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Community participation in relation to the success of health and well-being programmes

 One of the most defining events in the global public health arena that gave community participation a prominent place in public health was the WHO and UNICEF sponsored conference on primary health care (PHC) at Alma Ata in 1978.  The Alma Ata Declaration defined PHC as “essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (WHO, Alma Ata Declaration VI, 1978, p.1). Some of the principles adopted at Alma Ata were proposed much earlier in the Bhore Committee Report 1946 that guided the formulation of the Indian National Health Policy 1983 (Deodhar, 1982). Following the Alma Ata conference, other developments such as the Ottawa Charter (1986) and Agenda 21 (1992) amongst others, have helped placed community participation high on the political and public agendas of nations.

The emphasis on community participation ushered a paradigm shift in health planning and health care delivery that called for the involvement of the community in both decision and delivery of health services most appropriate to them. The Health For All by the Year 2000 campaign of the WHO having community participation at its core, led to the adoption of  this concept by many countries as the means by which important health problems can be addressed. Further, national efforts emerged to establish and strengthen mechanisms for community participation in health through social policy, legislation and other public means (Oakley, 1989)

 

 

 

 

 

What is community participation?

The term community participation has become so confused that it can mean anything from consultation of a few select power-holders, to citizen empowerment through developing responsibilities and decision-making options to local citizens (Smith, 1991). Studies that have shown that: different people tend to understanding the concept differently and planners, even those in the same programme, have defined community participation in different ways (Rifkin, 1986). One practical way is to look at community and participation separately and then applying that understanding in defining the concept as ‘a process by which people are enabled to become actively and genuinely involved in the defining the issues of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change’ (WHO, 2002, p.10). An essential understanding is that effective community participation in health entails a side-by-side involvement of community members with health care professionals and a responsible sharing of both power and responsibility.

 

Community participation in health programmes

Rifkin (2001) argues in her book “Ten Best Readings on Community Participation and Health” that despite there being no agreement among planners and professionals about the contribution of community participation to health improvements, it has continued to be promoted as a key to health development. The mission document of India’s National Rural Health Mission, NRHM 2005–2012 (Min. of Health & Family welfare, Govt. of India, 2005) spells clearly the importance of community participation as part of the decentralized process of health care management. Community participation can be seen as an essential element in national health strategic plans or policies of nations like India, Sri Lanka, Brazil, Kenya and other developing countries around the world, and seems to indicate a growing consensus among policy makers on its importance for effective planning and implementation of development programmes including health.

 

Notable successes

Programme planners at different levels in countries of Latin America, Africa and South Asia that have had experience in various developmental projects, have included community participation as one of the key project strategies by means of which the objectives could be achieved. This can be seen in countries like Nicaragua where major public health concerns such as vaccination, sanitation, nutrition and breast feeding were successfully addressed through the institutionalization of community participation (Frieden and Garfield, 1987). In some Latin American countries, passive case detection networks made up of unpaid community volunteers became the principal means of surveillance and drug treatment of vector-borne diseases like malaria and dengue fever amongst others (Winch et al, 1992). India has experimented with participatory approaches in health programmes since 1977 when it launched the Community Health Workers (CHW) scheme. The WHO defines CHWs as “men and women chosen by the community, and trained to deal with the health problems of individuals and the community, and to work in close relationship with the health services. They should have had a level of primary education that enables to read, write and do simple mathematical calculations" (UNICEF, 2004, p.2). Health promotion through health education is one of the CHW’s primary responsibilities, and as seen in the case of diarrhoeal prevention by BRAC (Bangladeshi Rural Advancement Committee), one of Bangladesh’s largest non-governmental organizations, the CHWs taught women in the community how to prepare oral rehydration solution to treat diarrhoea (UNICEF, 2004). An indication that emerges is that participatory programme initiatives that are designed to build the capacity of people in communities where they are implemented are likely to have a higher chance of success in terms of community participation and attainment of programme objectives.

Community participation in health also involves other actors (organizations or groups of people) apart from those with already defined roles (CHWs, volunteers). One example was the case of a malaria control programme in the Indian state of Karnataka, where a collaborative effort involving government and non-government agencies and local artists was successful in imparting health education using popular folk theatre (Kalajatha), resulting in an appreciable reduction of malaria cases (Ghosh et al, 2006). Programmes that maximise utilization of the existing human resources base within a community tend to achieve more in terms of community acceptance and participation. This in turn has a significant bearing upon the programme outcomes. To support this view, social marketing - application of commercial marketing techniques to plan, implement and evaluate programmes that are designed to induce change in perception and behaviour of a target population with the aim to improve their welfare and society - can be highlighted as an approach that has contributed to some of the important gains in public health programme interventions. By training community-based sales agents and involving others like HIV positive people and respected community and religious leaders, condom social marketing has been effectively used in many countries to combat the spread of HIV/AIDS since the mid-1980s (UNAIDS, 1998).

