery model: The implementation of the CB-IRS Delivery Model in the communities has to be as close as possible to families and individuals. A team or committee has to be constituted for mobilizing the community towards the successful implementation of the CB-IRS Delivery Model. A “Community Executive Committee” has to be developed from within the community for overseeing the implementation of the model.
Figure 4: Community action cycle for community mobilization for community IRS Model.
The committee has to
gather information about how best the model must be implemented in the
community. The committee together with the community must identify the needed
resources and constraints that exist in their area. The technical staff; the
EHTs, and the community have to jointly develop a community mobilization plan
and committee capacity has to be built on the way to implementation of CB-IRS
Delivery Model.
Organize the community for action: The community has to be oriented and
this time is for building relationships, credibility, trust and instilling a
sense of ownership with the community. The community has to be consulted,
involved, participate and totally engaged and finally empowered. The committee
must be from the NHCs or community members. The approach to community
mobilization has to be through the health promotion practice with IRS program
and within the existing primary health care management systems [50].
Evaluate together with the Community: Determine with the committee those who
must join to evaluate the progress of the CB-IRS Delivery Model. An evaluation
team needs to be formed with community members and other interested parties. It
has been important to know individuals who would want to learn from the performance
of CB-IRS Delivery Model evaluation. An evaluation team has to be put in place
including evaluation instruments.
The evaluation must
take the mode of community participation. The end results of the spray campaign
have to be analysed with the evaluation team members and a platform for
feedback to the community that has to be made through public feedback meeting.
All the progress of implementing the model has to be documented and all lessons
learned, best practices to be shared including the recommendations for future
improvement. The committee/group and community must prepare to re-organize to
scale up the model.
Prepare to scale up the Community: Based IRS Delivery Model-A vision has to
be shared for scaling up from the beginning of implementing the model. The
effectiveness of the approach has to be determined and the potential for the
model to scale up has to be assessed. The team and the community have to
consolidate, define and refine the approach through building consensus to scale
up the model together with the community. Supportive policies must be advocated
such as gender strengthening to implementation.
Explore the health issue (malaria problem) and set
priorities: The objectives
of the Model must be decided at this point. It has been found important to
explore the model issue with the committee, in the broader community
perspective. The information must be analysed and priorities have to beset for
action. The technical staff need to plan together with the community and the
objectives have to be known by every community member at joint planning session
towards creating a community action plan.
Act and supervise together with the community: The committee’s roles have to be
determined in a companying the community action. The information has to be
analysed and priorities have to be set for action cycle. Progress must be
monitored towards achieving the goal. As a committee with community members, a
room has to be provided for problem solving, trouble shoot, provision of advice
and mediation of conflicts as you go along implementing the CB-IRS Delivery
Model. The role must be defined, refined in an approach that can make impact.
General resources (local) must be defined. The monitoring and evaluation system
must be developed through a community score card. The community institutional
development for scale up must be supported by the technical team and the
community.
Community
participatory mapping for the successful implementation of the model
The resource mapping
for community –based interventions has been an important methodology for 1)
Building the community 2) Community understanding of their assets, strengths
and weaknesses 3) Sustainable economic viability. The community mapping for the
CB-IRS Delivery model must be participatory mapping that creates a tangible
display of people places including experiences that make up a community through
members of the community themselves identifying them on their community map.
The participatory asset mapping offers visual representation of community
knowledge. The maps are asset based approach that represent culturally and
socially distinct understanding of the community for implementing the model and
include information that must be excluded from the stream maps representing the
views of groups outside the community.
