The community partnerships that we discussed in the last lecture are an ideal example of community participation. We've noted that participation is one of the key words underlying the philosophy of the Alma Ata Declaration for primary health care. In the past 22 years, governments have signed on, have used the word participation, although often times it's merely the form of mobilization where people are expected to donate, to a project. In this lecture we'll look at what participation is about. And how it can be developed and sustained, and what the benefits are, participation. As noted, community participation is a centerpiece for primary health care. The photograph shown is a stakeholder's meeting, where the issue of malaria problem was introduced to the community and rural local government in Nigeria. Women's groups, social clubs, local leaders, village chiefs, private providers. Indigenous healers all came together to share their views about the nature of malaria in the community, and what should be done about it. In the ama the declaration, as we know that there, are, several references, to participation. The definition of primary health care as essential care, has the component of social acceptability in that definition. Social acceptability is not simply a passive issue, where people like or dislike a service, but also, social acceptability evolves through participation, where people feel a sense of ownership of a program. Participation is enhanced when services are accessible. Alma Ata clearly states that primary health care services should be provided through the full participation of community members. And such participation provides the context for determining the cost that the community can afford. Participation leads to self-reliance and self-determination. Primary health care requires and promotes maximum community and individual self-reliance. Participation in the planning, organization, operation, and control of services. Participation itself means that there's greater access to and fuller use of local, national and other available resources. So we've mentioned in coalition-building, different community groups have different access to different resources, through participation bringing these resources together, enhance access of the organizations and individuals to those resources. And specifically as an intervention strategy to promote participation, the Alma Ata Declaration recognizes the need for appropriate health education of communities. In essence, health education is more than providing information. In fact, it's enabling people to participate, to identify and solve their own problems. Participation is the active involvement of a population in decision making and implementation. The word's involvement and participation are often used interchangeably. The key issue here is taking part in making decisions and carrying those out. That is the underlying essence of participation. In community participation, the community has a clear role in formulating health programs, enabling residents, members of the community to understand and make choices. And reconciling the objectives of outside programs with community priorities. In other words, a dialogue is needed. Because in reality, agencies will be continuing to practice social policy planning. The issue is that they need at this point, in primary healthcare, to recognize the community as a partner to engage in dialogue and discuss the objectives and see how they really meet the priorities of the community. Because in fact, the community itself is who determines the collective needs and priorities. The community itself assumes responsibility and decisions. The agencies need to be aware of these and adapt to them as opposed to expect the community to swallow agency messages and programs. Participation often is promoted before lip service so that different countries and agencies can appear to be in tune with alma ata, which is adopted as the strategy for achieving health for all by the WHO. People want to appear as if they belong, as if they are politically correct in terms of participation. Although, in fact, participation may be antithetical to the political system in a particular locality or country. In fact, participation does have positive benefits for health. It increases the sense of, not just acceptance of a program but ownership. Community members who make decisions, help plan and implement. Then want to sustain a program because they feel it is theirs. Participation ensures that programs meet local needs. A one size fits all program may not succeed in every area. Participation can reduce cost because local resources are use. Participation can be efficient because local familiar community organizations and problem solving mechanisms are use. People find it easier to get involve if they understand what's going on because their local organizations are running the program. Some examples of the outcome, the benefits of community participation are seen in the examples that follow. The idea of filtering water to prevent Guinea Worm as we noted before. Does not necessarily appear to be a behavior that many individuals would want to adopt. Based on their beliefs about Guinea worm being inside the body, based on perceptions that filtering may be a second rate intervention compared to wells. But where the community had control over planning a filter distribution program. The results were somewhat different. Village health workers had been trained, in the small community of Idari. In 1978, they had organized some guinea worm control activities and reduced the prevalence in some of the the hamlet surrounding the town. Additional training was provided and more people were involved in 1983. The village house workers subsequently formed their own organization, so that they could collectevely buy medications from a wholesaler at a lower price, so that they could collectively organize campaigns and be recognized in the community. And so they took over the responsibility of organizing the filter program, to test the social acceptability of the filters through a WHO project. The association had members who were tailors and they organized the production. The group itself debated the costs. They decided that the filters would be sold at cost for the cloth plus a set modest amount that the individual seller could keep. The village health workers were located throughout the community and surrounding hamlets. And so, they were able to ensure that the product could get out to the place where it would be distributed. And the village health workers again, were trained how to promote the filter use. The pictures here show one of their training sessions, where the importance of demonstration of the filter and explanation to the villagers were shown. What occurred, since the village health workers themselves, these volunteers, were actively involved in the design of the program, the management of the program. In those hamlets, where they sold the filter themselves. Coverage was, was highest. Even in those hamlets where they lived, but did not decide to sell, but only advised their co-villagers to buy from the project staff the, the coverage, the number of people who bought was fairly high. In contrast to those hamlets where there was no village health worker, and only the project staff going around to sell. So the effect of their being involved enhanced the ability of them to sell, to promote. And they were much more successful than an outside person selling the filter. They were trusted by co-villagers. Here again, some of the concepts of social learning theory. Some of the concepts of peer education. Some of the concepts of the adoption diffusion model in terms of haemophilus communication were born out. So if participation builds on these theories and ideas to enhance the likelihood of people adopting health innovations. Interestingly enough, the profits that were made from selling the filters. The village health workers decided what to do with that. And they plowed that into a fund to be used to dig community wells, because again, people did say that they would prefer wells to filtering. Wells would be a more long term source of water. The ponds would dry up in the dry season, whereas wells, if sunk to a proper depth, would not. And so the community themselves, through their village health workers, planned