In South Asia, another development in recent years was the emergence and firm establishment of self-help groups (SHGs) that were formed as part of a developmental strategy with a primary focus on poverty alleviation and empowerment of women (Nayar et al, 2004). Today, SHGs formed either under government or NGO sponsorship dot the development landscape in many developing countries and are being used as vehicles for progress in improvement of human development indicators including gender-related indicators. Successful SHGs in South Asia like Self Employed Women's Association (SEWA) in India, BRAC and Grameen Bank in Bangladesh have in one way or another engaged in health related activities ranging from health education programs for child care by BRAC to training "health educators-cum-barefoot doctors" by SEWA (Nayar et al, 2004). Goetz and Gupta (1996) have argued that SHG activities have resulted in health benefits for members of the groups and their families despite some degree of scepticism about reported successes in terms of meaningful empowerment and effect on existing social structures that determine gender relations and health.

            It may be interesting to note the successes that community participation has yielded in some countries can serve as a pointer to its scope and potential for broader application and further development. Nevertheless, it is not a process without challenges or even setbacks and it is imperative that policy makers, organizations, programme planners and the community members develop a common understanding and response to overcome the challenges or prevent failure.

 

Community participation – Limitations and Challenges

It is important to understand that community participation is a dynamic process and there exist a host of influencing factors or determinants that can dictate the nature of outcomes of development or health programmes and their sustainability. Planners and professional development actors need to understand that in community participation, the emergence of issues from the community is a dynamic process where goals and strategies change over time (Hunt, 1990). The existing socio-cultural, political and economic environments within a community are likely to affect the degree of participation, the sustainability of which can be achieved only as long as the relevant actors remain committed (Morgan, 2001). For example, formation and cohesion of SHGs may be affected in countries with prevailing vertical and hierarchical social structures (India, Bangladesh). Further, communities entrenched in caste, class and gender hierarchies are likely to limit women’s participation in health (Lahiri-Dutt and Samanta, 2002) and may well affect participation by minority groups. Poverty is another issue that restricts people from participating in decisions that affect their health (Macfarlane et al, 2000). Hence having an understanding about the underlying issue/s within a given context may benefit programme planners in improving the prioritization and planning process while engaging with the community.

In community participation, there is also a risk of conflict if the community’s expectations clash with professional attitudes and behaviour of bureaucratic structures (Hunt, 1990), thus lessening the chance of success of a programme. This raises another issue of community ownership, an essential requirement and the absence of which can lead to failure or non-achievement of programme objectives. “Community ownership means that local people must have a sense of responsibility for and control over programmes promoting change so that they will continue to support them after the initial organizing effort” (Flynn, 1995, p. 28). A case to note is the Life Abundant Programme sponsored primary health care project in rural Cameroon that became sustainable due to the community assuming ownership and leadership of the project (Eliason, 1999).

 In some countries, structural, economic and social constraints may limit the extent and capacity of communities to participate in health or development programmes. As seen in Niger, social constraints such as the lack of knowledge and access to health care by the community people were some of the obstacles that acute flaccid paralysis (AFP) surveillance programme faced (Ndiaye et al, 2003). A study by Cruz et al (2003) taking a case in Nepal, showed that even though it was possible to overcome constraints like poor health knowledge and skills through training and capacity building of community health volunteers, another constraint (weak health system) hindered the extent of progress of the intervention that overcame the first constraint.

 

Conclusion

            Community participation is one of the pre-requisites in most development and health programmes around the world. It remains a challenge that programme planners and other actors in development continue to take up due to its scope and potential for success of such programmes. Community participation has brought not only new solutions to problems in development programmes but has also generated new questions about and challenges to the way development is being perceived or addressed upon.  It can be argued that though community participation offers much scope for improving the chances of success of development and/or health programmes, it is unlikely to succeed unless planners and development professionals address the challenges associated with it through active engagement and in close confidence with the community. The constraints that exist in a community also lend their effect to the environmental and contextual characteristics that can define or shape the strategies of health programmes, and hence it would not be far fetched to emphasize the need for a holistic approach in policy and planning to ensure fuller community participation and cooperation towards successful realization of programme goals and objectives.