Community
basic concepts of community-based IRS delivery model
The community concept
has been differently described depending upon the discipline using it or
handling the term [51]. Hillary collected and analysed the definitions of this
term and ended up concluding that there have been three major basic components
of the community. Bracht described the term community as a group of people that
share common values and institutions and Nutbean explains that the community
comprises a specific group of people who often live in a defined geographical
zone, share common values, norms and culture [52]. In order to fill this
definition the community has to be organized through social structure according
to the relationships that the community has developed over years [53]. I agree
to the descriptions by the trio about the community and their descriptions that
a community is a group of people who know each other better than outsiders can
know it. Rifkin argued that community knowledge automatically creates desired
changes in behaviours. Importantly, ensuring Community –Based IRS Delivery
Model sustainability has been critical for the targeted sparsely populated
communities or the community in disease hot spots. If the program has been no
longer sustainable its impact decreases, leading to unmet expectations that
affect the community as a whole such as resurgence of malaria. Sustainability
factors need to be scrutinized for the community based model to prove to be
essential. There have been several reasons why program sustainability must be
important 1) terminating an effective program that leads to the negative
effects for the implementing urgency and the community involved 2) The program
initial costs become high 3) The experiences the community comes in un expected
program termination lose trust for future Community-Based IRS Delivery Model
related programs.
Community
sustainability and sustainability factors for CB-IRS delivery model
Clearly, sustainability
for the model encompasses three suggested indicators such as households,
individual and community levels. It has been important to understand the
factors or features that differentiate it from the traditional projects:
·
That
rely on a community based approach [54].
·
That
imply community acceptance and involvement
·
That
require socio-cultural acceptability
·
That
require the management capacities of the community based capabilities [55].
However, there has been
an argument by some writers that sustainability of community programs has been
influenced by the social-political will champions or the capacity of community
stakeholders identified six critical factors for sustainability of community
programs: networking, partnering, information exchange, prioritizing, planning,
implementing and supporting/sustainability [56]. Further, eight contextual
factors were also identified that influence the capacity building process such
as existing capacity-coordination, roles, community connection, nature of
partners, funding, social context and geographical scale support for the program
political legitimation or the context of socio-economic spheres [57]. The Model
program sustainability factors must be divided in three categories such as: 1)
focused on the program itself 2) focused on the District Health Services
organization and 3) the overall impact for sustainability. The conceptual
sustainability model considers such types of factors for the Community –Based
programs; organization and the community. These factors have been found to have
an impact on the community based on the model;
Community-Based
IRS delivery model specific areas
However, above all the
list below hinges on the IRS program specific areas of success:
Coordination: Competence by health staff and partners in setting
up realistic goals for selected catchment areas for the model.
Transparency: Informing community stakeholders about the model or
its processes and outcomes through utilizing recognized and suitable approach
methods such as public meetings.
Responsibility to adapt: To meet the continued community health
needs and changes through community action cycle for social mobilization
Staff involvement and integration: Of qualified staff [EHTs, HPOs, SOs,
CHAs, Data clerks and CBVs and Support staff] in all stages of the model during
implementation.
Model funding and resources: Indicating the availability of funds
and community resources for the implementation of activities
Model theory: Describing the existence of coherent and clear
framework for the target population (hot spots, hard-to-reach, high refusal
areas, other special populations and community needs or the expected outcomes)
[59].
Model effectiveness and flexibility: The capability to document the
successes, lessons learnt, best practices and initiatives by disseminating them
to community stakeholders through community public meetings [60].
Model champions: Where individuals or organizations promote the
model in a wide array of activities that are considered separate sustainability
facts of their own management of practices for human and other local resources.
Model Organization Stability: Frequent changes of technical staff in
positions leads to program failure [61].
Partnering: The DHMT capacity to initiate and maintain strong
relations with many partners and stakeholders at grassroots level make interventions
succeed. Partnering initiates financing and community acceptance that in turn
could make the CB-IRS Delivery Model sustainable even through information
exchange and its transformation across IRS perspectives.
Specific sustainability model processes and actions: The specific sustainable model
describes actions that have been established by the DHMT targeting fund raising
strategies and scaling up maintenance of partnerships. Partnership initiatives
through funding and community acceptance that in turn must make the CB-IRS
Delivery Model more sustainable.
