WORLD HEALTH ORGANIZATION
OJH,ANISATION MONDIAlf DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Thirty-first session Manila 9-15 ~eptember 1980
WPR!RC3l!TP!1 25 August 1980 ORIGINAL; ENGLISH
COMMUNITY INVOLVEMENT IN THE DEVELOPMENT OF HEALTH SERVICES Technical Presentation
WPR/RC3l/TP/1 page 2 CONTENTS
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1.
INTRODUCTION
.............................................
3 4
2. 3.
THE IMPORTANCE OF COMMUNITY INVOLVEMENT
THE MEANING OF COMMUNITY INVOLVEMENT FACTORS INFLUENCING COMMUNITY INVOLVEMENT
5 8 8 9 9
4.
4.1 4.2 4.3
4.4 5.
Decision-making process in the community ••••••••••• Process for involving the community •••••••••••••••• Availability of resources in the community ••••••••• Nature of the activities ••.•••••••••••••••.••••••••
10 10 11 11 11
INDICATION OF COMMUNITY INVOLVEMENT 5.1
5.2 6.
Measurement of community involvement ••••••••••••••• Measurement of impact .....•.•......••....•.••••.••.
HOW COMMUNITY INVOLVEMENT IS DEVELOPED 6.1
6.2 6.3 6.4 6.5 7.
Existing situation ................................ . Initiative for action .••••..•.•............••..•.•. Community preparation •••••••••••••••••••••.•••••••. Cotllll\1n ity act ion ••••••••••••••••••.•••••••.•••••••. Continuing involvement •..•.•...•••...•.•.•..•..•.•.
13 13
13 13
14 14 14
ISSUES AND IMPLICATIONS
.................................. .............................. .
7.1 7.2 7.3
Health as a priority
7.4 7.5 7.6 7.7 7.8 7.9 8.
Health as a national policy •••••••••••••••.•••••••• How to sustain community involvement ••••••••••••••. When is the community ready? ••••••••••••••••••••••• Involvement may be a long process •••••••••••••••••• Coordination between sectors ••••••••••••••.•••••••. Exchange of information as a, factor •••••••.•••••••• Changed role of health workers ••••••••••••.•••••••• Impac t on heal th .................................. .
15 15 15 15 16 16 16 16 17
j
I
J
I
REFERENCES
............................................... ANNEXES
1.
CASE STUDIES 1. 2. 3. 4.
............................................. Women's committees .•..•.•.•......••.•.••.•••..
19 20 21 23 25
China: The cooperative medical service •••.•.•••••••• New Zealand: The Porirua community health project Philippines: The Carigara experiment •••••••.•••••••• Samoa:
2.
SELECTED BIBLIOGRAPHY ••.•••••.•••••••••.••••••••••••••••••
29
WPR/RC3l/TP/l page 3
1.
INTRODUCTION
At its thirtieth session, the WHO Regional Committee for the Western Pacific resolved that the topic of the Technical Presentation during the thirty-first sess ion in 1980 should be "Community involvement in the development of heal th services". This indicates that the Committee felt a strong need for further collective action and thinking to implement primary health care following the Alma-Ata Declaration. l Within WHO and among health officials of Member States, it is realized that the actual implementation of primary health care is a complex issue which poses several challenges. Some couutries made political decisions to implement it long before the Alma-Ata Declaration was adopted. The rest have done so only since the Alma-Ata Conference. 2 It was this Conference which dignified the concept of primary health care, bestowing upon it the respect and technical backing it deserves. As a result, countries are no longer so reluctant to solve their health problems in their own way, no matter how crude the means may appear. They are also no longer so concerned if they do not have the sophisticated facilities and technologies available in developed countries. The importance of, and concern for, primary health care implementation has been further reinforced by resolution WHA30.43,3 which established the goal of an acceptable level of health for all by the year 2000, and resolution WHA32.30,4 which identified primary health care as the key to achieving such a goal and called upon Member States to formulate national strategies for its attainment. It may be assumed, at present, that countries are at various stages of implementing primary health care and each may have its own definition of what it involves. Whatever the definition, what is important is that the strategy should envisage total coverage of the population, that the community should be involved and should actively participate, that the resources of the different sectors should be organized so that they all address the problem of community development in a coordinated and unwasteful manner, and that the technologies used to improve and protect the health of the population should be relevant to the problems identified, and a ffordab Ie.
lAlma-Ata 1978: Organization, 1978.
Primary health care.
Geneva, World Health
2International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, jointly sponsored by WHO and UNICEF. 3WHO Handbook of Resolutions and Decisions, Vol. II, 3rd ed., 1979, page 3. 4Thirty-second World Health Assembly~ (WHO document WHA32/l979/REC/l), page 27. Resolutions and Decisions
WPR/RC3l/TP/l page 4
There is an increasing awareness among Member States that they do not have the resources or the organizational infrastructure~ to provide what is needed by their people as a whole in terms of health care. Health problems are formidable and complex and the difficulties have been compounded by the limited resources of governments. Thus, by focusing attention on the community and attempting to shift it from its passive role of compliance to one of active partnership, governments are following a logical approach. It is undoubtedly encouraging that all governments in the Region have accepted responsibility for the health care of their peoples. And it is timely to discuss community involvement for the reasons previously mentioned. This Technical Presentation will attempt to focus the discussion on the practical aspects of the subject rather than on concepts.
2.
