4 THE PARTICIPATORY APPROACH IN THE NATIONAL HEALTH POLICY 2002
4.1. CASE STUDY: HIMACHAL PRADESH
4.1.2. Analysis
4.1.2.2. Community Participation
Civil service Hiring and firing permanent staff National civil service
Local civil service
No civil service Access
rules
Targeting Defining priority populations Law or defined by higher authority
Several models
for local choice No limits
Governance rules
Facility
boards Size and composition of boards Law or defined by higher authority
Several models
for local choice No limits
District
offices Size and composition of local
offices Law or defined
by higher authority
Several models
for local choice No limits
Community
participation Size, number, composition, and
role of community participation Law or defined by higher authority
Several models
for local choice No limits
Reasons for NGOs to Work on Health (in % of all answers)
0 10 20 30 40 50 60 70 80
community approached us to do so we did a survey our success in other projects depends on health health situation is so bad
n = 26
Sources of NGO Funding (in % of all answers)
0 10 20 30 40 50 60 70 80 90
State funding Central government
International agencies
Membership fees Community n = 26
(65 %), followed by the state (62 %). Funding through membership fees or from community is low, only 31 % and 27 % receive funding from these sources respectively.
Figure 4.12: Reasons for NGOs to Work on Health Issues in Shimla and Kangra
Figure 4.13: Sources of NGO Funding in Shimla and Kangra
In Murthy’s and Klugman’s framework the definition of community is the first step to assess the degree of community participation (see Table 2.1; Murthy/ Klugman 2004: i79).
Community in the health programmes is defined through the purpose of the programmes.
NGOs mostly target certain groups of population. Women are the major target group, 88 % of NGOs define them as target for their programmes, because they are perceived as a marginalized group in health care. General population comes next (68 %), followed by children and men. Women are not targeted as single persons but through women groups like Mahila Mandals. Although NGOs try to reach especially the marginalized groups, it is difficult to motivate them for health issues (see below). NGOs have only access to relatively easy to reach people in an area. Another definition of community is formulated through the establishment of PARIKAS and the regulation of membership for this group.
Since only heads and representatives of organizations are invited to participate,
NGO Outreach Activities (in % of all answers)
0 10 20 30 40 50 60 70 80 90 100
health camps
go to schools
PRI meetings
go to PHC organise events
other n = 24
marginalized groups are left out. Hence, community participation for the function definition of community reaches a middle degree (see Table 4.4).
The National Health Policy defines PRIs including PARIKAS and NGOs as representatives of community (see above). NGOs work through women groups and PRIs.
Most NGOs characterise PRI members as uneducated and unaware of health issues (NGOs 27.10.2003; 28.10.2003). None of the community groups know their rights or what to expect from the health system. NGOs voiced the opinion that the interests of community in health are low, because economic activities are the first concern for survival especially for the poor (NGO 08.10.2003; DHO 13.10.2003). However, in the questionnaire when asked about the importance of health for the community each rating from “very important”, “important”, “not so important” to “not at all important” received about the same percentage of positive answers. The ambiguity of these answers lies in the different perceptions. NGOs which answered that health is “very important” or
“important”, either expressed their own view that health should be important to them or they had already created the awareness. The answers “not so important” or “not at all important” mostly came from NGOs who had difficulties in motivating the PRIs for health issues or from NGOs which took a more holistic view on health. As one NGO realised during the training of female MPWs: “Without reducing their economic burden, people would not work on health.” (NGO 29.10.2003).
Figure 4.14: NGO Outreach Activities in Shimla and Kangra
Community participation is still far from the representation through marginalized groups, because they are difficult to reach and do not have the required education for participation (see above, see 2.2.1.2.). Furthermore, NGO outreach activities are mainly aimed at PRIs (see Figure 4.14). Although the majority of NGOs also organize health camps and visit schools as well as PHCs, their focus for these community contacts are mostly powerful groups. Therefore, it is powerful groups who represent community pointing towards a middle degree of community participation (see Table 4.4).
The health policy wants to use community participation as a means to improve quality of care including accountability, therefore, aiming at a higher degree of community participation (see Table 2.1). The goal is clear but it remains open if it can be achieved
NGO Services for Community (in % of all answers)
0 10 20 30 40 50 60 70 80 90 100
health check up personal referral
free medicine information assistance with doctor
help in decision making n = 25
(see below). The district level on the contrary views community participation rather as a means to expand the outreach of their services. They want NGOs to fill the gap between health workers and villagers and raise awareness for their services (CMO 23.05.2003).
Hence, the degree of community participation at the district level is low (see Table 4.4).
Depth, scope and mode of community participation are the remaining criteria to assess the degree of community participation. The main work of NGOs consists in awareness raising and IEC activities. Among the services offered to the community giving information on health comes first (see Figure 4.15). All NGOs in Shimla and Kangra undertake this activity. Doing health check-ups (72 %) and rendering help in health decision-making (64 %) are the next two in the hierarchy of NGO services. Thus, besides informing the community about health issues, NGOs also offer advice and consultation, which stand for a middle degree of community participation (see Table 4.4).
Figure 4.15: NGO Services for Community in Shimla and Kangra
The scope of community participation is hard to assess, because it depends on the representatives. NGOs in Shimla and Kangra who work on a state and national level partly try to influence health policy, health management and service delivery at all levels but only big NGOs with strong organizational capacity have the means to do so. In the two districts and also in the whole state of Himachal Pradesh only MNGOs such as HPVHA are involved in health policy and even their influence is marginal. The “right-based”
approach is rare among NGOs in the state (NGO 22.09.2003). Hence, the scope of community participation reaches a middle degree (see Table 4.4). It is also difficult to distinguish between the influence of NGOs on health policy and the influence of international funding agencies. While one could argue that NGOs became involved as they did good work in the health sector, one could also assume that funding from international agencies earmarked for NGOs forced the government to include them. Both assumptions were neither falsified nor verified by NGOs and public health officials. The mode of community participation in Shimla and Kangra is clearly through invitation by the government. Mass-based organizations with a health focus do not exist in Himachal Pradesh (see GTZ 1998). Since PRI members are elected representatives of the
community who form a small collective, a middle degree of participation is reached here (see Table 4.4).
Table 4.4: Degree of Community Participation in Himachal Pradesh, Shimla and Kangra District
(Murthy/ Klugman 2004: i79)
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 District administration
level
Central or State government level CP as a means to
CP as a means to
CP as a means to - expand outreach - improve management of
local health services (efficiency)
- increase effectiveness
- raise resources - improve accountability
Rationale for CP in health
- support infrastructure - CP as a right by itself Manipulation
Depth of CP
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
As individuals As members of small
collectives As members of mass-based organizations and small collectives
Through invitation by government
Often through invitation by government
Both through invitations and demands from below
Mode of CP
MO Cooperation with Health Professionals (in %)
0 10 20 30 40 50 60 70 80 90 100
Cooperate with Health Professionals
Anganwadi TBA Private
Practitioner
Traditional Healers
Community Health Committee
Other n = 27