Dependency syndrome: Must be reduced by every model action one takes.
Centre acting dependency remains implementer`s prime goal. When building the
community capacity about the model, the animator must keep that prime goal in
mind and act accordingly. Let no community receive anything for nothing that
encourages dependency on monetary gifts. Communities must always be encouraged
to carry out own activities or programs and offer them with skills and tips but
work must be done by them.
However, the community
empowerment increases the community strength, improvement in its capacity or
ability to accomplish goals. Community empowerment has been a process of the
community becoming stronger in contrast to the charity approach that aims at
strengthening the community rather than encouraging it to remain dependent upon
the outside resources. The empowerment methodology does not make everything
easy for the individual community because that has been seen as resistance and
struggle as physical experience produces more strength.
Community
engaged leadership in (Traditional &Political) CB-IRS delivery model)
Health has been a human
right and equity in health has implied everyone must have a fair opportunity to
attain their full potential and more pragmatic and that no one must be
disadvantaged from achieving the potential. However, it has been the
responsibilities of the health professionals implementing health programs to
ensure individuals, families and communities are healthy through collective
integrity-ethical based leadership that can promote community reduction of
health disparities and advance health equity everywhere in the community as in
the case of the CB-IRS Delivery Model [62].
Community
specific for CB-IRS delivery model
Following the IRS
program commitment, there are also community specific considerations such as:
Community participation: The level of community awareness and
involvement in planning and implementation of the model determines the
establishment of the model and its consolidation responses and adaptation to
meet the changing needs. Community context encompasses the community problem
like the relations with the government health workers, the social inequalities
that usually vary from study to study and from community to community. It
describes the relations with government agencies in particular. Conversely,
dependency syndrome remains an attitude and belief where a community fails to
solve own problems with outside help [45]. Dependency syndrome must be fought
and that the model must not be seen to belong to implementing institution
because when the organization leaves all the community efforts go to waste and
the community remains demotivated and fails to sustain the model.
Unquestionably, the community members must have a sense of responsibility for
the community model that has been described as “Ownership” by the community.
The sense of responsibility or ownership by the community has been involved in
the decision making process about program planning and management. As the
population increases every year the government reaches a fatigued phase and
gets access to fewer and fewer resources per capita every year. As fatigue
grows by government, it becomes no longer feasible for community interventions
to be funded adequately. However, there has been an argument by some writers
that sustainability of the community programs is influenced by the
social-political factors such as the existence of political will, champions or
the capacity of community stakeholders.
Organizational
specific needs for the successful CB-IRS delivery model
On the other hand, the
implementing leadership (DHMT& Partner) has to observe the following
similarly to the other two specifics mentioned above:
Leadership: Health management team capacity has to establish the
goals of MOH, congruent with the program for the community in order to
integrate IRS community model development and the pro-activeness in the
achievement of the goals. Under Innov8 “Leave no one behind” has been the core
principle of the Sustainable Development Goals (SDGs). Equity, human rights and
gender equality are central to all the goals, while SDG3 calls for universal
health coverage and health and well-being for all ages. Everyone has to make it
on the bus of the SDGs by using new approaches and tools (CB-IRS Delivery
Model) that help identify gaps and then address health inequity [44].
Organizational system: must be that which comprises an assessment of the
Community-Indoor Residual Spraying Delivery Model or rather analysis of
community socio-economic needs. Logistics are to be transported by the district
to health posts or RHCs for storage during the campaign for IRS campaign. The
equipment must be adequate at all costs with less problems of frequent breakdowns.
In most Community-Based IRS Delivery Models, mobile filter pits must be used,
wash areas at community, health posts and RHCs are encouraged, areas not
accessible by vehicle, logistics must be transported by community ox-carts or
any other means. Communities must be mobilized to dig soak-pits and help in
fencing the structures. Used masks must be collected together with empty
sachets and contaminated cartons and all to be stored at the health post or
RHCs.