THE IMPORTANCE OF COMMUNITY INVOLVEMENT
The difficulties facing governments in their endeavours to provide health care for their people are now all too familiar. The shortcomings of conventional health services are well known. Emphasis on a 'medical' approach has reinforced the development of inequitable, inefficient, and institution-oriented health services, which cover only a small proportion of the population. From a historical perspective, the evolution of the conventional type of health service institution is not difficult to explain. From being a humanitarian function of religious institutions, it has undergone various modifications until it has become the highly sophisticated hospital of the present day. It is clear now that this type of health service cannot provide the answer to present day health problems and needs. It can be said that health services based solely on modern medicine and sophisticated technology can solve only some of the health problems of some of the people. Even in industrialized countries, it is becoming recognized that this type of health service is not in harmony with community needs, and is uneconomical in terms of cost. In the Western Pacific Region, Member States accept and acknowledge that they have a responsibility to respond to the expectations of their peoples for health care. Industrialized and developing countries alike are seeking ways to modify their health services to make them more relevant and more economical. In connexion with these efforts there are several heartening examples of a new type of health service which, by mobilizing community resources in terms of motivation, behaviour and organization, is able to provide care that is not only appropriate and relevant but is also carried out with the involvement of the community itself. China has developed such a type of health service, and the cooperative medical service at commune and brigade level is a good example of what is meant by community involvement in health services. In Samoa, the health service infrastructure has involved the community through the network of women's committees.
WPR/RC31/TP/1 page 5
One can go further and cite exampl,~s where community involvement starts with research, designed and carried out by the community to ascertain the problem. Such examples can be found in New Zealand, in the Porirua community health study, and in the Philippines, in the primary health care research and development project in Carigara, Leyte Province. The technology is provided from outside, e.g. the government, while the community provides the social process by which the technology is applied. The social process will demonstrate the appropriateness or otherwise of the technology. Once the problem is acknowledged, the community needs to relate available technology to the resources available and prevailing conditions. An example is the complex cold chain for vaccines. It is tempting to provide cold rooms, freezers, refrigerators and other hardware. This in fact has been the conventional approach in more developed countries. However, whether these are the best things to provide, or whether other methods could be used will depend on many factors which determine their appropriateness, such as the availability of spare parts and skills for maintenance, the availability of fuel and the regularity of electricity supply. Health must be regarded as the business of everyone and not just of the health services. Once health has become a shared concern of all, the community has to take the initiative in solving health problems. This implies major attitudinal changes~ firstly, education of the people in health matters, secondly, acceptance by health professionals that their responsibility is to mobilize and involve the people. The problem is to transform health care from a professional service into self-reliant personal care exercised in a collective form.(l) Self-care is perhaps the ultimate expression of this approach. As Levin has pointed out, health is not a main objective of human beings, but happiness is.(2) There are many things people do which are unhealthy but appear to make-them happy. A good example is drinking or smoking or dangerous driving. If society and the individual are aware of the risks and social costs involved, then behaviours may change. Social acceptance of health activities will occur, and the stage will be set for community involvement. Community involvement in health activities is one way of changing heal th behaviours.
3.
THE MEANING OF COMMUNITY INVOLVEMENT
In the previous section some ideas were set forth on the importance of community involvement, together with economic and technical considerations to show that community involvement is essential if health care is to be accessible to all.
WPR/RC3l/TP/l page 6
One can go further and say that good heal th services cannot be provided unless the community is involved. An additional political argument for community involvement is the rising expectations of the people of the Region who can see what has been done, and what can be done, to improve their heal th. They now real ize that good heal th is within their reach. Another current trend is the po1iticization of health, where health care becomes an expression of political will at all levels. Certainly at international level, the United Nations agencies have unequivocally stated that health care should be an instrument of social justice. The report of the 1977 UNICEF/WHO Joint Committee on Health Policy, entitled Community involvement in primary health care, was an important step in identifying the factors in community invo1vement.(3) Since then the Alma-Ata Conference has taken place and the goal of health for all by the year 2000 has been endorsed by the World Health Assembly. Thus, there has already been a major change in thinking. No longer is it felt that the community has to be taught to accept or cooperate with health services. It is generally agreed that compliance is not enough. Only full partnership between the community and health professionals will give the necessary dynamism to health care systems. The whole concept of primary health care as enunciated at Alma Ata is one of partnership in solving health problems. At this point, it would be useful to examine more systematically what meant by community involvement in health services development. The goal of such involvement is the partnership already described. This partnership implies an active role in, and responsibility for, the identification of needs and priorities, and the planning, management and monitoring of appropriate health activities. ~s
Thus community involvement in the development of health services means the following~
(1) (2)
Education of the community so that health problems can be identified and understood. Organization of the community so that group decisions may be taken on health and the community may become self-reliant and accept responsibility for health measures. (Such organization should not exist only for health matters. Experience has shown that health committees set up in this way often become ineffective) • Development of a mechanism that allows the community to decide on resource allocation for priority problems. These priority problems may not be health problems and one has to accept the multisectoral nature of the process. . Y-
(3)
WPR/RC3l/TP/l page 7
(4)
Involvement of the community in a partnership for the planning and implementation of health or health related projects.
Ideally, community involvement starts with the individual, who learns that he can exercise some control over his own health. This leads to community awareness of health and diagnosis of health or health-related problems. At this stage technical and managerial support can come from outside the community to develop activities that will link up with government programmes. If this is what is meant by community involvement, then this may be the approach to ensure a relevant and dynamic health care service for all the people. Existing problems can be identified and solved, and, perhaps just as important for the goal of heal th fer all, new and emerging problems identified. The process can be illustrated as follows~
Community invol vemen t
Individual __________ --. Individuals Community groups awareness ~ receptive to--------~ .. • themselves diagno-s-e---' and self-care social action. and analyse problems 1 Organized group I action for health",
I Government involvement J Health and healthrelated government programmes. Intersectoral programmes Managerial and technical input from health services and other sectors
"
" Health services infrastructure. Other sectors
!
prOject~ implemented
~~~------
Projects initiated. Resources obtained
~
~4I~-------
Priority problems identi fied • .......- - _ ... Resources identified. Action planned
1
In this scheme, it should be noted that the key to the process is individual awareness and community action. The content of the process is also important. The kind of activities the community may be involved in to improve health will depend on the problems identified. Many of the essential health care services defined in the Alma-Ata Declaration can be carried out effectively and economically by the people themselves with the support of health services, provided they know what to do and agree that it is important to do it.
