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Community Participation

William R. Brieger, MPH, CHES, DrPhJohns Hopkins University

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Section A

What Is Participation?

3Community participation: The centerpiece of PHC

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From Alma Ata

Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technologyMade universally accessible to individuals and families in the communityThrough their full participation, and

Continued

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From Alma Ata

At a cost that the community and country can afford to maintain at every stage of their developmentIn the spirit of self-reliance and self-determination

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PHC Requires and Promotes

Maximum community and individual self-relianceParticipation in the planning, organization, operation, and control of primary health careMaking fullest use of local, national, and other available resources

Continued

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PHC Requires and Promotes

To this end, develop through appropriate education the ability of communities to participate

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What Constitutes Participation

Active involvement of the local population in the decision making and implementation of development projects

Continued

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What Constitutes Participation

Role of the community– Formulating a health program– Enabling its residents to

understand and make informed choices

– Reconciling outside objectives with community priorities

Continued

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What Constitutes Participation

The community both determines collective needs and priorities, and assumes responsibility for these decisions

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Why Participation?Assumptions about Participation Effects

Increases program acceptance, ownershipEnsures programs meet local needsMay reduce costs using local resourcesUses local/familiar organizations, problem solving mechanisms—more efficientSome examples follow

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Promoting Filters by VHWs

Product, price, place and promotion organized by VHWs

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Participation EffectsGuinea Worm Filter Sales Where VHW Takes Part

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1015202530354045

VHW sold VHW advised No VHW

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Community Involvement in Water Supply Improvements

Raising moneyHelping digDedicatingthe wellSupervisinguse andmaintenance Community involvement

15Community involvement

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Participation inWater Supply Project

Multiplier Effect on Immunization Participation

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participatory non-part no project

IndonesiaTogo

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Community-ManagedEssential Drugs

VHWs Buy and Maintain Stock

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% buy stock mean times buy

CommunityControlledLGA Controlled

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Community Meetingsto Discuss CDTI

Community organization for program specific goalsPrinciples of active participation are maintainedLocal decision making and commitment to decisions facilitated

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Community meeting

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CDTI vs Program-DirectedEffect on Ivermectin Coverage (TDR/APOC)

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Kaduna Enugu Yola Mali

CDTIProgram

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WARMI Means WomanSave the Children

Community organizationCommunity groups determine prioritiesPlan projectsAcquire resourcesAdminister and coordinate

Source: Save the Children

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WARMI: The Community Planning Cycle

Identification and prioritization of problemsPlanning togetherImplementation by community membersEvaluation by community members

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Community Problem Solving

Source: Save the Children

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Participatory Approachto Improve MCH

In Bolivia, Women’s Groups Plan Their Own Program

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PerinatMort

TTCover

TrainedAttend

Follow-up Baseline

ContraUse

ANCVisit

InitiateBF

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Section B

Levels of Involvement

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Levels of InvolvementInvolvement Vs. Participation

Acceptance—UtilizeMobilization—ContributeParticipation—ImplementInvolvement—PlanControl/ownership—Community directs; toward increasing community ownership

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Levels of Participation

0

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accept mobiliz particip involve control

Level of Participation

Am

ount

of i

nvol

vem

ent

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Acceptance Can Be Likenedto Passive Participation

Passive participation includes complete cooperation on the part of the community in the implementation of the program to achieve the objectives and targets set for the program– Does not ask of the community

contributions in terms of resources, cash, or labor

Continued

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Acceptance Can Be Likenedto Passive Participation

Education aims at motivation for completion of the tasks determined by the agency

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What Is Mobilization?

A broad-scale movement to engage large numbers of people in action for achieving a specific development goal through self-reliant effortA process of bringing together inter-sectoral social allies to raise awareness and demand for a particular development program, to assist in the delivery of resources and services

Continued

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What Is Mobilization?

This approach, combined with community participation, has also proved to be a very important tool in helping to create a supportive environment for sustainable behavior change

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Participation or Taking PartIn Something Designed/Planned by Others

Active participation—Inputs are provided by both the government and local populationThe importance of identifying appropriate community members to take a lead in community-based activities

Continued

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Participation or Taking PartIn Something Designed/Planned by Others

Although based in the community and with inputs from the community—including even leadership and resources—participation may not be of the community

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Involvement Addresses Ownership

The ideas may still come from outside but the community internalizes themDepends on the voluntary contribution (e.g., of labor, funds, and resources)Community ownership of the program or intervention is a key to its sustainability

Continued

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Involvement Addresses Ownership

Only when the intervention is seen as belonging to them can they be expected to take responsibility for maintaining the activities and improving upon them

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Community Control

Change is directed by the communityCommunity identifies the problemMakes all key decisions on goals and meansThe organization is willing to help [facilitate] the community at each step to accomplish its goalsThe approach to change is normative/re-educative

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Community control comes when members get together and make decisions

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Facilitation vs Participation

Facilitation is open-ended– “Do you have health problems?

What do you think causes them? What do you want to do about them? How can we help?”

– Issues perceived by the community to belong to themselves—more likely to be sustainable

Continued

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Facilitation vs Participation

Participation is program-specific– “We want to eliminate

onchocerciasis. We need your help. This is what you need to do. Will you help?”

– Issue perceived by the community to belong to the health workers—remains the ultimate responsibility of the health workers

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How to Facilitate?

How to promote community control?Can we listen?Can we learn from local knowledge?Can we adopt new roles?Can we allow and enable front-line health workers themselves to be involved in programming?

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Are Health Workers Ready for New Roles and Relationships?

Facilitating community involvementListening to community concernsRespecting community viewsWorking together as partnersEncouraging community decisionsStanding by community decisionsHelping communities link with resources