Gender
disparities in implementing the CB-Based IRS delivery model
Health inequality
between women and men continue to plague many societies in the 21st century.
All IRS meetings hosted in the community must allow women to attend the public
meetings. The disabled, the youth, the aged, the very poor, the disenfranchised,
the marginalized, the shy in public and those that retired from public service
must be present at every Community based IRS Delivery Model campaign meetings.
To sum up, there must
be measures that must allow more women to serve as team leaders, spray
operators, storage facility guards, porters and clerks etc. All positions for
spray teams must be open to all men and women in that particular Community. CB
– IRS Delivery Model advantages women and men to go home and sleep instead of
residing in camps. The spray team model must have at least two more women and
men as spray operators in community-based operations. The end spray operation
must provide feedback sessions with spray teams to get their perspectives and
recommendation on the process. The men and women’s views must both be solicited
at public meetings. All training must incorporate key gender messages about
equal respect and opportunity. Monitor gender issues that might arise during
the spraying campaign. Conduct community peer review through committees on the
spray operations to solicit men’s and women’s perspectives on their experience
with the model just like any other health program processes for improvement and
address about solving community problems observed by teams.
Influencing
forces that pull the community apart (Clan ethnic groups, Gender, ages,
education, mental abilities, occupation, home, wealth) for the successful
implementation of the model
The historical process
of the types of human communities such as the clan, tribe, nation and
nationality have influence to the implementation of the model in the community.
According to Adafa Balon, a clan has been described as the basic call of the
primitive social system [63]. The members of the clan are usually joined
together by blood and family ties, by clan ownership of the means of production
through collective production and consumption, and by religious beliefs and
clan customs. Implementers have to be cautious of the implications arising from
the clan and tribe forces. The main tool to be used must be public meetings in
which discussions become the centre future. The model implementer must
thoroughly be conversant and be informed with the community mobilization
aspect. The community confers no one and must not preach like a priest;
speeches must not be made like politicians and must not lecture like a
professor and must avoid pontificating, or dictating in speech. Therefore, it
has been emphasized that the facilitator must appear relaxed, confident and
informed of the model to be introduced. In public meetings brain storm sessions
must be introduced and must be used again in planning sessions of the
Community-Based IRS Delivery Model Executive Committee.
Challenging
the community on the model implementation approaches
It has been found that
resistance produces strength, it and is like one’s muscles when one wants to do
push – ups. When muscles do not meet resistance, they usually grow weak and
when you do too much for the community, it will not become strong. Does the
community have the capacity to build and maintain the community-based model
program? What problems will the CB – IRS –Delivery Model solve? And what likely
problems will it cause? At this point it has been important to empower the
community by letting them defend their choice [2]. The community has to be
reminded that it is them (Local people and resources) to remember that it is
their own resources that go into building the model to end malaria for their
community. It is more humane, cheaper and less risk to have own people running
the CB – IRS Delivery Model. Implementation must not passively accept the
community first choice goal is to end malaria.
Organizing
for community strength for the CB-IRS delivery model
Individuals mobilizing
the community must have a concern of the way the community must be organized
apart from contributions to capacity building, strength or empowerment. The
level and effectiveness of community organization towards the model determines
the group strength, the community or agency. Better organization makes better
capacity. However, community learning by doing has been found to be very
effective for any community in the world. The Executive Committee must be put
to micro-manage the CB – IRS –Delivery Model and must be detailed with
participatory assessment of conditions that include problems and resources in
the community [64]. Through brain storming techniques the committee must
prepare an action plan. The facilitators must guide the Community Executive
Committee in presenting the findings to the community as a whole. Then using
the brain storming techniques, the community modifiers/facilitators have to
approve the action plan. Train the community in the importance of monitoring
the implementation of the CB – IRS –Delivery Model and have them decide on what
must be done for them to be satisfied of their involvement, participation,
effectiveness and finally empowerment. According to Bartle, the community must
form an Executive Committee independently or jointly and inclusively from the
Neighbourhood Health Committee and assess community conditions surrounding the
implementation of the model. Together with the community develop a plan that
must be followed on how to implement the model. Obtain the community needed
resources/ skills, human resource, ox-carts, machinery/ IRS equipment, water,
bicycles and ensure that all community activities are monitored and organized
most effectively for action [65-70].