WPR/RC3l/TP/l page 8
A good example is the problem of smoking. The health problems caused by smoking are serious and well known. Smoking is on the increase in the developing world. Yet smoking is an individual activity and a risk taken by an individual. At present, the health services are unable to reduce the number of smokers. Community action can. Any ex-smoker will confirm that it is much easier to stop in a society that is anti-smoking. Another very important effect implied in community involvement in health is the generation of relevant information on the real health problems and status of the community. If community involvement implies the activities of lay individuals in health delivery, then a very useful aspect of this is the exchange of information between the community and the health services. An example of this occurs in the Carigara experiment in the Philippines. (~) It may seem an oversimplication, but for the health service to know accurately who is sick and who is pregnant would already represent a major breakthrough in health services development. One could say that a health service would operate much better if such information were available. At present, WHO is well aware of this aspect of primary health care, and the benefit that can come from the simple two-way exchange of information that characterizes it. Much work is being done on lay reporting systems and community self-surveys whereby more appropriate information can be provided to the health services.
4.
FACTORS INFLUENCING COMMUNITY INVOLVEMENT
Before deciding how the community can be involved in the development of health services, certain factors can be identified to show to what extent a community can be involved. These factors were identified in a report for the 1977 UNICEF/WHO Joint Committee on Health Policy.(l) In summary, they can be stated as: (1) (2) (3) (4) 4.1 the decision-making process in the community; the process for involving the community; the availability of resources in the community; the nature of the activities.
Decision-making process in the community
A loosely knit community where each family lives more or less independently is unlikely to develop, voluntarily, any collective action towards a common goal. The sense of belonging to a community is one of the important factors in community participation. Communities tend to organize a structure and decision-making groups in the face of external threat or competition or where there is an obvious and perceived advantage to be
.'
WPR/RC31/TP/l page 9
gained from so doing. Eventually, in any community, a social organization of some sort emerges. In some cases this may be inspired or imposed from above or outside the community. The point is that a political and administrative structure should exist in the community, and should be supported by the community. How to strengthen or generate this structure and involve the community in sustaining it is the preoccupation of health workers, as well as of community developers and policy makers. The political and administrative structure must provide for linkage and communication at all levels so that there is uniform policy setting. Once the community develops organized groups for decision making, leadership has to be provided. Individual or collective leadership is required for community involvement. As an illustration, good religious organization in communities has stimulated them actively to participate in concerted action.
4.2
Process for involving the community The steps for involving the community are as follows:
(1) Development of leadership in the community. An important question is the strengthening of managerial capabilities for planning and organizing community activities.
(2) Development of a community organization able to take decisions on health matters, e.g. rodent eradication campaigns, garbage disposal arrangements. A mass basis for the community organization is vital to the utilization of its resources. It is important to ensure a two-way flow of communication. (3) Communication with the health services. A community, through the community organization, must have effective contact with the health services or at least with health workers who have enough knowledge to advise it on health problems. In addition, it is essential that health problems which cannot be solved at community level should be referred to an appropriate service level. (4) Communication with other sectors. A community, through the community organization, should also come in contact with sectors other than health, when this is necessary for the alleviation of factors underlying its health problems. 4.3 Availability of resources in the community
Where there are few resources, the potential for development is limited. A community living at subsistence level, whose basic needs for food, water and shelter are barely met, cannot usually spare much for development. The most common resource available is human; unemployed or underemployed manpower is always available. Also available may be resources in kind: forest, pasture land, water sources, as well as agricultural resources. These may be used to generate income or surplus products which can be used to fund other community activities. Much of the history of community development has revolved around the identification of ways of realizing the potential resources available to a community.
WPR/RC3l/'J'P/l page 10
4.4
Nature of the activities
There is a significant difference between community involvement in a programme imposed on the community and community participation in the development of its own programme. In the former, the community usually plays a passive role. The health worker takes the initiative to present and explains the benefits of the programme to the community. If the community is convinced, it will passively accept the programme with a "wait"":and-see" attitude but does not really care whether the programme succeeds or not. In the latter, the health worker could also take the initiative, if he had not been approached earlier by the community, to open a dialogue on community problems or interests. In the dialogue he co~ld draw the attention of the community to certain "health" problems and their underlying factors. The role of the health worker is that of c~talyst and resource person. He assists the community ir;t.organizing itself and prepares it for management of the programme.
5.
INDICATION OF COMMUNITY INVOLVEMENT
Based on the foregoing, certain criteria for determining whether community involvement exists can be identified. These are as follows: (1) Existence of a community organization with popular support and organizational ability. This implies a motivated community that has information and awareness and the mechanism to take action on a collective basis. , . (2) Willingness on the part of the community to make available resources for action, either manpower or materials. Human resources are likely to be the most readily available. (3) Information is being exchanged on a two-way basis at levels of the social structure and between different sectors of the community. As community involvement becomes a determining factor in the development of health services, indicators to measure its progress and its effect on health services and on health problems have to be developed. For the purpose of this paper, it may be necessary to consider two types of indicators: those that measure community involvement in the health service system; those that measure the impact of such involvement.
