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This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this site.
Copyright 2006, The Johns Hopkins University and William Brieger. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.
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Community Participation
William R. Brieger, MPH, CHES, DrPhJohns Hopkins University
2
Section A
What Is Participation?
3Community participation: The centerpiece of PHC
4
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
5
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
6
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
7
PHC Requires and Promotes
To this end, develop through appropriate education the ability of communities to participate
8
What Constitutes Participation
Active involvement of the local population in the decision making and implementation of development projects
Continued
9
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
10
What Constitutes Participation
The community both determines collective needs and priorities, and assumes responsibility for these decisions
11
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
12
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
05
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
16
Participation inWater Supply Project
Multiplier Effect on Immunization Participation
0
10
20
30
40
50
60
participatory non-part no project
IndonesiaTogo
17
Community-ManagedEssential Drugs
VHWs Buy and Maintain Stock
0
10
20
30
40
50
60
70
% 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
19
Community meeting
20
CDTI vs Program-DirectedEffect on Ivermectin Coverage (TDR/APOC)
0
10
20
30
40
50
60
70
Kaduna Enugu Yola Mali
CDTIProgram
21
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
24
Participatory Approachto Improve MCH
In Bolivia, Women’s Groups Plan Their Own Program
0
20
40
60
80
100
120
PerinatMort
TTCover
TrainedAttend
Follow-up Baseline
ContraUse
ANCVisit
InitiateBF
25
Section B
Levels of Involvement
26
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
20
40
60
80
100
120
accept mobiliz particip involve control
Level of Participation
Am
ount
of i
nvol
vem
ent
28
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
29
Acceptance Can Be Likenedto Passive Participation
Education aims at motivation for completion of the tasks determined by the agency
30
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
31
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
32
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
33
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
34
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
35
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
36
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
37
Community control comes when members get together and make decisions
38
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
39
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
40
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?
41
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