Formulating
the community executive committee for CB – IRS – delivery model (CIM)
The Executive Committee
has to oversee the implementation of the model and chosen by the whole
community and not just a fraction or few fractions of the community. That is
why unity organization remains important. The executive must be part of the
community and be responsible to the community. The mobilizer or implementer
must make this clear to the community members. The communication skills must be
known that it is advisable to repeat oneself in different ways and to different
groups depicting in different circumstances and scenarios. The formulation of
the committee must be transparent and democratic process for good
representation of the community from NHCs and other community members
integrated. The community must undertake the implementation of the activity
from an informed base. The committee must make its resources assessment [CHWs,
HPOs, SOs, CHAs, MA, FBOs and other CBVs including CBOs] and this assessment
must be onsite and analysed then the findings must be presented to the
community as a whole at a public meeting. The resource map must be drawn on an
appointed day within the community or communities. The transect walk across the
community must help also identify mosquito breeding areas for the
implementation of Larval Source Management and Entomological Surveillance. The
Committee can put up a situational analysis of their findings [71-75].
Preparing
a community action plan (CAP) for the implementation of the model
However, in community
capacity building and encouraging the community; the executive must bear
stronger and more self-reliance. Impress upon the community the necessary
planning and management of the model. The community vision has to be “End
malaria”. “If you do know where you are going then any road will do”. Let the
community be unified and this has to be ensured. The four questions have to be
answered by the community about malaria elimination [76-80].
·
“What
do we want about malaria?”
·
“What
do we have to end malaria?”
·
“How
do we use what we have to end malaria?
·
“What
will happen when we work together in implementing the model?” The community
assessment must answer Q2.
Monitoring
of the implementation of the CB –Based IRS delivery model
The IRS campaign spray
days must involve the Community Executive Committee to ensure that all targeted
houses are sprayed. The community committee must constantly monitor, any small
deviations, and must quickly and easily be corrected and failure avoided and
reported to the whole community as implementers at public meetings [81-83]. The
role of the mobilizer or implementer is to facilitate needed teaching
activities and ensure there has been a need about the free information about
all aspects. Let there be strong capacity building to the community and promote
public knowledge acquisition, transparency and gender balance to empower them
in the implementation and monitoring of the model. The job of the
implementer/facilitator has been not to implement the plan, but facilitate the
community to do so. Continuously the Executive Committee has to be reminded
that monitoring has been part of the design, importance and must be always
carried out by it. The Community Executive Committee must hold public meetings
to ensure a good flow of information between the executive and the community as
a whole. The executive not to lecture but to get means of IRS activities. The
end of the spray campaign celebrations has been said to be very cardinal.
Organizing and the implementing of community celebrations for the hard work are
quite important and are vital part of community mobilization. Celebrations at
end of IRS campaign has been described as an exciting break from the monitoring
of the field work activities. In this situation, ensure that a variety of
entertainment during launching and celebration has been cardinal and use local
culture groups and ensure community shots attend to make speeches of public
praise and not politically hijack the occasion. It has been observed to be of
value to invite the media and press. The celebration adds public recognition,
validation and legitimacy to the whole development process of the model.
Launching and celebration have been described as good criterion for raising
awareness, improving transparency and making the community program more high
profile activity. The goal of the member or implementer has been sustainable
development of the activity.