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WPR/RC31/TP/l
page 11
5.1
Measurement of community involvement
It has to be admitted that to try and measure community involvement is not easy. Little has been done to relate community involvement to improvement in health care or even to cost effectiveness of services. Great care has to be exercised in deciding what it is exactly that is being measured. It would be useful to develop a simple argument as a framework. Community involvement means that more resources are available 'to the health services, which in turn leads to improved health services delivery. Thus, in terms of measurement of community involvement, indicators could be: measures of community resource allocation for health action; measures of the health habits of the people (use of latrines and safe water, personal hygiene, child rearing practices, fertility regulation and immunizatipn); measures of community participation in the management of health services; measures of info~tion
flow between community and health workers;
measures of health activities carried out by the community. 5.2 Measurement of impact
Here the question becomes more difficult. It should be possible to measure health services output, in terms of i~crease(i services, coverage and efficiency, with conventional service output indic,ators. This could be done before and after community involvement, as in a research and development project. Types of indicators used would be .those that measured the distribution of health resources, the use of appropriate technology, and improvement in the delivery of services. However, in terms of total health improvement or impact on the community as a whole, much more work needs to be done. It is probable that the health sec'tor alone cannot develop valid indicators to measure the real impact of community involvement. The community itself may need to do it and the challenge for health workers is to develop a process whereby it may be done.
6.
HOW COMMUNITY INVOLVEMENT IS DEVELOPED
Each community and society is unique; community behaviour is linked to the culture of the community. It is not possible to be too specific in saying how the community should be involved in health services development. In this section, certain points, taken from the case studies
WPR/RC3l/TP/1 page 12
presented in Annex 1, are made. The bibliography presented in Annex 2 gives the sources of information on the case studies. It is not attempted to make any recommendations based on the case studies. The following criteria were used in choosing the four examples of community involvement as case studies: each study to have been undertaken in the Western Pacific Region; each study to present a different facet of community involvement; documentation available; the studies to reflect reality as far as possible, that is to say the changes introduced could be adopted elsewhere. Thus, of the four case studies, two (Carigara, Philippines and Porirua, New Zealand) show the health services as an entry point for community development. The Chinese case study shows community involvement in the health services as part of the overall sociopolitical organization of the community. The Women's Committees in Samoa are an example of adaptation of the traditional social structure and organization. It is acknowledged that there are many similar studies in other countries of the Region which could have equally well been used as examples. Documentation or information on such activities would be welcomed by WHO so that experience can be shared. In considering how to develop community involvement in a practical way, the case studies indicate that a sequence of events is involved, similar to the conceptual scheme given in section 3. The steps in this sequence are as follows: (1) Existing situation: relationship between health services and consumer on the basis of provider and consumer. (2) Initiative for action: from either the health sector or the community or from a third source some initiative is taken that will involve the community. (3) Community preparation: there is real interaction between the community and the health services. (4) Community action: health activities are carried out by the community and the health services. (5) Continuing involvement: albeit dynamic, mechanism. the joint process becomes a permanent,
-
The case studies will help to illustrate the steps described above.
WPR/RC31/TP1 page 13
6.1
Existing situation
This is a hypothetical situation presumed to exist before the community becomes involved in the development of health services. As described in sections 1 and 2, the health services are, in general, provided by a network of health facilities staffed by health professionals, working either for the government or privately. The community is either not involved, or involved only in the role of consumer. This situation existed in the pre-project phase in the Carigara experiment and the Porirua community health project. 6.2 Initiative for action
To start the process of community involvement there has to be an initiative from somewhere. It may come from the community itself or from outside the community, from government or private agencies, or from the health services themselves. The underlying message of WHO in the primary health care approach is that the health services should take the initiative. In China, community involvement in the health services was a political initiative; in Samoa, it was a joint effort of the community and the health services through the women's committees; in Carigara and Porirua, the health services took the initiative. 6.3 Community preparation
Once the initiative has been taken, interaction between the community and the health services has to start. The social groundwork has to be carried out. Members of the community and health workers have to be prepared~ the former have to be made aware of health problems and the potential for development through community action; the latter have to learn about the real needs of the community and the different role they have to play. In China, social preparation is part of the political education process. In Samoa, social preparation falls within the context of the traditional "matai" system whose social network provides the mechanism. In Carigara and Porirua, the social preparation phase is most interesting and is described in more detail, since the approaches used appear to have been successful in generating community involvement. 6.4 Community action
The social preparation carried out by the community and the health services leads to action. Health-related joint activities are planned and implemented. It seems the community should be the major decision-maker since, if the health sector establishes the priority, involvement may be less certain. As part of the initial process in Carigara, activities considered to be important by the community were carried out. In Porirua, a more complex relationship was involved~ lack of a social structure on the one hand and anxiety about access to health care on the other. This led to health activities which strengthened the community structure.
WPR/RC3l/TP/l page 14
When a mechanism for community awareness with regard to health matters exists and priorities are shared, community involvement in health activities can be undertaken on a very ambitious scale, as in China. 6.5 Continuing involvement
Finally, the process of involvement has to be continuing and permanent if it is to be of long-term value. Here broader issues have to be taken into consideration. Demonstration projects and case studies can illustrate what has been done in certain situations. In the case studies selected, China and Samoa have established continuing involvement of the community in the health services. In Carigara, extension of the approach is being implemented in one region.
-
7.
