Community Participation

Community participation is the second principle. In the Alma Ata Declaration community participation contains involvement in all phases of primary health care (see Box 1: 5.). The WHO’s promotion of community participation was greatly influenced by the China example of ‘barefoot’ doctors. This programme consisted of part time health workers which provided basic health services in rural areas. It was very successful in China. For the transfer of this experience it is important to notice, that mobilisation for health in China was part of a much wider socio-economic and political upheaval (Chatterjee 1988: 102).

For the understanding of community participation it is essential to find out what community participation is and what its goals are, since the term can be interpreted in different ways.

In the Primary Health Care Approach community participation is one goal of health care reform and also a means to reach the other objectives like equity. The expected outcomes of community participation in the health sector include more health consciousness and

knowledge, further pushing up the demand, more access to health care through community-level workers, and improvements of community level health infrastructure (Ibid.: 106-107). The major theoretical framework for community participation has been done by the Cornell University (Uphoff et al. 1979).

The Cornell study is based on questions about the kind of participation, who participates and how participation occurs. Participation may take place in decision-making, in implementation, in benefits, and in evaluation. The participating individuals or groups may be local residents, local leaders, government personnel, and foreign personnel.

Heterogeneity in these groups should be considered by looking at age, sex, family status, education, occupation, income, and residence. For the qualitative assessment of participation the ‘how’ dimension is needed. It asks where the initiative for participation comes from (administrators or local communities), and whether the inducements are voluntary or coercive. Structure and channels of participation are evaluated by considering the basis for participation, which can be individual or collective. Furthermore, it looks if formal or informal organizations are involved and if participation is direct or through indirect representations. The duration and scope of participation and the empowerment are useful indicators too. Empowerment measures if community participation leads to the desired results by the involved people (Uphoff et al. 1979: 5-7). Westergaard criticises the

“lack of a theoretical and political framework in which to analyse popular participation” in this study (Westergaard 1986: 22). She considers power to be an important aspect of popular participation. Therefore, a theoretical framework of the causes of poverty, where poverty is “the outcome of a process of increased concentration of power and resources”, is needed for studying participation (Ibid.: 24). Since the Cornell study only delivers a vague definition, Westergaard develops a definition out of several studies which includes control as an element of power. Thus, popular participation in her view can be understood as “collective efforts to increase and exercise control over resources and institutions on the part of groups and movements of those hitherto excluded from such control.” (Ibid.:

25). Other studies also agree with Westergaard that participation is influenced by the political, social, economic and cultural environment (Kapiriri et al. 2003: 206).

While on the one hand community participation is highlighted in financing of health systems under the heading of “use of local resources” (World Bank 1993), other interpretations include the individual’s responsibility for her/his own health or the involvement in decisions about health care (Green 1992: 59). For individual responsibility and decision-making knowledge is required. Hence, education and empowerment on an individual and community scale are prerequisites for community participation. Mobilization of additional resources is in turn needed for community participation in the form of community financing. This category leaves it open to which extent individuals or the community can take part in decision-making (Ibid.: 61). Community participation is thought to enhance accountability on the one hand. On the other hand, it also needs the two elements of accountability namely ‘answerability’ and ‘enforceability’ to expand (Murthy/

Klugman 2004: i78-i79). The degree of community participation as well as the degree of accountability can rank from low to high, depending on issues like who represents

community, depth of community participation or how accountability is operationalized (see Table 2.1, Ibid.: i79-i80).

Lower degree of CP Middle degree of CP Higher degree of CP Definition of

community

Clients or users Relatively easy to reach people living in an area

Marginalized groups of the population

Who represents community

Powerful clients Powerful groups in population; NGOs who represent community

Marginalized groups in population; NGOs who represent their

interests Rationale for CP in

health

CP as a means to - expand outreach - raise resources - support infrastructure

CP as a means to - improve

management of local health services (efficiency)

CP as a means to - increase

effectiveness - improve accountability

CP as a right by itself Depth of CP Manipulation

Informing

Advice/ Consultation Collective or

community decision- making

Scope of CP Service delivery Service delivery and management at periphery

Health policy, health management and service delivery at all levels

Mode of CP As individuals

Through invitation by government

As members of small collectives

Often through invitation by government

As members of mass-based organizations and small collectives Both through

invitations and demands from below Table 2.1: Community Participation (CP): lower to higher degrees of participation (Murthy/ Klugman 2004: i79)

Table 2.1 shows six indicators to assess the degree of community participation. The definition of community is the first criteria. Community can be defined as clients or users, as relatively easy to reach people living in an area or as marginalized groups of the population. The highest degree of community participation is reached if community is defined as marginalized groups of the population who were hitherto excluded following Westergaard’s definition (see above). Representation of the community has a similar structure ranging from powerful clients indicating a lower degree of community participation over powerful groups to marginalized groups of the population having the highest degree of community participation. All six indicators show the highest degree of community participation the more people are involved and the higher the level of the

decision-making process is. The classification is very useful to assess the current status of community participation⁵.

Besides the rating of the extent of participation and the selection of indicators for operationalization, it is also important to look at the overall methodology. Rifkin distinguishes between the down” and “bottom-up” approach (Rifkin 1996). In the “top-down” approach planners decide the objectives and then try to convince people to accept them. This approach corresponds with Murthy and Klugman’s classification of lower degree of community participation (see Table 2.1). In this so called “target-oriented frame”

the aim of community participation is defined to improve the health status of people (Ibid.:

81). The “bottom-up” approach understands “community participation as the result of community people, essentially the poor, gaining information, access to resources and eventually control over their lives rather being dominated by the authorities (elites) by whom they have been exploited.” (Ibid.: 82). The second approach is also called

“empowerment frame”. It corresponds with Murthy and Klugman’s classification of higher degree of community participation (see Table 2.1). Furthermore, it highlights that poverty and poor health is caused by inequities in resource distribution and can only be overcome with a change in the existing power system. For this change information is the key to control and influence.⁶ Rifkin’s definition of participation shows many similarities to Westergaard. Both see control as the end goal of participation. The logical course or hierarchy of participation, namely first gaining information, then access and lastly control, is best explained by Rifkin’s definition. The “bottom-up” approach described by her reflects community participation as it is emphasised by the Primary Health Care Approach.