The important thing during participation and in terms of community capacity building is that the evaluation process enhances the community's commitment to continue. It helps them to see where they've succeeded, identify what went right, any problems they have. It helps them, through feedback, to take on new projects and new challenges. In fact, many of these programs, when they first come in appear to be and actually are somewhat of a social policy approach because the donor agency has decided that they want to promote filters, that they want to improve maternal and child health, that they want to distribute Ivermectine to control onchocerciasis. The issue is how they relate to the community and what role the community plays. And whether the project is a springboard toward community problem-solving and community participation and program sustainability or it's just another service being offered. To help understand this, we can look at the next slide which identifies five different levels of community involvement, other researchers have identified different levels, but this gives an idea that participation occurs along a continuum. And where one starts to work with a community, may be at one evel, but one can encourage the community to progress along this participation continuum. The lowest level would be simply to avoid, ignore the program. But in terms of participation, the minimum one can expect is acceptance, where people utilize a service provided. Health providers are often heard to talk about mothers participating in the immunization program by bringing their babies. That is really acceptance. The next level looks at the concept of mobilization that we have discussed before. The idea for change comes from outside, but community members are encouraged not just to accept or utilize the immunization program, but contribute resources to make it more successful. The third level, which is here term participation, again, is similar to some of the projects we start, we described. They started off with the idea coming from outside with community members are encouraged to implement the programs themselves, so they have a role in carrying it out. But they didn't have a role in prioritizing. At the involvement level, community members are partners and help plan and evaluate as well as implement the action, action. Finally, at the level of community control, the community comes up with its own needs, priorities and directs how the program goes. The community owns the program. Outside agencies are still involved but in a different way. The community requests them to come in because a community sees the certain agencies have resources they need. So, it's not the agency coming and telling the community what they need, but the community telling the agency what they want. The next slide shows this graphically. And as we noted, it may be possible to start a program with a defined agenda by an agency. But after some time, the community may develop skills, develop motivation and interest to take control and start planning new things for itself as has been done with the village health workers, who use the filter project as a stimulus and a source of revenue to get them started on community water supply, which was their real felt need. And they took over and manage that themselves. Another term for the acceptance level is passive participation. Sometimes, health workers say, we want the community to cooperate with us, to go along with our program, to do what we want them to do. At this stage, it's simply a matter of fulfilling targets and goals, getting enough children immunized. In this case, health education is used simply to encourage people to adopt the behavior that's been determined by the agency. Mobilization attempts to go beyond this, in part, because the programs involved often require a large number of people to be successful, such as at the immunization programs. Mobilization attempts a broad scale movement or involvement of different groups, different sectors of the community in achieving the goal, recognizing that the immunization program requires transportation, requires information. And so, the effort is to get these resources donated toward achieving the agency's goals. And it's recognized by those who promote mobilization that it needs to be combined with a higher level of community participation if it's going to be sustained. Participation can be redefined as taking part in something. But taking part in what? In many cases, taking part in things that someone else has designed. And active participation inputs are provided by both the government and the local population. Community members are identified who can take a lead in carrying out the program. What differentiates this from the level of community control is that although the community may be contributing, the community may be offering leadership, but the goal setting, it may not have occurred in the community. Involvement addresses the concept of ownership. If the ideas come from outside, the question arises, will the community internalize them? Will they take the ideas as their own? Will they accept the different approaches? This issue of internalization, was one of the change process models of Kalman that we talked about in the first module. Involvement requires voluntary contributions. It requires an understanding or matching of the program goals with community goals to see a connection. Involvement can only occur if there is a good dialogue between the health workers and the communities such that the idea and the intervention can be seen as relevant to and belonging to the community will actually meet needs that they perceive. But finally, as we mentioned, community control is change that is directed by the community. It may be through a locality development approach where the community identifies the problem, and uses its own resources. It may be a community action approach where community members identify the problem, plan action, but realize that they don't have all the resources and support they need. And therefore, reach out to lobby, pressure agencies in government to provide them what they need to carry out the program to meet their own needs. Community control is aimed at, ultimately, in the program for community directed treatment with Ivermectin for onchocerciasis control. Because it's recognized that during the past 22 years, primary healthcare where village volunteers and village health committees has taken over their health care has not succeeded in many places. And as we'll discuss later, the CDTI program, even though it's based on one issue, tries to get the community together in meetings, as seen in the picture, in this slide, to discuss their own needs, their own problems in terms of making Ivermectin available, getting it to the village, but then using that as a springboard where communities can experience some success with that program and decide on other health issues that they want to, to tackle. The key issue for the health worker is the role to play in the levels of community involvement and community control. It's important for the health worker to take the role of facilitator. In facilitation, we ask open-ended questions. We encourage the community to identify problems, address what they think causes them. Come up with ideas about what they want to do about it and then, articulate what help they think that they need, or they want. The issue of ownership is more likely to be addressed successfully, if community members, themselves, identified their own problems, if the issues addressed by a program are perceived as important to the community. A participation approach, as we noted, is lower down the ladder than community control or involvement. The issue is program specific. The health worker asks, tells the community, we want to eliminate onchocerciasis. We need your help. This is what you can do. So, this would either be mobilization or participation, giving them a role. The issue is perceived by the community to belong to the health workers. The community thinks it's not helping itself, but it's helping the health workers get their job done, depending on their relationship, they may go along with it or they may not. But anything that, that happens with the program, anything that succeeds or fails is ultimately considered to be the result of, or the responsibility of the, the health workers themselves, not the community. It's not easy to facilitate. Health workers are often trained to be authority figures. The health inspector visits homes, visits establishments in the market that sell and cook food, and is expected to carry out the letter of the law in terms of sanitation. The nurse is expected to encourage the patient to comply with medication. And in these various situations, the idea of being a facilitator, being, being a partner, does not occur. If we're doing community organization, it's very important that this partnership be established. If we're going to facilitate, we need to be able to listen to the community when they express their needs, when they talk about their limitations, when they talk about their hopes and desires. We need to learn from local knowledge. How do people recognize conditions are explanatory models? What local forms of organization exist? We mentioned age, age grades before. They serve a valuable purpose in terms of community mobilization. As health workers, can we adopt new roles, not always being the, the expert, but also being the learner? And within agencies, we're not just concerned about facilitating the community, but also, are we able to allow the front line health staff to make some decisions for themselves, to be involved in programming, to take initiative, instead of waiting for directives from above? Basic training for many health workers does not include community organization, counseling skills, client-centered work. So, the question arise, are health workers and are health organizations ready for new roles and relationships, that would faster, higher levels of community involvement and participation? Are health workers in a position to respect community viewpoints? Or are they afraid of community beliefs and views, as being unscientific or even dangerous? Are we willing to let the community make decisions and stand by the community in their decisions? And particularly, are we willing to help the community link with outside resources? Many times, communities express needs when they're encouraged to become involved, that are not within the realm of the health department to provide. The health department cannot provide new roads, the health department cannot build new market stalls, the health department cannot install electricity. But these are important needs to the community and even, in fact, relate to health. Better roads increase access. An improved market will enhance the economic condition of the community. Instead of ignoring such community needs as outside our realm, we need to be able to help link the community with other agencies. And this is why the Alma Ata Declaration talks about intersectoral collaboration such that the health workers who may be in closer contact with the community can help the community contact the Ministry of Works that's responsible for roads or contact the Ministry of Education about locating a school in their village.