ISSUES AND IMPLICATIONS
From the foregoing discussion and from the case studies, certain issues and implications arise that bear general consideration. The title of this paper, "Community involvement in health services development", has been interpreted widely to include other types of development that may be health-related. In the final section, it is necessary to address issues and implications as far as the health services are concerned. 7.1 Health as a priority
If the community is to be involved in health activities and ultimately to form a partnership with the health services, high priority must be given to solving health problems. This is not usually the case; communities tend to see other needs as having priority. A very important role for the health sector, if it is to take leadership, consists in linking health needs with other needs and in developing an integrated approach to problem solving. The case studies show that health workers may have to work with the community on development projects other than health ones. This may seem unorthodox but if it is the only way a mechanism for joint community health service action can be established it has to be done. It has been noted that communities do not, in general, attach high priority to health. Usually the economic productivity and development of infrastructure such as roads and school buildings are of more concern. The health sector has to seize any suitable entry point to start the process of community/health services interaction.
WPR/RC3L/TP/l page 15
7.2
Health as a national policy
If the community gives high priority to health problems, it is likely national authorities will also, but in few countries is investment in health development a priority. Health services usually have a low priority as far as a share of the national budget is concerned. Where it is declared national policy to give high priority to health, however, the climate for community involvement is more favourable. A most important issue, implicit in what has been written earlier, is the establishment of a mechanism that will allow the community to participate in the formulation of health policies. This is a po1itico- social question governments have to consider, in which there is trade-off. If communities participate in a policy formulation process, governments have the benefit of community resources for health programmes. 7.3 How to sustain community involvement
For this there is no simple formula. The case studies give an idea of how some communities have become involved in the health services. To develop such involvement is perhaps relatively easy; to maintain it as a permanent and dynamic process is much more difficult. The whole political and social fabric of the community and, by extension, of the country, is involved. The health sector, in collaboration with other sectors, can stimulate and sustain the process. 7.4 When is the community ready?
It has been learnt that a community will not, and cannot, be involved in health services merely because the health sector has decided it needs the community to participate. There is a process, often long, of preparing the community; it would be better to say the community has to prepare itself. Not all communities are willing or ready to do this. Where there is weak social organization and individuals live at subsistence level, it is difficult to enlist active community involvement in government health services, however desirable. At the other end of the spectrum, a highly developed urbanized community may not be ready to become involved in health until it becomes aware that problems exist and that they can be solved by community action. 7.5 Involvement may be a long process
In view of the many factors involved and the experiences quoted, time becomes an important element. The health sector or the government may have to wait for three to five years, while enough experience is being generated to allow a national policy to be formulated. However, some important policy decisions have to be made quickly which may have profound implications in terms of organization of the health services and other government sectors. How to reconcile long-term and short-term needs is an important issue facing national health planners.
WPR/RC3l/TP/1 page 16
7.6
Coordination between sectors
Implied in what has already been said is that at all levels, starting with the community, there will have to be a much greater degree of intersectoral coordination. How this coordination will be developed and maintained is not considered in this paper, except at community level. At provincial and national levels, new mechanisms will have to be developed. Examples are national health councils, regional development groups and intersectoral planning bodies. 7.7 Exchange of information as a factor
Much has been said about the processes and mechanisms that operate between the community and the health sector. An important factor seems to be improved exchange of information between the community and the health services. The health services have to learn about the community! how it works, what are its problems and needs. The community has to learn about health matters! what are the causes of ill health and what can be done about them. An exchange of information on a continuous basis will facilitate joint action between the health services and the community. The issue in question is how to develop such a mechanism for information exchange. 7.8 Changed role of health workers
It has been shown that the community has to be involved if proper health care is to be provided. If there is to be community involvement in the management of the health services, the role and attitude of health professionals will have to change so that they can work together with the community as an equal partner. This is implied throughout this presentation and emerges as a major issue. There are major implications for health manpower development and policy, an issue which needs to be faced by all countries. However, the question remains as to whether the health professional is willing or able to provide the type of health care that permits community involvement and participation. 7.9 Impact on health " I Ii 11
It is generally assumed that the health services will improve if there is community involvement. A much more important assumption is that the health status of the community will also improve. In view of the prevailing doubts about the impact of the health services on health, the second assumption becomes even more vital. It is believed that by involving the community in health, a much more systematic approach to all the factors that affect health is possible. Mention has been made of the need to develop indicators to monitor the involvement process so that progress and the real impact may be measured. For the present, the justification for this new approach to health services is provided by the successes already achieved by some countries. The challenge is to make success possible for all.
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II I
il
II
II " II I
~
WPR/RC31/TP/1 page 17/18
S.
REFERENCES
(1)
SEPULVEDA, C. and MEHTA, N., ed. Community and health: an enquiry into primary health care in Asia. UNAPDI, Health Technical Paper No. 35/BCS4, 19S0. LEVIN, L.S. Self-care oriented health education from the of the WHO role. Geneva, World Health Organization, 19S0 HED/SO.l). Community involvement in primary health care: a study of the process of community motivation and continued participation. Report for the 1977 UNICEF/WHO Joint Committee on Health Policy (document JC2l/UNICEF-WHO/77.2.Rev.2). NUGROHO, G. Community health information system, an important tool for the development of a primary health care programme. Manila, WHO Regional Office for the Western Pacific, 1980 (document WPR/ACMR/SO.14).
(2)
(3)
(4)
WPR/RC31/TP/l page 19
CASE STUDIES
These case studies are referred to in Section 6 of the text. The descriptions given are related to the following factors, identified as critical to the topic of community involvement. decision-making in the community; pro=ess for involving the community; availability of community resources; nature of activities. The sources of information from which the case studies were prepared are listed in the bibliography (Annex 2).
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WPR/RC31/TP/1 Annex 1 page 20
1.