the short-term, selling the filters, and the long-term. And they raised money initially to dig two wells. They supervised the wells, they actually charge people a small amount for each bucket of water they collected, and used that to maintain the wells and to dig more. So the filters, although it was an outside idea was able, the filters were able to provide a basis to start community fundraising and address the longer term problem of community water supply. Concerning water supply, research was done to look at what happened in two countries, Indonesia and Togo, where, USA id water programs had been underway, and other water supply programs. In some countries, the water supply had been established through Participatory process, where people in the village were involved in deciding where the water source, the well, would be located. participated in providing resources, labor. And it was interesting to see how this had an effect on the community in terms it, its overall health competence. The community competency model implies that individual health decision making is enhanced when the community as a whole is actively participating in addressing and solving its own health and development needs. The results from the study in Indonesia and Togo, show that this is likely to be true. In Indonesia is was possible to compare immunization coverage in villages that participated in establishing their own community water supply, in villages where water supply was provided by the government, without village participation. And in villages where there was no water supply project. And coverage was significantly higher in the participatory villages. Whereas, the non-participatory villages, there was no difference in their coverage with villages that even had no water project, no new project at all. And the interpretation was that, by community as a whole becoming actively involved in meeting a community need, developing its own competence that members of the community also felt a greater sense of efficacy in seeking health services. Yeah, similar result was seen, with the data from Togo. The idea of community involvement with the village health workers is again seen in the slide on community management of essential drugs. As we mentioned, one of the main reasons for the village health workers in this small town of Edari forming their own association was so that they could get low cost supplies of their essential drugs for their village drug kits. During subsequent years, the local government health department also trained village health workers. They received some federal funds to do that, and they were also suppose to provide with that money drug boxes and drug supplies to start off their village health workers, who would then sell those and come back and get new supplies. And the village health workers in Edari, during their association meetings. Would contribute a small amount of dues every two weeks that they met. They used that money to make drug boxes. And buy the first stock to start their revolving drug fund. The local health department trained village health workers simply were given the boxes. And the, and the first round of drugs by the local government. Some of our students a couple years later went out to find out what the situation was with the two different groups of village health workers. They found that nearly twice as many of the village health workers from the association would set up their own revolving drug fund, had purchased drug stock. Nearly twice as many as those village health workers trained by the local government and supervised by them. Likewise, they found that the village health workers who were managing their own fund were more likely to buy or bought more drugs more often during the year than those in the local government controlled program. So participation, in the program guaranteed, that, basic drugs for, problems like malaria, were available in the village, when the villagers themselves, through their, through their selected village health worker, participated in designing and carrying out their own program. The, African program, for onchocerciacis control that was set up in 1995 by WHO and collaborating agencies, adopted as its, main strategy, for getting the drug ivermectin, which was donated by the manufacturers, out to communities. They, selected as their, key, strategy a community-directed approach, basically community participation. The idea was that villagers, through community meetings, would be informed of the availability of the drug, that they would be asked to take responsibility for collecting the drug from the nearest health center, selecting some people who could be trained in the village on how to measure people and administer the dosage, manage simple side effects. So the community had, had the responsibility for the actual distribution of the drug. The local government health department had the responsibility for making sure that the drug was available in the district. And that villagers who were selected were trained. And then, of course, we said the donor agencies made sure that, money was available for training. And that the drug got from the manufacturers out to the different countries. The initial research that was done through the WHO/UNDP World Bank Tropical Disease Research Program. Convinced the African Program for Onchocerciasis Control, APOC, that this Community-Directed Treatment with Ivermectin, the CDTI, was the way to go. The initial research took place in several countries. And the results of four of them are shown here on the graph. Two approaches were taken. One set of villages was organized so that they could take responsibility themselves. They planned how they would get the drug, who would be trained, when they would distribute it. Would it be house to house? Would it be at a central place? What day, etcetera. Who will be their distributors, how they would do it. And then another set of villages received the Ivermectin through outreach. The health staff would simply come out to the village and provide them with the drug when the health staff were ready. So we had a program directed versus a community directed approach to distribution. Overall we see that, the, community-directed approach achieved a higher, level of coverage, and this is why, the APOC adopted, this approach, such that any country that receives a grant, to set up, onchocerciasis control using ivermectin, is expected to, adopt this approach, and subsequently guidelines have been developed to help them. Another example at participation is the Save the Children Project in Bolivia on Maternal and Child Health. The project was based on strategies of community organization. Community groups of women determine their own priorities to improve the health of women and children. These community groups did their own planning, including how they would get resources they needed and how they would get them. They administered and coordinated their own local efforts, and education, and service provision. The planning cycle included problem identification and prioritization, planning together. The women's groups and coalitions planned together. They carried out the projects, and outreached to their members, ensuring that everyone got services. And they actually sat down and evaluated what the outcome was. Was it acceptable? Was it successful to them? This particular project evaluation did not include a control group, but had before and after measures that were, inlarge part, collected and analyzed by the women in the community themselves with the assistance of the staff. And at the end, they could see that there was change. Perinatal mortality was much lower at follow-up. Other indicators in terms of health behaviors, the program coverage increased. The second pair of bars on the graph refer to contraceptive use and this increased quite markedly after intervention. Tetanus toxoid immunization during pregnancy rose after the program was started. The fourth set of bars look at the number of women who made an antenatal or prenatal care visit during their pregnancy. That increased. The number of women who gave birth under the supervision of a trained attendant, either a formal health staff, or community birth attendant who had received training, increased, and the number of women who initiated breast feeding the first day also increased.