Lessons
learned and awareness of possibilities from the model implementation
After the implementation of the model campaign
period, we must learn from both successes and failures, from achievements to
mistakes. The mistakes, failures and disasters have not been the same. A
mistake has not been failure; to err is too human. A failure is not a disaster;
failing to achieve something does not mean one has been a failure and a
disaster has not meant the end of life or time. Despite many participants’
satisfaction with IRS, some of them were found to refuse IRS campaign and have
their houses sprayed. The refusals were associated with spray operator
selection from different communities, performance of IRS and difficult in removing
household assets. Many participants during the engagement meetings in Southern
Province of Zambia specifically Sinazongwe district expressed dissatisfaction
with the selection of spray operators as having influenced their acceptance of
the IRS campaign. Community members and leaders expressed resistance in
allowing unknown individuals into their home because they were not trusted to
not damage their goods or later rob the homes. Another barrier to IRS
acceptance frequently stated by most participants was related to the need of
removing household goods during the spraying period. Participants frequently
mentioned that they found it difficult to accept that the Spray Operators would
see inside their houses when they remove their household assets during spraying.
For example, one man stated during the community engagement meetings that, at
his age, he can’t carry things from inside to the outside, so he denied his
house to be sprayed.
Given, the lessons
learnt outlined in the previous sections, it is quite predictable that the
relationships of community action cycle for community mobilization,
community-based development and community-based service provision remain
distinct community empowerment strategies for the model. In the community coalition,
it was found important that the focus of collaboration across has to
concentrate on the collective power from community members, CBVs, CBOs, CBAs,
FBOs and focus it on implementing CB-IRS Delivery Model. Collaboration has been
based on the concept of “Community practice for the model”. Community
engagement, motivation, mobility means must be conducted in a manner that has
to be respectful of all partners and being mindful of their need to benefit
from collaboration for the successful implementation of the model and
ultimately eliminating malaria.
Indoor Residual
Spraying(IRS) has been an effective strategy to control malaria and ultimately
eliminating the disease. The move from morbidity control to interruption of
transmission and achievement of malaria elimination, requires novel advanced
innovative technologies aimed at reducing the infection reservoir or reducing
the rate at which infections spread. This must be done by an innovation
research portfolio that has to be expanded such as Community-Based IRS Delivery
Model. The model lies upon capacity building, a key ingredient in redressing
social exclusion, inequality and vulnerability in the community. Good planning
by the implementing urgency helps communities to shape and exercise control
over their social, physical, economic and cultural environment. CB-IRS
–Delivery Model is the most appropriate model regards the desired outcome to
intervene to IRS community challenges. We recommend that, to get a good
outcome, the intending urgency to implement the model must have a good
operational plan and must begin with community action cycle for the community
mobilization. The implementation of community development must also be
facilitated to blend the “bottom–up” action driven by the community to remove
barriers that prevent people from participating in Indoor Residual Spraying
campaign. Collaborative leadership and empowerment approach must be provided.
Integration of the model into primary health care approach can yield good
results and outcome. Then, if all these strategies are followed, success of the
model is assured. Despite the efforts to have a good approach of the model,
more research is needed for quality spray of IRS performance activities for
impact for the model.
Ethics approval and
consent to participants
Not Applicable
Consent of
publication
Not Applicable
The data sets generated
during the analysis period are available from the Corresponding Author Dr
Emmanuel Hakwia Kooma on reasonable request
There are no financial
or other competing interests and the Authors declare that they have no
competing interests whatsoever.
All the Authors read
and approved the abstract and the final manuscript
In improving the
assignment, I had to take help and guidance from some respected Technical
officers in the contributors list above, who deserve my gratitude. The
completion of the decentralization on Community-Based IRS Delivery Model gives
me much pleasure. I really appreciate their inputs giving me good guidelines
for the article through numerous consultations. I would also like to expand my
deepest gratitude to those who also directly or indirectly guided in the
writing of the article.
Dr Emmanuel Hakwia
Kooma is working as a Public Health Vector Control Specialist for the National
Malaria Elimination Program-Zambia.