CHINA:
THE COOPERATIVE MEDICAL SERVICE
Since the directive of Chairman Mao Ze Dong in 1965: "In medical and heal th works put the stress on rural areas", the heal th care system has evolved from the community, with support from the existing health infrastructure. This infrastructure has itself been significantly modified as a result. The system in China fulfils the criteria for primary health care, inasmuch as care is provided by workers drawn from the community who are supported primarily by the community and secondarily by the government health services. The cooperative medical service is, in effect, a health service scheme usually operated by the production brigade, though some are operated at commune level. The members of the scheme pay a small annual sum and, in some cases, a small charge is made for services. The funds available to the cooperative medical service cover all running costs for health care at brigade level and a substantial portion of hospital costs for referred cases. The staff of the cooperative medical service (barefoot doctors and health aides) work part time and are paid in the same way as other peasants and workers in the brigade or commune. Community involvement in the development and operation of this system will now be considered in more detail. 1.1 Decision-making in the community
It is not possible to separate the development of health care services from the social changes that occurred in China following Liberation. 8iven the reorganization of society, which transformed the rural population into the commune/production brigade structure, the decision-making process by communities on matters that affect them is relatively straightforward. National policy is transmitted through representation on the People's Congress at each level and through the normal administrative infrastructure. The development and operation of the cooperative medical service within this framework presents no difficulty. The community is fully involved in the management of the service by means of a committee, which includes representatives of the community, cadres and barefoot doctors. The committee is responsible for the management and operation of the service. The important point is that, at the community level, the cooperative medical service is merely part of the cooperative endeavours of the community in many areas, such as agricultural production and education. 1.2 Involvement process II
To describe the process would mean describing what has happened in Chinese society since Liberation in 1949. That will not be attempted here but it is possible to make some remarks about the process for involving the community as it operates today. One can ask how it is possible in China
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WPR/RC3l/TP/1 Annex 1 page 21
to implement the "mass line" in health work. This mooilization of a large labour force to carry out preventive and environmental health tasks is an impressive manifestation of community involvement. There must be recognition and acceptance by the community of the fact that the mass activity to be performed is of high local priority in relation to other work activities. In some other countries of the Region, high priority is not given by the people to health activities. 1.3 Availability of resources
The resources available to a Chinese production brigade for health action are firstly, manpower; secondly, agricultural production and the funds generated by that production; and thirdly, herbal medicines grown in the community. The cooperative medical service is expected to be self-reliant as far as possible but it could not operate without technical support from the Government. The barefoot doctors have to be trained and they have to be supervised by regular visits from hospital teams during their work in the rural areas. A referral system to county hospital level and above is necessary to provide services that are not available within the cooperative health service. Thus there is interdependence between the Government health infrastructure and the cooperative medical service. 1.4 Activities undertaken
...
The health activities undertaken by the cooperative medical service are those normally considered as basic health services - promotive, preventive, curative and rehabilitative. In addition, there are the mass movements for disease control, for example against the four pests, environmental health engineering projects and other activities involving mobilization of the community. However, it would seem that control of the environment is not a function of the cooperative medical service but of the Government through the production brigade and the people's commune. Another most important aspect of health activities is the integration of scientific and traditional medicine. The use of acupuncture and herbal remedies by the barefoot doctors enables many communities to be largely self-reliant in all medicines - at least in herbal medicines. Many production brigades and communes can produce a surplus to their requirements and by the sale of this surplus generate additional income. Without community acceptance of traditional medicine this would not be possible. 2. NEW ZEALAND - THE PORIRUA COMMUNITY HEALTH PROJECT
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The report of this study is entitled "Community attitudes to sickness and heal th". I t includes two activities ~ the Porirua Community Heal th Project and the household health surveys conducted in Porirua and Hamilton in 1976. The title of the report is conventional enough and gives no hint of the fact that the study breaks new ground. It can be said to be one of the very few examples of a scientific approach being used to study and implement primary health care.
WPR/RC3l/TP/1 Annex 1 page 22
The study, and the project that grew from it, started in 1976 as a health survey of the City of Porirua, which is situated near the Capital City of Wellington. The initial survey was aimed at discovering the extent of ill health in the community and the groups most at risk and also at studying utilization of the health services and identifying problems related to their provision. The first innovation and the most important, as it set the pattern for what was to follow, was that from the very beginning the survey was developed and conducted with the involvement of the community. Through meetings of the Porirua community health pLoject, local people suggested questions for the survey and were involved in deciding how the results were to be used and presented. The results of the survey were interesting in two ways. In the first place, knowledge was obtained on how the community perceived illness and what action individual members took when they felt they were sick. These attitudes and the reaction to sickness appeared less related to the socioeconomic and ethnic characteristics of the community and more to geographical and sexual factors. In terms of health action taken by the community, however, a very revealing set of problems emerged. Access to health care was a major problem, caused mainly by lack of transport and inappropriate services. A broader problem was the isolation and loneliness of many individuals in the community. The problems identified were not specific health problems but social problems; anxiety was generated by apparent lack of support by the community of the family or the individual. The next innovation was the action that resulted from the survey. Through the Porirua community health project, definite action was taken to solve the major problems identified. The project first had to organize itself and establish its own role and identity. Discussion groups were formed and a training course held for community health workers. The project's headquarters became a focus for community health activities. A health van was acquired and the success of this indicated the degree of the transport problem. After three years, the action phase of the project is continuing but already it can be said that the initial contribution by the health sector has produced remarkable results in health development in the broadest sense, by involving the community. 2.1 Decision-making in the community
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Initially, the approach was centred on health problems or rather on the causes of ill health. By means of the community health project, the community participated in decisions related to the survey and to subsequent project action. It would seem that the project felt the need for community expression. Because of the rapid growth of Porirua, the existing social organizations were not adequate for the people to express their needs and channel them into action. In a variety of ways pressure built up, with concern over the health services as the focus.
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WPR/RC31/TP/l Annex·l page 23
2.2
Process of involvement
The mechanism developed was the community health project. The initiating activity was the health survey. The critical factor at the beginning was the transfer of the initiative from the health professionals on the outside to the representatives of the community themselves, which ensured "ownership" of the project by the community and consequently involvement. After a meeting of health professionals and community leaders called by the Porirua City Council, a steering committee was formed and the project started. It became a link between institutions and the community. Then the role of representatives of institutions became less important and the community representatives assumed greater responsibility for the management of the project.
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2.3
Community resources
Given the socioeconomic status of the community, resources, both human and financial, are not lacking. Once the mechanisms were established, resources were found. The resource created was a group or team within the community, able to take action with its agreement and support. The house for the project, the full-time staff, the van, and other items, followed this first step. 2.4 Nature of activities
The project has always focused on health, or rather on ill health. The community had expressed its anxiety concerning the lack of health care due to inaccessibility. The response to problems is still directed towards bringing health care within the community by means of the project and also providing links with the existing services. Through this, one can detect a much broader response on the part of the community to solving its other social problems, such as isolation and loneliness, and those of the. disadvantaged groups. The future activities of the project will beof considerable interest. 3. PHILIPPINES: THE CARIGARA EXPERIMENT
The political and administrative organization of the country is by region, province, municipality, barangay (village) and purok (sub-unit of a barangay). The health services are provided by a system of health centres and subcentres, called rural health units, and barangay health stations. Despite a recent major investment by the Government to strengthen and improve the system, it is recognized that problems of coverage of the rural population remain where the basic infrastructure is weak. To study how the health status of the people can be improved, the Institute of Health Sciences, University of the Philippines initiated a community health care research and development project in the area of Carigara, Leyte Province, one of the less developed areas of the country with a largely rural population. The lessons learnt from this study were used to examine the health development process at various levels of the administration and the whole of region VIII is now involved. This experience in turn has been adopted by the Ministry of Health as a key to developing a national strategy for 'health for all by the year 2000'.
WPR/RC/3l/TPl Annex 1 page 24
Research and development activities followed the sequence explained below! (a) Preparation phase. This included the identification of health problems in the various areas by means of a survey carried out by health workers. The next step was the social preparation of the barangays by contacting the leaders of the community and explaining the purpose of the project to the community. The final preparatory activity was the development of a structure to permit community participation. The municipal health officer, with the respective barangay captains, identified the existing barangay structure. Through a barangay "network" a two-way communication between the health system and the community was established. The barangays were subdivided into units composed of 5-10 families with a leader for each unit. This network of units was coordinated by the barangay council, the barangay captain acting as chairman. (b) Implementation phase. During this period, various activities to solve community problems were carried out. They included~ health activities such as tuberculosis case-finding and prenatal care; health-related activities such as the installation of water pipes and the construction of blind drainages; income generating activities such as pig raising and mat weaving; and, finally and most important, development of a community information system. As far as community involvement and participation are concerned, the Carigara experience showed the following! (1) The need for social preparation. The community must become aware of its problems and its potential ability to solve them, i.e. to develop. The community must have an organizational structure through which needs can be expressed and solutions formulated and agreed. (2) The community's expressed priority needs have to be met first, with its full participation in the planning and implementation of activities. The nature of these needs is not traditionally the concern of the health worker, for example, income generating projects or water pipe installation, but involvement of the health workers enhances their credibility later when health activities may be undertaken. 3.1 Community decision-making
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With the mechanisms described above, two processes are involved; motivation to develop and solve problems, and actual identification and solution of problems.
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WPR/RC3l/TP/1 Annex 1 page 2S
In Carigara, the unique feature was the development of a community decision-making structure that permitted the health services system to be involved in the joint solution of health and other problems. As has already been mentioned, this is an unorthodox role for health professionals and perception of the roles of such workers requires considerable change on the part of the community and the staff concerned. The implications for the health professions are very important. 3.2 Process for involving the community
This has already been described to a certain extent. The initiative comes from the health sector and is taken by the municipal health officer and his staff. To do this they have to be reoriented to accept their new role. A dialogue is then established with the community by making a survey or diagnosis and presenting it with the results. In that way a community structure is built up. Finally, using the structure, the community implements development activities. Such activities may at first concentrate on priorities outside the traditional health sector but will finally achieve the solution of health problems. 3.3 Availability of community resources
As has already been indicated, the Carigara area is a rural area, poor and not developed, yet resources which were not limited to manpower were mobilized through collective effort. 3.4 Nature of activities
The activities carried out were those identified by the community as being of the highest priority. They were not necessarily health activities. However, it is the underlying theme of the project that the peripheral health services must first establish a dialogue with the community in order to establish mutual knowledge and trust. By working with the community for the achievement of some of its aspirations and goals, health action and the solution of health problems will follow. During implementation of the project there wece crucial differences in perception of the problems that should receive priority. The interaction between the community and the health staff permitted a gradual sharing of objectives until agreement on what should be done was reached. This could not have been done without the two-way exchange of information built into the structure. 4. SAMOA: WOMEN'S COMMITTEES
The government health services follow an orthodox pattern of district hospitals/health centres, subcentres and some special function clinics. Basic health services are provided at village level by district nurses and assistant health inspectors. Traditional birth attendants are responsible for the majority of the deliveries, especially in the rural areas. Primary health care is not new in Samoa and is adapted to the existing social structure and the culture of the community.
WPR/RC3l/TP/1 Annex 1 page 26
The prime IOOver in the development and implementation of primary health care is the village women's committee. The women's committee organization is based on the traditional social structure of the community, the 'matai' system of community action. The leaders are usually wives of the influential and respected matais. The committees function at the village level and can be described as mechanisms whereby the individual contributes to a group effort in identifying and solving health problems. They work closely with the staff of the national peripheral health services, i.e. the district health team. The district medical officer, based in a district hospital/heal th centre, is the leader of the team. The women's committees are now an important political and social group in the community and by their collective action can have an important influence on government policy and national programmes. Thus they constitute a mechanism for ensuring that community needs are represented collectively at national level. 4.1 Community decision-making
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In Samoa, the structure and organization of the community is strong and traditional, based on a centuries-old hierarchical structure called the 'matai' or chieftain system. The structure is accepted and trusted by the community. The decisions on community action rest with the matai leaders, who must therefore analyse and implement the collective community opinion. As regards health matters, it is the women's committees who play the important role. They were started in the 1920s to deal with health matters and have developed to become a very important resource for the health services. The fact that the establishment of the women's committees harmonized so well with the existing community organization ensured their survival at the beginning. Their continued growth and regionalization resulted from their obvious value to the community in contributing to its health development. Although they deal mainly with health matters, the committees can and do contribute to other community activities. 4.2 Progress for community action
As has already been stated, the social organization is based on the 'matai', or chieftain, system and there is a hierarchy of chiefs within the society. The chiefs are selected through discussion and become the dec is ion-makers wi th in the community. The chie fta in s true ture forms a 1 ink with the extended family or clan type of grouping that exists in Samoa. The women's committees follow naturally from this social structure. The leadership is provided by the wives of the chiefs but the majority of women are members and all villages have such a committee. The village councils, which are the fora for the identification of problems and for agreement on priorities, meet regularly. The women's committees are expected to take responsibility for health matters and count on the support of the chiefs. Beyond the village level, there are women's ~istrict health committees, which organize support for the district hospitals. At national level, representatives of the women's committees form the National Council of Women.
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W~R/RC31/TP/I
Annex I page 27/28
4.3
Resources available
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The women's committees are a most important mechanism for mobilizing community resources for health activities. They provide support to the district nurses in terms of community health aides or primary health care workers, who are recruited and supported by the community. Also the women's committees often support and maintain the district hospitals, providing labour, materials and funds when necessary. Funds for the construction of health facilities have also been generated in this way. 4.4 Activities undertaken
The health activities of the women's committees have been listed as follows: (1) in relation to mother and child health activities, helping the district nurses to inform and gather together mothers and their babies for weight registration, immunizations and health education on nutrition, and encouraging pregnant mothers to use antenatal facilities;
(2) assisting district nurses and health inspectors to clean up the environment and inspect domestic facilities; 3) assisting the health personnel to carry out mass campaigns against, for example, yaws, filariasis, tuberculosis and leprosy; 4) improving the protein intake of the people by raising cows, engaging in poultry and farming, and cultivating vegetable gardens; 5) building "fales", which serve as meeting places for daily activities in primary health care and places where the district nurses carry out mother and child health activities and health education; (6) seeking funds to build hospitals, health centres, health subcentres, school houses and churches; (7) purchasing simple drugs and instruments for first aid;
(8) contributing labour for cleaning and maintaining the compounds of district hospitals, health centres and subcentres; (9) providing funds for plants to supply electricity to district hospitals; 10)
contributing local materials for the construction of water-seal
latrines. These are specifically health and health-related activities. What is not mentioned is the considerable role assumed by the women's committee in generating awareness in relation to health matters and in influencing policy and resource allocation for health activities, not only in the community but also at national level. \." ,. J \
WPR/RC31/TP/l page 29
ANNEX 2
SELECTED BIBLIOGRAPHY 1. 2.
Chang, Wei. Cooperative medical service is fine. Languages Press, 1978.
Beijing, Foreign
Community involvement in primary health care~ a study of the process of community motivation and continued participation. Report for the 1977 UNICEF/WHO Joint Committee on Health Policy. (Document JC2l/UNICEF-WHO/77.2 Rev.2). Djukanovic, V., Mach, E.P. Alternative a ~~~~~~~~~~==~~~~~~health needs in developing countries~ _a-Aj_o_i_n_t______~________~ Geneva, World Health Organization, 1975. Final report of the First Regional Working Group on Basic Health Services, Manila, WHO Regional Office for the Western Pacific, 1976. Gonzaga, E. Health for all Fili care through partnership (a case document, June 1980. Philippines •
3.
4. 5.
6.
Levin, L.S. Self-care oriented health education from the of the WHO role. Geneva, World Health Organ1zation, 1980 HED/80.l) •
7. 8.
Newell, K.W. ed. Health by the people. Organization, 1975.
Geneva, World Health
Nugroho, G. Community health information system, an important tool for the development of a primary health care programme. Manila, WHO Regional Office for the Western Pacific, 1980 (document WPR/ ACMR/ 80 • 14) • Reinken, J., de Lacey, A., Salmond, C.E. Communit¥ attitudes to sickness and health~ stimulus and response. Spec1al Report No. 56, Management Services and Research Unit. Wellington, New Zealand, Department of Health, 1979. Sepulveda, C., Mehta, N., ed., Community and health~ an enquiry into primar health care in Asia. UNAPDI Health Technical Paper, No. 35 BCS 4, 1980.
9.
10.
7
11.
Wilenski, P., The delivery of health services in the People's Republic of China. Ottawa, International Development Research Centre.